SchizophreniaSchizophrenia is a psychiatric diagnosis denoting a persistent, often chronic, mental illness variously affecting behaviour, thinking, and emotion. The term schizophrenia is best translated "shattered mind". Symptoms Psychiatrist Emil Kraepelin was first to make the distinction between what he called dementia praecox and other forms of madness. This classification was later renamed 'schizophrenia' by psychiatrist Eugene Bleuler as it became clear Kraeplin's name was not an adequate description of the condition. The diagnostic approach to schizophrenia has been opposed, most notably by the anti-psychiatry movement, who argue that classifying specific thoughts and behaviours as illness allows social control of people that society finds undesirable but who have committed no crime. More recently, it has been argued that schizophrenia is just one end of a spectrum of experience and behaviour, and everybody in society may have some such experiences in their life. This is known as the 'continuum model of psychosis' or the 'dimensional approach' and is most notably argued for by psychologist Richard Bentall. Although no definite causes of schizophrenia have been identified, most researchers and clinicians currently believe that schizophrenia is primarily a disorder of the brain. It is thought that schizophrenia may result from a mixture of genetic disposition (genetic studies using various techniques have shown relatives of people with schizophrenia are more likely to show signs of schizophrenia themselves) and environmental stress (research suggests that stressful life events may precede a schizophrenic episode). It is also thought that processes in early neurodevelopment are important, particularly those that occur during pregnancy. In adult life, particular importance has been placed upon the function (or malfunction) of dopamine in the mesolimbic pathway in the brain. This theory, known as the dopamine hypothesis of schizophrenia largely resulted from the accidental finding that a drug group which blocks dopamine function, known as the phenothiazines, reduced psychotic symptoms. These drugs have now been developed further and antipsychotic medication is commonly used as a first line treatment. However, this theory is now thought to be overly simplistic as a complete explanation. History This nonspecific concept of madness has been around for many thousands of years and schizophrenia was only classified as a distinct mental disorder by Kraepelin in 1887. He was the first to make a distinction in the psychotic disorders between what he called dementia praecox and manic depression. Kraepelin believed that dementia praecox was primarily a disease of the brain [2], and particularly a form of dementia. Kraepelin named the disorder 'dementia praecox' (early dementia) to distinguish it from other forms of dementia (such as Alzheimer's disease) which typically occur late in life. He used this term because his studies focused on young adults with dementia.22 The term schizophrenia is derived from the Greek words 'schizo' (split) and 'phrene' (mind) and was coined by Eugene Bleuler to refer to the lack of interaction between thought processes and perception. He was also the first to describe the symptoms as "positive" or "negative."22 Bleuler changed the name to schizophrenia as it was obvious that Krapelin's name was misleading as the illness was not a dementia (it did not always lead to mental deterioration) and could sometimes occur late as well as early in life. Bleuler intended the name to capture the separation of function between personality, thinking, memory, and perception, however it is commonly misunderstood to mean that persons with schizophrenia have a 'split personality' (something akin to the character in Robert Louis Stevenson's The Strange Case of Dr. Jekyll and Mr. Hyde). Although it is commonly confused with multiple personality disorder, schizophrenia has nothing to do with the manifestation of distinct multiple personalities within a person. The confusion perhaps arises in part due to the meaning of Blueler's term 'schizophrenia'. Interestingly, the first known misuse of this term to mean 'split personality' (in the Jekyll and Hyde sense) was in an article by the poet T. S. Eliot in 1933 [3]. Diagnosis and presentation (signs and symptoms) The most commonly-used criteria for diagnosing schizophrenia are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) although the International Statistical Classification of Diseases and Related Health Problems (ICD) is commonly used in European countries. Below is an abbreviated version of the diagnostic criteria from the DSM-IV-TR, the full version is available here. To be diagnosed as having schizophrenia, a person must display:
Historically, schizophrenia in the West was classified into simple, catatonic, hebephrenic, and paranoid. The DSM now contains five sub-classifications of schizophrenia. These are
Symptoms may also be described as 'positive symptoms' (those additional to normal experience and behaviour) and negative symptoms (the lack or decline in normal experience or behaviour). 'Positive symptoms' describe psychosis and typically include delusions, hallucinations and thought disorder. 'Negative symptoms' describe the inappropriate or a lack of emotion, poverty of speech and lack of motivation. It is worth noting that many of the positive or psychotic symptoms may occur in a variety of disorders and not only in schizophrenia. The psychiatrist Kurt Schneider tried to list the particular forms of psychotic symptoms which he thought were particularly useful in distinguishing between schizophrenia and other disorders which could produce psychosis. These are called first rank symptoms or Schneiderian first rank symptoms and include delusions of being controlled by an external force, the belief that thoughts are being inserted or withdrawn from your conscious mind, the belief that your thoughts are being broadcast to other people and hearing hallucinated voices which comment on your thoughts or actions, or may have a conversation with other hallucinated voices. It now seems that 'first rank symptoms' are not a reliable method of diagnosing schizophrenia [4], however the term might still be used descriptively by mental health professionals. Продвижение сайта предоплата. Поисковое продвижение сайта доходы. Com продвижение сайта. Diagnostic issues and controversies Proponents have argued for a new