Schizophrenia is a group of psychiatric disorders of unknown etiology with disorders of thought, emotion, and behavior characterized by incompatibility between mental activity and the environment. Some patients may have cognitive impairment. The onset of the disease is usually in young adulthood, often slow and prolonged, with a tendency to chronicity and the possibility of decline, but some patients can maintain a state of recovery or basic recovery.
Clinical manifestations
(A) Perceptual disorders
The most prominent perceptual disorder in schizophrenia is hallucinations, with hallucinations of hearing being the most common. Patients can hear voices when no one is talking, and the content of hallucinations in schizophrenia is mostly argumentative, such as two voices discussing the good or bad of the patient; or critical, with voices constantly commenting on what the patient is doing. For example, when a female patient in her 50s went out to buy groceries, a voice said, “The big shoe is out again”. For example, when the doctor asks the patient for his name, the voice tells the patient “don’t say your real name” and the patient makes up a fake name; hallucinations can also be expressed in the form of thinking sounds, i.e., the patient’s thoughts are read out by his own voice.
Other types of hallucinations, although rare, can also be seen in patients with schizophrenia. For example, a patient refuses to eat because she sees a plate containing broken glass (phantom vision),; a patient feels that someone is cutting herself with a scalpel and has the sensation of an electric current burning the wound (phantom touch), etc.
The hallucinatory experiences of schizophrenia can be very specific and vivid, or they can be hazy and blurred, but they will mostly have a significant impact on the patient’s thinking and actions, and the patient will act against his or her nature and behave in a way that is not normal under the domination of the hallucination. For example, some patients insult or even beat their relatives under the influence of hallucinations, and some patients petition frequently to avoid the “harassment” of hallucinations, asking the authorities to remove the “announcer” installed in their heads. There was an elderly woman who, because she always heard voices saying that the water was poisonous, walked more than 20 miles with a thermos in order to drink “clean” water, spending four hours on the road.
(B) Thought and thought association disorder
Delusions The absurdity of delusions is often evident. Perhaps in the early stages of the disease, the patient is still skeptical of some of his or her apparently unconventional thoughts, but as the disease progresses, the patient gradually becomes one with the pathological beliefs. The most common delusions are delusions of victimization and relationship delusions, which can be seen in all age groups. The subject of the delusions gradually extends from the person with whom the patient has initially been in conflict to colleagues, friends, relatives, and even strangers. Every smile and every movement of another person has a hidden meaning, and every greeting and conversation has a deeper meaning. In severe cases, the patient may even think that the contents of newspapers, magazines, radio and television are related to him. The content of the delusion is related to the patient’s life experience and educational background to a certain extent. For example, an engineer working in the chemical industry believes that the cup he drinks from has been tampered with, releasing a daily amount of poison and causing chronic poisoning; an old nurse believes that she was injected with HIV during her last hospitalization; an uneducated housewife claims that she lost a Roman watch worth “50,000 yuan” and that her neighbor stole it and gave it to her. An uneducated housewife claimed that she had lost a Roman watch worth “50,000 yuan” and that her neighbor had stolen it and given it to the national leader.
Normal people have full autonomy over their mental and physical activities, i.e., they are able to freely dominate their own thinking and movement and experience this sense of subjective dominance throughout the process. However, in patients with schizophrenia, problems with the autonomy of mental and somatic activities are often present. Patients lose their sense of dominance and instead feel that their somatic movements, thinking activities, emotional activities, and impulses are controlled, and have a passive experience of being imposed, often describing thinking and acting out of their own control.
Passive experiences are often associated with delusions of victimization. Patients assign various delusional explanations to this completely unfamiliar passive experience, such as “being under the influence of some kind of radiation”, “being tricked into taking some kind of drug”, “being fitted with advanced equipment”, etc. “etc.
One patient expressed her passive experience in this way: “I feel like I have become a puppet, and my every move is manipulated by someone. What to think, what to say, what to make expressions are all arranged. The most uncomfortable thing is that what I say and what I do is no different from my usual behavior, and outsiders can’t see any change in me. Only I know that I am not me anymore, I am completely at the mercy of others.”
