Schizophrenia
An Overview on Schizophrenia
In order to properly synthesize the recent understanding on the causes and approaches on the treatments of schizophrenia, it is therefore an imperative to discuss how the disorder was derived and defined from the past, and how modern understanding of schizophrenia has evolved.
The word schizophrenia is less than a century old, the illness itself is said to have accompanied mankind throughout history. Written documents that detail schizophrenia identified the disease to have existed since the old Pharaonic Egypt. The disturbances that are commonly found during the onset of schizophrenia like depression dementia and thought distortions have been described in past literatures such as the Book of Hearts. However, long before the introduction of schizophrenia as a mental disorder, the aforementioned symptoms were once associated with poison and demons. Although early Romans and Greeks were aware of psychotic disorders, each condition was treated and considered to fall in a single category. In fact, no specific condition diagnostically met the criteria for schizophrenia. Early theories supposed that all mental disorders are caused by evil possession of the body. As such, the most common treatment was exorcising, ranging from innocuous approaches such as exposure to certain types of music to dangerous and deadly means like drilling holes in the skull of the individual so as to release the evil spirit (Schizophrenia.com, 2004).
German physician, Emil Kraeplin was one of the pioneers of the classification of mental disorders into varying categories. Dr. Kraepelin employed the term dementia praecox for individuals exemplifying symptoms that are now associated with schizophrenia. Although the concept of madness has been existent for thousands of years, schizophrenia was only distinguished as a distinct mental illness in 1887. In order to do so, Kraepelin first made a distinction between dementia praecox and manic depression. His observations showed that dementia praecox is a disease of the brain, specifically a form of dementia. He named the disease as such so as to distance it from other forms of dementia like Alzheimer s disease (Schizophrenia.com, 2004).
By 1911, Swiss psychiatrist Eugen Bleuler coined the term schizophrenia as a replacement for Kraepelin s initial term, as he deemed that dementia praecox was misleading because the symptoms of the disorder does not have any relation with dementia. In place of the course and outcome emphasized by Kraepelin in his initial studies, Bleuler emphasized the signs and symptoms of schizophrenia. He made distinctions between the negative symptoms (fundamental symptoms), which are often specific, chronic, and permanent features of schizophrenia, and positive symptoms (accessory symptoms), which may be completely absent during or all part of the cause of the disorder, or at times very prominent among schizophrenics (Schizophrenia.com, 2004).
Both Kraepelin and Bleuler laid the groundwork for the categorization of schizophrenia based on its prominent symptoms and prognoses. Over the years, experts working on this field has continuously found means in order to classify the subtypes of schizophrenia. The DSM-III delineated the five categories of the disease identified by Kraeplin and Bleuler disorganized, paranoid, catatonic, residual, and undifferentiated, the first three of which were originally proposed by Kraeplin himself. Although DSM-IV still employs these classifications, it was shown that they were not helpful in predicting the outcome of the disease, as the types are still not reliably diagnosed. Today, experts are using other systems in classifying the types of schizophrenia in accordance to the superiority of positive and negative symptoms, disorder progression, co-occurrence with other mental illnesses (Schizophrenia.com, 2004).
Since then, schizophrenia has been identified as a severe and disabling brain disorder, characterized by abnormalities and distortion of perception and expression of reality (Regier et al., 1993 as cited in NIMH, 2009). People suffering from this condition manifest diverse symptom presentation ranging from hearing voices that other people do not usually hear to hallucinations and delusions. Schizophrenics may not make sense about what they are talking about. They may sometimes become catatonic, or at times may appear perfectly fine until they voice out what they are thinking. Due to these, people diagnosed with schizophrenia are terrified about their illness causing them to withdraw or become extremely agitated. Although there are various treatments capable of relieving the symptoms of schizophrenia, no known cure that will fully eliminate the disease is still developed. As such, people who have the disorder would have to cope with the symptoms throughout their lives. However, researchers are also continuously developing effective treatments and employ new research tools to further understand the causes of the disorder (NIMH, 2009).
Causes of Schizophrenia
Psychological Theories of Schizophrenia
Following the groundwork set by Kraeplin and Bleuler, early attempts forwarded to understand the origin of schizophrenia were grounded in psychological theories. For instance, Sigmund Freud, proposed that psychological process plays a role in the development of psychotic symptoms (Howells, 1991 as cited in Maddux Winstead, 2003). Frieda Fromm-Reichmann, in 1948, also proposed that schizophrenia was a result of the rearing of a schizophrenogenic mother (Fromm-Reichmann, 1948 as cited in Walker, 2005). Subsequent theories about the causes of schizophrenia were centered on family interaction models. However, just like earlier theories, these studies contributed little in synthesizing the etiology of schizophrenia, although in some way these also provided ideas about the importance of familial support among the sufferers of schizophrenia (Howells, 1991 as cited in Walker et al., 2005).
