I. Definition of schizophrenia
Schizophrenia is a group of mental illnesses whose etiology has not been fully elucidated, with multiple impairments in thinking, perception, emotion and behavior, characterized by incompatibility between mental activities and the environment. Some patients may have cognitive impairment. The onset of schizophrenia is usually in young adulthood, often slow, with a prolonged course and a tendency for chronicity and decline, but some patients can remain cured or basically cured.
Second, the incidence and prevalence of schizophrenia
Schizophrenia is a disease with a low incidence but a relatively high prevalence. The annual prevalence of schizophrenia investigated using a loose definition of schizophrenia and current diagnostic criteria may be 0.17% o a 0.54% o If more rigorous diagnostic criteria were used, the prevalence would be reduced by a factor of about 2 or 3. (Oxford Psychiatry)
The total prevalence in the general population is 3-8‰, with an annual incidence of 0.1‰ and a lifetime prevalence of 7.0-9.0‰, with an average of 8.6‰ (shields & slater 1975). The results of a nationwide epidemiological survey of mental illness in 12 regions in China from 1982 to 1985 showed that the total prevalence of schizophrenia in the population aged 15 years or older was 5.69‰, with a point-in-time prevalence of 4.75‰. The point-in-time prevalence rate in urban areas was 6.06‰, which was significantly higher than the rural prevalence rate of 3.42‰.
According to the latest data (Ministry of Health 2005), the prevalence of schizophrenia: in 1993, the total prevalence in urban areas was 8.18‰, with a point-in-time prevalence of 6.71‰, while the total prevalence in rural areas was 5.18‰, with a point-in-time prevalence of 4.13‰.
III. Clinical manifestations of schizophrenia
The clinical manifestations of the disease are complex and varied, and the clinical manifestations of different types and stages can vary greatly, but they all have characteristic features of incoordination of thinking, emotion, and behavior and detachment from the real environment.
1. Perceptual disorders
The most common is hallucinations, especially hallucinations, mainly verbal hallucinations. Patients hear neighbors, relatives, colleagues or strangers talking out of thin air, and the content is often unpleasant, such as hearing several voices talking about the patient, arguing with each other, commenting on the patient in the third person, threatening or ordering the patient. The patient may also experience hallucinations of vision, smell, taste, etc.
2. Thought association disorder
In the early stages of the disease, it can only be manifested as a weak association in the meaning of the thought association process, the patient’s answers to questions are not pertinent, irrelevant, and make the doctor feel difficult to contact with the patient (lax thinking). The patient uses a common phrase, noun, or even an action to express a particular meaning that cannot be understood by anyone other than the patient (pathological symptomatic thinking).
The process of putting together two or more completely unrelated conceptual words or incomplete words or phrases to give a special meaning (verbal novelty). The associative process can be suddenly interrupted without the influence of external factors (thought interruption), or a large number of compulsive thoughts can emerge (thought clouding), and sometimes the thought can suddenly turn around or some unrelated unexpected associations can appear. This type of association disorder is often accompanied by a clear sense of involuntary, the patient feels difficult to control their own thoughts, that their thinking is controlled or manipulated by external forces.
3. Thought content disorder
Delusions are one of the most common symptoms of schizophrenia, with delusions of relationship, delusions of victimization, and delusions of influence being the most common. Most of them occur suddenly, with bizarre content and absurd logic, and the scope involved has a tendency to expand and generalize or have special significance. The delusion that every action of people around him is directed at him, that he is being talked about everywhere he goes, and that newspapers, radio and television all insinuate that he is a victim. Changes in nature, wind, rain, and even birds flying in front of the window are also hints of what is going to happen. The patient does not reveal the content of the delusion.
4.Emotional disorder
Emotional indifference, emotional reactions do not cooperate with the content of thought as well as external stimuli. The earliest involves more delicate emotions, such as care for comrades, consideration for relatives, emotional responses to things around them become sluggish or flat, and the requirements for study and life diminish, and interests decrease. As the disease progresses, the patient’s emotional experience becomes increasingly impoverished, and even for those events that cause great pain to the general population, the patient shows indifference and loses the emotional connection to the surrounding environment.
5.Voluntary behavior disorder
Decreased activity, lack of initiative, passive behavior, withdrawal, lack of requirements for socializing, studying and working, not actively interacting with others, lazy behavior, not going to work or attending classes for no reason, in severe cases bedridden or sitting all day, doing nothing, not cutting hair for years and years, not combing hair, not spitting out saliva in the mouth. Some patients eat things they cannot eat or hurt themselves, stubbornly refuse everything or mechanically carry out any requests from the outside world, let people manipulate their posture, or mechanically repeat the words and behaviors of people around them.
Fourth, the subtypes of schizophrenia.
