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Schizophrenia

This web content is designed and presented by Maurice Sadak. PWDC Clinic Assistant.

                               

Introduction: 

The purpose of this website page is to offer information about Schizophrenia.  This information includes a general overview, history, symptomology, neurobiological basis, genetics and most importantly helpful tips for people living with schizophrenia and for their family caregivers. This webpage is intended for everyone who is interested in learning about this disease. I hope that viewers of this page will get a deeper insight into Schizophrenia and better understanding of living with this disease.

I work as a clinic assistant at the Psychiatric Wellness and Dementia Care.  In this role I see people who live ith different disorders, and in my experience, schizophrenia is one of the most fdifficult to live with.  This is why I am very interested in this disease and in how patients and their families can learn to coope with this illness. 

Schizophrenia is one of the most devastating and tragic diagnoses that a person can receive.  This disease effects the brain, mental state (mood, thinking and reasoning), and ability to partake in normal daily life. Schizophrenia can be defined as a lack of connection with reality and a mental state of confusion and cognitive dissonance.

                                                                                

Please watch this breif video about the neurobiological basis of Schizophrenia.

A Breif History

                                            

Schizophrenia was first recognized back in early Greece when physicians encountered bizarre symptoms like: hallucinations, delusions, and paranoia (Chiko, 2015). At that time, these symptoms were considered a form of madness. In the 19th century it was coined as a medical condition by Emil Kraepelin and Eugene Beuler (Chiko, 2015).

The Dopamine Hypothesis

Through the years there has been many hypotheses of schizophrenia. One of the most recognized is the dopamine hypothesis (Cazaban, 2003). It states that the body has too much dopamine activity in the brain causing over activity in certain brain centers. Dopamine is an inhibitory brain chemical (neurotransmitter). Dopamine is produced in the parts of the brain called: substantia nigra, midbrain and hypothalamus (Sadock, Sadock, & Ruiz, 2015). Dopamine is derived from an amino acid Tyrosine. In the neuron, a hydroxyl group is added to tyrosine by the enzyme tyrosine hydroxylase. Tyrosine is then converted into L-DOPA (L-3,4-dihydroxyphenylalanine); which in turn is converted by another enzyme - aromatic L-amino acid decarboxylase into dopamine (Gilmore et al., 2014). Dopamine is stored in synaptic vesicles. It is released by action potential into the synaptic cleft and then it interacts with postsynaptic receptors. Dopamine travels from neuron to neuron via pre-and-post synaptic clefts. If there is too much dopamine, it is pumped back into the presynaptic neuron(Gilmore et al., 2014). In schizophrenia, this reuptake mechanism does not work well. If dopamine is too high in certain parts of the brain, the patient may experience psychotic symptoms, and if dopamine is too low in other parts of the brain, one may experience depression (Gilmore et al., 2014). A supporting fact for this hypothesis is that most antipsychotic drugs are designed to lower dopamine levels in the brain. These medications are moderately effective, they reduce and control symptoms in about 40% of people living with schizophrenia (Pies, 2011). Another example is when stimulant drugs like cocaine and amphetamines which boost dopamine levels, are ingested they create symptoms similar to those in someone with schizophrenia Lastly, Computerized Axial Tomography (CAT) scans of schizophrenic patients show increased dopamine receptor activity in the brain. On the molecular level, as stated earlier, dopaminergic hypothesis of schizophrenia is one of the oldest and most proven.

Glutemate Theroy

Another example of the neurotransmitter theory is abnormal levels of glutamate (Pies, 2011). This theory was originated by observing patients that ingested phencyclidine (PCP), and exhibited many symptoms similar to schizophrenia. Glutamate (C5H9NO4), an excitatory neurotransmitter, is one of the most common and important chemicals in the brain because in correct amounts it helps to regulate may brain processes like learning, memory and emotions, but when a lot of glutamate is released at once, it is very toxic causing the neurons to die and the brain to shrink. Glutamate is created from a non-essential amino acid, glutamic acid (glutamine).

