Schizophrenia, a distortion of thought
Schizophrenia, without a doubt, is one of the disorders best known to all. Still, many people tend to mythologize it, exaggerate it, or demonize it. It is a disorder that arouses both fascination and fear. Since psychological processes began to be studied, schizophrenia is one in which they have been investigated the most and of which there are still many unknowns. Its etiology is still not clear and its treatment includes different therapies.
Throughout this article, the diagnostic criteria for schizophrenia will be presented, as well as its most prominent symptoms. It will differentiate between positive, negative and disorganized symptoms. Finally, evaluation and treatment will be addressed. For the diagnostic criteria, the DSM-V has been used as a reference. It is the last update in 2013 of the "Diagnostic and Statistical Manual of Mental Disorders", published by the APA (American Psychiatric Association).
- Schizophrenia and thinking
- Onset and prevalence of schizophrenia
- Diagnostic criteria for Schizophrenia
- Positive, negative and disorganized symptoms
- Positive symptoms
- Negative symptoms
- Symptoms of disorganization
- Assessment of schizophrenia
- Types of Schizophrenia
- Paranoid schizophrenia
- Disorganized Schizophrenia
- Catatonic Schizophrenia
- Simple Schizophrenia
- Hebephrenic Schizophrenia
- Residual or defect states
- Schizophrenia Prognosis
- Good prognostic factors
- Poor prognosis factors
- Schizophrenia Treatment
Schizophrenia and thinking
Schizophrenia is a serious mental illness characterized by a distortion of thought with hallucinations and loss of contact with reality. Those who suffer from it often have the feeling of being controlled by foreign forces. They have delusions that can be extravagant, with altered perception, abnormal affect unrelated to the situation and autism understood as isolation.
The deterioration of mental function in these patients has reached a degree that markedly interferes with their ability to cope with some of the ordinary demands of life or maintain adequate contact with reality. The psychotic does not live in this world (dissociation between reality and his world), since there is a denial of reality unconsciously. He is unaware of his illness.
The cognitive activity of the schizophrenic is not normal, there are incoherencies, disconnections and there is a great impact on language, since they do not think or reason in a normal way.
Onset and prevalence of schizophrenia
The onset of the disease can be acute, that is, it can start from one moment to another with a delusional crisis, a manic state, a depressive picture with psychotic content or a confused dream state. It could appear in a cunning way or progressive.
The average age of onset is in men between 15 and 25 years old, and in women between 25 and 35 years old. However, it can appear before or after, although it is rare that it appears before the age of 10 or after the age of 50..
The prevalence of this disease is between 0.3% and 3.7% depending on the area of the world where we are. A certain hereditary prevalence has been observed, if one of the parents suffers from schizophrenia the child has a 12% chance of developing this disorder and if both are schizophrenic the child has a 39% chance. A child with healthy parents has a 1% chance of suffering from this disorder, while a child with a sibling with this disorder has an 8% chance. Therefore, the causes of schizophrenia are both biochemical and environmental..
Schizophrenia can occur mainly in association with Substance Related Disorders. From 30 to 40% of schizophrenics have alcohol abuse problems; 15-25% problems with cannabis; 5 to 10% abuse or depend on cocaine. Nicotine abuse, very common in these patients, is also included. Drugs and alcohol reduce the levels of anxiety and depression caused by schizophrenia.
Diagnostic criteria for Schizophrenia
There is no single clinical picture, but there are multiple characteristic symptoms; emotional, cognitive, personality, and motor activity symptoms.
Symptoms must be present for at least 1 month and persist for at least 6 months.
A. Two (or more) of the following symptoms. Each of them present for a significant chunk of time over the period of one month (or less if successfully treated). At least one of them must be 1, 2 or 3:
- Disorganized speech.
- Very disorganized or catatonic behavior.
- Negative symptoms.
B. The individual's level of functioning in different areas is well below the level before the onset of the disorder for a significant part of the time.
C. Ongoing signs of the disorder persist for at least six months. At least one month of criterion A symptoms must be included in the six-month period and may include periods of prodromal and residual symptoms.
D. Schizoaffective disorder and depressive disorder or bipolar disorder with psychotic features have been ruled out because of:
- No major manic or depressive episodes have occurred concurrently with the symptoms of the active phase.
- If these episodes have occurred during the active phase, they have been present for only a minimal part of the total duration of the active and residual periods of disease.
E. The disorder is not due to the direct physiological effects of any substance or another medical condition.
F. In the case of a history of an autism spectrum disorder or a childhood-onset communication disorder, the diagnosis of schizophrenia will be made only if the delusions or hallucinations are prominent and present for a minimum of a month.