3. Thought association disorder . An experienced psychiatrist can make a judgment of a tendency toward schizophrenia based on intuition alone through a general conversation with the patient. This intuition specifically means that it is “hard” to talk to schizophrenics. Indeed, talking to a schizophrenic patient, even to gather general information, requires a great deal of patience and skill; it is often very difficult to have an in-depth conversation with the patient. Reading written material written by the patient is often uninformative. Because of the primary impairment of mental activity, patients with schizophrenia often have problems with verbal fluency and narrative integrity as they ignore conventional rules of rhetoric and logic in conversation.
The patient often wanders from the topic of the conversation, especially when answering the doctor’s questions, but every sentence seems to be a little bit on point, making it difficult for the listener to grasp the main points (scattered thinking). In severe cases, the speech is so fragmented that it is impossible to talk about it (broken thinking).
Some patients talk in circles, do not answer the question, or make unnecessary and overly specific descriptions of things, which is puzzling, when it is clear that we can use a common name, but unnecessarily use specific concepts to explain, such as patients when asked “what do you do”, answer For example, when asked “What do you do?”, the patient replied “I do counting in the unit,” when in fact the patient works as an accountant in the unit.
Contrary to the above, some patients inappropriately use symbols, formulas, self-made words (words newly made), and diagrams to express very simple meanings. For example, a female patient drew a large diagram with non-intersecting curves, English “10Ve” with teardrops, etc., just to say “my boyfriend broke up with me”; some patients inappropriately used written language in the spoken language, such as a patient praised the doctor. “A certain doctor always speaks to people in such an unobtrusive manner.”
Another reason why patients’ speech is incomprehensible is the confusion of logical relationships. For example, a female patient said, “My brain is all messed up because I’m so smart. My blood is all smart and thick and thick. I have to have a baby and share half of my smarts with him before I can get well. Otherwise I’ll have to drink Minute Maid soda to wash down my smarts a little …… I want to drink Minute Maid soda.” Here there is also confusion about the meaning of the concept, such as the patient sees the abstract “smart” as a concrete substance that can be diluted by “soda”.
4.Poor thinking is judged by the amount and content of the patient’s speech. Poverty of speech, lack of active speech, unusually short answers to questions, mostly “yes” “no”, rarely played. There is also a long delay in responding to each question. Even if the patient has enough language to answer the question, the content is vague and too general, and the amount of information conveyed is very limited.
(iii) Affective disorder
The main manifestation is emotional retardation or flatness. Patients also have reduced spontaneous movements, lack of body language, little or no use of gestures and body postures to support the expression of ideas in conversation, monotonous speech tone, lack of intonation, little eye contact with the other person when talking with them, mostly staring blankly ahead; patients have lost their sense of humor and their response to humor. Patients lose their sense of humor and their response to humor, and it is difficult for the examiner’s wit to elicit a smile from the patient; patients have cold feelings for their loved ones, and the pain of their loved ones is irrelevant to them. A female schizophrenic patient who was hospitalized only cared about what snacks her 70-year-old mother brought her on each visitation day. Once her mother fell on her way to the hospital, and when she arrived, the patient took the snacks and ate them, not caring about the injuries on her mother’s face or body. A small number of patients have emotional inversions. However, depression and anxiety are not uncommon in patients with schizophrenia.
(iv) Will and behavior disorders
1. Decreased will Patients have great difficulty in holding down a job, completing school, or taking care of household chores, and often have no concern for their future, have no plans, or have plans but never carry them out. Activity decreases and the patient can sit for hours without any spontaneous activity. Some patients claim, “I just like to lie in bed.” Patients neglect their appearance and do not know how to take care of their personal hygiene. One young male patient had never changed his clothes for 3 years in a row, and when the patient was given a bath after the hospital, the first few tubs of water were black.
2. Tension syndrome is named after the increased muscle tone of the patient’s whole body, and includes two states of tension rigidity and tension excitement, which can alternate and are typical of the tension type of schizophrenia. It is characterized by silence, reduced or absent random movements, and psychomotor unresponsiveness. In severe cases, the patient remains in a fixed position, does not speak or move, does not eat or drink, does not have automatic bowel movements, and does not respond to any stimuli. In patients with lignocardia, wax-like flexion may occur, characterized by the patient’s limbs being at the mercy of others and remaining in an uncomfortable position for a longer period of time. If the patient’s head is elevated as if it were resting on a pillow, the patient can maintain such a position for a period of time, which is called “air pillow”. Sometimes the patient can suddenly appear impulsive behavior, that is, nervous excitement.
