How is schizophrenia a disease?
Like high blood pressure or stomach ulcers, schizophrenia is a disease, a common disease. In general, schizophrenia affects about one in a hundred people, which means that the prevalence rate is about 1%. In schizophrenia, there are serious problems with brain function, but we don’t know exactly what changes occur, except in general terms.
We know that in the human brain, there are more than 10 billion brain cells. Each brain cell has many branches, and so many brain cells are interconnected by these branches. From the end of the last brain cell branch, something is released, called ‘neurotransmitters’. In layman’s terms, they can be compared to a postman, responsible for passing information to the next brain cell’s ‘mailbox’, or ‘receptor’. In this way, a complex network of information is formed between more than 10 billion brain cells by postmen and mailboxes.
Under normal circumstances, the postmen and mailboxes between brain cells work well together, that is, there are no errors in the transmission of information between neurotransmitters and receptors, and mental activity is normal. With schizophrenia, there may be too many of a certain neurotransmitter, or there may be a problem with their quality; let’s say there are too many postmen, or they are incompetent, and they deliver the mail in a messy way, and deliver the wrong mail. When there is too much information and too much chaos, the mind is not normal, and they show all kinds of psychotic symptoms. The medications currently used to treat schizophrenia symptoms do not treat the root of the disease, but rather act pharmacologically like a ‘lid’ on these mailboxes, thereby blocking the transmission of too much disorganized information and thus restoring normal mental function.
It seems that schizophrenia is a pathological change in the human brain, and it is the same disease as hypertension, pneumonia, or stomach ulcers, not a problem with the mind, style, quality or personality of the patient suffering from schizophrenia, so they should not be discriminated against. We believe that with the progress of science, sooner or later the root cause of its onset will be found, and by that time, it will be completely cured.
What are the symptoms of schizophrenia?
The first symptom is “lack of self-awareness and denial of illness”.
According to a survey, about 97% of people with schizophrenia, especially during acute episodes, do not admit that they have a mental disorder. Generally speaking, people who have abnormal mental states, such as anxiety, worry, depression, fear, insomnia, etc., are self-aware and realize that their current state of mind and behavior is different from before and from others, so they ask for help and treatment. In contrast, people with schizophrenia often lack self-awareness and simply do not recognize that they are not normal. Therefore, if a person shows signs of mental disorder, but denies it and refuses to seek treatment, this is evidence that he or she is suffering from schizophrenia.
The second type of symptom is “psychotic symptoms”.
The so-called psychotic symptoms are characterized by detachment from reality and the creation of something out of nothing. There are three main types of psychotic symptoms: hallucinations, delusions, and bizarre behavior.
Hallucinations are perceptions that are created out of nothing. The patient may hear a voice scolding him when no one is actually speaking (i.e., ‘hallucination’), or ordering him to do something, or hearing some speech commenting on his current behavior, or hearing a voice talking about something when he thinks of it (called ‘thinking voice ‘). Some patients may see ghosts and gods out of nothing, or smell something special, which can be called ‘hallucinations’ and ‘phantom smells’ respectively. Some patients taste strange flavors from food or drinks, some feel their body shape change, feel their head become smaller, legs become shorter, etc., which can be called ‘phantom taste’ and ‘somatic hallucination’ respectively.
Delusion is a pathological false belief. It is characterized by 1) having no basis in fact at all, 2) being incompatible with the patient’s religious beliefs or cultural background, and 3) yet the patient is convinced of it. Some patients feel that he himself or his relatives are being persecuted, that someone is constantly following him and spying on him, that the room is bugged, that poison is being put into food and water; these are all delusions of victimization. Some believe that they are not born of their biological parents and absurdly claim to be the descendants of foreigners, which can be called delusions of non-ancestry. Some think they are leaders and rich people, which is called exaggerated delusion. Some feel that some apparatus or airwaves are controlling his thoughts or actions, which is called the sense of being controlled. Some feel that their thoughts are being broadcast so that everyone knows what they are thinking, called a sense of being inspected.
