UNDERSTANDING PSYCHIATRY

34

SCHIZOPHRENIA

Schizophrenia, literally meaning 'split mind', is one of the most serious

psychiatric disorders. It accounts for a large proportion of patients who need long
term psychiatric care in hospitals and even outside hospitals, on supportive basis, in
the community. The illness is usually associated with deterioration of personality and
the patient's thought process, perception, behaviour and emotional life are all
affected. There is a tendency of withdrawal from social contact and retreat from
reality. A disturbance of the development and maintenance of adequate ego-
boundaries is a central feature of the schizophrenic disease process.

Kraeplin, in 1896, was the first to group these disturbances of thoughts,

feelings and volition under the term dementia praecox. He mentioned that this illness
started at an early age and invariably led to a complete deterioration of personality
and ultimately to dementia. Bleuler, who introduced the term schizophrenia, in 1911,
believed that the disorder was due to a loosening of association between different
psychic functions, which, although, often left a personality scarred, was likely to
remit in several cases, without severe deterioration of personality.

Incidence
Schizophrenia is found world-wide, with an almost uniform distribution in
various countries and cultures. About 1% of the general population suffers from
schizophrenia or, in other words, about 10 people out of every 1000 are likely to
develop schizophrenia at some time in their lives. The disorder usually begins in late
adolescence or early twenties, though it can develop at any age. Males and females
are equally affected.

Aetiology
Aetiology of schizophrenia still eludes precision and remains one of psychiatry's
greatest challenges. No single factor has been found to cause schizophrenia and the
aetiology is perhaps multifactorial. The following theories have been put forward.

Genetics
While genetic predisposition to schizophrenia is quite well known, the nature of
its transmission is still unclear. However, different studies have proposed polygenic
inheritance with partial penetrance. Representative figures for concordance are about
50% for monozygotic (MZ) pairs and 17% for dizygotic (DZ) pairs. Approximate
life time expectancy of developing schizophrenia for relatives of patients suffering
from schizophrenia* is given below:
35 UNDERSTANDING PSYCHIATRY

Parents 6%
Siblings 10%
Children (one parent schizophrenic) 14%
Children (both parents schizophrenic) 45%
Adapted from Shields (1980)

Biochemistry
(a) Dopamine hypothesis: This is, by far, the most widely accepted hypothesis,
which could explain the positive symptoms in acute schizophrenia. The
hypothesis states that in the meso-limbic system of the brain, there is an excess
of dopaminergic activity which could be due to excess of dopamine, deficiency
of dopamine antagonists or increased sensitivity of dopamine receptors.

This hypothesis is supported by the observation that most neuroleptic drugs,

which are effective in the treatment of schizophrenia, act by blocking dopamine
receptors, thus lowering dopaminergic activity. Certain drugs, like amphetamine
and LSD, lead to an increase in dopaminergic activity and produce a clinical
picture which can hardly be differentiated from schizophrenia.

(b) Serotonergic transmission; This hypothesis states that serotonergic transmission

may be increased in the brains of schizophrenic patients.

(c) Noradrenaline hypothesis: Increased noradrenaline levels have been found in

CSF and plasma of schizophrenic patients.

(d) Glutamate hypothesis: It proposes that glutamate and glutamate receptor genes
are involved in neuro- development and that abnormalities in these systems lead
to neuro-developmental schizophrenia.

(e) Transmethylation: According to this hypothesis, schizophrenic symptoms result

from methylation of amine neurotransmitters, as some patients of schizophrenia
have been shown to excrete in their urine dimethoxyphenylethylamine
(DMPEA), a methylated derivative of dopamine, giving a 'pink spot' on
chromatography.

(f) Virus-like agents: These have been isolated from the CSF of some schizophrenic
patients. Moreover, winter births are more common in schizophrenic patients
than in the general population. Prenatal viral infections, e.g. influenza, during
the winter months, may be responsible for this increased frequency.

(g) Monoamine oxidase hypothesis: Murphy and Wyatt (1972) reported reduced
levels of monoamine oxidase (MAO) in the platelets of schizophrenic patients.
This finding was later replicated by other workers like Belmaker (1976). Some
other workers could not replicate the same finding. However, it was found that
SCHIZOPHRENIA 36

some non-schizophrenic disorders also had lower MAO levels suggesting that
low MAO activity may predispose to schizophrenic illnesses.

Abnormal family processes

(a) Lidz (1968) has postulated that schizophrenia develops as a reaction to or defence
against abnormalfamily communication. The characteristics described within
families of schizophrenic patients include over protective yet hostile mother, and
a distorted relationship between mother and father.