approach that would use the presence of specific neurocognitive deficits to make a diagnosis. These often accompany schizophrenia and take the form of a reduction or impairment in basic psychological functions such as memory, attention, and problem solving. It is these sorts of difficulties, rather than the psychotic symptoms (which can in many cases by controlled by antipsychotic medication), which seem to be the cause of most disability in schizophrenia. However, this argument is relatively new and it is unlikely that the method of diagnosing schizophrenia will change radically in the near future. The diagnostic approach to schizophrenia has also been opposed by the anti-psychiatry movement, who argue that classifying specific thoughts and behaviours as an illness allows social control of people that society finds undesirable but who have committed no crime. They argue that this is a way of unjustly classifying a social problem as a medical one to allow the forcible detention and treatment of people displaying these behaviours, which is something which can be done under mental health legislation in most western countries. An example of this can be seen in the former Soviet Union, where an additional sub-classification of sluggishly progressing schizophrenia was created. Particularly in the RSFSR (Russian Soviet Federated Socialist Republic) this diagnosis was used for the purpose of silencing political dissidents or forcing them to recant their ideas by the use of forcible confinement and treatment. In 2000 similar concerns about the abuse of psychiatry to unjustly silence and detain members of the Falun Gong movement by the Chinese government led the American Psychiatric Association's Committee on the Abuse of Psychiatry and Psychiatrists to pass a resolution to urge the World Psychiatric Association to investigate the situation in China. Western psychiatric medicine tends to favour a definition of symptoms that depends on form rather than content (an innovation first argued for by psychiatrists Karl Jaspers and Kurt Schneider). Therefore, you should be able to believe anything, however unsual or socially unacceptable, without being diagnosed delusional, unless your belief is judged to be held in a particular way. In principle this would stop people being forcibly detained or treated simply for what they believe. However, in practice the distinction between form and content is not easy, or sometimes possible, to make (see delusion). This had led to accusations by anti-psychiatry, surrealist and mental health system survivor groups that psychiatric abuses exist to some extent in the West as well. Cause A recent review listed seven genes as likely to be involved in the inheritance of schizophrenia or the risk of developing schizophrenia [26]. Evidence comes from research (such as linkage studies) suggesting multiple chromosomal regions are transmitted to people who are later diagnosed as having schizophrenia. Some family association studies have demonstrated a relationship to a gene known as COMT that is involved in encoding the dopamine catabolic enzyme catechol-O-methyl transferase [27]. This is particularly interesting because of the known link between dopamine function, psychosis, and schizophrenia. While highly heritable (close to 70%), schizophrenia is a disorder of complex inheritance (analogous to diabetes or high blood pressure). Thus, several genes interact to generate risk for schizophrenia. Genetic evidence for the role of the environment comes from the observation that identical twins do not universally develop schizophrenia. A recent review of the genetic evidence have suggested a 28% chance of one identical twin developing schizophrenia if the other already has it [7]. There is also considerable evidence indicating that stress may trigger episodes of schizophrenia. For example, emotionally turbulent families [8] and stressful life events [9] have been shown to be risk factors for relapses or triggers for episodes of schizophrenia. Other factors such as poverty and discrimination may also be involved. This may explain why minority communities have much higher rates of schizophrenia than when members of the same ethnic groups are resident in their home country. Although no definite causes of schizophrenia have been identified, most researchers and clinicians currently believe that schizophrenia is primarily a disorder of the brain. It is also thought that processes in early neurodevelopment are important, particularly during pregnancy. For example, women who were pregnant during the Dutch famine of 1944, where many people were close to starvation, had a higher chance of having a child who would later develop schizophrenia [10]. Similarly, studies of Finnish mothers who were pregnant when they found out that their husbands had been killed during the Winter War of 1939 - 1940 have shown that their children were much more likely to develop schizophrenia when compared with mothers who were found out about their husbands' death before or after pregnancy [11], suggesting that even psychological trauma in the mother may have an effect. In adult life, particular importance has been placed upon the function (or malfunction) of dopamine in the mesolimbic pathway in the brain. This theory, known as the dopamine hypothesis of schizophrenia largely resulted from the accidental finding that a drug group which blocks dopamine function, known as the phenothiazines, reduced psychotic symptoms. These drugs have now been developed further and antipsychotic medication is commonly used as a first line treatment. However, this theory is now thought to be overly simplistic as a complete explanation. Partly as newer antipsychotic medication (called atypical antipsychotic medication) is equally effective as older medication, but also affects serotonin function and may have slightly less of a dopamine blocking effect. Psychiatrist David Healy has also argued that pharmaceutical companies have promoted certain oversimplified biological theories of mental illness to promote their own sales of biological treatments [12]. Much recent research has focused on differences in function in certain brain areas in people diagnosed with schizophrenia. Studies using neuropsychological tests and brain scanning technologies such as fMRI and PET have shown that differences seem to most commonly occur in the frontal lobes, hippocampus, and temporal lobes [13]. These differences are heavily