Schizophrenia: causes, treatment, prognosis

overview

Schizophrenia is a psychosis-related disease associated with extremely complex and diverse symptoms. As a rule, parts of thinking, the perception, the emotional world as well as the arbitrariness are disturbed. But not every schizophrenia manifests itself in the same way, which can often complicate and delay a diagnosis. In many cases, however, the three main symptoms during the course of the disease are hallucinations (especially of an acoustic nature), delusions and ego disorders.

Symptoms: too much or too little

In general, the symptoms of schizophrenia are classified according to whether the healthy initial state "something added" (so-called positive symptoms such as hallucinations) or "something subtracted" (so-called negative symptoms such as emotional depletion). While the positive symptoms are often treated well, negative symptoms are associated with a poorer course of the disease.

Diagnosis is made according to certain criteria of the so-called ICD-10 catalog, which continues to divide schizophrenia into different forms. The most common form is paranoid schizophrenia, which has to be differentiated from other forms such as hebephrenic or catatonic schizophrenia.

Three pillars of treatment

For the treatment of schizophrenia, various measures are used, which can be subdivided into medical, psychotherapeutic and social measures, used in combination and, in many cases, enable an approximately normal life.

The medication is administered by the administration of so-called antipsychotics, which influence the dopamine balance in the brain and can have a favorable effect on the positive symptoms of schizophrenic episodes. Well-proven psychotherapeutic measures include psychoeducation and cognitive behavioral therapy, both of which aim to improve understanding of the symptoms and manifestations of the disease. Living with schizophrenia is not easy and in many cases requires not only the cooperation of the person concerned, but also that of the social environment.

definition

Schizophrenia is a psychiatric disorder associated with the group of psychoses. Psychosis is characterized by the loss of the separability of reality and its own perception, which leads to a blurring of the ego-environmental boundary and explains the typical symptoms of the disease. These include:

  • I Disorders
  • delusional perception
  • hallucinations

The onset of the disease is often insidious and occurs in spurts, whereby schizophrenia is often recognized late and can be treated. It is also characteristic of the disease that the environment first registers the personality change of the diseased person in many cases.

frequency

About one in 100 people around the world suffer from schizophrenia, regardless of their origin or ethnicity. Schizophrenia manifests itself preferably in young adulthood between 16 and 35 years. Men are as ill as women, but on average four to five years earlier.

Schizophrenia, unlike many other diseases, has no differences in regional frequency of occurrence. However, the risk of schizophrenia increases with familial stress: the incidence rate increases from 1% in the general population to 5% if one parent is ill and up to 50% if both parents have schizophrenia.

Read also:
All questions and answers about the basics of schizophrenia

causes

Schizophrenia is a disease that causes several factors. For this reason, one speaks of a multifactorial genesis. An important attempt to explain the origin of the disease is provided by the Vulnerability-Stress-Coping-Model, which describes the interplay between susceptibility to the disease, stressors and the lack of coping mechanisms and ultimately explains the origin of the disease.

vulnerability

It is believed that some people are more prone than others to developing schizophrenia. Why this is so, could not be clarified so far. However, genetic predisposition seems to play a role, as the likelihood of developing schizophrenia increases when close relatives also become ill. This neuropsychological susceptibility thus exists well before the outbreak of the first symptoms and forms a kind of foundation for the development of the disease.

stress

Stress combines certain factors that affect the body and contribute to the development of schizophrenia. A distinction is made between endogenous, ie the body's own, and exogenous, that is to say, factors originating from the environment.Endogenous causes include hormonal changes such as puberty, while cannabis use is a known exogenous trigger for schizophrenia. People who have a predisposition to schizophrenia should therefore refrain from regular cannabis use.

coping

Coping describes coping with a difficult situation. In the case of schizophrenia, existing susceptibility and stressors do not provide sufficient coping skills to prevent disease progression or to deal with symptoms that occur, to properly classify them and to prevent disease progression. The respective coping strategies therefore play a decisive role in determining whether a disease breaks out or not.

