The term “schizophrenia” was introduced by the Swiss psychiatrist Bleuler into the medical language. It is a major mental disorder, or group of disorders, the causes of which are still unknown. It involves a complex set of disturbances of perception, thinking, affect and social behaviour. So far, in the world no society or culture has been found free from schizophrenia and according to some evidence it is seen that this puzzling illness represents a serious public health problem.
Schizophrenia refers to a disorder which is associated with high levels of social burden and cost, as well as an infinite amount of individual pain and suffering. However, there is evidence that the outcome of care can be as successful as it is in many other diseases treated by medical or surgical procedures (National Advisory Mental Health Council, 1993).
Implementation of an effective care system for schizophrenia, however, is more than a technical Endeavour. It has to be sustained by a vision and must be put within a unifying overall frame of reference. The vision can be that of a recovery- oriented mental health system, i.e. a service oriented to promote recovery from mental disorders by fostering self-esteem, adjustment to disability, empowerment and self-determination (Anthony, 1993). Psychosocial rehabilitation can provide this vision with a frame of reference, linking mental health services to a complex and ambitious social perspective that encompasses different sectors and levels, from hospitals to homes and work settings, with a central aim of ensuring full citizenship for people irrespective of their disabilities (WHO, 1996).
Schizophrenia is a mental disorder that is part of the psychotic group of disorders (American Psychiatric Association (APA), 2000). The syndrome of schizophrenia was first described in 1896 by Emil Kraeplin who termed groupings of behaviour he observed in ‘mental asylums’ as dementia praecox. He divided the symptom clusters into ‘catatonic’ and ‘dementia paranoides’ (Boyle, 2001) and believed the disorder was early onset dementia due to brain degeneration (Marenco & Weinberger, 2000). In his 1911 book, Dementia Praecox or Group of Schizophrenias, Eugen Bleuler continued Kraeplin’s work and developed the label ‘schizophrenia’ for the disorder described by Kraeplin. Their work was continued by other researchers, with Kurt Schneider helping to develop the Diagnostic and Statistical Manual of
Mental Disorders’ early diagnostic criteria for the disorder in the 1950’s (Boyle, 2001).
Schizophrenia is a challenging disorder that often makes it difficult to distinguish between what is real and unreal, to think clearly, manage emotions, relate to others, and function normally.
Schizophrenia is a brain disorder that affects the way a person behaves, thinks, and sees the world.
Schizophrenia is a mental disorder characterized by abnormal social behavior and failure to understand reality. Common symptoms include false beliefs, unclear or confused thinking, hearing voices that others do not, reduced social engagement and emotional expression, and a lack of motivation. People with schizophrenia often have additional mental health problems such as anxiety, depressive, or substance-use disorders. Symptoms typically come on gradually, begin in young adulthood, and last a long time.
Schizophrenia is a chronic brain disorder that affects about one percent of the population. When schizophrenia is active, symptoms can include delusions, hallucinations, trouble with thinking and concentration, and lack of motivation. However, when these symptoms are treated, most people with schizophrenia will greatly improve over time.
Schizophrenia affects between 0.5 and 1.5% of the world’s population (APA, 2000; Jablensky, 2000). Regier et al. (1993) found the one month prevalence rate of schizophrenia in a sample of areas in the United States of America to be 0.6%.
INCIDENCE AND PREVALENCE
Incidence studies of relatively rare disorders, such as schizophrenia, are difficult to carry out. Surveys have been carried out in various countries, however, and almost all show incidence rates per year of schizophrenia in adults within a quite narrow range between 0.1 and 0.4 per 1000 population. This has been the main finding from the WHO 10-country study (Jablensky et al., 1992).
In the last 15 years a variety of reports from several countries have suggested a declining trend in the number of people presenting for treatment of schizophrenia (Der et al., 1990).
The course of the disorder can vary. It is considered to have a prodromal phase, defined as a period during which specific symptoms are present before a diagnosis has been made This can appear months to several years before full onset and/or diagnosis (Häfner & an der Heiden, 2003; Yung & McGorry, 1996). During this phase the individual experiences functional decline, and exhibits specific behaviour and cognitions that are considered precursors to an episode of psychosis (Häfner & an der Heiden, 2003; Miller et al., 2003). Prodromal features include reduced concentration and attention, depressed mood, brief psychotic symptoms, and sleep disturbance (Yung & McGorry, 1996). Approximately 40-50% of people who have prodromal symptoms will go on to develop psychosis (Miller, et al., 2003; Yung et al., 2003).