(b) According to the famous double-bind hypothesis of Bateson (1956), the

schizophrenic disorder develops due to distorted communications in a family.
The child is exposed to excessive double-bind communications, i.e.
communications in which opposite meanings are implied, e.g. a child is told to
do a certain thing but at the same time the opposite meaning is conveyed by
nonverbal means. Rational thinking and the ability to distinguish clear meaning
is a learned process passed on from parents to children. If the patient's world is
confused and a double-bind method of communication is used, then the child
gets all mixed up and schizophrenia results.

(c) Studies about life events and expressed emotion, starting in 1960s (Brown,
Birley) and continuing presently (Leff 1992), found that relapses in
schizophrenic patients may be preceded by increased life events. They are also
increased in families with high expressed emotions, e.g. with features of
hostility, critical comments and emotional over-involvement.

Social processes
It has been shown that patients suffering from schizophrenia are over
represented in disadvantaged areas of community. Some workers have reported high
rates of schizophrenia amongst migrant population. Schizophrenic patients are also
known to be living alone, unmarried and with few friends. The disorder becomes
more prevalent as one goes down the social scale. Two different hypotheses have
been put forward in this regard: drift hypothesis and breeder hypothesis. The first
implies that a person suffering from schizophrenia drifts down the social scale
because of his illness while the second hypothesis postulates that the lower social
stratum breeds the illness as it is more prone to stresses because of natural reasons.
The first hypothesis is now largely accepted.

Psychological theories
(a) The 'sensory filter', which limits the amount of sensory information reaching
consciousness, is supposedly defective in schizophrenic patients and as a result,
they are over stimulated by their environment and cannot channelise their
attention properly.

(b) Because of abnormal ways of making concepts, the schizophrenic patients

develop thought disorder which further leads to over inclusive and concrete
thinking.
37 UNDERSTANDING PSYCHIATRY

Neurological abnormalities
Neurological abnormalities like non-localizing (soft) neurological signs,
thickening of corpus callosum, ventricular enlargement in chronic schizophrenic
patients beside widening of sulci and atrophy of the cerebellar vermis and EEG
abnormalities like decreased alpha activity, increased theta and delta activity, fast
activity, paroxysmal activity and specific activity have been reported by different
workers.

Constitutional factors
Some workers have pointed out that factors like asthenic body, schizoid type of
personality, higher birth orders or first born and birth complications have something
to do with the genesis of schizophrenia in certain patients.

Precipitating factors
Certain events like child birth, physical illness, viral infections and psychosocial
stresses have been reported to precipitate schizophrenia. Interpersonal, social and
cultural factors have been postulated to influence the course of schizophrenia.

Neurodevelopment theories
These theories propose that a combination of genetic and environmental factors
leads to defective development and maturation of the brain which, later, leads to the
development of schizophrenic illness. Retrospective studies of schizophrenic patients
report more obstetric complications than do studies of normal controls. The more
recent studies, however, have not found a consistent relation. It has been suggested
that such positive associations between obstetric complications and schizophrenia
may be confined to males or that birth injury may corelate with other aspects of the
disorder such as early age of onset. These notions are consistent with recent research
findings, e.g. enlargement of cerebral ventricular size antedates the development of
schizophrenia and is not progressive in the majority of cases; boys who develop
schizophrenia have shown more abnormalities in their premorbid personality, social
adjustment and intelligence levels as compared to their peers; structural
abnormalities of the brain in schizophrenia, especially a reduction in temporal lobe
and hippocampal size, are not associated with gliosis, which would normally be
expected if a degenerative process was at work.

Clinical features
Many different clinical pictures may occur in schizophrenia and the onset of
illness may be acute or insidious, leading to a gradual deterioration of personality in
many cases.

Disorder of thought and speech

This is one of the most important symptoms in schizophrenia. The patient
complains of having confused or muddled thoughts. The normal association of ideas
becomes disconnected and it may be difficult to follow the patient's flow of talk
which is, more often than not, vague and woolly. The patient comes to have
delusional ideation which, mostly, develops 'out of the blue'. The delusions can be
SCHIZOPHRENIA 38

primary or secondary. A primary delusion is that particular disturbance of thought

where the patient attributes a personal meaning to an event or situation, which, in
fact, does not concern him. A secondary delusion develops logically from the
patient's attempt to understand his symptoms. He believes that his thoughts are being
interfered with by means of radio or television or that a neighbour is poisoning his
food. Ideas of reference are very common. The patient feels or believes that things
said and done by people around him refer to him in certain ways. Delusions of
control are also very common. The patient believes that his thoughts, emotions or
movements are under the control of external forces. Thought blocking, in which the
patient's train of thinking is suddenly cut off and he, at times, complains of blank
spells, is a typical feature of schizophrenia.

