In the past, individuals demonstrating the symptoms of schizophrenia were thought to be possessed by demons. Banishment, imprisonment, and torture were the only forms of treatment available. Fear of the perceived possession dictated responses to the behavior. The inappropriate ideas, hallucinations, and strange behavior remains as difficult to understand today as it was in medieval times.
The medical profession struggles to address the presence of schizophrenia in society. McGrath, Saha, Chant, and Welham (2008) state the psychopathology affects 1% of the worldwide population and incurs substantial costs to families, society, and the patient. In addition, evidence points to a shortened life span of the schizophrenic. In fact, 30% to 50% odf affected individuals believe they have an illness (Baier 2010) There are some patterns to symptoms and peak periods for onset that assist in diagnosis. Specific influences in genetics and the environment combine to create the mental disorder.
Symptoms
Hirsch (2003) states patients diagnosed with schizophrenia show pattern of behavior demonstrating emotional difficulty, with 20,000 deaths resulting in 2010 attributed to the disease. Worldwide, 24 million people were diagnosed to some degree in 2011. While many members of the general public perceive schizophrenics as being violent, patients are actually significantly more likely to be victims of violent and non-violent crime. The association of patients with acts of violence are primarily due to the use of drugs used for self-medication, which is true of the general population.
Positive and negative
Symptoms are sometimes described as positive or deficit (negative). An impending episode of psychosis may be proceeded by the following positive symptoms generally not seen in people with normal behavior:
- Withdrawal and social isolation
- Odd beliefs or irrational statements
- Increased absence of emotion
- Hostility and suspicion.
- Paranoia or doubting the motivation of others
- Changes in sleep patterns, either oversleeping or insomnia
- Unfamiliar and disordered speech patterns.
- Hygiene and personal appearance degeneration
- The use of alcohol and/or drugs to self-medicate
- Hallucinations involving physical sensations, noises, visual, or even taste (Kneisi 2009).
Negative symptoms do not respond as well to medication as positive ones and include:
- Decrease in motivation.
- Cannot experience pleasure
- Decreased desire for relationships
- Speech frequency decreased.
Onset
There are peak periods for the manifestation of schizophrenia symptoms. Older adolescents and individuals entering adulthood are in developmental periods triggering onset (van Os 2009). Patients with a familial history of schizophrenia have a 20% to 40% chance of disease detection approximately within one year (Drake 2005). It is possible to predict onset up to thirty months prior to manifestation of symptoms and institute treatment.
Causes
The causes of schizophrenia remain difficult to isolate. Genetic influence and impact by the environment combine to create a developmental role (Picchioni 2007).
Genetic
It is difficult to separate how much influence genetics makes on estimating the inheritance of schizophrenia and how much from the environment. If one parent is diagnosed with the disease, the risk is approximately 13%. If both parents are diagnosed, the risk rises to 50% (Herson 2011).
Problems arise in identifying specific genomes associated with bipolar-disorder and those with schizophrenia. The mental illness affects 1.4 times more men than women.
Environment
As mentioned previously, prenatal stressors are environmental factors that contribute to possible development of schizophrenia later in life. The use of drugs or other aspects of the living environment also promotes symptoms. Curiously, parenting style is of little or no consequence. Risk increases with incidences of abuse, bullying, childhood trauma, or occasions of family separation. Urban environments promote schizophrenic behavior by a factor of two. Ethnic groups, degree of socialization, and drug use do not figure into this risk equation.
People diagnosed with schizophrenia suffer from loneliness and boredom associated with social isolation, depression, and anxiety result in use of drugs and alcohol to self-medicate. If a patient with a genetic predisposition to the disease uses cannabis, symptoms may be exacerbated; however, use of cannabis alone does not cause it (Parakh 2013).
The brain enters a period of critical change that makes it vulnerable to pathological psychosis, possibly as a result of early trauma prenatally. Risk increases 5% to 8% with fetal exposure to infection, hypoxia, malnutrition, and stress.
Mechanisms
The interplay of psychological mechanisms on schizophrenia is complex. On the one hand, effects of psychotherapy modify display of symptoms. Although a blunted affect distances others from an individual with this mental illness, many are actually very sensitive. This creates a psychological impact non-schizophrenic people could experience. Delusional beliefs contribute to psychological effects, while psychological effects may lead to delusional beliefs. A patient may avoid threats, either real or imagined, with words or gestures. These “safety behaviors” can lead to delusions are long-lasting (Cohen 2014).