1. Paranoid type
Also known as delusional type. This type is the most common. The age of onset is mostly after 25 to 35 years old, with a slow or subacute onset. Symptoms are mainly delusions, with relationship and victimization delusions being common, followed by exaggerations, self-criminalization, affect, love and jealousy delusions. Delusions can be isolated or accompanied by hallucinations, mainly hallucinations. Emotional, volitional-behavioral and verbal disturbances are not obvious. The course of the disease is slow, and the ability to work can be maintained for a long period of time after the onset of the disease, and personality changes are slight.
2.Adolescent type
The disease starts in youth and is dominated by disorders or disturbances in thinking, emotion and behavior. For example, there are obvious lax thinking, broken thinking, emotional inversion, and strange behavior. The change of emotion is the prominent manifestation, superficial and uncoordinated emotion, sometimes with a smile on the face, but give people a silly feeling; sometimes with a high attitude, appearing unbearable; or temperamental, playing ghosts, pranks, regardless of the occasion and object, making some childish jokes. The thinking is broken, the content of speech is loose, incoherent and incomprehensible, sometimes accompanied by fragmentary hallucinations and delusions. The behavior is unpredictable and lacks purpose. The disease progresses rapidly and the prognosis is poor.
3.Tension type
The onset of the disease is relatively rapid, with the main manifestation being catatonic rigidity or (and) catatonic excitement. The course of the disease is mostly episodic. The prognosis is good, and there is a trend of decrease.
4.Simple type
Poverty of thought, emotional indifference, and hypotonia are the main negative symptoms, from no obvious positive symptoms; social function is severely impaired, tending to mental decline; the onset of insidious, slow development, the course of the disease at least 2 years, often in adolescence.
5.Other types
(1) Undetermined type: symptomatic manifestations cannot be classified into the above types.
(2) residual type: after the acute symptoms in the developmental stage have subsided, there are still pieces of insignificant hallucinations and delusions, or there are some mild symptoms, but they are not serious and can still perform daily work.
(3) Declining type: the illness has been prolonged, with extremely poor or broken thinking, emotional indifference, lack of will, retreating infantile behavior, and less fluctuations in the fixed condition.
V. Etiology of schizophrenia.
The exact etiology and pathogenesis of schizophrenia have not been clarified despite the existence of many hypotheses, and most scholars believe that schizophrenia is the result of the interaction of genetic and environmental factors. Maternal viral infections during pregnancy, perinatal comorbidities, trauma, forced separation from both parents at an early age, interpersonal relationships, life events, social and family conflicts all have an impact on the occurrence of schizophrenia:.
1. Genetic factors
There is more evidence that schizophrenia is hereditary, and the closer the blood relationship, the higher the likelihood of potential morbidity.
2, physiological factors
The dopamine hypothesis is the most widely accepted hypothesis for the etiology of schizophrenia. The effect of antipsychotic drugs on dopamine (DA) neurotransmitters can improve psychiatric symptoms supporting this hypothesis.
3. Mental stimulation
Stimulating life events have a predisposing effect on the onset of the disease. Stimulating life events can directly trigger people with a tendency to develop schizophrenia and make their onset earlier and their clinical manifestations more pronounced.
4. Environmental factors
Patients from poorer classes have poorer living conditions and do not receive timely and thorough treatment, which, together with the tendency to conflict with family members, leads to repeated hospitalization and eventually leads to prolonged treatment.
Sixth, the course of schizophrenia and prognosis
The onset of schizophrenia is slow, with gradual progress and a prolonged course. After treatment, the disease may remit, but some may relapse, or relapse several times. The stress type is better, followed by the paranoid and adolescent types, and the simple type is less good. The shorter the duration of the disease, the higher the remission rate. The remission rate is 60-70% if the disease duration is less than six months, and the remission rate decreases if the disease duration is more than one year. Antipsychotic medications can lead to improvement in 3/4 of patients, and the relapse rate of those who adhere to maintenance treatment is significantly lower than that of those who do not.
1. Good prognostic factors for schizophrenia
Abrupt onset, short duration of episodes, no pre-morbid psychiatric history, rich affective symptoms, paranoid type, late onset, married, good psychosexual adaptation, good premorbid personality, good work performance, good social relationships, good compliance.
2. Poor prognostic factors for schizophrenia
Invisible onset, long episodes, pre-morbid psychiatric history, negative symptoms, enlarged lateral ventricles, male, early onset, unmarried, separated, widowed, divorced, poor psychosexual adaptation, abnormal pre-morbid personality, poor work performance, social isolation, poor compliance.