Patients with schizophrenia may also engage in a variety of actions and behaviors that are incongruent with the environment and situation, making others feel ridiculous, peculiar, or incomprehensible, called bizarre behavior. Some patients may make a lot of noise for no apparent reason, hurt people or destroy things out of the blue, or jump off a building or into a river when they are not depressed. Some patients do not say a word all day and night; some even refuse to eat …… some patients will lie down all day, do not eat, do not move, do not speak, like a wooden sculpture, called the state of wood stiffness.
The third symptom is “thinking disorder”
Because the transmission of information between brain cells is impaired, patients with schizophrenia may have problems with their thinking, including associative processes or reasoning logic. They may speak in a way that is not connected to what they are saying, or they may speak in a way that is so fragmented and incoherent that no one can understand them. Depending on the degree, the symptoms can be subdivided into: lax thinking, scattered thinking, and incoherent thinking (a mixture of words). For example, a patient refuses to eat and says “white represents reactionary, so you can’t eat white rice, you have to eat red rice”; and another patient Another patient refused to eat apples, saying that he would “die of illness” if he ate them. These are all disorders in the form of thinking. In addition, there are some patients who spend all day in fantasy thinking, he thinks it is a new theory or invention, but in fact is ridiculous nonsense, can be called ‘solitary thinking’.
The fourth symptom is “emotional indifference and reduced will”.
The longer the disease lasts, the more serious the emotional indifference becomes. They are indifferent to things that are of immediate interest to them, and take an indifferent attitude. Their faces lack expression, their voices are flat, and they are very cold to their loved ones, hence the term ’emotional indifference’. Some patients do not have a happy expression when they encounter good things, and they smile on occasions when they should be sad, which can be called ’emotional discomfort’. They tend to give little thought to their personal studies, work, life, marriage and future, and are satiated and unmotivated, which is called ‘hypoactive will’.
Why do you get schizophrenia?
The key, the main cause of schizophrenia is endogenous, that is, he has the pathological gene for schizophrenia. People who have this gene are prone to schizophrenia. The so-called psychological stress or shock is only the causative factor; for the onset of schizophrenia, the causative factor is dispensable. If your loved one has schizophrenia and you go to the trouble of finding these triggers, it is a waste of effort. If the trigger is falling out of love and schizophrenia develops, even if she gets married quickly, she will not get better. With schizophrenia, no matter how you try to ‘untie the knot’, you will not be able to cure the disease. Because these are only the triggers. Just like lighting a firecracker with a lighter, even if the lighter is thrown away, the firecracker will still explode in the air. Therefore, we say that the internal causes must be addressed, and the internal causes of the onset of schizophrenia must be addressed with medication or other methods in order for the disease to get better.
As mentioned earlier, people with schizophrenia have genes that predispose them to the disease. Some people have relatives with schizophrenia, so the gene is inherited from a previous generation. Some patients do not have these relatives, so where do the genes for schizophrenia pathology come from? We need to know that just like physical characteristics such as the size of a person’s eyes, whether they have double eyelids, or personality traits such as whether they are introverted, they are burned into the chromosomes in the nucleus of the cell, called genes, which can be likened to the blueprints for building a house. When our parents give birth to us, they let the cells of the fertilized egg, divide in two, divide in two, divide in four, …, just like making copies with a photocopier. Sometimes, for some reason, the handwriting appears blurred in certain places on what is copied. If this blurring is in an insignificant place, it doesn’t matter; but if it appears in places related to thinking, perception, etc., then a schizophrenia pathology gene is formed, called a ‘gene mutation’.