Glutamate has many receptors, one of them is called N-Methyl-D-Aspartate (NMDA). This receptor is primarily present in the hippocampus and the frontal lobe, areas that are already heavily affected by schizophrenia. Excess glutamate saturates NMDA receptors affecting memory and executive function. A lot of other neurotransmitters are also implicated in schizophrenia. For example; serotonin, GABA, and norepinephrine, but the findings for these neurotransmitters are not consistent.

Viral Infection Hypothesis

Another reputable hypothesis of schizophrenia is the Neurodevelopmental Hypothesis of Viral Infection (McGrath, 2012). This hypothesis proposes that when a pregnant mother contracts a certain virus and the brain of her developing fetus is affected by this virus, the fetus has a higher risk of developing schizophrenia in later life. 

Schizophrenia Symptoms

One of the main reasons that schizophrenia is such a devastating disease is because of the effects it has on the brain's functionality.

One of the most common symptoms in schizophrenia are hallucinations. Hallucinations are distorted perceptions of reality. They can include visual (seeing something that is not there); auditory (hearing voices or other sounds that no one else hears); olfactory (smelling something the no one else is smelling); tactile (ex. feeling bugs crawling on skin). The most common hallucinations in schizophrenia are auditory and visual (American Psychiatric Association, 2016). Patients frequently hear voices they describe as different from their own voice. It is not like hearing your own thoughts, but like hearing someone, or several others speaking, and sometimes yelling in your head.

I learned about this by interviewing a patient at the psychiatric clinic where I work. The patient told me that one way to understand what she experiences is to turn on the TV and the radio on full volume and to try to carry a conversation. For this patient, voices started when she was 12. At first, she heard one voice, but now at the age of 49 she hears seven voices. Most of them are mean and derogatory. They wake her up at night and tell her to harm herself. This patient had over 30 near lethal suicide attempts by overdose and cutting. She also recently burned 80 % of her arm, inflicting second degree burns, because the voices commanded her to do so. Visual hallucinations in schizophrenia are frequently frightening. For example, the patient I interviewed said that when her psychosis is severe, at times when she is not taking medications, she sees demons.

Other major symptoms include: psychosis - break with reality; disordered thinking - inability to concentrate, plan and use logic; thought insertion - patient perceives everything they read, see on TV, or hear on the radio is about them, or a command they need to obey; word salad - mixing existing words to a point where they make no sense; neologisms - making up words; loose associations - jumbled train of thoughts that are illogical; cognitive impairment - difficulties with memory and language; poor judgment and insight - usually don’t understand that they are sick and need help (American Psychiatric Association, 2016).

Other symptoms include loss of sleep, social awkwardness, anxiety, loss of concentration, loss of focus, inability to have normal conversations with others, and substance abuse (American Psychiatric Association, 2016). About fifty percent of schizophrenia sufferers self-medicate with substances (American Psychiatric Association, 2016).

These patients have up to 3 times higher rates of smoking then general population Hanson (Hanson, 2009). Several studies showed that nicotine helps ease sensory and cognitive symptoms of schizophrenia (Hanson, 2009). People with schizophrenia have fewer nicotinic receptors in the areas of the brain that are in charge of cognition, memory, and executive function. Nicotine plays an important role in cognition, this is why using nicotine containing products could be effective for cognitive symptoms of schizophrenia society (Neuroscience., 2009). Another example of substance use is a patient that I interviewed, who told me that she frequently uses marijuana to help her relax and sleep. If you are interested in this topic please read the articles in the resources section bellow. 

In order to partiallly understand what a Schizophrenic patient has to go through every day, check out this video. 

Please watch this brief video that ofers insight into living with Schizophrenia

Structural and Functional Brain Changes in Schizophrenia

Reduced number of nicotinic receptors is just one example of neurophysiological deficits in schizophrenia. Most, but not all people with schizophrenia have similar structural and functional changes in their brains. Some of the structural changes include: shrunken amygdala resulting in emotional instability, shrunken hippocampus resulting in mental and cognitive abnormalities, and abnormal changes in different brain structures (ex. CAT scans show enlargement of the third and lateral ventricles indicating the reduction of the brain mass) (Sadock et al., 2015). Some functional abnormalities include: abnormal changes in blood flow, and the uptake of glucose and oxygen. The creation of functional imaging technology allows scientists to measure the blood flow and intake of glucose and oxygen in the brain. By looking at these images, scientists can monitor function of the brain. Some of the main findings in schizophrenic patients are reduction of the blood flow and glucose intake in the frontal lobe (Sadock et al., 2015). This may be the reason why people with schizophrenia have difficulty thinking and using good judgment. 

