SCHIZOPHRENIA

Schizophrenia is a mental health condition characterized by delusions, disturbed thought process,

hallucinations, and abnormal behaviours and flattening of affect. It must not be considered as a
single disease rather conglomeration of different types of illness. The deleterious effect on
cognitive process and resultant effect has garnered attention of healthcare scientists and health
care professionals round the world. The effect on quality of life and the associated effects on
families warrant understanding of the disease, signs and symptoms and treatment and therapies
available. The current essay will provide a brief account of illness and treatment available based
on evidence.

The individuals suffering from schizophrenia seems they are not living in reality; however it is
the underlying mechanism of the disease that affects their thought and motor process. The
disabling effect of the disease warrants understanding the pathophysiology of the disease.

PATHOPHYSIOLOGY

The pathophysiology of Schizophrenia is complex like the disease symptoms and signs.
Anatomic, immune system and neurotransmitters play simultaneous role in manifesting the
disease.

Neuroimaging studies carried out to study anatomic differences in brain of schizophrenic patients
and normal patients have shown larger ventricles, reduced brain volume in temporal areas,
changes in hippocampus region are reported in patients suffering from schizophrenia unlike
normal people. Similarly, researchers have taken much interest in different parts of the brain
against a single portion of the brain. Magnetic Resonance imaging (MRI) studies have revealed
existence of anatomic abnormalities in limbic and neocortical network region and
interconnecting white matter tracts.

Involvement of neurological system has also been reported in pathophysiology of Schizophrenia.

Recent studies have shown important role of dopaminergic system in schizophrenia. The two
drugs that has positive effects on schizophrenia treatment are reserpine and chlorpromazine
although they are structurally different but they have antidopaminergic properties. The
antipsychotic drugs reduce the firing rate of mesolimbic dopamine D2 neurons. Drugs like
amphetamines exacerbate psychotic symptoms by stimulating the neurons. In schizophrenia both
positive and negative symptoms might co-exist due to hypodopaminergic activity in mesocortical
system or hyperdopaminergic activity in mesolimbic system. The new antipsychotic drugs
discovered have the capability to block both serotonin receptors and dopamine D2 receptors.

Clozapine is an effective antipsychotic agent however it is weak dopamine D2 antagonist. The

other neurotransmitter system that includes serotonin, norepinephrine and gamma-aminobutyric
acid (GABA) must be involved. The current research focuses on N-methyl-D-aspartate (NMDA)
which is a subclass of glutamate receptors that can lead to psychotic symptoms in healthy
individuals. The best example is ketamine and phencyclidine. Some researchers also believe
schizophrenia as a hypoglutamatergic disorder.

Immune system might be involved in the pathophysiology of schizophrenia because immune

system gets disturbed in patients suffering from schizophrenia. Immune system overactivation
originating from postnatal stress and prenatal infection might result in over expression of
inflammatory cytokines that in turn alter the structure and function of the brain. High levels of
pro-inflammatory cytokines have been found in schizophrenic patients that activates kynurenine
pathway. In this pathway tryptophan get metabolized into quinolinic acid and kynurenic acid.
These acids regulate NMDA receptor activity therefore they might be involved in dopamine
regulation.

Studies have shown people with schizophrenic condition have metabolic disorders like insulin
resistance that complements inflammation in this population. Thus inflammation might be linked
with psychopathology of schizophrenia and metabolic disorders very often seen in patients of
schizophrenia.
.
SIGNS AND SYMPTOMS OF THE DISEASE

The onset of schizophrenia occurs in between ages 16-30 and in some rare cases children gets
schizophrenia. The symptoms of schizophrenia can be classified into three broad categories i.e.
positive, negative and cognitive.

Positive Symptoms- Symptoms that is unusual in healthy subjects and people with positive
symptoms at times seems to stay away from reality. The symptoms include – delusions,
hallucinations, and movement disorders, thought disorders (cognitive disorders). The second
category is Negative Symptom. Negative symptoms implicate disturbances in normal behaviour
and emotion. The symptoms are reduction in expression that can be inferred from flat facial
expression or voice. Reduction of senses to pleasure (emotional sense), reduced communication,
difficulty in sustaining and leading life.

