Schizophrenia And Social Withdrawal

Introduction

Have you ever imagined having an imaginary friend who could accompany you when no one else could? This friend gives you commands on how to live, controls your relationship with people, and tries to convince you that someone else is watching you or that others are planning to harm you. Imagine living with this friend every day of your life. This is exactly how a schizophrenic patient suffers.

So, what is schizophrenia? And why do schizophrenia patients tend to be socially isolated?

Schizophrenia is a serious mental illness that affects how people live, think, and see the world. It includes a range of symptoms, such as hallucinations, delusions, social isolation, and memory problems that affect the patient's quality of life. Additionally, schizophrenic patients might lose touch with reality, and they won't be able to differentiate between what is real and imagined. Thus, they avoid being with people and prefer to be socially isolated.¹

Symptoms of schizophrenia

People with schizophrenia may experience various symptoms. These symptoms are grouped into positive, negative, and cognitive symptoms.

Positive symptoms

Positive symptoms include changes or exaggerations in behaviours or thoughts, such as hallucinations (hearing or seeing things that are not present) or delusions (false beliefs not based on reality and unlikely to occur).²

Negative symptoms

Negative symptoms refer to losing interest and motivation in everyday activities. These symptoms include social withdrawal with a desire to stay in the house, lack of motivation, and reduced facial and emotional expressions.²

Cognitive symptoms

Cognitive symptoms relate to problems with memory and thinking that affect the patient's attention and ability to learn and function in daily life.²

Social withdrawal in schizophrenia

Positive symptoms of schizophrenia have received major attention. These symptoms are managed with the available typical and atypical antipsychotics. In contrast, negative symptoms and cognitive impairments are poorly responsive to the available medications. Negative symptoms, in particular, are disabling for patients because they are persistent during the remission periods and can lead to poor functioning and quality of life.³

Definition

Social withdrawal is the core aspect of the negative symptoms, in which patients tend to isolate themselves and avoid social interactions. It is characterised by a lack or absence of interest in usual activities and motivations, depressed mood, low energy, reduced communication with family and friends, and the preference to stay alone for a long time.⁴

Prevalence

Social withdrawal is the most prevalent symptom in the category of negative symptoms. It affects most patients diagnosed with schizophrenia and is usually associated with reduced emotion and lack of motivation.

Causes

According to previous studies, changes in dopamine activity contribute to the symptoms of schizophrenia. Dopamine is a neurotransmitter that helps nerve cells communicate with each other. Dopamine is associated with multiple physical and psychological processes like happy mood, motivation, reward, movement, memory, attention, and learning. Thus, having the right level of dopamine is essential for optimal brain function.

The positive symptoms of schizophrenia develop due to the increased dopamine activity in one of the dopamine pathways in the brain called the mesolimbic pathway. In contrast, the negative and cognitive symptoms develop due to the decreased dopamine activity in the mesocortical pathway. Messages sent along the mesocortical pathway go to the prefrontal cortex area of the brain. This area is associated with emotional control, motivation, attention, and memory. Therefore, the low activity of dopamine leads to decreased motivation, depression, and social isolation.⁵

Impact on quality of life

Social withdrawal in schizophrenia can negatively affect the patient's quality of life. It can lead to loneliness, depression, and social isolation, which can further exacerbate symptoms of schizophrenia. Social withdrawal can also make it difficult to maintain employment, pursue educational opportunities, and engage in social activities, which leads to a decreased sense of purpose and fulfilment in life.⁶

Factors contributing to social withdrawal in schizophrenia

Various factors could contribute to social withdrawal in schizophrenia. Some of these factors include:

Social cognition impairment

Social cognition refers to cognitive abilities that apply to the social situation, like emotional recognition, understanding the intention of others, attributional styles, and social knowledge. Schizophrenia patients often experience impairment in social cognition. These patients face difficulty interpreting social hints, emotions, and intentions, leading to miscommunication and social anxiety. As a result, they tend to be socially isolated and avoid being with people.⁷