Brain cells are connected to other brain cells by nerve endings, forming a network. But they are not as close to each other as an electrical plug and socket, and must rely on the last brain cell to release neurotransmitters to transmit information. There are many kinds of neurotransmitters, such as dopamine (DA), norepinephrine (NE), 5hydroxytryptamine (5HT), acetylcholine (ACh), and so on. The schizophrenia pathology genes mentioned above determine how much of this neurotransmitter, dopamine, is produced, but even though it is more, there is not yet an immediate onset. However, just like pulling the trigger of a pistol with your finger, the ‘trigger’ of some trigger activates this pathological gene, releasing too much dopamine and sending messages indiscriminately, thus creating hallucinations and delusions out of nothing. It is clear from here that psychological triggers such as loss of love only play a ‘trigger’-like role, and even if we find ways to address these psychological triggers, we cannot solve the problem of schizophrenia. The problem of too much production of dopamine, a neurotransmitter, must be addressed at the root in order to cure schizophrenia. There is another way to fix or modify the pathological genes of schizophrenia, called gene therapy; however, scientific research, at this time, has not yet reached this level, and we can only treat from the one doorway of reducing dopamine transmission.
How should I treat schizophrenia if I have it?
When you have schizophrenia, it is important to seize the opportunity to treat it. The first onset is the most critical moment, and an experienced doctor should be consulted first to confirm the diagnosis and then immediately put the patient on the best antipsychotic medication. This is the time when medication is most effective; the time is not lost. Generally speaking, within 2 years, the disease is easy to treat; after 2 years, it is more difficult to achieve good results, or even delayed to become chronic. Therefore, do not have the idea of “leaving the good drugs for later when you are seriously ill”, but should use the best drugs at the beginning. Some family members “rush to the doctor”, looking for herbal remedies everywhere, and even spend a lot of money. We advise families not to take hearsay at face value or trust treatments that have not been confirmed by experts, so as not to waste money and delay their loved one’s condition.
There are many kinds of medications for schizophrenia, and the most commonly used in China used to be the first generation of antipsychotics (formerly known as ‘classical antipsychotics’) that were marketed in the 1950s and 1960s, such as chlorpromazine, fenadine, trifluoperazine, and haloperidol. The common feature of these antipsychotics is that they block dopamine receptors so that information does not travel down the line and psychiatric symptoms gradually get better.
As we can imagine, there are so many nerve cells in the human brain and so many dopamine receptors that need to be blocked that the antipsychotics must be taken in sufficient doses to be effective. If the dose is too small, it will not be enough to block that many receptors, and it will be difficult to achieve a therapeutic effect even if you take it for several years. The therapeutic dose of chlorpromazine is about 300 to 600 mg per day; fenadine is 20 to 40 mg per day. Taking only one or two tablets a day is not helpful at all. Since these drugs have certain side effects, the dosage can only be increased gradually until it works, or until the above-mentioned therapeutic dosage is reached. In about 20% – 50% of cases, dopamine transmission in the extrapyramidal system of the brain is also blocked after taking these drugs. When the extrapyramidal system, which is responsible for the coordination of muscle movements, is blocked, ‘extrapyramidal side effects’ occur, such as slow movements, shaky hands, or fidgeting, and the side effects are relieved with the addition of Benzedrine, which can be taken as one tablet in the morning and one tablet at noon. It is not necessary to take Benzedrine at bedtime because the extraconal side effects will disappear automatically after going to sleep. In addition, a few patients may develop ‘delayed dyskinesia (TD)’, which manifests as involuntary writhing of the face, lips and tongue, or hands and feet, and is a more serious side effect that is difficult to treat and often even left for life.
It is generally said that drugs such as chlorpromazine are not comparable in efficacy. Therefore, if the efficacy of chlorpromazine is not satisfactory, there is no need to switch to Endrin or combine the applications. In general, the efficacy of chlorpromazine or fenpropathrin is not very good, and patients often do not recover completely. Haloperidol has good efficacy, but the extraconjunctive side effects are more serious and have been used less frequently in recent years. Sulpiride is another antipsychotic drug, although it has fewer extrathecal side effects, it is irregularly absorbed after oral administration; therefore, it works well in some patients and not in others. In addition, the effects of sulpiride on menstruation are the most severe of the first generation antipsychotics.
