Schizophrenia And Antipsychotic Medication

Schizophrenia overview

Psychosis is a broad construct or an umbrella term for a state of mind/being in which a person loses contact with reality in fundamental ways. Psychosis takes on numerous different forms; therefore, there is a cluster of disorders known as ‘psychotic disorders’ that exist. Each psychotic disorder is characterised by a distinct class of symptomatology, though they are quite similar conceptually.

Schizophrenia is proposed to be a specific form (i.e. subset) of psychosis. It is a mental disorder that disrupts the way people interpret reality, thereby influencing them to act, think and feel abnormally. Notably, schizophrenia may impair a person's ability to function as an individual as they may experience hallucinations, disordered thinking and delusions. All these symptoms have a profound impact on a person's quality of life. Therefore, schizophrenia is a mental disorder that requires long-term treatment to enable the individual to live an ordinary life.

Symptoms

Schizophrenia significantly alters the way one thinks, feels and acts. However, the precise way in which it does this may vary from person to person, and it may not be consistently presented.

Symptoms may present as a gradual change before any obvious, defining symptoms begin; this is known as the prodrome phase (i.e., an early symptom indicating the onset of a disease/illness).

During the height of a schizophrenic episode, the symptoms are most severe, with individuals being unable to discern whether certain ideas and perceptions are real or not. Often, those affected aren’t aware that they have schizophrenia and rarely see any fault or abnormality in their behaviour and perception unless they are told by a doctor or counsellor.

Symptoms of schizophrenia are grouped into three categories:

1. Positive symptoms (e.g., hallucinations, delusions and thought derailment)
2. Negative symptoms (e.g., social withdrawal, poverty of speech and restricted affect)
3. Cognitive symptoms (e.g., disturbances of attention, memory and executive cognitive functions)

Further information regarding each of the symptoms, alongside specific examples of what they refer to, are presented below.

Positive symptoms

Positive symptoms seem to be excesses of or abnormal additions to normal thoughts, emotions, or behaviour. Such symptoms include:

• Delusions – Refers to believing certain ideas wholeheartedly despite being false. Delusions can be of persecution, reference, grandeur or control.
• Hallucinations – PAre perceptions that a person thinks are real but only exist in their mind in the absence of external input. These can be auditory or visual in nature.
• Disorganised thinking and speech – Collective called formal thought disorders. However, it causes great confusion and makes communicating extremely difficult.
• Heightened perception – Results in intensification of perceptions and attention as individuals feel as though their senses are being flooded.

Negative symptoms

Negative symptoms seem to be (‘pathological’) deficits in normal thought, emotions or behaviours (i.e., demonstrating abnormal behaviour). Such symptoms include:

• Poverty of speech (alogia) – A reduction in speech or speech content.
• Blunt affect – Displaying less emotion than normal, which can be positive or negative.
• Flat affect – Showing no emotion, characterised by lack of facial expression.
• Loss of volution – Extreme levels of apathy and inability to start/complete a course of action.
• Social withdrawal – Due to lack of motivation or preoccupation with focusing on positive symptoms.

Different phases of schizophrenia

Schizophrenia is commonly thought to occur in a cyclical fashion consisting of three different phases.

Each of these phases may last from days to years, depending on the individual. Moreover, the course of schizophrenia differs for individuals and how long phases last varies between them.

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders (DSM 5)¹ is the scientific criteria used by clinicians and healthcare professionals to guide diagnoses by outlining the specific descriptions, symptoms and other criteria for each condition.

The DSM-5-TR’s classification of schizophrenia is listed below:

Characteristic symptoms

Individuals must present two (or more) of the following symptoms, each for a significant portion of time during a one-month period:

• Delusions²
• Hallucinations³
• Disorganised speech (in terms of derailment or incoherence)
• Grossly disorganised or catatonic behaviour (i.e., disrupted awareness of the world around you)
• Negative symptoms, such as:
  • Affect flattening (i.e., difficulty expressing emotions normally)
  • Alogia (i.e., poverty of speech)
  • Avolition (i.e., total lack of motivation, which makes it challenging to get anything done)

Social/occupational dysfunction

One or more areas of function (e.g., work, interpersonal relations, or self-care) will be significantly impaired for a substantial period of time.

Duration

Continuous signs of these disturbances should persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.

Schizophrenia causes

Researchers are unsure precisely what the causes of schizophrenia are. However, it is widely thought that a combination of genetics, brain chemistry and environment all play a contributing role.