Once diagnosed with schizophrenia the disorder can be chronic or acute with exacerbations and remissions (APA, 2000). The long-term prognosis of the disorder is varied. People with schizophrenia can have a remission that is followed by relapse, remission with no further relapse, or have no remission at all. Women have a better long-term prognosis than men, and are more likely to have a permanent remission (Haro, Novic, Suarez, & Roca, 2008).
The lifetime risk of suicide for people with schizophrenia is cited as being
between 4% and 10%. The risk is greatest in the early stages of the disorder (Palmer, Pankratz, & Bostwick, 2005; Tsuang, 1978).
Schizophrenia Diagnosis Criteria
Patients must meet the criteria outlined in the DSM (Diagnostic and Statistical Manual of Mental Disorders). This is an American Psychiatric Association manual used by healthcare professionals to diagnose mental illnesses and conditions.
The patient must:
Have at least two of the following typical symptoms:
-disorganized or catatonic behavior,
-negative symptoms that are present for much of the time during the last 4 weeks
-Experience considerable impairment in the ability to attend school, carry out their work duties, or carry out everyday tasks.
-Have symptoms that persist for 6 months or more.
Early warning signs of schizophrenia
In some people, schizophrenia appears suddenly and without warning. But for most, it comes on slowly, with subtle warning signs and a gradual decline in functioning long before the first severe episode.
The most common early warning signs include:
1. Depression, social withdrawal
2. Hostility or suspiciousness, extreme reaction to criticism
3. Deterioration of personal hygiene
4. Flat, expressionless gaze
5. Inability to cry or express joy or inappropriate laughter or crying
6. Oversleeping or insomnia; forgetful, unable to concentrate
7. Odd or irrational statements; strange use of words or way of speaking
While these warning signs can result from a number of problems—not just schizophrenia—they are cause for concern.
Positive Symptoms (more overtly psychotic)/SIGNS – Things That May Start to Happen (“Positive” Symptoms)
• Hallucinations: They might hear, see, smell, or feel things no one else does. Most often they’ll hear voices in their heads. These might tell them what to do, warn them of danger, or say mean things to them. The voices might talk to each other.
Hallucinations and delusions are classified in the positive grouping of schizophrenia symptoms. These symptoms are an increase in normal behaviours and/ or distortions in these behaviours (APA, 2000). Hallucinations can occur in the visual, olfactory, gustatory, and tactile modalities. However, they are most commonly experienced in the auditory modality.
1. Visual (seeing things that are not there or that other people cannot see),
2. Auditory (hearing voices that other people can’t hear,
3. Tactile (feeling things that other people don’t feel or something touching your skin that isn’t there.),
4. Olfactory (smelling things that other people cannot smell, or not smelling the same thing that other people do smell),
5. Gustatory experiences (tasting things that isn’t there).
• Delusions: These are beliefs that seem strange to most people and are easy to prove wrong..
Delusions may also be referential and/or religious, and can include
believing that song lyrics, other people’s gestures, or news items contain content directly intended for, or about the individual (APA, 2000).
Often, these delusions involve illogical or bizarre ideas or fantasies, such as:
-Delusions of persecution – Belief that others, often a vague “they,” are out to get you. These persecutory delusions often involve bizarre ideas and plots (e.g. “Martians are trying to poison me with radioactive particles delivered through my tap water”).
-Delusions of reference – A neutral environmental event is believed to have a special and personal meaning. For example, you might believe a billboard or a person on TV is sending a message meant specifically for you.
-Delusions of grandeur – Belief that you are a famous or important figure, such as Jesus Christ or Napoleon. Alternately, delusions of grandeur may involve the belief that you have unusual powers, such as the ability to fly.
-Delusions of control – Belief that your thoughts or actions are being controlled by outside, alien forces. Common delusions of control include thought broadcasting (“My private thoughts are being transmitted to others”), thought insertion (“Someone is planting thoughts in my head”), and thought withdrawal (“The CIA is robbing me of my thoughts”).
-Somatic Delusions-These are false beliefs about our body – for example that a terrible physical illness exists or that something foreign is inside or passing through your body.
• Behavioral disturbances: Behavioural disturbances often manifest in disorganised speech and distortions in behaviour. The individual’s speech may be tangential, opaque, have loose associations, be disorganised, and/or be incoherent. As such, their ability to communicate is impaired (APA, 2000).
Behavioural disturbances may also manifest in the form of lack of hygiene, unusual or inappropriate dress, agitation, and problems with goal directed behaviour (APA, 2000). Other behavioural symptoms may include catatonia in the form of reduction of body movements and the maintenance of single posture, lack of response to the environment, or movements without apparent goals or direction (APA, 2000).