VII. Mortality in patients with schizophrenia
The mortality rate of schizophrenic patients is relatively high in all studies with long-term follow-up.Harris and Barraclogh(l998) found in a reanalysis of 36,000 schizophrenic patients that the risk of death from all causes increased I.6-fold, with almost 40% of deaths from non-natural causes, mainly due to suicide, and the risk of suicide increased 10-fold. The commonly cited lifetime risk of suicide in patients with schizophrenia is about 10%.
VIII. Treatment of schizophrenia
Patients with schizophrenia should receive comprehensive, full, or even lifelong treatment including antipsychotic medications:.
1. Antipsychotic medication.
(1) Typical antipsychotic drugs
neural blockers – blocking DA receptors: chlorpromazine, fenadine, haloperidol, etc.
(2) Atypical antipsychotic drugs
Balanced blockade of 5-HT and dopamine receptors- risperidone, clozapine, olanzapine, etc. The safety, tolerability and efficacy of atypical antipsychotics are mostly superior to those of typical antipsychotics, especially in terms of safety and tolerability.
(3) Principles of drug selection
the selection must be based on the individualized characteristics of the patient’s disease duration, clinical manifestations, efficacy, adverse effects and pharmacogenetics, combined with the receptor pharmacological characteristics, pharmacokinetic characteristics and pharmacodynamic characteristics of antipsychotic drugs.
2. Antidepressant drug therapy
Suitable for schizophrenia with depressive symptoms.
3.Convulsion-free electroconvulsive therapy
For patients with schizophrenia accompanied by catatonia and severe depressive symptoms, electroconvulsive therapy can be used for patients whose “positive” symptoms have not been improved despite adequate antipsychotic treatment.
4. Psychotherapy.
(1) Objective – to enhance the patient’s interpersonal and social skills
To promote the independence of the patient’s community life; to reduce the severity of symptoms and related co-morbidities (e.g., substance abuse); to improve the personal management of the disease.
(2) Treatment methods
Mandatory community treatment; family intervention; social skills training and self-management of illness; cognitive-behavioral therapy.
(2) Schizophrenia treatment course.
1.Acute phase
Acute treatment, effective dose within 2 weeks, until symptoms are controlled, usually at least 6-8 weeks.
2.Recovery period
Consolidation treatment, still continue to apply the effective dose for 4-6 months, consolidation treatment (continue treatment) for the recovery period after acute symptom control, using the original effective dose to continue treatment, relapse mostly in the acute phase of treatment after about 6 months, consolidation treatment time should try to span this phase, recommended at least 4-6 months
3.Stabilization period
Maintenance treatment, maintenance dose is usually lower than the effective dose. The U.S. Textbook of Comprehensive Psychiatry, 7th edition, mentions – first-time users of drugs to maintain 1-2 years; multiple users of drugs to maintain at least 5 years; with suicidal, violent or aggressive behavior of drugs to maintain longer, or even lifelong medication.
IX. Prevention and treatment of schizophrenia.
1. insist on maintenance treatment with antipsychotic drugs; maintenance treatment is an important and effective way to prevent relapse of schizophrenia.
2. avoid as much as possible the stimulation of various psychological factors and the influence of the environment.
3. insisting on regular follow-up visits to the outpatient clinic, receiving home visits from the community nurse, and warning the patient and his or her family to seek medical help promptly if there are signs of recurrent conditions
4. develop a treatment plan that is acceptable to the staff involved, the patient and his or her family, and designate a staff member who maintains contact with the patient, whose task is to monitor changes in the condition as well as to ensure that the treatment plan is implemented and to regularly assess the patient’s progress and needs.
5. treat their illness correctly, adapt to the real environment with a positive and optimistic attitude, and properly deal with and treat their personal life, work, marriage, family future, etc.
X. Early manifestations of schizophrenia.
1. Emotional changes
Emotions become indifferent, lose their previous enthusiasm, do not care about their loved ones, lack proper emotional communication, distant from friends, not interested in things around them, often lose their temper over the slightest thing, inexplicably sad and in tears or elated, etc.
2.Sleep changes
Poor night sleep, difficult to fall asleep, easy to wake up, wake up early, dreamy or too much sleep.
3.Sensitive and suspicious
Nervousness, fear, always feel insecure, often associate things around him with himself, suspicious that others are always against him, suspicious that his lover is unfaithful to him, etc., but still have the ability to judge these thoughts.
4.Behavior abnormalities
Prefer to be alone, chasing after the opposite sex, not knowing shame, talking and laughing to oneself, living a lazy life, dazed and dazed, sleeping in the dark, wandering out, not returning home at night, etc.
5.Change in personality
The original lively and cheerful, hospitable people become silent, sitting alone as if thinking about the problem, not interacting with others. The person who was always clean and smart becomes unkempt, lazy, loose discipline, and inattentive. People who have always followed the rules become late, leave early, miss work for no reason, work sloppily, do not care about criticism, etc.