Read about causes too:
All questions and answers about causes and risks

symptoms

The symptoms of schizophrenia are very diverse and, with every symptom taken on their own, they also occur in many other diseases. Only the interaction of the symptoms leads to the clinical picture of schizophrenia. Typical of schizophrenia are the occurrence of positive and / or negative symptoms.

Positive symptoms are also called plus symptoms and are characterized by the fact that, in simple terms, "something is added" that is not normally experienced. These include:

  • I Disorders
  • delusions
  • hallucinations
  • abnormal thinking

Negative symptoms, also called negative symptoms, lead to limitations of normal experience compared to healthy people. Put simply, something is subtracted from the "normal state". Examples of negative symptoms are:

  • Affektabflachung
  • Emotional and social withdrawal
  • apathy

I Disorders

Psychology speaks of ego disorders when the ego-environmental boundary disappears. For example, the environment is perceived as altered, manipulated or perceived as completely alien. I-disorders can express themselves in very different ways. Typical of schizophrenia are derealization, depersonalization, thought-entrainment, thought-withdrawal, and thought-propagation:

  • Derealization: The actually known environment is perceived as foreign, unfamiliar and unreal, which can be very tormenting and is often described with the feeling of alienation.
  • Depersonalization: The own body is perceived as foreign. For example, you may feel that you are living in a dream world or that your body and mind are completely separate from each other.
  • Intellectual thought: Describes the feeling that thoughts and ideas are dictated or directed by the environment and are not free.
  • Mind withdrawal: Describes the sensation that thoughts and ideas are being withdrawn from the environment (for example, from other people).
  • Thought Propagation: Indicates that thoughts can become loud, readable or heard by others, and are no longer personal and environmentally inaccessible.

delusions

Delusions occur in the context of schizophrenia with about 80% very often. Typical appearance is the so-called delusional perception, which describes a misinterpretation or a reinterpretation of a real event. For example, a car with darkened panes is no longer simply perceived as such, but interpreted as an agent car of the intelligence service following the casualty. As a result, a calm situation creates a situation of overarching threat that can fuel fears and lead to inappropriate behaviors.

Read to the delusion also:
All questions and answers about delusions and delusions

hallucinations

Hallucinations occur at 50% less often than delusions. In contrast to delusion, hallucination is a hallucination that sees or hears things that do not exist in real life.

Typical for schizophrenia are acoustic hallucinations, which express themselves in the form of imperative, commenting or dialogue voices. Imperative voices issue commands, commentators judge the behavior and conversational lead dialogues that are inaudible to outsiders. Acoustic hallucinations are very stressful because they give no rest and make concentration on a thing almost impossible.

abnormal thinking

In the context of schizophrenia, there are mainly formal disturbances of thought. It is not the content, but the course of thought that is disturbed, which is reflected in verbal utterances.

Classic examples of a formal disturbance of thought are the inhibition of thought, in which there is a slowing down of the train of thought or thought circles in which one and the same idea is thought again and again. These symptoms occur mainly in the context of depression.

For schizophrenia, however, other formal disturbances of thought are typical, in particular the disorienting thinking as well as mental leaps with illogical links between content and words. For example, words are reinvented (neologisms) or very different contents are discussed in one sentence without creating a transition. For outsiders, formal thinking disorders are strange and often associated with reduced intelligence.

affective disorders

Disturbances of affect are typical negative symptoms of schizophrenia, which manifest themselves, for example, in emotional deprivation or emotional coldness, but also in helplessness.But even totally inappropriate feelings can occur in the context of schizophrenia: So it is not untypical when the response to a joyful message is mourning and vice versa.

Often behavior or facial expressions and gestures are not appropriate. So it happens, for example, that a serious situation with silliness is answered (silly affect).

More on this topic can be found here:
All questions and answers about signs and symptoms of schizophrenia

progressive forms

There are many variations in which schizophrenia can be present. The different forms differ in some cases severely from each other on the basis of their symptoms. The most common form is paranoid schizophrenia, often referred to simply as schizophrenia.