• Catatonic behaviors: These are characterized by a marked decrease
in reaction to the immediate surrounding environment, sometimes taking the form of motionless and apparent unawareness, rigid or bizarre postures, or aimless excess motor activity.
• Trouble concentrating: For example, someone might lose track of what’s going on in a TV show as they’re watching.
• Different movements. Some people with schizophrenia can seem jumpy. Sometimes they’ll make the same movements over and over again. But sometimes they might be perfectly still for hours at a stretch, which experts call being catatonic. Contrary to popular belief, people with the disease usually aren’t violent.
• Other symptoms: sometimes present in schizophrenia but not often enough to be definitional alone include affect inappropriate to the situation or stimuli, unusual motor behavior (pacing, rocking), depersonalization, derealization, and somatic preoccupations.
Negative (deficit) Symptoms/signs-(ABSENCE OF NORMAL BEHAVIORS)
The so-called “negative” symptoms refer to a decrease in the occurrence of normal behaviours. This may include:
• Flat or empty affect/ Affective flattening: It is the reduction in the range and intensity of emotional expression, including facial expression, voice tone, eye contact, and body language. It is an inability to experience pleasure, and poverty of speech, reflected in a decrease in the quantity and frequency of speech. Additionally, speech content may be empty or have reduced complexity (APA, 2000).
• Poor eye contact- Individuals with schizophrenia may also display poor eye contact, an inability to initiate or follow though goal directed behaviours, and/or be physically inactive. (APA, 2000).
• Lack of emotional expression – Inexpressive face, including a flat voice, lack of eye contact, and blank or restricted facial expressions.
• Lack of interest or enthusiasm / Avolition- is the reduction, difficulty, or inability to initiate and persist in goal-directed behavior; it is often mistaken for apparent disinterest. (examples of avolition include: no longer interested in going out and meeting with friends, no longer interested in activities that the person used to show enthusiasm for, no longer interested in much of anything, sitting in the house for many hours a day doing nothing).It is the Problem with motivation; lack of self-care. Seeming lack of interest in the world – Apparent unawareness of the environment; social withdrawal.
• Disorganized speech /Speech difficulties and abnormalities /Alogia – or poverty of speech, is the lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts, and often manifested as short, empty replies to questions.
Inability to carry a conversation; short and sometimes disconnected replies to questions; speaking in monotone. Schizophrenia can cause people to have trouble concentrating and maintaining a train of thought, externally manifesting itself in the way that you speak. You may respond to queries with an unrelated answer, start sentences with one topic and end somewhere completely different, speak incoherently, or say illogical things.
Common signs of disorganized speech include:
-Loose associations – Rapidly shifting from topic to topic, with no connection between one thought and the next.
-Neologisms – Made-up words or phrases that only have meaning to you.
-Perseveration – Repetition of words and statements; saying the same thing over and over.
-Clang – Meaningless use of rhyming words (“I said the bread and read the shed and fed Ned at the head”).
• Lack of emotion – the inability to enjoy regular activities (visiting with friends, etc.) as much as before.
• Low energy – the person tends to sit around and sleep much more than normal.
• Inability to make friends or keep friends, or not caring to have friends.
• Social isolation – person spends most of the day alone or only with close family.
• Social withdrawal – when a patient with schizophrenia withdraws socially, it is often because they believe somebody is going to harm them.
• Unawareness of illness – as the hallucinations and delusions seem so real for patients, many of them may not believe they are ill. They may refuse to take medication for fear of side effects, or for fear that the medication may be poison, for example.
• Cognitive difficulties – the patient’s ability to concentrate, recall things, plan ahead, and to organize their life are affected. Communication becomes more difficult.
The average age of onset of schizophrenia is in the early to mid twenties for males, and in the mid twenties to early thirties for females (APA, 2000; Faraone, Chen, Goldstein, & Tsuang, 1994). Diagnosis before the teenage years is very exceptional (APA, 2000). The lifetime rates of schizophrenia diagnosis for males and females are equal. Although men generally have an earlier onset than women, women have a second spike in onset approximately between the ages of 45 and 54. Due to this, it has been suggested that oestrogen may play a protective role in woman until menopause (Häfner et al., 1993). Onset can be acute: symptoms appear within a week; sub-acute: symptoms appear and are established in one month, gradual: slow development over greater than a one month period, or insidious: establishing the time of onset is difficult (Jablensky et al., 1992).