 

Genetics of Schizophrenia.

Scientists do not yet agree about what causes these structural and functional changes. As the field of genetics advances, scientists are beginning to understand the influence of genes on the symptoms of schizophrenia. Schizophrenia has a strong genetic component, most people with schizophrenia have a relative with this disease (Sadock et al., 2015). The occurrence of schizophrenia is more prominent in monozygotic (identical) vs. dizygotic (not identical) twins. The closer a patient is to a relative with schizophrenia in their bloodline, the more likely he/she is to develop this disease.

                                                             

The occurrence of this disease in the general population is less than one percent. However, if a first-degree relative is diagnosed with schizophrenia, then the risk increases up to seventeen percent. If a twin has the disease, then the risk can go up to fifty percent (see figure). Chromosomal abnormalities that are implicated in schizophrenia have been identified, but many scientists believe that it is not a single gene mutation, but minor mutations on multiple genes and how the genes interact with each other and the environment that causes the disease. 

Several genes have been identified that increase the risk of schizophrenia, but routine tests are not performed to check for these genes, because the presence of these genes may not guarantee the development of the disease (Arato, Frecska, Beck, An, & Kiss, 2004). In other words, there are a lot of false positives.

Different environmental factors like stress, viruses, childbirth complications, or psychological trauma, may play a role in schizophrenia, but scientists believe environmental factors may not be the cause, but a major contributor to developing schizophrenia in someone with genetic mutations. One of the newest and most advanced theories is in schizophrenia, is that due to genetic and environmental factors, neurons are not migrating and connecting properly in the brain resulting in abnormal production of brain chemical signals (neurotransmitters) that in turn, causes many structural and functional abnormalities (Wildenauer, 2009). 

 

Schizophrenia Treatments.

There are many different treatment options but the most effective and common methods are medications. Many antipsychotics are used to help improve symptoms but no cure is yet available. There are two different types of antipsychotics. Older medications are called typical (ex. Zyprexa, Risperidone) and newer are called atypical (ex. Latuda, Abilify). Newer medications have fewer side effects while older generation antipsychotics have many harsh side effects. These significant side effects that include weight gain, movement disorders, and heart problems. Most dangerous side effect of these medications is the neuroleptic malignant syndrome (Sadock et al., 2015). It can be caused by both old and new generation antipsychotics, and it can be fatal. When this side effect occurs, the patient has high fever and very rigid and painful muscles. This is a medical emergency that can be fatal if not treated. Another dangerous side effect that is more common for typical antipsychotics is Tardive Dyskinesia - involuntary movement of body parts. This condition is frequently not treatable and may last for life (Sadock et al., 2015). When this symptom occurs, antipsychotics need to be stopped, or dose reduced.

Since schizophrenia has many harsh side effects like hallucinations and delusions, some of these symptoms may lead to hospitalization where a patient is put into overnight care (or even long term care) because it is decided that they are unfit to live alone. Schizophrenia sufferers also have higher rates of suicidal ideations (thoughts and plans) and completed suicides (up to 13% of patients die by suicide) (Sadock et al., 2015). Hospitalizations are indicated when patients have suicidal ideations.

Another common treatment for schizophrenia is therapy. Therapy may help patient's mental state but it doesn't really help the effects of the disease on the physical body (ex. reduced blood flow and volume of the brain). Only people who are not actively psychotic benefit from therapy, because it requires that patient is able to interact and follow the therapist.