Paranoid schizophrenia

In paranoid schizophrenia, delusions and hallucinations are the main symptoms. In many cases there is the feeling of being persecuted or "something is going on". Paranoid schizophrenia usually occurs in young adulthood from 20 to 30 years and has a relatively good prognosis.

Hebephrenic schizophrenia

By hebephrenia is meant a disturbance of the affect, which is accompanied by silly utterances and inappropriate behavior. Typical are inappropriate emotional behaviors such as immature silliness or exaggerated merriment, although there is no reason for these emotions.

Characteristic are also erratic ways of thinking, an unpredictable occurrence and the absence of hallucinatory symptoms. Hebephrenic schizophrenia often develops as early as adolescence and often in individuals with a preference for religion, philosophy or other abstract topics.

Catatonic schizophrenia

Catatonia refers to a complex of symptoms consisting of motor and psychological symptoms characteristic of this form of schizophrenia. At the center of the disease are movement disorders that can either lead to excessive arousal or may be accompanied by stupor.

The movement disorders include, among others:

  • Akinese: slowing down the movement
  • Stupor: Absolute motionlessness while preserving consciousness
  • Catalepsy: Long standing postural rigidity in postures that can be very uncomfortable. One example is the so-called Oreiller psychique, which describes a lying posture in which the patient's head floats in the air as if it were lying on a pillow.
  • Movement stereotypes: designate repetitive movements that do not fulfill any function. An example of this are weighing movements of the trunk or shaking the head.

Mental symptoms that often occur in the syndrome of catatonia are:

  • Mutism: Taciturnness or complete silence without impairing the ability to speak
  • Negativism: behavior in which always exactly the opposite of what is said or desired is done
  • Echolalia and echopraxia: Automatic follow-up or imitation of what has been said or done, without paying attention to meaning or content

Schizophrenia simplex

Schizophrenia simplex is characterized by the progressive increase in negative symptoms resulting in a gradual loss of concentration and efficiency. Also typical is a decreasing interest in all things that used to be important or fun. Positive symptoms such as hallucinations and delusions may occur in the course, but are more of an exception. To outsiders, people with Schizophrenia Simplex seem "singular" and "cranky."

diagnosis

It is difficult to diagnose schizophrenia because the disease can be very different, especially at the beginning. There is no special schizophrenia test, so the diagnosis is made on the basis of certain criteria (so-called ICD-10 diagnostic criteria).

According to these criteria, schizophrenia is present if at least one of the following points persists for at least one month:

  • 1. ego disorders: such as thought-impulse, thought-withdrawal or thought-propagation
  • 2. Delusion: Typical are above all persecutory mania, control mania, poisoning mania and delusions.
  • 3. Persistent delusion: culturally inappropriate, bizarre or completely unrealistic delusions such as the belief that you are Messiah or have superhuman powers
  • 4. Acoustic hallucinations: above all commenting or dialogue voices

Or if at least two of the following criteria persist together over a period of at least one month:

  • 5. Persistent hallucinations regardless of sensory modality occurring daily for weeks and months
  • 6. Formal disturbances of thought: Schizophrenia is characterized by thoughts, thought, or neologisms.
  • 7. Catatonia
  • 8. Negative symptoms such as apathy, speech deprivation, social withdrawal or inadequate affect on certain situations

Careful clarification wichitg

If one or more of these symptoms is present, schizophrenia is likely. At first diagnosis, however, a series of further investigations should be carried out in order not to overlook any other cause of the symptoms.

It is important to have comprehensive laboratory diagnostics to rule out inflammation, poisoning due to liver or kidney failure, thyroid dysfunction and drug intoxication.Furthermore, imaging of the brain using MRI or CT should be performed to exclude treatable changes in the central nervous system such as tumor, hemorrhage, or trauma.

differential diagnosis

There are numerous clinical pictures that are similar to schizophrenia, but need to be differentiated from it. This is not always easy, but it is essential for choosing the right form of therapy.

