Psychotic Conditions (Schizophrenia and Other Psychotic Disorders)

 Psychotic Conditions (Schizophrenia and Other Psychotic Disorders)

The term psychosis has been used to describe individuals who misinterpret reality or experience distortions in thought leading to disruption in function with family, friends at school, or at work. Some psychotic conditions may run in families and their causes are not fully understood while other psychotic conditions are due to medical conditions or substances affecting the mental state. In many societies there is a limited knowledge and understanding of psychosis and other mental conditions, leading to stigma toward those who are affected. Psychosis is treatable – therefore it is important to identify individuals with conditions so that support may be provided to them and their caregivers. Treatment within the community (as opposed to hospitals and long-term institutions) is possible to achieve where there are well trained health professionals working in collaboration with the family and community.

 

 Schizophrenia

 

Although dementia praecox (Kraepelin, 1971) or schizophrenia (Bleuler, 1950), has been considered a unique disease entity for the past century, its definitions and boundaries have continued to vary over this period. At any given time, the changing concept of schizophrenia has been influenced by available diagnostic tools and treatments, related conditions from which it most needs to be distinguished, extant knowledge and scientific paradigms. There is significant heterogeneity in the aetiopathology, symptomatology, and course of schizophrenia. It is characterized by an admixture of positive, negative, cognitive, mood, and motor symptoms whose severity varies across patients and through the course of the illness. Positive symptoms usually first begin in adolescence or early adulthood, but are often preceded by varying degrees of negative and cognitive symptomatology. Schizophrenia tends to be a chronic and relapsing disorder with generally incomplete remissions, variable degrees of functional impairment and social disability, frequent comorbid substance abuse, and decreased longevity. Although schizophrenia may not represent a single disease with a unitary aetiology or pathogenetic process, alternative approaches have thus far been unsuccessful in better defining this syndrome or its component entities (Tandon, 2009:1).

 

The word schizophrenia comes from Greek terms meaning “splitting of the mind.” People with schizophrenia, however, do not have a split personality. They have a disorder that affects thinking and judgment, sensory perception, and their ability to interpret and respond to situations appropriately. There usually are drastic changes in behaviour and personality. Lack of insight about the illness is one of the most difficult symptoms to treat, and may persist even when other symptoms (e.g., hallucinations and delusions) respond to treatment.  There may be several psychotic episodes before a definite diagnosis is reached.

 

Schizophrenia is a chronic disorder. Theories regarding the cause have been proposed and have included a genetic, biological, psychosocial, and infectious basis for the disease. Schizophrenia has been described in many cultures. Theories focused on social causes argue that the prevalence will be influenced by a culture‘s perceptions of mental disorder and system of social support, family support, and communication. In some developing countries where patients may utilize a system that incorporates family and com-munity support, schizophrenia has been reported to have a more benign prognosis than in some highly, technically developed western societies.

  Aetiology

 

We do not yet understand a great deal what causes schizophrenia. Scientists generally agree that schizophrenia is a group of conditions rather than one simple disease and may therefore be found to have several causes. It is generally accepted by researchers that differences in the brain — chemical or structural, or both — may play a part in the disorder. Genetic research also suggests that while no one gene has been found for schizophrenia, several genes may cause a predisposition that can be triggered by life events. Below is a schema that shows the possible causes of the disorder.

 

Biological

 

It has been hypothesized that symptoms may be due to:

 

·       Hypersensitive dopamine receptors or increased dopamine activity;

·       Increased symptomatology may result in sensitization to sensory input;

·       Decreased GABA activity may lead to increased dopamine activity;

·       Both in-creases and decreases in serotonin have been proposed as a factor;

·       Cortical atrophy and enlarged lateral/third ventricles; may also have abnormal pet scan, cerebral blood flow, evoked potential, immunological, and endocrine studies.

 

Genetic

 

·       Incidence in families is greater than in general population and incidence is greater among monozygotic twins than in dizygotic twins;

·       Concordance rate is the same for monozygotic twins raised apart as for twins raised together;

·       Children whose biological parents do not have schizophrenia do not have increased rates if raised by schizophrenic parent.

 

Environmental

 

·       Higher relapse rate has been associated with caretaker settings where there are high levels of over criticism, hostility, or emotional over-involvement (i.e. formerly referred to as a―high EE/ setting).

 

Infection

 

·       Past infections (e.g. slow viral infection) causing pathologic changes in neural tissue.