Genetics and Environment
More than 80 years of behavior genetics research in the context of twin, family, and adoption studies highlighted the concept that schizophrenia is highly heritable. Several family studies have shown that schizophrenia runs in families, and that the likelihood of acquiring the disorder is much higher among individuals whose close relative is suffering from schizophrenia (Nicol Gottesman, 1983 as cited in Beck et al., 2008). Accordingly, a recent quantitative review of 11 well-conducted family studies presents that first-degree relatives of individuals with the disorder are 10 times more likely to acquire schizophrenia than those individuals with non-psychiatric family history (Sullivan, Owen, ODonovan, Freedman, 2006 cited in Beck et al., 2008).
Similarly, adoption and twin studies also provide more support in reinforcing the causative contribution of genetic factors in the development of schizophrenia. Irving Gottesmans (1991) twin study found that Monozygotic (MZ) twins, who share almost 100 of their genes, have the highest tendency of schizophrenia concordance (as cited in Walker et al., 2005). Gottestman (1991) also noted that among MZ co-twins of schizophrenic patients, 25 to 50 are at risk of developing the same disorder (as cited in Walker et al., 2005). As for dizygotic (DZ) twins and other siblings that share about half of their genes, about 10 to 15 of DZ co-twins of the patients were diagnosed with the disorder (Gottesman, 1991 as cited in Walker et al., 2005).
Meanwhile, although a quantitative review of adoption studies found no difference in the rate of schizophrenia among adoptive relatives of persons with and without the disorder, it was also inferred that biological relatives of schizophrenia patients are five times more at risk in acquiring the disorder compared to the biological relatives of healthy adoptees (Sullivan et al., 2006 as cited in Beck et al., 2008). These studies provide ample evidence on the role of genetic components in the etiology of schizophrenia.
Although behavior genetics highlight the role of genes in the development of schizophrenia, the specific genes and mechanistic details that trigger the onset of such illness remain trivial and yet to be discovered. However, the field of schizophrenia genetics maintain their conviction that many susceptibility genes serve as contributors to the development of the disorder, and each of these genes, though still not identified, has a small effect in the overall etiology of schizophrenia (Gottesman Gould, 2003 Sullivan et al., 2006 as cited in Beck et al., 2008).
Aside from the attribution of schizophrenia to biological factors, recent findings have also indicated that genetic influences of the disorder are also concerted with environmental factors. For instance, a study in Finland found that the rate of psychoses including that of schizophrenia was profoundly higher among matched control adoptees. There were also indications that genetic vulnerability of adoptees is associated with disruptive environment (Tienari, Wynne, Moring, Lahti, 1994 as cited in Walker et al., 2005). Similarly, a study by Mary Canon and colleagues (2002) associated obstetric complication with the onset of schizophrenia. It was found that the risk of having the disorder linked to obstetric complications is double compared to having no such complications (as cited in Beck et al., 2008). Some studies also implicated that schizophrenia is disproportionately higher in urban environments (McGrath et al., cited in Beck et al., 2008), although there are still no clear indications whether such observed elevations are due to prenatal or perinatal factors of urban birth of whether urbanicity does confer the risk of developing schizophrenia at a later point in the form of social isolation and psychosocial stress (Boydell Murray, 2003 as cited in Beck et al., 2008). These findings are clear indications that the interaction between genetic and environmental factors plays a significant role in the development of schizophrenia.
Neurobiological Factors
Different brain chemistry and structures were also pointed out as contributors to the rise of schizophrenia aside from the outlined genetic and environmental factors above. Several studies presented that abnormalities in the structural connectivity of the brains are evident among schizophrenic individuals. Based on clinical results, it was found that more neurotransmitters are released between neurons of schizophrenic brain, which causes the symptoms of the disorder. Initial studies thought that the problem was solely caused by excess dopamine in the brain. However, recent studies also pointed out that aside from dopamine other forms of neurotransmitters like glutamate and GABA also contribute to the onset of the disorders symptoms. For instance, glutamatergic neurons, which are part of the pathways that connect the hippocamus, thalamus, and prefrontal cortex, were found to have been implicated among schizophrenia patients. Diminished activity at glutamatergic receptors region of the brain was also observed among patients, (Carlsson, Hansson, Waters, Carlosson, 1999 Goff Coyle, 2001 Tsai Coyle, 2002 as cited in Walker et al., 2005). while GABA, an inhibitory neurotransmitter, is said to have effects in the increase of psychotic disorders. Postmortem brain tissue of schizophrenics patients showed abnormalities such as the reduced uptake and release of GABA, (Lewis, Pierri, Volk, Melchitzky, Woo, 1999 as cited in Walker et al., 2005), abnormalities in the interconnections of GABA neurons (Benes Beretta, 2001 as cited in Walker et al., 2005), as well as the loss of cortical GABA interneurons (Walker, 2005).
