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Most
of the educated peopie who read newspapers, magazines and
watch scientific programmes on T.V. are aware of schizophrenia
as a major mental disorder, formerly known as insanity,
because of the unusual, queer and eccentric behaviour of
the patient and because it appears out of this world. Such
patients are branded as 'mad' and are rebuked and ridiculed
by uncultured people. This pushes such unfortunate victims
of severe mental disorder deeper into the process of desocialisation,
which later affects the patient's social rehabilitation
after treatment.
It is
therefore absolutely necessary for the guardians of psychiatric
patients and responsible people in general to know what
really is meant by schizophrenia. Is it incurable? Should
such patients be treated as outcasts, like 'lepers' who
were ostracised in the last century or like AIDS patients
who are condemned these days! Family members of such mental
patients suffer not only from the patient's behaviour and
the uphill task of giving him regular treatment but also
from the prejudiced community by way of a near boycott.
Schizophrenia,
though a difficult mental disorder to cure, is quite treatable
by easily available modern treatment methods. Most of such
patients improve sufficiently enough to return to their
original position in the society.
The
concept of schizophrenia is still not definite even in scientific
circles. Its definition differs from country to country
and has therefore become a very controversial issue; though
there is some agreement about its causes, symptoms, course
and treatment.
Historical
Overview of the Concept
The very first reference to a severe mental disorder was
made in Ayurveda as early as in 1400 B.C. However, in modern
times the earliest description of schizophrenia as illness
was made in late 18th century. The first scientific description
of such an illness was made by Morel in 1856. He called
it "Demenca Precocie". He mentioned negative symptoms
(social withdrawal and inactivity) and ultimate deterioration
of personality in adolescents.
Kahlbaum
(1868) described 'katatonie', equivalent to 'catatonia'
(with rigid postures, mutism and impulsivity). Soon afterwards
Hecker (1871) described 'Hebephrene' equivalent to Hebephrenia
of today, with oddities in speech and conduct.
The
first valid description of schizophrenia, as it is understood
today, was made by E-Kraepelin in Germany in 1896 calling
it 'Dementia Praecox, meaning premature intellectual deterioration.
He classified major mental disorders into two main groups,
viz, Manic Depressive Insanity and Dementia Praecox. He
incorporated the diseases described by Kahlbaum (Katatonie)
and Hecker (Hebephrenie) as the types of Dementia Praecox.
He also added another type of his own, viz. Dementia Paranoidies
(equivalent to Paranoid Schizophrenia). He speculated that
this was a brain disorder of unknown pathology, causing
intellectual deterioration after some years. This was earlier
suggested by Griesinger in 1845. Most of the psychiatrists
in Europe, UK and USA could not accept this classification
because of its poorly known etiology and pathology. Bleuler,
a Swiss psychiatrist, developed Kraepelin's concept of Dementia
Praecox and called it 'schizophrenia' in 1911 for the first
time. He emphasized its psychogenic origin. Hence the Latin
term for "split mind". He was influenced by the
theories of Sigmund Freud, the father of psychoanalysis
and stated that the disease meant 'loosening of associations'
between the different mechanisms of the mind. He named the
main symptoms of schizophrenia as 'Fundamental symptoms'
which were later described as "Four A's". They
were: 1. Loosening of Associations, 2. Blunting and Incongruity
of the emotional apparatus of "Affect", 3. Autism
(shutting off from the social environment and blocking of
communication), 4. Ambivalence (love and hate relationship
with parents). Other symptoms of hallucinations (perception
in the absence of sensation), delusions (false and firm
beliefs) were called accessory phenomena of lesser importance.
He also added 'simple schizophrenia' to the three types
viz. Hebephrenic Catatonic and Paranoid, as described by
Kraepelin, to constitute one disease entity of schizophrenia.
These ideas were widely accepted in the USA because of the
Psychoanalytical bias there.
As the
boundaries of Bleuler's schizophrenia were loose, many other
syndromes having such symptoms were diagnosed as schizophrenia
in the USA, whereas Kraepelin's concept was accepted and
followed more in U.K. and Europe, with the result that the
number of cases diagnosed as schizophrenia were much lesser
in UK than in USA.
In 1960
Langfeldt differentiated Schizophrenia from Schizophrenieform
psychosis to explain the variability and inconsistency of
these disorders. He found that, ECT and Insulin Therapy
(prevailing then; now out of vogue) were ineffective in
true schizophrenia. The latter was called Process Schizophrenia.
Elgin,
Phillips and Kantor devised rating scales to differentiate
between Process (True) and Non-Process Schizophrenia on
the basis of premorbid personality and psychosocial adjustment.
Poor prognosis was stated as the feature distinguishing
Process schizophrenia from Non-Process Schizophrenia. The
former was hereditary and endogenous, whereas the latter
was psychogenic and exogenous. Kraepelin believed that schizophrenia
was endogenous and hereditary with prevalence of hallucinations
and delusions, poor prognosis. They ultimately became chronic
and true symptoms of dementia followed later. This was found
to be the result of herding together of chronic patients
with patients of good prognosis in mental hospitals.
K. Schneider
(1959) propounded a new concept of schizophrenia and described
first rank symptoms viz, auditory hallucinations and insertion
of undesirable thoughts by other persons (due to loss of
Ego Boundaries), thought broadcasting (thoughts shared by
others), and delusional misinterpretation of real perception.