Thought disorders render the patient's conversation unintelligible and the use of
neologisms or newly invented words by the patient renders the speech nothing more
than a word salad and can hardly be understood.

Disorders of emotion
Incongruity of affect, i.e. the expression of an emotion not appropriate to the
occasion, is sometimes very marked in a schizophrenic patient. Emotions and
feelings become blunted and the individual appears insensitive. During the early
stage, depression is common but there may be sudden outbursts of panic or
bewilderment. Gradually, the patient becomes withdrawn and isolated. Thus,
emotional coldness or lack of rapport can be felt even at the first interview and has
been described as 'having a pane of glass between you and the patient'.

Disorders of perception
Perception is distorted and external objects and events assume a different
meaning and significance. Hallucinations may occur, which may be auditory or
visual. Auditory hallucinations are the commoner of the two and take the form of
voices, talking about the patient and addressing him directly or echoing his thoughts.
The schizophrenic patient complains that voices comment on his actions, referring to
him in the third person.

Disorders of volition
The schizophrenic patient becomes passive and lacks the will and drive to go
through the day to day processes of living. He becomes more and more withdrawn
and asocial with diminished interest in the outside world. Personal hygiene and
appearance get neglected and there is a decline in personal, domestic, social and
occupational competence.

Passivity phenomena
These are very common and may take the form of:
(a) Thought insertion, i.e. thoughts being inserted into one's mind.
(b) Thought withdrawal, i.e. thoughts being removed or taken away from
one's mind.
39 UNDERSTANDING PSYCHIATRY

(c) Thought broadcasting, i.e. one's thoughts becoming known to the outside
world.
(d) Made feelings or impulses, i.e. feelings experienced as being imposed by
an outside force or agency.
Schizophrenic symptoms usually represent an increase or distortion of normal
functioning, i.e. positive symptoms, which are formal thought disorder, inappropriate
affect, disorganized behaviour, delusions and hallucinations. However, schizophrenic
symptoms also represent decrease or loss of normal functioning, i.e. negative
symptoms, which are blunt affect, poverty of speech and thought, impaired volition
and social withdrawal.

Clinical subtypes
Clinically, this sub-division into groups, is of a limited value and many patients
present with one type at one time and with another at another and there may be
considerable overlapping of symptoms.

1. Paranoid schizophrenia
2. Hebephrenic schizophrenia
3. Catatonic schizophrenia
4. Simple schizophrenia
5. Undifferentiated schizophrenia

Paranoid schizophrenia
It starts much later in life and persecutory delusions and auditory hallucinations
are prominent. Paranoid delusions may be transient or fixed. Delusions of
persecution are more common but personality is often well preserved for a number of
years. Sexual delusions are particularly common in middle aged women.
Disturbances of affect, volition and speech and catatonic symptoms are not
prominent.
Hebephrenic schizophrenia
The onset is insidious and the patient often presents with prominent affective
changes. Mood is inappropriate and speech is incoherent. There is a marked
volitional disorder and disorganization of personality. This type of illness is
characterized by the presence of gross delusions and hallucinations, which may be
fleeting and fragmentary. Hebephrenic schizophrenia accounts for a large number of
schizophrenic patients residing in the mental hospitals.
Catatonic schizophrenia
This usually has an acute onset and is characterised by motor abnormalities
accompanied by hallucinations and delusions. The patient's behaviour is withdrawn
and negativistic. Bizarre mannerisms, posturing and grimacing occur and a particular
posture may be maintained over a prolonged period of time. The patient may resist
attempts to alter postures or may become curiously malleable. This state is known as
waxy flexibility.
SCHIZOPHRENIA 40

Simple schizophrenia
The onset of the illness is insidious but there is progressive development of
oddities of conduct, inability to meet the demands of society and decline in total
performance. Delusions and hallucinations are not evident. The symptoms, at times,
can be traced back to childhood with history of eccentricities and odd behaviour but
the typical onset is in adolescence. There is loss of interest in studies and a
deterioration of school record. Relations with the family become strained. Simple
schizophrenics show extreme apathy and total lack of ambition or plans for the
future.