This is in line with the diathesis-stress perspective, which attests that people have a biological predisposition to develop a disorder only if certain kinds of events or stresses are also present, as these will act as triggers. In turn, it is thought that a combination of biological and environmental factors play a causal role in the development of a mental disorder, here that being schizophrenia.

Biological factors

Genetic researchers believe that some individuals inherit a biological predisposition to schizophrenia, which makes them more vulnerable to developing this disorder. There are a number of studies that have been done to support this theory; these include:

• Studies of relatives of people with schizophrenia: These studies show a greater incidence in relatives with schizophrenia compared to those without any family history.⁴ Moreover, one’s lifetime risk increases with more diagnosed relatives and relatives who are more closely related to them.⁵
• Twin studies: There was an estimated 81% heritability of schizophrenia when looking at pairs of twins who have schizophrenia.⁶
• Parent studies: One’s risk of developing schizophrenia increases if one of their parents has the disorder, and even more so if both parents have it.⁷

Beyond genetic factors, research points towards two kinds of inheritable biological abnormalities that likely contribute to the development of schizophrenia:

1.  Biochemical abnormalities

The dopamine hypothesis argues that schizophrenia is the result of excessive activity of the neurotransmitter (i.e., chemical brain messenger) dopamine.⁸ Excessive dopamine causes certain neurons to fire more often and transmit too many signals, thus producing the symptoms of schizophrenia.

2. Dysfunctional brain structures & circuitry

Brain scans show the dysfunction brain structure that work together, notably the schizophrenia-related circuit.⁹ Under varying circumstances, particular structures in the brain circuits are hyperactive or underactive in terms of activity, and their interconnectivity (i.e., the flow of communication between brain structures) may be excessive or diminished.

It is thought that two distinct subcircuits operate in schizophrenia, where one is responsible for evoking positive symptoms and the other for negative symptoms.

When weighing up both arguments, overall, it is thought that abnormal dopamine function is seen as part of a broader circuit dysfunction which can ultimately propel people towards schizophrenia.

Sociocultural factors

The family explanation argues that families of those with schizophrenia tend to be emotionally fraught and over-protective/involved in the lives of others. This phenomenon is termed high negative expressed emotion.

Furthermore, people in recovery from schizophrenia are almost four times more likely to relapse if they live with such a family than if they live with one in low expressed emotion.¹⁰

Role of antipsychotic medication in treating schizophrenia

Antipsychotic medication is one treatment method used to reduce or relieve the symptoms of schizophrenia to enable affected individuals to live a more functional lifestyle.

The medication can help manage symptoms within hours or days by acting on the neurotransmitters serotonin and dopamine. Therefore, the drugs are effective in immediately relieving symptoms and preventing further episodes.

Importantly, whilst such medication helps to control symptoms, they do not treat or eradicate the underlying condition; therefore, other forms of treatment may need to be taken in conjunction with taking antipsychotics.

In terms of effectiveness, positive symptoms respond to treatment in most patients, although negative and cognitive symptoms do not respond well.¹¹ Additionally, side effects of the drugs are a major problem which reduces compliance and adherence.

Mechanism of action

There are numerous explanations for why antipsychotic medication is able to help reduce psychotic symptoms, these include:

• Blocking dopamine – In line with the dopamine hypothesis as a cause of schizophrenia, antipsychotics block the action of some dopamine receptors in the brain. Blocking dopamine prevents the flow of chemical messages within the brain which in turn reduces positive symptoms.
• Modulating other brain chemicals – The production and destruction of neurotransmitters, such as those responsible for regulating mood, are altered by antipsychotics. Examples of neurotransmitters include serotonin, glutamate, and noradrenaline.

Types of antipsychotic medication

Antipsychotic medications fall into one of two categories:

1. First-generation (older) or 'typical’ antipsychotics
2. Second-generation (newer) or ‘atypical’ antipsychotics

Both types have contrasting mechanisms of action, work differently for different people, and have varying side effects.

The main difference between typical and atypical antipsychotics is that first-generation drugs block dopamine, whilst second-generation drugs block dopamine and alter serotonin. Moreover, second-generation drugs have milder movement-related side effects than first-generation drugs.