Clozapine, which was introduced in the 1970s, outperformed varieties such as chlorpromazine. Some cases that did not work may be able to remit quickly after switching to clozapine. However, there are many side effects of clozapine, which should be noted when using it: (1) Clozapine basically has no extra-cone side effects, and can be used without benzhexol (Antan); (2) The drowsiness of clozapine is heavy at the beginning, and will be reduced by itself after several weeks of adaptation. (3) Clozapine may increase the secretion of saliva at higher doses, even from the corners of the mouth during sleep, but it is not harmful to the body. (4) A small number of patients may experience leukopenia after taking clozapine, which may even be life-threatening, so the leukocyte count must be checked regularly during the dosing period; in the initial stage, it should be checked once a week, then once every two weeks, and then once a month. It is generally said that if leukopenia does not occur after six months or a year of taking the drug, then it is unlikely to occur in the following years. (5) Some patients (at least 15%) experience obsessive-compulsive symptoms after taking clozapine, which should not be mistaken for an exacerbation of the disease; this is the only time to switch to another drug. The therapeutic amount of clozapine is usually 300-500 mg per day. Due to the numerous side effects mentioned above, the therapeutic dose is often not achieved when applied in practice, so the efficacy is not satisfactory.
In the 1980s, some new drugs were developed from the mechanism of clozapine. In the previous period, they were referred to as ‘atypical antipsychotics’ and recently renamed as ‘second-generation antipsychotics’. At first, they were considered to have three characteristics: 1) better efficacy than first-generation antipsychotics, especially for negative symptoms; 2) few extraconjunctive side effects and no TD; 3) no increase in prolactin and no effect on menstruation. After research and application, it is now found that, for the whole group (except for individual varieties), the efficacy is not necessarily better than that of the first generation drugs, with fewer extraconjunctive side effects
Risperidone is one of the earliest to be marketed, although the efficacy is slightly better, but the side effects are not as little as advertised, many patients will also experience extra-conjunctive side effects after taking the drug, and all have to use Antan; and there has been a TD, because it will greatly increase the secretion of prolactin, can be said to be the most antipsychotic; female patients in the use of the drug, often nine out of ten, there will be amenorrhea.
Another new drug is olanzapine, which is somewhat more effective. We have found that in cases where other drugs (including risperidone or quetiapine) have not worked for a long time, more than half of them actually improve significantly after switching to olanzapine, and half of them return to full normalcy. Even patients who were fussing were seen to be quiet after 20 mg of the drug. It is popular with patients because it has few side effects and does not cause amenorrhea when applied short-term. The starting dose is 10mg per night, which is often the therapeutic dose, so the effect is quicker; however, in some cases it needs to be increased to 20 or 30mg per night to be effective.
Newer drugs that came on the market later, such as quetiapine or ziprasidone, are not necessarily more effective in practice than, for example, chlorpromazine. Ziprasidone has a greater effect on cardiac function and care must be taken when applying it. As for aripiprazole, it is another new drug with average efficacy, but it does have fewer side effects.
How long does the medication course take?
Patients with schizophrenia will improve significantly after a few to ten days of medication. At this time, the therapeutic dose should be continued for 1-2 months and then gradually reduced to about 1/3 to 1/4 of the original therapeutic dose over the next 1-2 months as a maintenance dose, usually 2.5-5 mg per night.
Some family members or the patients themselves always inquire about the availability of drugs that can cure psychosis; unfortunately, there is none until now. As you can see from the principles mentioned earlier, antipsychotics work by blocking receptors, that is, temporarily blocking excessive and disorganized messaging, and therefore are not a cure, so to speak.
Without the proper amount of medication for long-term maintenance, the disease will often relapse. The reasoning is similar to that of treating hypertension: once the anti-hypertensive drug is taken, the blood pressure becomes normal, and once the drug is stopped, the change is not visible when the treatment is temporarily targeted, but it does not take long for the blood pressure to go up again. From this point of view, it seems that maintenance doses must be taken for 9, 10 or more years until there are newer findings.
The drug has to reach a certain concentration in the body before it will be effective. However, the body also destroys and excretes a certain amount of the drug, which must be replenished daily, which is the ‘maintenance dose’. Since the ability to excrete drugs varies from person to person, the amount of medication that should be replenished each day varies; that is, the maintenance amount can be large or small, depending on the person. Chlorpromazine is at least 100 mg per day; clozapine may be 75 mg; risperidone is 1 mg; and olanzapine is 2.5-5 mg. However, some patients may need more, and families must watch for it and adjust it whenever necessary.