Undifferentiated schizophrenia
This includes those clinical pictures which do not seem to fit in any of the above
described types or which exhibit the features of more than one of them, without a
clear predominance of one or the other. This type should only be diagnosed after an
attempt has been made to classify the condition into one of the above four types.

Schizoaffective disorders are episodic disorders, in which both affective and

schizophrenic symptoms are prominent within the same episode of illness, preferably
simultaneously or at least within a few days of each other. These patients usually
make full recovery, especially those with manic rather than depressive symptoms.

Diagnosis
As no laboratory tests are available, detailed psychiatric history and mental state
examination are the only diagnostic tools currently available. According to the ICD-
10, at least one of the symptoms (a) - (d) or at least two of the symptoms (e) - (i)
should have been present during a period of a month or more:
(a) thought echo, thought insertion, thought withdrawal or thought broadcasting.

(b) delusions of control, influence, or passivity, clearly referred to body or limb

movements or specific thoughts, actions or sensations; or delusional perception.
(c) hallucinatory voices, giving a running commentary on the patient's behavior or
discussing the patient among themselves or other types of hallucinatory voices
coming from some part of the body.

(d) persistent delusions of other kinds that are culturally inappropriate and
completely impossible, such as religious or of political identity or superhuman
powers and abilities.

(e) persistent hallucinations in any modality, accompanied either by fleeting or half-

formed delusions, without clear affective component, or by persistent
overvalued ideas occurring every day for weeks or months on end.

(f) breaks or interpolations in the train of thoughts, resulting in incoherence or

irrelevant speech, or neologism.

(g) catatonic behavior, such as excitement, posturing, or waxy flexibility,

negativism, mutism or stupor.
41 UNDERSTANDING PSYCHIATRY

(h) 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 they are not due to
depression or to neuroleptic medication.

(i) a significant and consistent change in the overall quality of some aspects of
personal behavior, manifesting as loss of interest, aimlessness, idleness, a self-
absorbed attitude and social withdrawal.

An important point to remember in the diagnosis of schizophrenia is that the

presence of persecutory delusions is not diagnostic of the condition, as these
delusions can occur in affective disorders as well. The possibility of organic factors
should also be kept in mind.

Some medical conditions that can give rise to a schizophrenia-like picture are
endocrine disorders, cerebral tumours, neurosyphilis, Wilson's disease, temporal lobe
epilepsy and other organic brain diseases, e.g. Huntington's disease and the adult
form of metachromatic Ieukodystrophy. In most cases focal findings suggest the
correct diagnosis. When these are lacking, the presence of true disorientation may
also be used as a fairly reliable indicator of the presence of a dementing illness.

Psychiatric illnesses which can cause symptoms suggestive of schizophrenia

include persistent delusional disorder, in which the contents of the delusions are not
bizarre and other schizophrenic symptoms are absent; acute and transient psychotic
disorders, which are short lived; and schizoaffective disorder, which has already been
mentioned above. However, it must be remembered that in certain cases of affective
disorders, it may be quite difficult to distinguish them from schizophrenia, as
symptoms of mania and depression are, sometimes, present in schizophrenia. In
mania, which occurs as an episodic illness, affective symptoms appear first and the
mood of a patient with mania is typically infectious, whereas in schizophrenia, which
is a chronic illness, psychotic symptoms precede the excitation seen in mania and the
mood is rather silly, with shallow hilarity, which is not infectious.
Paranoid personality disorder is sometimes quite difficult to distinguish from
paranoid schizophrenia but the presence of delusions or hallucinations favour the
diagnosis of schizophrenia. Schizotypal disorder can be distinguished from
schizophrenia by the absence of psychotic symptoms. Patients with borderline
personality disorder can experience delusions and hallucinations under stress but this
can be differentiated from schizophrenia on account of the fact that hallucinations
and delusions are persistent in schizophrenia.

Malingering or factitious disorder can cause diagnostic difficulty. However, the

presence of mannerisms and similar symptoms would favour the diagnosis of
schizophrenia because these symptoms are generally not known to the public.