His second rank symptoms were perplexity, emotional blunting,
other kinds of (nonauditory) hallucination and delusions.
In the
sixties and early seventies, there were different concepts
of schizophrenia all over the world, thus lacking in a standard
definition of schizophrenia. So in 1973, WHO organised a
project of "International" study of schizophrenia
in Colombia, Czechoslovakia, Denmark, India, Nigeria, Taiwan,
UK, USA and USSR.
The
last two countries had a broader concept of schizophrenia
resulting in it's over diagnosis. Subsequently, tendency
to diagnose on the basis of symptoms and its course became
rudimentary because etiology was neither clear nor confirmed.
Different
countries followed different definitions of schizophrenia,
and duration and mode of onset were considered to be better.
Diagnostic aids than the symptoms of acute illness. Now
it is almost agreed by various defining institutions that
duration of symptoms must be at least for one month.
At present,
the most widely used definitions of schizophrenia, at least
for research purposes, are the St. Louis Criteria (Feighner
eta11972), the Research Diagnostic Criteria (RDC) (Spitzev
etal 1975) and the American Psychiatric Association's DSM
IV (1994) Criteria as well as W.H.O's lCD 10 Criteria (1992).
They
all require clear evidence of psychosis at present or in
the past and all but the Feighner Criteria specify particular
kinds of hallucinatory experiences or delusional ideation.
All the four stipulated that affective symptoms must not
be prominent and all require a minimum duration of illness.
(Only 2 weeks for RDC definition), 1 month for lCD and 6
months for Feighner. All definitions are arbitrary, justified
only by their usefulness. They are liable to be altered
or supplemented.
Though
schizophrenia and its types are discussed as a single disease,
it probably comprises a group of disorders with heterogeneous
causes, and definitely includes patients whose clinical
picture, treatment responses and defined causes of illness
are varied.
Mayergrom
defined schizophrenia as a group of mental illnesses characterised
by specific psychological symptoms and, in the majority
of cases, leading to a disorganisation of the patient's
personality.
Some of the recent etiological themes are -
1) Dopamine hypofunction in mesofrontal areas of the brain
are associated with manifestations of negative symptoms.
2) There is Computer Tomographic evidence of cerebral atrophy,
enlarged ventricles causing extensive cognitive impairment
in schizophrenia with negative symptoms which are often
unresponsive to neuroleptic treatment.
What
schizophrenia should mean to ordinary folks?
After this explanation of the scientific concepts and definition
of schizophrenia I have to write about what schizophrenia
should mean to ordinary people especially parents and close
relatives or friends of persons diagnosed to be afflicted
with schizophrenia.Unfortunately, even today schizophrenia
is regarded with great prejudice, abhorrence and apprehension
just like leprosy in the last century and AIDS in recent
years.
Whereas
we all must understand the implications of such a diagnosis
in adolescents and young adults and take prompt therapeutic
measures, it is equally important that we show a realistic
and healthy attitude of sympathy, courage as well as determination
to do everything possible to help doctors to bring the patient
out of the snake pit as early as possible. The patient as
well as his guardians should remember that there is a possibility
that the diagnosis is incorrect. Fears of incurability are
exaggerated by rumors and hearsay.
Indian
research has identified a disorder named Acute Psychotic
Disorder which is often mistaken for acute schizophrenia
(Wig & Singh, ICMR). The lCD classification also contains
another disorder named Acute and Transient psychotic disorder
which also could be mistaken for schizophrenia. Both the
above stated disorders have much better prognosis than schizophrenia.
My own
experiences of over a long period of 50 years are more encouraging.
About 25% of the patients treated for schizophrenia recover
and stay well for long periods after recovery. Another 30%
get short attacks at longer intervals but recover enough
to return to their occupation and family life. Only about
20% do not recover adequately and have to be kept under
psychiatric observation and treatment over a long period.
They may not be fit to return to their family or society.
About 10% of patients become chronically ill.
Recent
addition of atypical antipsychotic drugs to psychiatrist's
repertoire has raised the hope of continuous and prolonged
medication even for chronic patients without significant
side effects. The demented schizophrenia patients seen by
Kraepelin were desocialised, rejected or untreated patients
of old style mental hospitals, when there were no antipsychotics
at all. However he later did admit that 15% of all his patients
recovered fully.
I have
treated scores of chronic patients who later continued in
their jobs till retirement, of course with the sympathetic
help of colleagues and superiors. Some have helped their
close relative to run small shops or trades over a long
period.
One
could compare schizophrenia patients with those of diabetes,
hypertension, bronchial asthma, which also run a very long
course in spite of regular treatment perhaps even for a
lifetime. They are also not 'curable'. Often such chronic
physically ill persons are a burden to the family and perhaps
to the society.
Yet
they are not rejected like the persons afflicted with schizophrenia.
The prejudice of the people is often based on superstitious
beliefs that the person is possessed by evil spirits and
should be avoided. Few of such prejudiced people realise
that they can also act almost like the patients they reject
when they lose control due to the influence of extreme joy
or anger or under the effect of alcohol or a religious trance.
In short, persons afflicted with schizophrenia under treatment
are in no way much different from those who are physically
ill over a long period. Their relatives must have hope of
cure and show courage and determination to give their unfortunate
relatives best chance for recovery and for returning to
family life.
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