What you need to know about schizophrenia

Schizophrenia is a neologism first used by the Swiss psychiatrist Eugen Bleuler; it is a term that comes from the Greek and means divided mind, separated mind. Today, schizophrenia encompasses diverse syndromes with a common denominator: all of them have psychotic symptoms as a prominent aspect of their clinical picture. The term psychotic refers to delusional ideas and overt hallucinations (DSM IV-TR).

The definition of schizophrenia we find in the DSM IV-TR is a disturbance persisting for at least 6 months and including at least one month of active-phase symptoms, at least 2 of the following symptoms:

Delusional ideas:

These are mistaken beliefs that usually involve a misinterpretation of perceptions or experiences. Depending on the theme of these ideas, we distinguish subtypes: ideas of persecution, of self-reference, somatic, of grandiosity, jealous (delusional jealousy), of religiosity, of control, bizarre delusional ideas… The common denominator of all of them is that they are ideas that do not occur in reality, whose probability of occurrence is extremely low, but which the person experiences as an absolute truth despite clear evidence to the contrary. Some very typical examples are: everyone speaks badly of me, there is a conspiracy against me, they control my mind, they are persecuting me, someone has stolen my organs and replaced them…

Hallucinations:

These are false perceptions and can occur in any sensory modality (auditory, visual, olfactory, gustatory and tactile). The most common are auditory ones, which are voices that are heard and that are not the person's own thoughts; they are voices that are perceived clearly and are external. In schizophrenia, voices that talk among themselves, or voices that speak to the subject, are very characteristic.

Disorganized language:

It is very characteristic of people with schizophrenia to lose the thread of the conversation, continually jumping from one topic to another (derailment). Responses are usually tangential and bear no relation to the question asked. It is also frequent for them to invent words or to give inappropriate responses. Sometimes, language is so incoherent that it becomes difficult to understand (word salad).

Severely disorganized or catatonic behavior:

Disorganized behavior can manifest itself in different ways; it may be childlike behavior or uncontrollable psychomotor agitation. In general, they have difficulty finishing actions and, for this reason, present serious problems in their daily life (hygiene, clothing…). We can also encounter catatonic behaviors characterized by a poor or absent response to the environment, such as lack of attention (catatonic stupor) where the subject seems absent, catatonic rigidity (maintaining a rigid posture) or catatonic posturing (strange postures that the person maintains for long periods of time), and many times they refuse to be moved out of the posture (catatonic negativism).

Negative symptoms:

These symptoms are very characteristic of more advanced stages of schizophrenia, what is known as residual, although they can appear at any time. It is important not to confuse them with the side effects of antipsychotic medication. Within this group of symptoms would be affective flattening: they appear unexpressive, with poor eye contact and reduced body language. Alogia or poverty of speech: it is very characteristic, there is a decrease in the fluency and productivity of speech that is closely related to the slowing of thoughts. And finally, avolition or the inability to initiate and finish goal-directed activities; the person may remain seated for long periods of time doing nothing. They have a clear lack of interest and motivation in social or interpersonal activities and no initiative to participate in any kind of activity (reading, walking, going out with friends,…).

Schizophrenia is what has been understood as madness since ancient times. There is little connection with reality and the person seems to be in another, different world. They believe their delusions and many times live embittered by their hallucinations. It is very frequent for the voices to be threatening and insulting and to give orders to the subject. There is a high rate of suicide.

It is very frequent for the family and the person's environment to say that they have always been a strange person, unsociable and uncommunicative (prodromal phase). It is rare to find a person with schizophrenia who, overnight, goes from being a totally normal and well-adjusted person to suffering from psychosis. Normally, a stressful event appears at the onset of the illness (they went off to do military service and went mad, the death of a close relative, etc.). This does not mean it is the cause; it is simply the trigger of a genetic illness that would have appeared sooner or later.

As for severity, the onset of the illness seems to be very relevant: the earlier it appears, the worse the prognosis. Depending on the subtype of schizophrenia, the prognosis will be better or worse, but as a general rule it is chronic, with episodes of exacerbation of the symptoms appearing alongside episodes of remission. It is very uncommon, once the illness has begun, to return to the premorbid state. In addition, each acute phase (appearance of positive symptoms and agitation) causes cognitive deterioration and a worsening of the person's own illness.

Is there treatment for schizophrenia?

It is clear that the treatment of choice is pharmacological; without it, these people could not lead a normal life, and even so, many times they do not achieve it and must remain admitted in institutions.

Psychological treatment has been shown to be very effective in the person's awareness of their symptoms and in the timely detection of an exacerbation, which is very important in order to stop an active phase at its onset and thus avoid deterioration. Therefore, the main objective should be the stabilization of the person's positive symptomatology. Another objective, no less important, is to alleviate the negative symptoms and maintain the activity and motivation of people with schizophrenia.

It also has a psychoeducational function, both so that the person with schizophrenia understands their illness and so that their family and social environment understand it too.