Stigma and discrimination

Most schizophrenia patients face some form of stigmatisation and discrimination. Stigmatisation is a set of negative attitudes and false beliefs about the diagnosis of schizophrenia that affects the illness's understanding by others.⁶ The different types of stigma, like public, self, and label avoidance stigma, may result in discrimination, leading to disadvantages in access to care, poor health service, and frequent life events that can damage self-esteem and social functioning. The threat of social disapproval and low self-esteem associated with label avoidance stigma can cause delays in treatment-seeking behaviour and underuse of services.⁸

Medications

The available antipsychotic medications used to treat schizophrenia are associated with serious side effects, known as extrapyramidal side effects. These side effects include tremors, involuntary movement, inability to sit, stiff muscles, and involuntary facial movements. All these might make social interaction uncomfortable or result in embarrassment in social situations.⁹

Lack of social support

Social support is a person's assumptions and perceptions regarding the extent to which they feel adored, respected, and admired by others; and feel as if they belong in a circle of communication and collective accountability. Family and friends' support plays an important role in schizophrenia treatment. Lack of social support can lead to social withdrawal, non-adherence to medications, a high relapse rate, and an increase in the frequency of hospitalisation for schizophrenia patients.¹⁰

Management of social withdrawal in schizophrenia

Effective management of social withdrawal in schizophrenia involves a combination of pharmacological and psychosocial interventions.

Medications

Typical and atypical antipsychotic medications are commonly prescribed to manage the symptoms of schizophrenia, like hallucinations and delusions, which contribute to social withdrawal. Other medications, such as antidepressants and antianxiety medications, can also be prescribed to manage mood changes and anxiety symptoms that could lead to social isolation.¹¹

Psychotherapy

Psychotherapy can assist in addressing the social and emotional aspects of schizophrenia that antipsychotic medications alone cannot. The most common type of psychotherapy is cognitive behaviour therapy (CBT). This therapy helps patients change how they think and react to things. It also teaches patients to identify and challenge negative thoughts and beliefs that may contribute to social withdrawal. In addition, CBT assists patients in setting and achieving goals in therapy and daily life.¹²

Social skills training

Social skills training refers to techniques that assist schizophrenia patients in improving their coping skills, enhancing their social interactions, promoting problem-solving, engaging in relationships, and adhering to medications. By addressing specific skill deficiencies, patients will begin to control the negative symptoms of schizophrenia and improve social functioning, which helps them maintain healthy relationships and positive interpersonal interactions. Some social skills training techniques include role-playing, didactic instruction (teacher-directed instruction), and reinforcement techniques, which assist patients in engaging in social situations more effectively.⁴

Family therapy

Family therapy focuses on educating the family about the nature and course of schizophrenia and specific management strategies to help control the symptoms. It also teaches the family how to cope with stress and to work together whenever problems arise after one member is diagnosed with schizophrenia. Both patient and family will learn to communicate and discuss the problems to determine the best solution for everyone.¹²

Cognitive remediation

Cognitive remediation (CR) is also known as cognitive rehabilitation intervention. It is a system of behavioural training based on an intervention designed to enhance memory, attention, motivation, and social cognition with the goal of durability and generalisation. CR strategies are classified into two models:

• Compensatory model: This treatment aims to eliminate or bypass the cognitive impairment by using the person's residual cognitive abilities or manipulating the environment to influence and facilitate cognitive functions
• Restorative model: This method is based on knowledge obtained from neuronal plasticity and aims to correct specific deficits using the ability of the brain to develop and repair itself throughout life¹³

Summary

• Negative symptoms and cognitive impairments of schizophrenia are poorly responsive to medications, particularly antipsychotics, and are disabling for patients 
• Social withdrawal is a core aspect of the negative symptoms, which negatively affects the patient's quality of life and leads to loneliness, depression, and social isolation. 
• Certain factors contribute to social withdrawal, like social cognition impairment, stigma and discrimination, medications, and lack of social support 
• Treatment strategies for social withdrawal may vary depending on the severity and the associated symptoms. Therefore, a comprehensive treatment plan should be developed in collaboration with a mental health professional. This plan could include a combination of antipsychotic medications, social skills training, psychotherapy, and family education