 

 

General Signs and Symptoms of Schizophrenia Include:

 

• Young persons tend to have prodromal states. Before the appearance of typical schizophrenic symptoms, there is sometimes a period of weeks or months - particularly in young people - during which a prodrome of nonspecific symptoms appears (such as loss of interest, avoiding the company of others, staying away from work, being irritable and oversensitive). These symptoms are not diagnostic of any particular disorder, but neither are they typical of the healthy state of the individual. They are often just as distressing to the family and as incapacitating to the patient as the more clearly morbid symptoms, such as delusions and hallucinations, which develop later. Viewed retrospectively, such prodromal states seem to be an important part of the development of the disorder, but little systematic information is available as to whether similar prodrome are common in other psychiatric disorders, or whether similar states appear and disappear from time to time in individuals who never develop any diagnosable psychiatric disorder. If a prodrome typical of and specific to schizophrenia could be identified, described reliably, and shown to be uncommon in those with other psychiatric disorders and those with no disorders at all, it would be justifiable to include a prodrome among the optional criteria for schizophrenia.
• Alteration of the senses. The senses (sight, hearing, touch and/or smell) may be intensified, especially early in the disease.
• Inability to process information and respond appropriately (also known as “thought disorder”). Because the individual has difficulty processing external sights and sounds, and because he/she experiences internal stimuli that others are not aware of, the response is often illogical or inappropriate. Thought patterns are characterized by faulty logic, disorganized or incoherent speech, blocking, and sometimes neologisms (made-up words). He/she may relate experiences and concepts in a way that seems illogical to others, but that holds great meaning and significance for that person.
• Delusions. These are basically false ideas which the person believes to be true, but which cannot be, and to which the individual adheres in the face of reason. However, unusual beliefs may be the product of a person’s culture, and can only be evaluated in this context. Two common kinds of delusions are paranoid delusions, characterized by belief that one is being watched, controlled, or persecuted; and grandiose delusions, centred on the belief that one owns wealth or has special power, or is a famous person, often political or religious.
•  Hallucinations. Hallucinations are sensory perceptions with no external stimuli. The most common hallucinations are auditory; hearing “voices” which the person may be unable to distinguish from the voices of real people. Delusions and hallucinations are the result of over acuteness of the senses and an inability to synthesize and respond appropriately to stimuli. To the person experiencing them, they are real. Medications can be very helpful in controlling illogical thinking and hallucinations.
• Changes in emotions. A person with schizophrenia can experience sudden, inexplicable changes in mood, such as intense sadness, happiness, excitement, depression or anger that come on without reason or warning. Lack of feelings can be equally disturbing. Early in the illness, the person may feel widely varying, rapidly fluctuating emotions and exaggerated feelings, particularly guilt and fear. Emotions are often inappropriate to the situation. Later there may be apathy, lack of drive, and loss of interest and ability to enjoy activities.
• Changes in behaviour. Slowness of movement, inactivity, withdrawing is common. Motor abnormalities such as grimacing, posturing, odd mannerisms, or ritualistic behaviour are sometimes present. There may also be pacing, rocking, or apathetic immobility.

  Essentials of Diagnosis of Schizophrenia

 

Although no strictly pathognomonic symptoms can be identified, for practical purposes it is useful to divide the above symptoms into groups that have special importance for the diagnosis and often occur together, such as:

 

1. Thought echo, thought insertion or withdrawal, and thought broadcasting;
2. Delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;
3. Hallucinatory voices giving a running commentary on the patient's behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;
4. Persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. Being able to control the weather, or being in communication with aliens from another world);
5. Persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end;
6. Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;
7. Catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor;
8. "negative" symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication;
9. A significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

 

The World Health Organisation International Classification of Diseases (WHO ICD-10) uses the following criteria for diagnosis of schizophrenia:

 

• The normal requirement for a diagnosis of schizophrenia is that a minimum of one very clear symptom (and usually two or more if less clear-cut) belonging to any one of the groups listed as (a) to (d) above, or symptoms from at least two of the groups referred to as (e) to (h), should have been clearly present for most of the time during a period of 1 month or more.
• Conditions meeting such symptomatic requirements but of duration less than 1 month (whether treated or not) should be diagnosed in the first instance as acute schizophrenia-like psychotic disorder and reclassified as schizophrenia if the symptoms persist for longer periods. Symptom (i) in the above list applies only to the diagnosis of Simple Schizophrenia and duration of at least one year is required.
• The minimum duration of the symptoms above required for diagnosis of schizophrenia under the WHO-ICD 10 is one month.

 

Treatment of Schizophrenia and Other Psychotic Disorders

 

Counselling Interventions for Schizophrenia and Other Psychotic Disorders

 

Counselling and support for the patient may include helping him identify situations that can increase anxiety and stress and helping him manage his schedule, activities, and interactions in a manner that minimizes stressors. Offering praise when he manages his schedule, activities, and interactions well can be useful. In addition, emphasizing taking medicines regularly and attending mental health practitioner’s appointments as scheduled is important. If the family values the input of an alternative approach, gaining this support in advising the patient may be important. Specifically do the following if need be:

·       Help the patient develop a routine schedule. Outline a weekly schedule with the patient. A structured routine helps one to know what to do and expect - this can reduce the stress and anxiety that can precipitate symptoms. Clearly list the core activities of daily living (ADLs) so that basic self-care skills are fostered and maintained (showering, shaving, dressing, supply shopping, food preparation, cleaning). Include chores so that a sense of responsibility is maintained. Have the patient decide on pleasure activities to be included. Be sure there is a good balance between indoor and outdoor activities. Also be sure to incorporate activities that involve social interaction.