IV. Clinical typing
Schizophrenia can be divided into several subtypes according to its clinical features. This division is based on a preference for psychopathology.
1. Paranoid type is the most common type of schizophrenia. Its clinical manifestations are dominated by relatively stable delusions, often accompanied by hallucinations (especially hallucinations). Emotional, volitional, verbal and behavioral disorders are not prominent. The onset of the disease is mostly after the age of 30. These patients are less likely to have significant personality changes and decline, but hallucinations and delusions are retained for a long time.
2. Catatonic type is characterized by marked psychomotor disturbance. It may alternate with catatonic rigidity and catatonic excitement, or automatic compliance and disobedience. Typically, the patient presents with a catatonic syndrome. The catatonic type has a tendency to decrease in clinical practice.
3. The hebephrenic type has a rapid onset and progresses rapidly, reaching a peak within 2 weeks. The main manifestation is emotional changes, superficial and uncoordinated emotions, sometimes smiling, but giving people a silly feeling; sometimes arrogant attitude, seemingly unbeatable; or moody, playing ghosts, pranks, regardless of the occasion and object, making some childish jokes. The thoughts are broken, the speech is loose, incoherent and confusing, sometimes accompanied by fragmentary hallucinations and delusions. The behavior is unpredictable and lacks purpose. The disease progresses rapidly and the prognosis is poor.
4.Simple type has a slow onset and continues to develop. In the early stage, it mostly shows symptoms similar to “neurasthenia”, such as subjective fatigue, insomnia, decreased work efficiency, etc. Gradually, it becomes increasingly withdrawn and withdrawn, emotionally indifferent, lazy, loss of interest, poor social activities, and purposeless life. In the early stage of the disease, it is often not taken seriously, and it may even be mistaken that the patient is “unmotivated”, “not cheerful enough” or “depressed after a blow ” and so on. Often, the patient is not seen until years after the disease has progressed. The treatment effect is poor.
A significant number of patients cannot be classified in any of the above categories and are sometimes placed in the “undifferentiated” category, indicating that the patient’s clinical presentation is characterized by more than one subtype. However, there are no distinctive subgroup characteristics.
Some patients meet the diagnostic criteria for schizophrenia and have been ill for more than 3 years, but the last year has been dominated by negative symptoms, with severe impairment of social functioning and psychiatric disability, called the declining type.
There are also some patients whose clinical manifestations met the diagnostic criteria for schizophrenia in the past and have not been in complete remission for at least 2 years. Although their condition has now improved, they have residual individual positive symptoms or individual negative symptoms, which is called the residual type.
Some patients with partially controlled symptoms or largely stabilized disease who develop a depressive state are called post-schizophrenic depression. Depression can be either a component of the disease itself or a psychological reaction that occurs after the patient’s symptoms have been controlled. It should be taken seriously because of the risk of suicide.
Course and prognosis
The course of schizophrenia can vary after the initial onset of remission. Approximately l/3 of patients are clinically cured, i.e., they no longer have psychopathic symptoms. Even among these “recovered” patients, however, they may find that their self-perceptions change after recovery because of the profound impact of schizophrenia on their normal lives and experiences.
Other patients may have an episodic course with varying lengths of episodes and intervals, and the number of relapses varies, with relapses being related to psychosocial factors. There are no sudden shifts or clear boundaries between episodes and discontinuations of schizophrenia.
Some patients may experience personality changes and decline in social functioning after recurrent episodes, and present clinically with varying degrees of disability. When the disability is mild, the patient retains some ability to adapt to society and work.
In a small percentage of patients, the disease progresses progressively, or each episode causes further personality decline and disintegration. The worsening of the disease eventually leads to prolonged hospitalization or repeated hospitalizations.