                                                    Woman and rebellious teen in therapy

 

Tips for Family/Friend Caregivers

Caregivers Need Care, Too

More than 60% of caregivers who look after people with schizophrenia say it's tough to find time for themselves. But self-care is especially important for caregivers, who have an increased risk for depression, anxiety, and extreme stress. Tend to your emotional, mental and physical. 

The following tips were provided by http://healthguides.healthgrades.com/advances-in-schizophrenia/11-tips-for-taking-care-of-schizophrenia-caregivers

Tip 1. Keep a Journal 

Writing down your feelings and experiences can help you find solutions to problems. It can also be an emotional release. You could start with something like, "Today I feel ..." Or simply write down what happened that day.

Tip 2. Get Enough Sleep 

Many caregivers report trouble sleeping. To fall asleep more easily, try to avoid stressful discussions or activities before bedtime. Instead, do something relaxing, such as listening to calm music or taking a warm bath. If your mind is racing as you try to sleep, write down your thoughts or make a to-do list.

Tip 3. Join a Support Group 

It can be comforting hearing from fellow caregivers and learning that you face similar challenges. Members offer each other emotional support, information and advice. Find a group through the National Alliance on Mental Illness here.

Tip 4. Find a Listening Ear 

You might be more comfortable talking one-on-one instead of with a support group. That's OK. Just be sure to share your feelings with someone instead of bottling them up. A therapist, spiritual leader, friend, or another caregiver may be able to offer support.

Tip 5. Nourish Your Body 

A nutritious diet helps you manage stress, gives you energy, and keeps your immune system strong. Save time by cooking a big batch of a dish and freezing the leftovers. Looking for quick, healthy new recipes? Try the USDA's What's Cooking site.

Tip 6. Nurture Your Relationships

It's important to maintain your own identity and relationships outside of your role as a caregiver. Make an effort to spend some quality time with your spouse, family, and close friends. Even a five-minute phone call can help you reconnect with loved ones.

Tip 7. Stay Physically Active 

Exercise lifts your mood and boosts your energy. Choose an activity you enjoy, such as walking, biking, gardening, or dancing. Try to exercise at least five minutes every day. Work up to half an hour of physical activity five days a week.

Tip 8. Make Time for Fun 

It’s the best antidote for stress. At least once a week, do something that makes you happy. Watch a movie, go to brunch with friends, or play a round of golf. Try to make time for the hobbies you enjoy, whether it’s taking a walk with your camera or experimenting with a new recipe.

Tip 9. Put Your Health First 

It’s hard to care for another person if you’re in poor health yourself. So be sure to keep up with regular checkups, vaccinations and screenings. Talk honestly with your doctor if you feel depressed or burned out.

Tip 10. Ask for Help 

Friends and family members often want to help but don’t know how. Suggest they take on specific tasks, such as shopping for groceries or picking up medications. You don’t have to manage everything by yourself.

Tip 11. Let Go of Guilt 

Remember, it’s not selfish to take time for yourself or ask other people to help you. Your needs matter, too. When you take care of yourself, you can do a better job of caring for others.

 

Helpfull Recources 

Lived experience of Schizophrenia

https://www.amazon.com/Center-Cannot-Hold-Journey-Through/dp/1401309445

Elyn R. Saks is an esteemed professor, lawyer, and psychiatrist and is the Orrin B. Evans Professor of Law, Psychology, Psychiatry and the Behavioral Sciences at the University of Southern California Law School, yet she has suffered from schizophrenia for most of her life, and still has ongoing major episodes of the illness. The Center Cannot Hold is the eloquent, moving story of Elyn's life, from the first time that she heard voices speaking to her as a young teenager, to attempted suicides in college, through learning to live on her own as an adult in an often terrifying world. Saks discusses frankly the paranoia, the inability to tell imaginary fears from real ones, the voices in her head telling her to kill herself (and to harm others); as well the incredibly difficult obstacles she overcame to become a highly respected professional. This beautifully written memoir is destined to become a classic in its genre.

