ĐĎॹá>ţ˙ ]_ţ˙˙˙\˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁ@ đż04bjbjîFîF .NŒ,Œ,0,˙˙˙˙˙˙ˆ2222222F.,.,.,.,J,DF\3śš,š,š,š,š,š,š,š,Ű2Ý2Ý2Ý2Ý2Ý2Ý2$4Rd6†32‡-š,š,‡-‡-322š,š,3ő/ő/ő/‡-Ę2š,2š,Ű2ő/‡-Ű2ő/ő/30|22ż2š,Ž, ĐŐxĄÝęĹ.,Q.ŽŻ2Ű2,30\3ˇ2ę6ß. ę6ż2FF2222ę62ż2š,"ź,ő/Ô,č,Ÿš,š,š,33FFÄ $ë/ FF Schizophrenia - Signs and symptoms Man is split. His life is full of contradictions. He clings desperately to the things he knows, hoping they are the right thing to do. Every day choices have to be made between good or bad, dark or light, love or hate. Sometimes the choices are not that easy to distinguish and it gets more and more difficult to figure out which is which. This creates a lot of stress and sometimes utter despair. It takes a lot of courage to loosen the grip and dive into the unknown. That too is risky, you never know where the current may take you Schizophrenia Definition A severe mental illness of unknown cause characterized by the presence of hallucinations, delusions, disordered thought, and problems with feelings, behaviour, motivation, and speech. Incidence 1-2 per 10,000 population / year. Male = Female (affected men tend to develop schizophrenia 3-4 years earlier than women.) Peak age of onset: (late teens - early twenties for men, later twenties for women. Women have a second peak in incidence in their late forties.) (Jablensky et al, 1992; Stefan et al, 2002) Risk Factors Genetic and environmental Having an affected relative Half of all monozygotic twins of an individual with schizophrenia also develop the illness so other factors must also have a triggering role. A 'stress-vulnerability' model has been proposed to explain why there are so many different triggers, and so many different rates of relapse and remission Acute presentation Delusions and hallucinations, and occasionally disturbances of thought, such as paranoia and thought insertion. (often referred to as positive symptoms - American Psychiatric Association, 2000). Chronic schizophrenia Acute episodes are usually followed by a more chronic illness with: lack of interest in social interactions reduced motivation reduced emotions reduced speech (often referred to as negative symptoms - Stefan et al, 2002). Prodomal period 1 May be long with ill-defined, insidious, and non specific symptoms and a gradual deterioration in personal functions: peculiar or uncharacteristic behaviour, poor communication, unusual ideation, social withdrawal, poor personal hygiene, and reduced interest and motivation (National Collaborating Centre for Mental Health, 2003). Prodomal period 2 Many people present with these types of symptoms, most do not go on to develop schizophrenia! Prodomal period 3 The minority develop schizophrenia, some have 'attenuated' positive symptoms first: mild thought disorders ideas of reference suspiciousness odd beliefs perceptual distortion (Attenuated positive symptoms are milder than those seen in established schizophrenia - National Collaborating Centre for Mental Health, 2003) Early environmental risk factors People with schizophrenia before 25 years of age are 2x as likely to have had complications at birth as the general population. Schizophrenia more common in those born in late winter and early spring. Children who later go on to develop schizophrenia show early motor, language, and cognitive abnormalities compared with peers or siblings. Only a small number of all the children with developmental abnormalities will later develop schizophrenia. Later environmental risk factors Heavy cannabis users 6x more likely to develop schizophrenia than non-users. Many drugs of abuse, such as amphetamines, cocaine, ketamine, and lysergic acid diethylamide (LSD), can induce an acute schizophrenia-like illness. Adverse life events can contribute to schizophrenia (although to a smaller extent than in depression). All kinds of life events appear to be important, not just those involving loss. Immigrants from other countries show an increased rate of schizophrenia compared with both the population they left, and the UK population, e.g.the incidence of schizophrenia is 2-3x higher in Afro-Caribbean immigrants. Impact of the new environment, social isolation, and alienation are probably the crucial factors. Positive symptoms Positive symptoms reflect the presence of an abnormal mental process. Hallucinations, delusions, and thought disorders are positive symptoms. Hallucinations Hallucinations are false perceptions that occur in the absence of a real external stimulus [Stefan et al, 2002]. They are perceived to be real by the person with schizophrenia. Many people with schizophrenia experience auditory hallucinations. Voices are the most common. Can be muttering voices or clear conversations. Some experience voices that provide a running commentary on their actions, argue about the person, or repeat their thoughts. Others hear whistling, or machinery sounds. Hearing voices is a real experience, and may be due to a disorder of inner speech (thinking in words). Visual, smell, taste, or tactile hallucinations can also occur. Visual hallucinations occur in about 10% of people with schizophrenia, but organic disorders should be excluded. Olfactory hallucinations are more common in temporal lobe epilepsy than in schizophrenia. Delusions A delusion is a fixed, false, personal belief held with absolute conviction despite evidence to the contrary [Stefan et al, 2002]. Some have delusions that do not seem to be connected with any previous events or experiences (primary delusions). e.g. 