Brain structures that are slightly different contributed to schizophrenia in 40 to 50% of the cases (van Os 2009). Sections of the brain involved are temporal lobes, frontal lobes, and the hippocampus. Changes in the volume of the brain in the temporal lobes and the frontal cortex may exist before the disease or be progressive after the onset of symptoms. However, the use of antipsychotics may contribute to the decrease in brain volume.
Diagnosis
The diagnosis of schizophrenia is based on the patient reporting experiences and abnormal behavior reported by others. Next, a mental health professional performs a clinical assessment. However, there is not an objective test as of 2013 (American Psychiatric Association 2013).
In order to be diagnosed with schizophrenia, two criteria must occur over most of one month which has significant reduction on job function or social activity for no less than six months. It is essential hallucinations, disorganized speech, or delusions be present for one criteria. The other criteria could be catatonic behavior, symptoms classified as negative, or very disorganized behavior (American Psychiatric Association 2013).
Subtypes
The diagnosis of schizophrenia contains five sub-classications as defined by the DSM-5
(Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) work group:
- Paranoid: Delusions are present of persecution, jealousy, grandiosity, religiosity, or a collective delusional form called somatization. Somatization includes complaints of sexual problems, pain, amnesia, problems breathing, and gastrointestinal distress. Confusion arises in diagnosis because somatization can occur when an actual medical condition exists. The patient demonstrates high levels of anxiety due to the physical symptoms (Burton 2010).
- Catatonic: A decreased response to stimuli, staying in a posture with immobility, or movements that are purposeless or agitation exist.
- Disorganized: A flat affect combines with thought disorder in this type.
- Undifferentiated: The criteria for catatonic, disorganized, or paranoid type are not sufficiently met, but psychotic symptoms remain present.
- Residual: The symptoms are present only at a low intensity.
Two more types are identified by !CD-10 coding:
- Post-schizophrenic depression: After a schizophrenic episode, depression exists with some symptoms of low-level amplitude may continue to be present.
- Simple schizophrenia: A patient with no history of schizophrenic episodes exhibits progressive development of symptoms that are classified as negative.
Differential Diagnosis
The psychotic symptoms present in schizophrenia are also present in other types of mental illness. For instance, the obsessive behavior seen in some types of schizophrenia are also observed with obsessive-compulsive disorder. A misdiagnosis of the disease occurs when a patient is withdrawing from some medications since the symptoms may last a long time. Even with children, schizophrenic episodes may be assumed to be childhood fantasies. In order to differentiate other mental illnesses, physical condition or unrelated mental states, a more intensive neurological and medical examination is required. The challenge to physicians is to know when these additional tests are required.
Prognosis
Individuals functioning with a diagnosis of schizophrenia experience a life span shorter than non-patients by 10 to 25 years. Poor diet, lifestyles lacking in exercise, obesity, and smoking in addition to almost 90% of the patients smoking contributes to these figures. In addition, higher rates of suicide contribute to a less degree. Interestingly, use of antipsychotic drugs increase the risk of suicide. Also, being male, of a higher intelligence, and depression contribute to the risks.
Schizophrenia is ranked as the third most debilitating cause of disability with 16.7 people in the world suffering from symptoms ranging from mild to severe. While most patients live with community support publicly, there is a poor outcome of treatment for 27%. It is evident that patients with a diagnosis of paranoid schizophrenia live independently and function adequately in an occupation better than those with other types of schizophrenia. During onset or the first case of hospitalization, the schizophrenic population has a suicide rate of 4.9%. However, 20% to 40% will attempt suicide at least one time.
Conclusion
Rates of schizophrenia, along with other mental illnesses,is rising world-wide. In America, direct costs of schizophrenia include drug treatment, outpatient care, inpatient care, and long-term care. Non-healthcare costs include loss of productivity in the workplace, law enforcement expenses, and unemployment. Combined, an estimated $62.7 billion was spent in 2002.
While partially in response to changes in definitions and criteria used in diagnosis, modern societies continue to be more stressful and make more demands on an individual that in previous eras. Economic pressures, societal expectations of success, and the skills need to establish and maintain a supportive circle of friends and relatives make functioning in urban settings increasingly difficult for people struggling to function in communities. Treatment provides some relief from symptoms, and education of those surrounding the schizophrenic patient is important in assistance with adjustment.
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