After one year of the disorder, the following points should be specified:
- First episode, currently in acute episode. An acute episode is one in which the symptomatic criteria are met.
- Multiple episodes, currently in acute episode. These types of episodes can be determined after a minimum of two episodes.
- First episode, currently in remission. Diagnostic criteria are only partially met and are in remission.
- Multiple episodes, currently in partial remission.
- First episode, currently in full remission. Symptoms of the disorder are no longer present after an initial episode.
- Multiple episodes, currently in full remission.
- The current gravity. It is carried out on the symptoms of criterion A.
Positive, negative and disorganized symptoms
Despite the name, positive symptoms are those that present themselves in excess or as an exaggeration of normal functions. Negative symptoms, on the contrary, represent the absence of behaviors or loss of normal functions. Finally, disorganized symptoms have been included in the positive ones for many years, but after various investigations, it was decided to create a different category claiming that they represent a "factor of thought disorder".
- Delusions. These are misconceptions or beliefs that cannot be understood in the cultural context in which they occur. The convictions of the subject are ironclad despite showing that they lack validity. At the same time, the person cares about his belief and becomes emotionally involved. On the other hand, this thought usually causes discomfort and those who suffer from it do not usually try to alleviate it. The most common delusions are: prejudice (conspiracy thinking), persecution, control, reference (elements of the environment refer to the person), grandiosity and guilt.
- Hallucinations Hallucinations take place in the absence of a real external stimulus. The most frequent are auditory (voices, noises and voices that speak to the patient). In general they tend to be unpleasant although it does not always have to be that way. However, the most dangerous are those that give negative orders to the patient. In this case, hospitalization may be required. In visual hallucinations, the most common is seeing people. With regard to the olfactory and taste buds, they are usually unpleasant stimuli. Tactile can range from burning to itching.
- Motor symptoms or catatonia. Stuporous states stand out (paralysis without speaking and isolated from the external world), inhibition or psychomotor agitation, catalepsy or immobility and echopraxia (repeating movement that another person has just carried out).
- Praise. It is about alterations of thought that is expressed through language disorders such as lack of production or fluency. Short responses, monosyllables, or blocks may be seen.
- Abulia-apathy. It is appreciated for a lack of energy and motivation in the behavior, both to initiate it and to maintain it. It can also be observed in the lack of hygiene of the subject.
- Anhedonia. Loss to experience pleasure. Activities that used to be entertaining are no longer interesting.
- Affective flattening or dullness. Decrease or absence of emotional reactions to different stimuli. It can be seen through poor eye contact and impaired body language. It can also be observed that they leave their gaze fixed or no tonality is added to the words.
Symptoms of disorganization
- Disorganized language or formal thought disorder. When the subject speaks, he goes from one sentence to another or from one topic to another with no relation of content. If the patient is asked, the answers may be indirect and the meaning irrelevant..
- Disorganized behavior This is unpredictable behavior. This type of behavior usually occurs in patients with disorganized or catatonic type schizophrenia. Disorganization could also be a symptom of hallucinations.
- Inappropriate affection. The emotion that the person expresses is not related to the situation.
Assessment of schizophrenia
The evaluation of schizophrenia must be as complete as possible. The areas in which the patient usually operates on a daily basis should be evaluated. In this way, you can get results from your coping style and abilities. This type of assessment can be carried out through interviews, for example the "Structured Clinical Interview for the DSM-III-R" (First and Gibbon, 2004) or the "Current Status Assessment" (Cooper and Sartorius, 1974 ).
There are also scales and inventories such as:
- Brief Psychiatric Rating Scale (Overall and Gorham, 1962).
- Positive and negative symptoms scale (Kay, Fiszbein & Opler, 1987).
- Inventory for Affective Disorders and Schizophrenia (Endicott and Spitzer, 1978).
- Negative Symptom Assessment Scale (Andreasen, 1983).
- Positive Symptom Assessment Scale (Andreasen, 1984).
Types of Schizophrenia
- Preoccupation with one or more delusions of grandeur or persecution.
- Frequent auditory hallucinations.
- There is no disorganized language, no catatonic or disorganized behavior, no flattened or inappropriate affectivity.
- They may also present with anxiety, anger, a tendency to argue and violence..
- Disorganized language and behavior.
- Flattened or inappropriate affectivity.
- May present delusional ideas revolving around an incoherent topic.
- It is usually early onset.