Side effects

Antipsychotic medication has numerous side effects that are not all inherently desirable. Examples of such side effects include:

• Dry mouth
• Dizziness
• Blurred vision
• Constipation
• Seizures
• Weight gain (particularly amongst women)
• Muscle stiffness or spasms
• Metabolic syndrome / cardiovascular changes
• Sexual dysfunctions
• Tardive dyskinesia (i.e., a disorder characterised by uncontrollable, sudden, irregular movements)

Choosing the right antipsychotic medication

Finding the right antipsychotic medication for you is pivotal in helping you manage your conditions. It is important to discuss how best to proceed with your doctor or psychiatrist. The right antipsychotic medication will depend on:

• How well it treats symptoms
• Your willingness to cooperate with drug treatment and adherence
• The side effects of medication
• The type of form the medication is delivered in
• The type of antipsychotic medication
• How easily and often you can get it
• How much it costs
• Any dietary restrictions or intolerances
• The half-life of medication

Combining medication with other treatments 

In addition to antipsychotic medication, alternative treatment options should also be integrated into one’s treatment plan. This is primarily because antipsychotic medication will only help to manage and suppress symptoms. Therefore, alternative treatment options such as therapy and counselling provide long-term benefits as they do aim to challenge and correct the root cause of schizophrenia.

Below are various forms of psychological intervention that could be undertaken in conjunction with antipsychotic mediation.

Psychotherapy

Psychotherapy is a form of treatment for mental health issues which stems from talking to a psychologist, psychiatrist or mental health provider. Psychotherapy is also more commonly known as counselling, therapy, talk therapy, or psychosocial therapy.

As part of psychotherapy, one learns about their specific issue and, more precisely, how their thoughts, emotions and behaviour all affect one another as well as their overall mood. Psychotherapy helps an individual to take control and ownership of their life and teaches them effective ways to respond to challenging situations by using healthy coping skills that they can integrate into their everyday lifestyle.

There are various forms of psychotherapy, and choosing the right one for you will depend on your situation and what issues you are trying to face.

Cognitive behavioural therapies

Cognitive behavioural therapy (CBT) is a form of talking therapy that helps identify unhealthy, negative beliefs and behaviours while learning healthier coping strategies to deal with them.

There are two kinds of cognitive-behavioural therapies available for people with schizophrenia:

1. Cognitive remediation – A treatment that focuses on the cognitive impairments that often characterise people with schizophrenia, particularly their difficulties in attention, planning, and memory.¹² This intervention is effective in people with schizophrenia¹³ and such cognitive improvements extend to people’s everyday lives and social relationships.
2. Hallucination reinterpretation and acceptance – Helps change how people view and react to their hallucinations by guiding them to more accurately interpret these experiences in a non-fearful or confusing way.¹⁴ Such intervention does not eliminate hallucinations; instead, it renders them less powerful and destructive, so they do not significantly debilitate individuals.

Family therapy

Families often play a key support role for individuals with schizophrenia. Therefore, this therapy aims to help the individual and their family cope better with the condition.

In family therapy, family members develop more realistic expectations and improve their tolerance, decrease their sense of guilt, and learn new patterns of communication. Moreover, the individuals themselves learn how to cope with the pressures of family life and better utilise family resources to avoid troublesome interactions or potential conflicts.

Social therapy

It is widely believed that treatment should also extend to include techniques that address the social and personal struggles of individuals. Clinicians offer practical advice by working with clients on solving problems, enhancing memory, solving problems and improving social skills. Clinicians also make sure that the clients are taking their medications properly and may even help them find work, financial assistance, appropriate health care, and proper housing.¹⁵

Art therapy

Designed to promote a more creative and safe expression of experiences during an episode of schizophrenia, art therapy has been shown to be particularly effective for individuals who suffer from negative symptoms as it helps to alleviate them.

Summary

Schizophrenia is a mental disorder that disrupts the way people interpret reality, thereby influencing them to act, think and feel in an abnormal manner. Notably, schizophrenia may result in impaired daily function as individuals may experience hallucinations, disordered thinking, delusions and paranoia. All these symptoms have a profound impact on an individual, and therefore, the condition is often one that requires long-term treatment to enable the individual to live an ordinary life. The predisposition of schizophrenia in an individual depends heavily on both environmental and genetic factors. Schizophrenia is often treated with a combination of pharmacological and psychological methods. Antipsychotic medication is beneficial in managing positive symptoms by altering the levels of neurotransmitters in the brain, whereas talking therapies are used to treat negative symptoms by rationalising thoughts and learning healthy coping mechanisms. It is important to recognise that individuals suffering from schizophrenia go through a cycle of symptoms emerging and subsiding throughout their lives, and managing schizophrenia requires a great support system that would involve family members or healthcare professionals.