Schizotype disorder

The schizoid disorder is a personality disorder that can be schizophrenic on third parties. Typical is an eccentric behavior with bizarre, almost paranoid ideas and mental anomalies. Similar to schizophrenia, the schizoid type shows a diminished affect as well as tendencies for social withdrawal. Frequently, there are episodes of delusional states that can be accompanied by auditory hallucinations. These phases are often self-limiting and rarely have the same emotional and social consequences that are typical of paranoid schizophrenia.

Delusional disorder

In the case of the delusional disorder, the only symptom is a long-lasting delusion of at least three months duration. The other symptoms of schizophrenia are not met.

It is characteristic of the delusion that it is incorporated as a complex system in the everyday life of the person concerned and does not exist as a single component of a disease. Individual life events are linked together and made into a delusional construct. For example, cars passing by are considered proof of being tracked, while construction workers across the street are busy populating the house with interception lines.

Induced delusional disorder

An induced delusional disorder is a very interesting phenomenon that rarely occurs. It is a delusional disorder of two people who are emotionally in close connection. While one of the two is actually suffering from a psychotic disorder, the second person experiences a symbiotic delusion. This means that due to the first illness, the second partner also develops a delusional disorder, which usually regresses after the couple's separation. The induced delusional disorder is similar to addiction co-dependence.

treatment

The treatment of schizophrenia is based on different pillars and pursues the goal of enabling a life that is largely independent of the schizophrenic symptoms. The focus of treatment is drug therapy, which is usually accompanied by psychotherapeutic and social measures.

Medical therapy

The treatment with psychotropic drugs is the most important element in the treatment of schizophrenia. Medicines from the group of antipsychotics, which can influence both positive and negative symptoms through various mechanisms, are used.

Be available:

  • Typical antipsychotics, which in turn are divided into high and low potent typical antipsychotics, and
  • Atypical antipsychotics

 

Typical antipsychotics

Depending on the mechanism of action, active ingredients from the group of typical antipsychotics are subdivided further into high- and medium- and low-potency antipsychotics. What they all have in common is that they can inhibit the action of dopamine by blocking so-called D2 receptors and thus reduce the positive symptoms of schizophrenia. Furthermore, they have a drowsy effect, which increases continuously with decreasing potency of the drug.

Among the most potent substances are:

  • Haloperidol (Haldol®)
  • Benperidol (Glianimon®)
  • Flupentixol (Fluanxol®)
  • Fluphenazine (Lyogen®)
  • Perphenazine (Decentan®)

The group of medium and low potency substances includes the following substances:

  • Chlorpromazine (Megaphen®)
  • Melperone (Eunerpan®, Melneurin®)
  • Levomepromazine (Levium®, Neurocil®)
  • Chlorine prostheses (Truxal®)
  • Promethazine (Atosil®, Closin®, Proneurin®, Prothazine®)

No effect without side effect

Typical antipsychotics all lower the seizure threshold in the brain and can provoke seizures as an important side effect. For the group of highly potent antipsychotics as a side effect further disorders of voluntary movements (extrapyramidal-motor disorders, also called EPS) typical.

EPS can express themselves in different ways. At the beginning of tongue and throat, but also convulsions occur frequently. In addition, a lack of exercise, trembling hands, increased muscle tone and sitting or standing agitation may occur. In the course it often comes to uncontrollable stereotyped chewing and smacking movements and worm-like, extending movements of the arms and legs.

EPS are less common in low- and medium-potency antipsychotics, but these drugs often cause dry mouth, glare sensitivity, constipation and arrhythmia. Weight fluctuations are also classic side effects of the low- and medium-acting typical antipsychotics.

 

Atypical antipsychotics
Drugs from the group of atypical antipsychotics have their effect not only on dopamine receptors, but also on a number of other receptors.It could be shown that some atypical antipsychotics have a good effect on the negative symptoms, which distinguishes them from the typical substances, which mainly influence the positive symptoms.