Subtypes of schizophrenia

Within this large diagnostic category, we find different subtypes that are very distinct from one another both in their symptomatology and in their course, onset and prognosis. Let us look at them:

Paranoid Schizophrenia:

It is the least severe of all and usually has a late onset (around the age of 30). Its main characteristic is the predominance of delusional ideas of harm (they want to hurt me), of persecution (they are persecuting me), self-referential (they are talking about me) or of grandeur. These are ideations that are not far removed from reality, that is, they are not bizarre or improbable; although they are not real, they could be (“the neighbor spies on me” could occur in reality). The clinician must assess the degree of certainty of these ideas to determine whether they are delusional or not. Normally, the hallucinations are very related to this ideation, following a specific and coherent theme. They are people who tend to present an air of superiority and vehemence, with a great tendency to argue, and they are very prone to filing complaints. They present little cognitive impairment, they can be violent and they show no deterioration in neuropsychological tests. If they take medication and follow up well, they can come to lead a normal life, but they will always show that tendency to argue and that attitude of constant perspicacity and distrust of others. It is the subtype with the best prognosis.

Disorganized schizophrenia:

It is the one formerly known as hebephrenic and would be situated at the opposite pole from the previous one. It is the most severe; its onset is usually early and insidious. Normally, the person presents an impoverished and strange premorbid personality (they are usually described as isolated, uncommunicative, odd, without social relationships,…). Once the illness begins, remissions are rare. The most characteristic symptoms of this subtype are: disorganized language (derailments, incoherence, use of neologisms -invented words-, ..). It is usually accompanied by incoherent or inappropriate behaviors such as inappropriate laughter or silliness. It is a language that is hard to understand and it is very difficult to follow the thread of a conversation. The disorganization of behavior is usually the most striking thing, because the person is incapable of carrying out daily-life behaviors such as washing, dressing or preparing food. They are unable to initiate goal-directed behaviors and need support in the activities of daily living. If there are delusional ideas, they are totally disorganized and do not follow a coherent theme as happened with the paranoid type. They are strange, poorly elaborated and fragmented ideas. The hallucinations are usually auditory and also appear fragmented, unclear and incoherent. They present a very marked affective flattening, without expressiveness of emotions; they feel neither sad nor happy. Because of its insidious onset, its severity and its disorganization, it is a subtype that is easy to diagnose but difficult to treat. They are people who seem to have little contact with reality and show no interest either in interpersonal relationships or in activities, nor do they show joy at visits from relatives. Their affectivity is inappropriate.

Catatonic schizophrenia:

It is also a severe subtype and very characteristic for its marked psychomotor disturbance. In order to diagnose it, at least two of the following symptoms must appear:

##### Catalepsy:

Motor immobility; the person does not move or shows a waxy flexibility, may spend hours in truly uncomfortable postures without showing any discomfort. If you move the person, they may stay in the new posture for long periods of time; even if you take a cushion away from them, they remain with their head raised as if the cushion were still in its place.

##### Excessive motor activity:

This would be just the opposite, a motor activity without any purpose and lacking meaning. It is not influenced by any external stimulus. It is difficult to restrain the person when they show this activity. It differs from psychomotor agitation, which is very characteristic of schizophrenia, in that the agitation usually responds to some external stimulus (anger, conflict, decompensation,..), has a purpose (which may be aggression) and you can physically restrain it.

##### Extreme negativism or mutism:

The person does not obey any order or refuses to be moved out of a posture, maintaining a rigid posture despite attempts to be moved. Mutism is the refusal to speak.

##### Strange voluntary movements:

Such as mannerisms, strange and uncomfortable postures, stereotyped movements, striking grimaces,…

##### Echolalia / Echopraxia:

Which is the repetition of phrases or words and/or echopraxia, which is the repetition of another person's behaviors. They imitate and constantly repeat what the other person does or says.

It is a severe and disabling subtype, but it is becoming less and less frequent. It has been found that over the years this type of schizophrenia has been declining, and it is thought that it may disappear over time.

Undifferentiated schizophrenia:

This subtype is a catch-all, where we would include those disorders that meet the criteria for schizophrenia (delusional ideas, hallucinations, disorganized behavior, negative symptoms,…) but which cannot be classified into any of the previous subtypes. It meets the criteria neither for the paranoid, nor the disorganized, nor the catatonic type.

Residual schizophrenia:

This subtype is diagnosed when the symptoms the person presents are negative (affective flattening, poverty of language, avolition…) but in the current picture there is no active symptomatology (delusions, hallucinations) or, if there is, it is very attenuated, and usually strange behavior, disorganized language or odd beliefs persist. The only requirement is to have had at least one episode with clear active and positive symptomatology, that is, there must have been an acute exacerbation of the symptoms. This type usually occurs in the period that goes from one active episode to another, or it may appear after several exacerbations and become chronic in this type with a predominance of negative symptoms; it would be like the residual symptoms after an active episode. Many patients with other subtypes of schizophrenia, over the years, are usually diagnosed with this subtype: they achieve a stabilization of their positive symptoms but the negative ones persist and become chronic.

References

• American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).
• MedlinePlus. Schizophrenia. U.S. National Library of Medicine. medlineplus.gov

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