Overall, 75% of patients with a first episode of schizophrenia can be cured and about 20% remain healthy for life. Therefore, the prognosis for schizophrenia is not as pessimistic as one might think. Due to continuous advances in modern therapeutics, about 60% of patients can achieve social remission. This means that they can function socially.
For a specific patient, it is more difficult to determine the prognosis in the early stages of the disease. Some of the factors that favor prognosis are: late age of onset, acute onset, significant affective symptoms, normal personality, good social and adaptive skills prior to the disease, and a strong psychogenic relationship between the onset of the disease. The prognosis is usually better for women than for men.
Treatment and rehabilitation
(i) Drug treatment
Antipsychotic drugs can be divided into two categories according to the mechanism of action: classical drugs and non-classical drugs. Classical drugs, also known as neural blockers, mainly play an antihallucinatory and delusional role by blocking D2 receptors, and are divided into two categories of low and high potency according to clinical characteristics.
In recent years, non-classical antipsychotic drugs have been introduced to play a therapeutic role by blocking 5-HT and D2 receptors in a balanced manner, which are effective not only for positive symptoms such as hallucinations and delusions, but also for negative symptoms such as emotional flatness and hypoactive will. The representative drugs are risperidone, olanzapine, quetiapine, clozapine and others.
Schizophrenia drug treatment should be systematic and standardized, emphasizing early, adequate amount and full course of “whole-course treatment”. Once the diagnosis is clear, medication should be started early. Medications should be administered at therapeutic doses, and the acute phase of treatment generally lasts for 2-3 months. Some patients, family members and even doctors are overly worried about the adverse drug reactions often take low doses of drugs, the symptoms are not controlled for a long time, not to achieve the desired therapeutic effect. Treatment should start with a low dose, gradually increase the dose, and pay close attention to adverse reactions at high doses. The dose of medication for outpatients is usually lower than that for inpatients, and generally cannot be stopped suddenly.
Maintenance therapy has a definite effect on reducing relapse or re-hospitalization. Maintenance therapy should be given for 3-5 years for the first episode, and longer for the second or multiple relapses, or even for life. The dose of maintenance therapy should be individualized, generally 1/2 to 2/3 of the dose during the acute treatment period, and the outpatient dose is usually the maintenance dose for patients treated on an outpatient basis. Maintenance doses of non-classical antipsychotics are appropriately reduced from the acute phase of treatment, but there is a lack of established models as to the extent of the reduction.
Regardless of the acute phase or maintenance treatment, in principle, a single drug is used, and drugs with similar mechanisms of action should not be combined in principle. For patients with depressive mood, manic state and sleep disorders, antidepressants, mood stabilizers and sedative-hypnotics can be used as appropriate, and benzhexol hydrochloride (Antan) can be used in combination with extrapyramidal reactions.
(B) Psychotherapy
Psychotherapy must be part of the treatment of schizophrenia. Psychotherapy can not only improve the patient’s psychiatric symptoms, increase self-awareness, and enhance treatment compliance, but also improve the relationship between family members and facilitate the patient’s contact with society.
Behavioral therapy can help correct some of the patient’s functional deficits and improve interpersonal skills. Family therapy allows family members to identify long-standing communication problems, helps to ventilate bad feelings, and simplifies communication styles.
(iii) Psychological and social rehabilitation
It is not enough for the patient to eliminate psychiatric symptoms. The ideal state of clinical recovery is that the patient has regained the energy and physical strength caused by the disease, achieved and maintained good health, regained the original work or study ability, and re-established appropriate and stable interpersonal relationships, so as to achieve full social recovery.
Patients who are clinically cured should be encouraged to participate in social activities and engage in work that they are capable of. For patients with chronic schizophrenia showing withdrawal, training in daily living ability, interpersonal skills and vocational labor training can be conducted so that patients can retain some of their social life functions as much as possible and reduce the degree of disability.
Health education should be provided to the patient’s relatives to let them understand the basic knowledge about schizophrenia, with a view to increasing understanding and support for the patient and reducing the pressure that may be brought to the patient such as too much blame and too high expectations.
Mental health knowledge should be popularized to the public so that society will be more tolerant and caring and less discriminatory and isolating to people with mental illness.