Unpleasant: often weight gain

Furthermore, atypicals have far fewer motor side effects (EPS) than typical substances. Nevertheless, they are not always less side effects. Among atypical antipsychotics occur mainly impairments of the metabolism such as weight gain or diabetes mellitus. In addition, there may be changes in the blood count as well as various side effects on the heart. The most important substances from the group of atypical antipsychotics are:

  • Clozapine (Elcrit®, Leponex®)
  • Olanzapine (Zypadhera®, Zyprexa®)
  • Quetiapine (Seroquel®)
  • Risperdon (Risperdal®, Riscon®, Rispecare®, Risperigamma®)
  • Amisulpride (Solian®, Deniban®)

More about medicines and their active ingredients can be found here:
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Around individual drugs and preparations

Supportive psychotherapeutic measures

In the treatment of schizophrenia, psychotherapeutic procedures to support drug therapy are very important. Especially psychoeducation and cognitive behavior therapy have proven to be supportive measures in everyday life with the disease.

 

psychoeducation

Psychoeducation is the education about the mental illness and treatment options as well as methods for recurrence prophylaxis understood. The aim of this form of therapy is to train you in dealing with your illness, to motivate you to act responsibly and to support you in your disease processing. Psychoeducation is performed by physicians or psychologists and can be particularly effective in combination with behavioral or talkative therapies.

 

Cognitive behavioral therapy

Cognitive behavioral therapy has become especially popular in recent years for the treatment of schizophrenia. This form of therapy aims to recognize, accept and manage schizophrenic traits and patterns of behavior. For example, hallucinations are not considered morbid, but rather phenomena of the human brain that can occasionally occur in perfectly healthy people.

This is to create an acceptance that allows you to differentiate yourself from the hallucinations and not let them guide you. Through this path psychologists also see a way to treat negative symptoms such as lack of drive and emotional coldness.

Social measures

The diagnosis of schizophrenia can turn your whole life upside down. In many cases, however, it also represents a relief for those affected and their relatives, since with the recognition of the disease, treatment is also possible.

Dealing with the disease is not always easy. Friends and relatives often do not know how to respond to the diagnosis or how to treat it in the future. For this reason, an open dealing with the disease is important. Only then can uncertainties or scary questions be discussed and further plans can be forged. Especially for families, assistance such as family therapy or day clinic places are being increasingly offered for this purpose.

Read also:
The most important questions and answers around the topic of treatment

complications

As a result of schizophrenia may lead to longer-lasting depressive phases, which can change the clinical picture completely and in many cases also make a therapeutic change required. Postschizoid depression is referred to when some schizophrenic symptoms are still present but the clinical picture is dominated by depression. The transition to depression is often insidious and in many cases goes unnoticed, which is an increased risk of suicide.

forecast

How schizophrenia develops in the longer term is difficult to predict. While some people can cope with the disease very well, the drugs tolerate well and can lead a nearly normal life, for others always inpatient hospital stays are needed. A number of studies have now identified predictors of a negative or positive course of schizophrenia.

Factors associated with a favorable course of the disease include:

  • female gender
  • extroverted personality
  • married marital status
  • many social contacts
  • acute onset of illness
  • short and rare schizophrenic episodes

Factors associated with a rather unfavorable course of schizophrenia include:

  • male gender
  • single
  • socially badly integrated
  • creeping onset of illness
  • predominantly negative symptoms
  • long and frequent schizophrenic episodes

Read more about:
All questions and answers about the course and prognosis of schizophrenia

Further helpful information can be found here:
Everything about everyday life with schizophrenia
Important questions about dealing with schizophrenia patients

 

Author: Lisa Wunsch

sources

M. Berger: Mental Illness, Clinic and Therapy, Elsevier, 2012.

T. Payk, Checklist Psychiatry and Psychotherapy, Thieme, 2013.

German Society for Psychiatry, Psychotherapy and Neurology (DGPPN): S3 Guideline Schizophrenia, http://www.awmf.org/uploads/tx_szleitlinien/038-009k_S3_Schizophrenie_01.pdf, last accessed on 02.03.2017.

Aerzteblatt international: Cognitive Behavioral Therapy Shows Action in Schizophrenia, https://www.aerzteblatt.de/nachrichten/57523/Kognitive-behavior therapy-aus-wirkung-bei-Schizophrenie, last accessed a, 02.03.2017.