Meanwhile, the brain structure as a contributor to the onset of schizophrenia remains controversial. However, there have also been extensive postmortem evidences as well as current imaging technologies proving that many regions of schizophrenic are structurally abnormal (Wright, Woodruff, Bullmore, 2000 as cited in Emental-health.com, 2001). The most common finding in the structural imaging of the brains of schizophrenia patient is their enlarged lateral ventricles. There are also evidences citing that schizophrenics have reduced volume of brain and smaller cerebral cortex, frontal and temporal lobe structure, though these findings remain controversial (Wright et al., 1999 Velakoulis et al., 1999 Hirayasu et al., 1998 and Shenton et al., 1992 as cited in Emental-health.com, 2001). Although experts have learned a lot about schizophrenia, research has yet to come up with coherent and agreed-upon studies on the role of neurobiological factors and processes in the emergence of this disorder (Williams, 2006 cited in Beck et al., 2008).
Schizophrenia Treatments Interventions
It is worthy to note that despite the improvements in the diagnosis of schizophrenia, this disorders complexity and its symptoms blurring boundaries with other mental illnesses make it difficult to develop a cure that would totally eliminate the disease. However, it should also be taken into consideration that schizophrenia has various treatment options that are focused on reducing the symptoms of the disorder so as to improve and restore productive quality life for patients. Common optimal treatments available for schizophrenia are that of pharmacotherapy and psychosocial treatments.
Pharmacotheraphy Medication treatment
Pharmacotherapies are contemplated as the most extensively used intervention for the reducing schizophrenia symptoms. Since mid-1950s antipsychotic medications have been in circulation. Majority of people treated with antipsychotic medications manifest substantial improvements in their conditions. Conventional forms of early antipsychotic medications include Perphenazine (Etrafon, Trilafon), Fluphenazine (Prolixin), Chlorpromazine (Thorazine), and Haloperidol (Haldol). Newer forms of these drugs emerged during 1990s and are commonly referred to as atypical because of their different mechanisms of action. They are found to be more effective against reducing negative symptoms of schizophrenia, to have limited side effects, and to show the promise of recovery for individuals to whom older forms of antipsychotic medications were not effective. The most commonly prescribed atypical medications include Clozapine (Clozaril), which is notable for its capability to treat hallucinations and delusions. However, one of the major drawbacks of this drug is the loss of white blood cells that serve as the protection of individuals from infections a condition known as agranulocytosis. Because of this potential occurrence, treatment with the use of Clozapine can be difficult for many people however, other forms of antipsychotic drugs can be employed as a replacement for clozapine such as Paliperidone (Invega), Risperidone (Risperdal), Olanzapine (Zyprexa), Aripiprazole (Abilify), and Ziprasidone (Geodon), (NIHM, 2009).
Psychosocial Interventions
While antipsychotic drugs are proven to be crucial in reducing the psychotic symptoms of schizophrenia, they are not consistent in relieving the behavioral symptoms of such disorder. Even if patients are already free of psychotic symptoms, many still exemplify difficulties in other aspects of their lives such as communication, self care, and establishing relationships with other. Adding up to this is the fact that just like any other forms of drugs, antipsychotic medications have unwanted effects that could further lead to more serious problems. Hence, psychosocial treatments are also put in place so as to complement the medications used in the treatment of schizophrenia. These forms of interventions assist patients to maximize their functioning and regain their control over themselves so as to help them deal with the daily challenges of life, may it be at home, school, or work. Psychosocial interventions include illness management skills, rehabilitation, integrated treatment for co-occurring substance abuse, family education, self-help groups, and cognitive behavior therapy (NIHM, 2009).
In illness management skills, patients are taught how to properly manage their illness by teaching them methods about watching over the signs of their disorder, and how they can possibly prevent relapses. Rehabilitation is a process through which patients undergo social and vocational trainings for them to function better in their communities. Such intervention may range from communication skills training, public transportation learning, counseling for money management or even job trainings. Integrated treatment for co-occurring substance abuse is an intervention that addresses co-occurring disorders among schizophrenia patients. As substance abuse is common among many schizophrenics, this intervention is prescribed for the general population of schizophrenia patients along with other treatment programs. Family education is an intervention designed to educate the family members of patients. By engaging in this form of intervention, family members are taught about the disease and the coping mechanisms so as to encourage loved ones to continue going through treatments. Self help groups, though they do not necessarily involve professional therapists, include group members that can relate to the affected individuals and in turn provide them with support and care they need. People who usually participate in this form of intervention usually are the ones who advocate the research and intervention of treatment programs for schizophrenia and draw public attention toward the discriminatory practices against people suffering from the disorder. Finally, Cognitive Behavior Therapy (CBT) is a form of psychotherapy that addresses the patients way of thinking and behavior. Therapists who facilitate this treatment teach patients how to set reality apart from fantasy, to avoid listening to voices, and to manage the symptoms of their illness. CBT is aimed at profoundly reducing the severity of symptoms and possible relapses of schizophrenia (NIHM, 2009).
Based on the outlined discussion, it can be inferred that schizophrenia is indeed a debilitating illness that to date remains without a cure and definite cause. Despite these perspectives though, continuous research and understanding about this disorder made it possible to develop treatments that are centered on improving the conditions of individuals suffering from such mental illness through reducing the symptoms and possible relapses, thereby providing a positive outlook in the future of this clinical disorder. In the meantime, it is perhaps best to encourage people to conduct further studies about schizophrenia so as to help people afflicted with it and allow them to maximize their potentials.
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