Also use the analogy of the letterbox and lid in front of you, those ‘lids’ on the letterbox will fall off some every day and must be replenished at any time, otherwise the information will be passed around again, the psychiatric symptoms will reappear and the condition will deteriorate; this is the reason for what to take long-term maintenance doses for advanced breast cancer.
How should I choose the medication for schizophrenia?
Generally, olanzapine can be used to bring the symptoms of schizophrenia into remission in the shortest possible time, and then switched to pentoxifylline for maintenance. I call this ‘let olanzapine fight the world and use pentoxifylline to keep the peace’. Because olanzapine has fewer side effects in the short term, there is no need to gradually increase the dosage, it can be done in one step, starting with 10 mg per night and increasing to 20 mg per night if no change is seen for a few days or a week, and then continuing for 2 to 3 weeks if it works. Thereafter, the dose is reduced by 5 mg every 2 weeks until 5 mg per night, when pentoxifylline is added twice a week, half a tablet (10 mg) each time; after 2 weeks, olanzapine can be discontinued as a maintenance drug, and pentoxifylline is used all the time to prevent relapse.
What should I do if the patient refuses to take the medication?
Some psychiatric patients refuse to take medication, it is generally said that there are several possibilities: First, they are in the onset of the disease and do not admit that they are sick, so they are neither willing to seek medical help, nor willing to take medication. Second, after treatment, the patient with non-small cell lung cancer thinks that the disease has been cured and does not need to continue to take medication. Third, the patient refuses to take medication because of some side effects which affect work and life. Fourth, some drug side effects are very heavy and unbearable.
As a family member, you should first analyze the reasons for refusing to take the medication, and then take different countermeasures. For patients whose condition has basically improved, they should be frequently reminded that “stopping the medication will lead to relapse again, which may have serious consequences”. If there are side effects of varying degrees, you can switch species or adjust the dose, or combine the application of some drugs that can reduce the side effects. For patients who do need long-term medication and refuse it, they can switch to long-acting drugs. There are two types of long-acting antipsychotic drugs: one is injectable, such as fluphenazine enanthate, haloperidol aconitate, or risperidone long-acting preparation (“Hengde”), one injection can maintain the effect of 2-3 weeks; the other is oral long-acting drugs, such as pentafluoridol. Previously, it was mistakenly believed that the sedation of pentoxifylline could not have too many side effects, so it was not widely used. We found that the efficacy of this drug is actually quite good, as long as the weekly dose does not exceed 20mg, no serious side effects will occur. Especially after changing the usage of ’20mg once a week’ to ‘5mg every other day’, there are almost no side effects of Xyroda, and many cases that have been treated with other drugs for a long time have actually worked. Another feature is that it is insoluble in water, colorless and tasteless, and can be mixed in things, which is suitable for patients who refuse the drug.
How should we judge the therapeutic effect?
We should judge the efficacy from two aspects: first, whether the mental symptoms disappear completely? Second, is self-knowledge restored? In some patients, the symptoms may disappear completely after treatment, but in some patients, some of the symptoms may remain more or less chronic. In some cases, after the symptoms disappear, the patient may suddenly realize that he or she can correctly recall the onset of the disease, analyze and recognize the psychiatric symptoms he or she had, such as hallucinations, delusions, and disorganized behavior, and admit that he or she was once mentally disturbed, and cooperate with the doctor and obey the treatment. This is called ‘restoration of self-knowledge’. These patients will then actively ask for relapse prevention and will voluntarily ask for maintenance doses. But some patients will not be able to recover so well.
Can all schizophrenia be cured by medication?