linked to the neurocognitive deficits which often occur with schizophrenia, particularly in areas of memory, attention, problem solving, and social cognition. Incidence and prevalence Schizophrenia is also a major cause of disability. In a recent 14-country study [15], active psychosis was ranked the third most disabling condition after quadreplegia and dementia and before paraplegia and blindness. Treatment Hospitalisation may occur with severe episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Mental health legislation may also allow a person to be treated against their will. However, in many countries such legislation does not exist, or does not have the power to enforce involuntary hospitalisation or treatment. Psychotherapy or other forms of talk therapy may be offered, with cognitive behavioural therapy being the most frequently used. It has been shown to be effective in helping people diagnosed with schizophrenia [17], and may focus on the direct reduction of the symptoms, or on related aspects, such as issues of self-esteem, social functioning, and insight. Other support services may also be available such as drop-in centres, visits from members of a 'community mental health team' and patient-led support groups. In many non-Western societies, schizophrenia may be treated with more informal, community-led methods. A particularly sobering thought for Western psychiatry is that outcome for people diagnosed as schizophrenic in non-Western countries may be actually be much better [18] than for people in the West. The reasons for this are still far from clear, although cross-cultural studies are being conducted to find out why. Prognosis There is an extremely high suicide rate associated with schizophrenia. A recent study showed that 30% of patients diagnosed with this condition had attempted suicide at least once during their lifetime [20]. Another study suggested that 10% of persons with schizophrenia die by suicide [21]. Schizophrenia and drug use It has been noted that the majority of people with schizophrenia (estimated between between 75% and 90%) smoke tobacco. However, people diagnosed with schizophrenia have a much lower than average chance of getting and dying from lung cancer. While the reason for this is unknown, it may be because of a genetic resistance to the cancer, a side-effect of drugs being taken, or a statistical effect of increased likelihood of dying from causes other than lung cancer [22]. It is argued that the increased level of smoking in schizophrenia may be due to a desire to self-medicate with nicotine. A recent study of over 50,000 Swedish conscripts found that there was a small but significant protective effect of smoking cigarettes on the risk of developing schizophrenia later in life. [28] Whilst the authors of the study stressed that the risks of smoking far outweigh these minor benefits, this study provides further evidence for the 'self-medication' theory of smoking in schizophrenia and may gives clues as to how schizophrenia might develop at the molecular level. Alternative approaches to schizophrenia Psychiatrist Thomas Szasz has argued that psychiatric patients are not ill but are just individuals with unconventional thoughts and behaviour that make society uncomfortable. He argues that society seeks to unjustly control such individuals by classifying their behaviour as an illness and forcibly treating them as a method of social control. An important but subtle point is that Szasz has never denied the existence of the phenomena that mainstream psychiatry classifies as an illness (such as delusions, hallucinations or mood changes) but simply does not believe that they are a form of illness. Similarly, psychiatrist R. D. Laing has argued that the symptoms of what we call mental illness are just reasonable (although perhaps not always obviously comprehensible) reactions to impossible demands that society and particularly family life puts on some individuals. Laing was revolutionary in valuing the content of psychotic experience as worthy of interpretation, rather than considering it simply as a secondary but essentially meaningless marker of underlying psychological or neurological distress. It is worth noting that neither Szasz nor Laing ever considered themselves to be 'anti-psychiatry' in the sense of being against psychiatric treatment, but simply believed that it should be conducted between consenting adults, rather than imposed upon anyone against their will. The 1976 book The Origin of Consciousness in the Breakdown of the Bicameral Mind, by psychologist Julian Jaynes proposed that until the beginnings of historic times schizophrenia or a closely similar condition was the normal human consciousness; a "bicameral mind" in which a normal state of low affect suitable for routine activities would be interrupted in moments of crisis by "mysterious voices" giving instructions, which early people characterized as interventions from the gods. This theory was briefly controversial but continued work has not provided additional support. Psychiatrist Tim Crow has argued that schizophrenia may be the evolutionary price we pay for a left brain hemisphere specialisation for language [25]. Since psychosis is associated with greater levels of right brain hemisphere activation and a reduction in the usual left brain hemisphere dominance, our language abilities may have evolved at the cost of causing schizophrenia when this system breaks down. Researchers into shamanism have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman [24]. Certainly the experience of having access to multiple realities is not uncommon in schizophrenia, and is a core experience in many shamanic traditions. Equally, the shaman may have the skill to bring on and direct the alternative state of consciousness psychiatrists label as illness. (See anti-psychiatry.) Alternative medicine tends to hold the view that schizophrenia is primarily caused by imbalances in the body's reserves and absorption of dietary minerals, and/or the presence of heavy metals. The body's reactions to gluten are also implicated in some alternative theories (see gluten-free, casein-free diet). Famous people affected by schizophrenia
References [1] Evans, K., McGrath, J., & Milns, R. (2003) Searching for schizophrenia in ancient Greek and Roman literature: a systematic review. Acta Psychiatrica Scandanavica, 107(5), 323-330. |
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