Drug induced psychosis sometimes causes schizophrenia-like picture. However,

it is short lived and resolves within a few days after abstinence from drugs.
SCHIZOPHRENIA 42

Differential diagnosis of delusional disorder

Disorder Delusion Hallucination Other
Paranoid Multiple Usually Present Thought disorder
schizophrenia Mood changes
Negative symptoms
Persistent delusional Present , well May be present Personality well
disorder (paranoia) encapsulated preserved
Multiple Usually present Other psychotic
features
Late onset schizoph-
renia (paraphrenia)
Paranoid personality Absent Absent Anger
disorder Suspiciousness
Organic delusional Multiple or single May be Present Other organic
disorder features
Depression with Present Maybe present Other depressive
psychotic features features
Borderline personality Fleeting Fleeting Other symptoms of
disorder personality disorder

Clinical characteristics associated with good prognosis in schizophrenia

1. Acute onset
2. Well integrated personality
3. Psychological or physical precipitating factors
4. Absence of family history of schizophrenia
5. A well preserved affective response
6. Stable work record
7. Catatonic symptoms
8. Harmonious family relationships
9. Some degree of confusion
10. Female gender
11. Low expressed emotions
12. Late age of onset
13. Early initiation of treatment
14. Above average intelligence
43 UNDERSTANDING PSYCHIATRY

Management
In cases where florid psychotic symptoms exist with deterioration in meaningful
relationships within the family, hospitalization is essential

Pharmacotherapy
It is now generally accepted that antipsychotic drugs play an important part in
the treatment of schizophrenia. Since the introduction of chlorpromazine, many other
phenothiazines and other classes of neuroleptic drugs have been introduced with very
good results. Apart from newer, atypical antipsychotics, e.g. clozapine and
resperidone, older neuroleptics have almost similar efficacy and indications but
different side effect profile. Extrapyramidal side effects are common. Akathesia, i.e.
generalized restlessness, is a very common side effect. Acute dystonic reactions like
abnormal face and body movements, tongue protrusion or torticollis may be seen
with drugs like phenothiazines and butyrophenones. Features suggestive of
Parkinsonism, like tremors, rigidity, mask like expression and pill rolling movements
of the fingers are also seen. Tardive dyskinesia is a serious complication, which
includes grimacing, tongue rolling and bizarre facial and body movements. In spite
of these side effects, these neuroleptics have been the mainstay in the treatment of
schizophrenia as they exert specific therapeutic effects and have proved very useful
in preventing relapse, especially when given for a period of 25 years. Compliance
can be a major factor in effective therapy and this can be improved by the use of long
acting phenothiazines or depot preparations in patients where compliance is doubtful
or unsatisfactory.

Summary of anti-psychotic pharmacology, post synaptic Receptor

blockade
Drug D2 D1 5HT2 Alpha1 Alpha2 H1 M1
Chlorpromazine + + + ++ +
Haloperidol ++ + +
Clozapine + + + + + + ++
Lanzapine + + + + ++
Risperidone ++ + ++ ++ + ++
Quetiapine + + + ++ ++

Receptor Type Side Effect

Dopaminergic Extra pyramidal (akathesia, tardive dyskinesia ,
dystonia) Hyperprolactinaemia (gynaecomastia,
galactorrhoea, amenorrhoea, impotence, infertility
5HT Nausea, anorexia, insomnia, anorgasmia
Muscranic Dry mouth, blurred, vision, constipation
Alpha1 Delayed ejaculation, hypotension, tachycardia
SCHIZOPHRENIA 44

Histaminergic Sedation, weight gain, hypotension

Electro convulsive therapy (ECT)

ECT is given either in cases of acute catatonic excitement or in extremely
withdrawn cases, stupor or where progress is very slow. ECT may make the recovery
slightly quicker but its role is doubtful unless there are clear-cut depressive features.

Psychotherapy
In schizophrenia, formal psychotherapy is of limited value. However,
psychotherapeutic approach is very important. Behaviour therapy and social skills
training are quite useful in chronic schizophrenic patients. An attempt should be
made to make contact with the patient because of the terrifying experiences, which
he might be having. Later, involvement in group therapy is useful.

Rehabilitation
This is perhaps the most important aspect in the treatment and maintenance of
remission in schizophrenia. An effort is made to provide favorable opportunities for
the patient, to re-establish meaningful relationships with other people. The
acceptance of patient's behaviour and communication helps him to develop
confidence and minimizes his anxiety. Occupational and industrial therapy is very
useful especially in chronic schizophrenic patients, so that they do not lose touch
with the day-to-day routine of living. In some cases, these patients can be taught new
trades in order to enable them to earn their living. The emphasis, now, is on keeping
the schizophrenic patients in the community and avoiding institutionalization.Psycho
educational and family intervention strategies based upon High Expressed Emotion
(HEE) of relatives ( e.g. Critical comments, hostility, emotional over involvement)
are helpful in preventing relapse.