'I woke up and knew that my daughter was the spawn of Satan and should die so that my son could be the new Messiah.' Others have delusions that relate to their hallucinations (secondary delusions) and try to make sense of what they are experiencing. e.g. 'voices' may be thought to come from the television, or they could be thought to be magic, or given a religious explanation. Delusions can take many forms: persecutory, controlling, telepathic, grandiose, religious, science-fiction, paranormal, or somatic. Some have delusions about infidelity (their partner is always being unfaithful); doubles (a person known to them - often their spouse - has been replaced by someone else); or infatuation (another person is in love with them). Disorders of thought possession Thought insertion is the belief that the thoughts in their head are not their own, and that they are being put there by an outside agency. Thought withdrawal occurs when someone believes that thoughts are being removed from their mind by an outside agency. Thought broadcasting occurs when they believe that their thoughts are being 'read' or 'heard' by others. Thought blocking involves a sudden interruption of the train of thought before it is completed, leaving a blank. The person suddenly stops talking and cannot recall what they were saying. Other thought disorders Thought echo is when they their own thoughts as if they were being spoken aloud. Disordered forms of thought can make speech incoherent, and it may not seem to follow a logical sequence. 'Knight's-move thinking' is when they move from one train of thought to another that has no apparent connection to the first. Some may invent new words (neologisms), repeat a single word or phrase out of context (verbal stereotypy), or use ordinary words with a different, special meaning (metonyms) [Stefan et al, 2002]. Negative symptoms 1 Negative symptoms reflect the reduction or absence of a mental function that is normally present. They are much less dramatic than positive symptoms, but tend to be more persistent, and are harder to treat. They are the most important cause of long-term disability. Negative symptoms 2 People with negative symptoms may: Talk less spontaneously (poverty of speech) Express and/or experience less emotion (flattening of affect) Have less energy, drive, and interest (avolition-apathy) Become less able to concentrate (attentional impairment) Become indifferent to social contact (anhedonia-asociality) Be happy to stay up all night and sleep all day Have abnormal body language Over ˝ of all people with schizophrenia have a degree of negative symptoms, these may be primary symptoms, or secondary to florid positive symptoms, or adverse effects of medication. Often families only realize with hindsight that their relative's behaviour has changed subtly over a period. Recognizing this can be difficult if the illness develops in teenagers, when it is quite normal for changes in behaviour to occur. Secondary symptoms It is important to remember that the secondary symptoms accompanying schizophrenia, such as depression and demoralization, may in themselves be disabling. Concurrent depression increases the risk of suicide in people with schizophrenia [Tandon and Jibson, 2003]. The reaction of the family members and friends will also have some impact, if through misunderstanding they think that their relative is fantasizing, seeking attention, or simply lying. Other functional disorders Schizo-affective disorder: where both schizophrenia and affective symptoms (depression or mania) develop together, even if the symptoms of schizophrenia would be severe enough on their own to warrant a diagnosis of schizophrenia. Schizotypal disorder: with eccentric behaviour, unusual thinking, and disturbed affect, features resembling those seen in schizophrenia, although no definite and characteristic symptoms of schizophrenia have occurred. Dual diagnosis: with both symptoms of schizophrenia and a drug or alcohol misuse problem. Persistent delusional disorders Acute and transient psychotic disorders Depression with psychotic symptoms Mania Organic disorders Misuse of alcohol or illicit drugs e.g. amphetamines, cocaine, ketamine, and lysergic acid diethylamide (LSD) Epilepsy, particularly temporal lobe epilepsy Stroke Early dementia Brain tumour Brain damage, following head injury or surgery Endocrine causes e.g. Cushing's disease, rarely thyroid disorders Central nervous system infections e.g. encephalitis, meningitis, neurosyphilis [WHO, 1992; Stefan et al, 2002; Rethink, 2003b] Prognosis 1 Biggest functional decline in first 5-10 yrs, often there are several exacerbations of positive symptoms, followed by a more stable phase. 2/3 experience an episodic illness. No. of episodes, and extent of recovery in between, variable One episode - complete recovery Occasional episodes - complete recovery in between Occasional episodes - never recover fully in between 1/3 experience more continuous illness, never symptom free, severity of symptoms fluctuates. (Mason et al, 1996; Stefan et al, 2002) Prognosis 2 Approximately: 20% who are admitted to hospital for their first episode of schizophrenia do not have another acute episode, and about 25% have no further admissions [Mason et al, 1996]. 50% with schizophrenia treated in standard services will relapse and require re-admission within the first two years of their illness [Mason et al, 1996]. 30% experience a more continuous illness, where they are never free of symptoms, although the severity of symptoms changes over time. 20% remain completely resistant to drug treatment, including clozapine. 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