Schizophrenia Support Groups for Patients

http://www.nami-greaterseattle.org/support-groups

Schizophrenia Support Groups for Caregivers

http://www.nami-greaterseattle.org/support-groups

Canibas and Schizophrenia

  • https://www.medicaljane.com/ailment/schizophrenia/#what-is-schizophrenia
    • This website contains comprehensive information about the topic that includes:
      • Systematic review of the use of THC in schizophrenia
    • This website presents only one side of the story, listing only positive findings that say that TCH helps schizophrenia symptoms.
  • http://www.health.harvard.edu/blog/teens-who-smoke-pot-at-risk-for-later-schizophrenia-psychosis-201103071676
    • This is a link to a different perspective. Harward Medical School published findings that teenages that smoke canibas are at higher risk for developing psychosis in later life. 

Schizophrenia Research Videos 

 

Aging with Schizophrenia. Resources for Older Adults and Their Caregivers.  

  • Please take a look at this very detailed article about aging with chronic schizophrenia: http://www.managedhealthcareconnect.com/content/the-aging-patient-with-chronic-schizophrenia
    • This article presents statistics and discussed the course of disease and changes in the level of function. It may be more helpful, for health care providers, but everyone can find something interesting. 
  • Here is some information about how symptoms change as the person ages with schizophrenia, including a discussion of memory issues: http://www.mdedge.com/currentpsychiatry/article/64022/schizophrenia-other-psychotic-disorders/schizophrenia-older-adults
    • This article presents case studies that describe the symptoms and the challenges that people with schizophrenia experience as they age
      • I found it interesting that positive symptoms (ex. delusions, hallucination, paranoia) do not improve with age
    • I found it interesting that some of the factors that may be protective against schizophrenia complications in late life are:
      • female gender
      • being married
      • access to appropriate care
      • developping illness later in life
  • Very interesting article about biological mechanisms of accelerated aging in schizophrenia: http://www.mdedge.com/currentpsychiatry/article/116751/schizophrenia-other-psychotic-disorders/accelerated-aging
    • Possible cause of accelerated aging are listed as:
      • Inflammation
      • Telemere shortening 
      • High oxidative stress
      • Disruption of mitochondrial function

References

American Psychiatric Association. (2016). DSM-5 classification. Arlington, VA: American Psychiatric Association.

American Psychiatric Association. (2000). Electronic DSM-IV-TR plus (pp. 1 CD-ROM).
Arato, M., Frecska, E., Beck, C., An, M., & Kiss, H. (2004). Digit length pattern in schizophrenia suggests disturbed prenatal hemispheric lateralization. Prog Neuropsychopharmacol Biol Psychiatry, 28(1), 191-194. doi:10.1016/j.pnpbp.2003.09.020

Cazaban, A. . (2003). The effects of Schizophrenia on the brain. . Retrieved from http://serendip.brynmawr.edu/bb/neuro/neuro03/web2/acazaban.html

Chiko, Brian. (2015). schizophrenia.com.
Gilmore, T., Jou-Zhang, R. , Darwent, R., Guzman, R., & Pandya, J. (2014). Methamphetamines:

An Overview.
Gustafson, J. (2013). How schizophrenia affects the brain. Retrieved from https://owl.english.purdue.edu/owl/resource/560/01/

Hanson, M. (2009). Why Do Schizophrenics Smoke Cigarettes? Retrieved from http://brainblogger.com/2009/07/03/why-do-schizophrenics-smoke-cigarettes/

McGrath, J. (2012). The neurodevelopmental hypothesis of schizophrenia: a review of recent developments.

Neuroscience., Society for. (2009). Smoking and Schizophrenia. . Retrieved from http://www.brainfacts.org/diseases-disorders/psychiatric-

disorders/articles/2008/smoking-and-schizophrenia/

Pies, R. (2011). Dopamine Hypothesis of Schizophrenia.
Sadock, B., Sadock, A., & Ruiz, M. (2015). Synopsis of Psychaitry. Walters Kluver. Philadelphia.

Baltimore. New York. London. .
Wildenauer, Dieter B. (2009). Molecular biology of neuropsychiatric disorders. Berlin: Springer 

American Psychiatric Association. (2013). disorders (5th ed.). Washington, DC: Author. Diagnostic and statistical manual of mental Health