·       Reward constructive actions. Determine the items or situations that the patient values and reward him/her with them when appropriate behaviour is displayed (e.g. offer a valued reward for having completed all chores and activities of daily living adequately).

·       Help the patient identify situations that cause stress or anxiety as these can be triggers for a relapse of illness. Help the patient limit involvement in these situations. If the situation is unavoidable, help the patient think in advance about what may occur and how he/she will respond. Breathing and relaxation exercises can be incorporated to help reduce anxiety felt in these situations (see chapter on ―Anxiety Disorders‖ for breathing and relaxation exercises).

·       Emphasize medication compliance. Discuss with the doctor medication options and regimens that will make taking pills easy (e.g. using pill organizer boxes; once a day dosing; use of a depot injection 1-2 times/month).

·       Explain the kind of side effects that might be expected and what to do about them. Provide information directly or refer the patient to the doctor.

·       Emphasize keeping track of appointments. Missed appointments can lead to the patient‘s running out of medication. Missing doses of medicine can put the patient at risk for a return of symptoms and a relapse of illness.

·       Educate family or caretakers. Educate the family and patient that agitation or odd behaviour are symptoms of schizophrenia and are not intentional. Relapse is possible and should be anticipated. Review with them the signs and symptoms of schizophrenia. Also, help them understand that a home environment that is hostile, critical, or encourages emotional over-involvement can have a negative impact on the behavioural patterns of the patient. Emphasize the importance of medication compliance.

 

Family Support

 

When mental disorder strikes, family members are overwhelmed by feelings of bewilderment and guilt. Most deny the seriousness of the situation, at least at first. Exhaustion from being on call 24 hours a day to attend to a family member who has a mental disorder may be coupled with frustration and anger when professionals are unable to accomplish what the family sees as basic: prompt diagnosis and treatment, and assistance to help their relative regain a productive life. It is not “unloving” to feel resentment in response to the behaviour of the relative with mental disorder. Realizing the person is ill does not always overcome the hurt, dismay, and anger felt by those trying to help. He/she may rebuff attempts to reach them, and may be fearful or accusatory toward those trying to help. Understandably, families, friends, and co-workers have problems with these symptoms, yet a hostile reaction will almost certainly intensify or lengthen the episode.

 

It is natural and necessary to grieve for the person who used to be. But strength and determination are needed to meet the coming challenges. Caring, supportive family members can play a vital role in helping their relative to regain the confidence and skills needed for rehabilitation. Therefore family members are frontline providers and they may provide the emotional and physical support and may also manage the economic expenses related to mental health treatments and care.

 

One in four families has at least one family member who suffers from a mental or behavioural disorder. Being exposed to distress, family members are vulnerable to becoming distressed. In addition, they may become victims of stigma by association - they may be rejected by others in the community who do not understand mental conditions, leading to a feeling of isolation and limited social activity.

 

Providing families with specific information and practical methods of sup-port is important. Teaching family members about signs and symptoms of a condition, treatments, and what to expect (or not expect) from treatments is necessary. Providing advice on how to structure time and their living environments to reduce stress is helpful. Family members may find it useful to meet with a group of others who share the same situation as a means for emotional support.

 

 Medication Therapy for Schizophrenia and Other Psychotic Disorders

 

There is yet no cure for schizophrenia, but there are many medications available which can reduce the symptoms. Finding the right medication(s) is a very complex process and demands a working relationship with a doctor that is based on trust. The outcome can be very successful when the individual is treated appropriately with medications and also has access. If a patient needs to remain on medication to control severe psychotic symptoms, EPS may be reduced with anticholinergic medicines such as trihexyphenidyl or diphenhydramine and, for akathisia specifically, propanolol and benzodiazepines (i.e. diazepam).

For health workers who prescribe medicine, if the patient is not taking his medicine as recommended, ask why. Did he feel better and stop medication because he thought it was no longer necessary? If so, you will need to educate him about the chronic nature of his condition and the need to re-main on medicine. In addition, he may have experienced side effects that discouraged him from using the medication (please refer to the chapter that includes Guidelines for Managing Medication Side Effects for details on how to address adverse reactions to medicine).

 

If the patient is taking his medication regularly and he still does not improve, try an increase in the dose of antipsychotic medication. If there is no response after a period of treatment with the increase, re-evaluate the symptoms and history (particularly the medical and substance abuse histories). If he continues to have prominent psychotic symptoms try a different antipsychotic medication. If there is a prominence of mood symptoms, he may actually have a primary mood disorder with psychotic features. Continue antipsychotic for the psychosis but add a mood stabilizer (if manic symptoms are prominent) or an antidepressant (if depressive symptoms are prominent).

 

The following are some of the drugs one could use to treat extra-pyramidal symptoms caused by antipsychotic medications. Children, the elderly, adults with small body composition, and individuals with medical illness or nutritional deficiencies may require smaller initial and maintenance doses for effect and may be more susceptible to side effects.