Cognitive Symptoms- The symptoms that are related to thought process are categorized under
cognitive symptoms. The severity and expression of the symptoms are different in each suffering
i.e. change in memory and perceptions. The symptoms include- reduced executive functioning,
issue with working memory, trouble in attention and focusing.

TREATMENT AND THERAPIES AVAILABLE

There is no cure to the illness however current treatment and therapies are restricted to
symptomatic management. In this section different treatment considerations will be discussed in
brief. Treatment of schizophrenia is multidisciplinary that warrants intervention medical,
psychosocial and psychological

Antipsychotics

Antipsychotics are taken either in pill form or in liquid form. Certain antipsychotics are taken in
inject able form once in a month. The first antipsychotic medications used in the treatment of
schizophrenia involve haloperidol and chlorpromazine. The drugs belonging to this category are
known as first generation antipsychotic drugs. The other anti-psychotic that starts with clozapine
is known as second generation antipsychotics. But both the generation of anti-psychotic drugs
have adverse effects such as first generation of anti-psychotics can cause high level of prolactin
level and extra pyramidal effects. The second generation anti-psychotic drugs can lead to poor
glucose and lipid control as well as weight gain.

Other Pharmacological Therapy

Anticholinergic agents like diphenhydramine, benztropine and triexyphenidyl aamantadine are

used in treatment of schizophrenia. It can be used with conventional anti-psychotic agents to
prevent extrapyramidal and dystonic movements. Akathisia a condition usually seen in
schizophrenia is difficult to treat however it responds to anticholinergic agent. In many patients
along with antipsychotic medications psychotropic medications are also given. Although
polypharmacy is less evident in research literatures, however it is practiced widely. Medications
also include mood stabilizers, antidepressants and anxiolytic agents. Clozapine and
Carbamazepine must not be used together.

Psychosocial Interventions

Along with pharmacologic treatments, psychosocial treatments such as cognitive behavioural

therapy, skills training, social cognition training, and cognitive remediation can be used.
Currently recovery oriented approaches are followed in psychosocial intervention. As per this
model, the objectives for schizophrenia patient are – preventing hospitalizations, reduce the
symptoms, self management of funds and medications, concentrate on working and other
engagements. Hope, community reach, empowerment and client autonomy are emphasized
through this treatment approach.

DIET AND ACTIVITY

The adverse effects of second generation anti-psychotic medication are weight gain and
disturbed glucose and lipid control. At times, the patient develops odd food habits . Similarly
patients having less funds or inability to manage their funds usually stay near fast food outlets.
Therefore, the chance of getting poor nutrition further worsens the condition. In such condition
nutritional and diet counseling is required. Since psychotropic medications can lead to increase
in weight, therefore exercise can be recommended to reduce co-morbidities associated with the
disease.

Vocational rehabilitation
Many patients suffering from this disease want to work, but to disabling effect of this disease
they are not competitive for day to day work. But people with disease or condition must be
facilitated with supported employment opportunities. Such therapies can improve the self
confidence in them.

PRIMARY HEALTH CARE STRATEGY

The primary health care strategy must not be limited symptomatic management of the disease but
also address the disease from public health perspective. Therefore based on evidences, the
primary healthcare strategy can be developed as follows

Along with anti-psychotics the schizophrenic population along with the family must be imparted
psychoeducation that can reduce the disability and improve the adherence of patients to
treatment regimen. The psychoeducation must be of low intensity and regular follow ups can
improve the quality of life of schizophrenic patients.

Another primary health care strategy should be training of general healthcare professionals and
nursing professionals to address the schizophrenia patients. Since most of the psychiatric
specialist, psychiatric nurses and psychiatric social workers are urban centered based. Thus, the
mental health patients suffering from this condition living in rural area must be attended by
trained professionals. The main work of such trained professionals would be identifying the
patients and bringing them to care settings for getting specialized care in a recovery oriented
model.

BIPOLAR DISORDER.

According to the current research studies, the collaborative practice developed to address the
depression in mental health can be employed to address the bipolar disorder in community health
settings. Several studies have evaluated the effect of collaborative practice and effect on bipolar
disorder patients. Based on such studies, the following primary health care strategies in
community settings are recommended to improve the quality of life in bipolar disorder patients.