Generally speaking, the effectiveness of medication is only 70%-80% of the total number of patients taking medication; patients for whom medication is ineffective should be treated with other treatments. Experience tells us that electroconvulsive therapy is a relatively effective treatment method, especially for cases of passive suicide or rigid refusal to eat, and also for patients for whom medication alone does not work in time. Some family members shake their heads when they hear about electroconvulsive therapy, mistakenly believing that it will produce damage to the patient. In fact, electroconvulsive therapy uses a very small amount of electric current to stimulate the brain for a very short period of time to achieve therapeutic effects. For the patient, there is no pain and it is like sleeping. This treatment is generally said to be safe; a course of 6-12 sessions. In particular, Modified Electroconvulsive Therapy (MECT) is administered after the patient is put to sleep by intravenous medication, the patient does not feel any pain or fear at all, there is no danger, no side effects, and individual patients forget things more easily after the treatment, but will recover completely within 3 or 4 months. Therefore, it is worth trying if the case is treated with medication alone and the effect is not satisfactory.
How should family members treat the patient?
First, the patient should be brought to the clinic early.
In the outpatient clinic, the family should first describe the patient’s abnormal presentation to the doctor and tell him/her about the symptoms that have appeared before and after. But it is not necessary to analyze the so-called ’causes’ at all, because what you think is the cause is not the real cause of the disease, and it is not helpful for diagnosis, nor for treatment. Then, let the doctor examine the patient himself. The doctor’s conversation with the patient is a mental examination, and each sentence has a purpose. At this time, family members should never interrupt, let alone answer questions instead of the patient. If family members have questions about the condition, the future, or the treatment, they should ask them after the patient leaves.
Second, do not argue with the patient.
What should be the attitude toward the patient’s pathological manifestations (e.g., hallucinations) and erroneous thoughts (e.g., delusions)? We believe that one should never argue with the patient for this reason. This is because it is a pathological manifestation, not a problem of ideology, and it is simply impossible to convince to correct it by presenting facts and reasoning. When the patient speaks about these hallucinations or delusions, we can only adopt a ‘non-committal’ attitude; after active treatment with medication, these pathological manifestations and wrong ideas will disappear on their own.
Third, do not discriminate against the patient.
Schizophrenia is a disease and definitely not a problem of moral quality or thought, so patients should not be discriminated against; on the contrary, they should be given great care and sympathy. If early treatment with good drugs can be applied within 2 years of the onset of the disease, the majority of patients may recover completely and can live and work completely unlike normal people. If the disease is recovered, they can of course fall in love and get married. Because schizophrenia, like many diseases, has a certain degree of hereditary potential, the issue of having children or not should be treated with caution. Children born to ordinary people have a 1% chance of developing schizophrenia; children born to people with schizophrenia have a greater chance of developing the disease, about 5 – 10%. If a patient decides to have children, it is important to note that maintenance doses of antipsychotic medication must be maintained before and after pregnancy and childbirth. It is completely safe to assume that maintenance doses of antipsychotics do not cause malformations. If antipsychotics are discontinued after pregnancy, there is a risk of relapse of psychosis, which would be too harmful to oneself, to the fetus, and to the family.
Fourth, patients should be urged to take their medication.
If a patient’s condition is not yet under control, they will often refuse to take their medication. Even if the condition is in remission, the possibility of them spitting up the medication or pretending to take it should be fully estimated. So it is the responsibility of the family to supervise and check their medication; especially to supervise them to take maintenance doses for a long time. Even for patients who have recovered and have regained their self-knowledge, they also have to be reminded frequently to take their maintenance doses. To be honest, before science is advanced to a certain level, that is, before the pathological gene for schizophrenia is found and a corresponding gene therapy is invented, long-term medication is still the most reliable way to prevent relapse.
Fifth, patients should be counseled not to take diet pills.
In addition, schizophrenia patients should never take diet pills. This is because almost all current diet pills have added drugs like ‘fenfluramine’, for example. They increase the neurotransmitter dopamine, which causes the person taking them to lose weight by decreasing appetite. But the key to the pathology of schizophrenia is too much dopamine, which leads to symptoms such as hallucinations and delusions. Even people who do not suffer from schizophrenia may develop psychotic symptoms after taking fenfluramine; when people with schizophrenia take it, they inevitably relapse as a result, so families must pay special attention.