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Schizophrenia is a chronic and disabling mental disorder. The main characteristics of the disease include cognitive impairment, which leads to deteriorating quality of life in professional and social spheres. The disintegration of the personality and loss of cognitive ability are an especially difficult challenge for both the patient and his or her family. The cases of schizophrenia are found throughout the world in all cultures and eras, regardless of family type and level of education. The onset of the disease usually occurs between the ages of 15 and 30 (Brichford, 2012). The disease affects men and women with equal frequency. Increased risk of suicide and the health problems cause the low life expectancy, which is 10-12 years less than in people without schizophrenia (Brichford, 2012). Thus, schizophrenia is a serious social and medical issue accompanied with severe intellectual, behavioral, and emotional disorders.
Signs and Symptoms
In some people, schizophrenia develops suddenly, without any anxiety symptoms. However, most often, the first signs of the disorder appear gradually along with anxious signs. Friends and relatives of people with schizophrenia usually say that they saw something wrong with a person is happening, but they did not know what it could be. At this early stage, people with schizophrenia often seem eccentric, unmotivated, devoid of emotions, and mysterious. They isolate themselves from society, begin to neglect their appearance, say strange things, and demonstrate a general indifference to life. They can give up their favorite hobbies, and their productivity at work or at school deteriorates sharply. The most frequent first signs of schizophrenia include social self-isolation; hostility or suspicion; deterioration of personal hygiene; blank look; inability to cry or express joy; crying or laughing without an evident reason; depression; excessive drowsiness or insomnia; inconsistent or irrational speech; forgetfulness and disorganization; a strong reaction to criticism; and use of strange or non-existent words. There are also five types of symptoms characteristic of schizophrenia. According to the DSM-5, schizophrenia is “the prototypical psychotic disorder that involves delusions, hallucinations, disorganized thinking and speech, grossly disorganized or catatonic behavior, and negative symptoms” (DSM-5). Nevertheless, the signs and symptoms of schizophrenia vary considerably from person to person, like the overall course and degree of the disorder. Not every person with schizophrenia will have all the above-mentioned symptoms, and they may change over time.
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Pathophysiology of the disorder is unknown. However, there are several hypotheses that try to adequately explain the pathophysiological mechanisms of schizophrenia. Abnormalities in the formation of the nervous system and degenerative changes in the brain are the most likely causes of the disorder. The nervous system abnormalities lie in the incorrect formation of contacts between nerve cells and the impairment of neuronal migration during intrauterine development and the first months of life (Van Haren et al., 2008). Nerve cells that did not occupy a proper place in the brain and did not establish the necessary contacts with other cells, eventually, in the years of growing up, affect the work of the nervous system (Van Haren et al., 2008). The brain development also involves the death of certain neurons (Van Haren et al., 2008). The death of the wrong cells also leads to a disruption of the nervous system (Van Haren et al., 2008). Thus, the nervous system abnormalities may be the pathophysiological mechanism of schizophrenia.
The basis of schizophrenia may include another physiological mechanism. Actually, these two mechanisms can complement each other. This is about premature degenerative processes in the brain (Van Haren et al., 2008). The premature death of nerve cells can explain the irreversibility of changes in schizophrenia (Van Haren et al., 2008). There is a theory of toxic excitation, which connects the death of neurons with excessive excitation, mainly glutamatergic one (Van Haren et al., 2008). The mechanism of toxic excitation is triggered by certain factors provoking the excessive release of glutamic acid. Irreversible changes occur in postsynaptic neurons and lead to death as a result of excessive excitation of those neurons (Van Haren et al., 2008). If this theory succeeds in making practical conclusions, it would be possible to formulate a fundamentally new approach to the treatment of schizophrenia.
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Genetic and Environment Factors
The causes of schizophrenia are unknown. However, the disorder is often the result of the crossover of genetic factors and environment factors. Schizophrenia is closely related to genetics. First-degree relatives have a 10% chance of developing this disorder while the total Earth population has only 1% risk (Iritani, 2015). Nevertheless, the schizophrenia development is influenced not only by genetic factors. Schizophrenia is common in the family, but about 60% of schizophrenia patients do not have family members affected by this disorder (Iritani, 2015). Moreover, people, who seem to be more genetically prone to developing schizophrenia, do not always suffer from this disease, so it can be assumed that biological factors are also important. Studies have shown that the development of schizophrenia is often associated with stress (Iritani, 2015). A high level of stress can cause schizophrenia through the production of cortisol, which is a steroid hormone (Iritani, 2015). The study points to several stress factors which are caused by the environment and can be involved in the development of schizophrenia (Iritani, 2015). The factors include perinatal effects of viral infection; low oxygen levels during labor, namely prolonged or premature labor; contact with a virus during infancy; early loss of parents or separation from the family; physical or sexual abuse in childhood (Iritani, 2015). Thus, despite the fact that the exact cause of schizophrenia remains unknown, genetic factors and environment factors may contribute to the development of the disorder.