- Marked psychomotor disturbance that may include motor immobility or excessive motor activity.
- Extreme negativism, or muteness.
- Peculiarities of voluntary movement with strange postures, stereotyped movements, grimaces.
- Copy what someone else says or does.
- It is a type of schizophrenia without hallucinations or delusions, but the patient loses his capacities, he does not give enough.
- It has an early onset (between 12-13 years), at first it seems mental retardation.
- Suffers from behavioral disturbance.
- Flattened affectivity.
Residual or defect states
- Negative symptoms predominate, it occurs when the previous alterations become chronic.
From 20 to 30% of patients manage to lead a relatively normal life. The other 20-30% experience moderate symptoms. And the remaining 40-60% lead lives disturbed by the disorder.
Good prognostic factors
- Late age of onset.
- Acute onset of the disease.
- Existence of precipitating factors: drugs.
- Absence of affective blunting.
- Clearly identifiable precipitating factors of the disease.
- If the person had good social, sexual and work adaptation before the onset of the disease.
- Favorable social and family environment.
- Good compliance with treatment.
- Family history of mood disorders.
- Confusion and atypical symptoms.
- The subtype with the best prognosis is Paranoid Schizophrenia.
Poor prognosis factors
- Early onset.
- Progressive or insidious onset of the disease.
- Prevalence of negative symptoms.
- Social isolation or few social support systems.
- Previous personality disorder.
- Affective dullness.
- Family history of schizophrenia.
- Long evolution before the first medical contact.
- Drugs abuse.
- Presence of clear brain abnormalities (dilated ventricles).
- When the disease does not remit in three years and there are multiple relapses.
- Disorganized-type schizophrenia is the most serious.
As the psychologist and researcher Vicente Caballo (2014) affirms: "taking into account the enormous diversity of symptoms that characterize it, the treatment of schizophrenia must be oriented towards their control and the rehabilitation of the neuropsychological deficits that the patient presents". Because of this, a large number of psychological techniques are often used..
The treatment is pharmacological, the antipsychotic drugs used are neuroleptics (Haloperidol, Largacil, Meleril, etc.) They are very effective in the treatment of schizophrenia but have important side effects such as tremors, stiffness, internal restlessness, sweating and even seizures. It also produces undesirable non-neurological effects such as jaundice (yellowing of the skin), high fever, aplastic anemia, dermal hypersensitivity, hypotension, weight gain and in extreme cases "neuroleptic malignant syndrome" that can lead to death. Neuroleptics appeared in the fifties, currently there are new forms of presentation that reduce these side effects such as Clizamine or Risperidone, thanks to this advance, patients do not abandon treatment so easily, as they do not suffer so much discomfort.
The patient is frequently admitted to stabilize the medication, prevent him from hurting himself or others, protect him from suicidal or homicidal ideas, to provide basic care, food, hygiene, reduce the level of stress and help him structure his daily activities. The duration will depend on the severity of the condition and the availability of resources for outpatient treatment..
At first individual psychotherapy is contraindicated, but not group or family therapy, which are usually very beneficial. Psychosocial interventions strengthen the person's ability to cope with stress or adapt to the effects of illness.
Group psychotherapy is very useful for social skills training. They allow the social and occupational rehabilitation of the patient, who learns to relate to others and to deal with daily life after contracting the disease. The important thing is that they can have an appropriate behavior within the home as well as a better social life.
It should also include:
- Complex skills training (everyday skills).
- Family intervention.
- Prediction of relapse.
- Training in protective factors.
- Díaz Marsá M, Coping with Schizophrenia. Guide for patients and families. Approach Editorial S.C. 2013.
- APA Clinical Guidelines. American Psychiatric Association. Practice guidelines for the treatment of patients with schizophrenia. 2004
- Lemos, S. (2009). Assessment of the CPG on Schizophrenia and Incipient Psychotic Disorder. Infocop Online
- López M, Laviana M, Fernández L, López A, Rodríguez AM, Aparicio A. The fight against stigma and discrimination in mental health. A complex strategy based on the information available. Rev Asoc Esp Neuropsi. 2008; 101: 43-83.
- Travé, J. and Pousa, E. (2012). Efficacy of Cognitive-Behavioral Therapy in patients with recent-onset psychosis: a review. Psychologist Papers, 33, 48-59
- American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Edition). Madrid: Editorial Médica Panamericana.
- Caballo, V., Salazar, I. and Carrobles, J. (2014). Manual of psychopathology and psychological disorders. Madrid: Pyramid Editions.