Typical Patient Initial Presentation
Intellectual and emotional disorders are characteristic of a typical patient suffering from schizophrenia. The patient can be talkative and can take bizarre poses. His or her behavior can be sometimes hostile so that he or she uses violence due the effect of hallucinations. The majority of patients often have moderately expressed social communication disorder, egocentricity, an impairment of spontaneous speech or movements, and the absence of purposeful behavior (Lauriello, J., & Pallanti, 2012). Other pathological manifestations observed in these patients include strange clumsy movements or stiffness of body movements, and failure to comply with accepted social norms of behavior, including refusal to bathe, fecal smearing, and echopraxia. The patient can experience a jubilant feeling of omnipotence, religious ecstasy, fear of his soul being separated from the body, or extreme anxiety about the destruction of the universe (Lauriello, J., & Pallanti, 2012). Other feelings include confusion, unreasonable fear, a feeling of isolation from others, and ambivalence. Auditory hallucinations are most common for patients with schizophrenia. Patients complain that they hear one or more voices that frighten them, call them indecent words, and accuse or insult them (Lauriello, J., & Pallanti, 2012). Visual hallucinations are less common. Sometimes tactile, olfactory or gustatory hallucinations take place, but in this case, a physician should examine the patient as carefully as possible to exclude organic brain disease (Lauriello, J., & Pallanti, 2012). Also, patients with schizophrenia may experience a feeling that some organs of the body are damaged without indicating any real cause, for example, the patient may feel like his brain is burning.
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A typical patient with schizophrenia may also have thought disorder. Delirium is a disorder more definitely associated with an impairment of the content of thinking. Delusions in schizophrenia can be very diverse, including persecution, grandiosity, religious or somatic delusions. The patient sometimes believes that some creature from outside influences his thoughts or behavior, or, on the contrary, that he himself controls external events in some bizarre way (Gaebel, 2011). For example, the patient may believe that he makes the sun to rise or set, or that he prevents earthquakes. The patient can be passionately and completely obsessed with abstract, symbolic, psychological or philosophical ideas that only he understands. The patient may experience a loss of ego boundaries (Gaebel, 2011). This term describes the patient’s absence of a distinct sense of where his own body and mind begins and where they end, and where is all this in other animate and inanimate objects (Gaebel, 2011). For example, a patient feels that other people, television programs, or newspapers have something to do with him. Sometimes the patient feels that he is merging with external objects, for example, with a tree or other person. Though disorder can be objectively diagnosed on the basis of oral and written speech of the patient. These disorders include inadequate associations, incoherence, tangentiality, circumstantiality, neologisms, echolalia, verbigeration, and mutism (Gaebel, 2011). Finally, a typical patient suffering from schizophrenia may be in a state of agitation, so his behavior may be sometimes impulsive. The patient often disregards the accepted norms of behavior in society, for example, he can grab cigarettes belonging to another patient, suddenly switch the television program, or throw food on the floor (Gaebel, 2011). A part of impulsive actions, including attempts aimed at committing suicide and homicide, are due to imperative hallucinations that cause the patient to act in accordance with them. Thus, the behavior of a typical patient with schizophrenia includes a range of impairments in the intellectual, behavioral, and emotional sphere.
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Treatment and Medications
The treatment of schizophrenia has two main phases. The first phase is the acute phase, when large doses of medication may be needed to treat psychotic symptoms. The phase is followed by a support phase that can last a lifetime. During the support phase, the dosage is gradually reduced to the minimum necessary to prevent future schizophrenic episodes. If symptoms return with a small dose, a temporary increase in dose may help prevent a relapse. The best medications to use in the treatment of schizophrenia are antipsychotics. Antipsychotic drugs, also known as neuroleptics, have proven to be effective in treating acute psychoses and reducing the risk of psychotic episodes in the future (Mueser & Jeste, 2011). The atypical antipsychotics are the most recommended antipsychotics in treating schizophrenia since they received regulatory approval of federal health agencies in many countries. One of the antipsychotics used in treating schizophrenia is clozapine. Its use is not associated with extrapyramidal side effects, but it has other side effects, including a possible reduction in the number of white blood cells, so it is necessary to monitor the blood every week for the first six months of treatment and every two weeks thereafter to quickly detect this side effect if it occurs (Mueser & Jeste, 2011). Other atypical antipsychotics are risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole. Despite their greater efficacy and tolerability, the use of these medications is also associated with the side effects. Most of these medications need 2-4 weeks to have some positive effect (Mueser & Jeste, 2011). Thus, antipsychotics are the best medications to treat schizophrenia.
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It is important that patients with schizophrenia follow the treatment plan developed with their doctors and families due to the fact that the risk of recurrence increases if neuroleptics are taken irregularly or out of time. The treatment plan includes taking prescribed medicines in the right doses and at the recommended time, making regular medical appointments, and following other recommendations (Sadock, Kaplan, & Sadock, 2015). It is important to mention that patients with schizophrenia often do not believe that they are sick or that they need treatment (Sadock, Kaplan, & Sadock, 2015). Other possible things that can interfere with the implementation of the treatment plan are the side effects of medications, the abuse of alcohol or drugs, a negative family’s or friends’ attitude toward treating, or even unrealistic expectations. If any of this hinders the treatment, it is necessary to recognize and solve these issues in order to ensure a successful recovery.
Schizophrenia leads to severe health problems associated with emotional blunting, intellectual deterioration, social isolation, and disorganized speech and behavior. Signs and symptoms of schizophrenia vary depending on the individual. In general, they include hallucinations, obsessions, chaotic thinking, lack of ambition or emotional responsiveness, depression, anxiety, and other cognitive impairments. Pharmacological intervention includes the antipsychotic medicines, which mainly provide the control of the psychotic episodes. The important risk factors for the disease are the genetic predisposition, living conditions in early childhood, neurobiological disorders, and psychological and social interactions.
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