Schizophrenia is a sophisticated psychological condition
Schizophrenia is a sophisticated psychological condition characterized by varied symptoms, including disorganized behavior or speech, hallucinations, demotivation, social withdrawal, low emotional expression, cognitive impairment, and delusions. The condition has a gradual manifestation of the symptoms. Typically, symptoms commence from the young adulthood stage and often relapse as an individual advances in years. Due to its early onset, schizophrenia becomes a disabling condition to many infected individuals and their relatives. Diagnosis relies mainly on mere behavioral observations, as there are no objective criteria. For this diagnosis procedure, symptoms have to be present and persistent for at least half a year. People with schizophrenia often demonstrate other comorbidities such as substance use and anxiety disorders (depressive disorder, panic disorder, and obsessive-compulsive disorder). The disease has a global distribution with about 20 million patients globally. Schizophrenia is common in males, and its causes include genetic and environmental factors. Antipsychotic medication is often the prescribed treatment, besides social rehabilitation, counseling, and job training. The complexity of schizophrenia limits its study, thus understanding the causes, signs and symptoms, diagnosis, treatment, and management of the condition is invaluable for research and prognosis.
Environmental, vulnerability, and genetic factors play crucial roles in schizophrenia development. These risk factors have a complex association with various experiences from conception. Often referred to as a neurodevelopmental condition, schizophrenia lacks a definite boundary in definition. For instance, without interactions, genetic predispositions cannot result in schizophrenia development. However, 70% to 80% of the cases are hereditary. Different genes influence the development of schizophrenia, some with unknown expression and transmission, and some with little effect. The cumulative impact explains the 7% in the polygenic risk score for schizophrenia liability variability. At least 5% of the cases are known to associate with rare polymorphisms (copy number variations, CNVs). Some of these variations result in genetic disorders. Ultimately, these variations burgeon the risk of schizophrenia development by about twenty times and often project intellectual disability and autism as the possible comorbid. Conversely, genes such as CRHR1 and CRHBP correlate with severe suicidal behavior. Moreover, these genes express proteins associated with HPA axis orientation. Their communication affects the HPA axis, which influences stress and anxiety, which may, in turn, have a negative effect on homeostasis, emotional regulation, and negative feedback mechanism affecting behaviors.
On the other hand, environmental factors such as oxygen deficit, prenatal maternal stress, malnutrition during the development of the fetus, and infection influence the development of schizophrenia. Obesity of the maternal, dysregulation of serotonin and dopamine pathways, and escalated oxidative stress also increases the risk of schizophrenia. Fetal neurodevelopment is often affected by maternal infection and anxiety, which heightens the stimulation of pro-inflammatory cytokines. Also, minimal risks have been presented when one is born during the winter; this supposition is linked to the deficiency of vitamin D. Infections during pregnancy also contribute significantly to schizophrenia’s development. These infections include chlamydia and Toxoplasma gondii. Childhood viral infections of the brain have also been associated with schizophrenia. Social isolation, racial discrimination, poor housing conditions, unemployment, and family dysfunction are also causes of schizophrenia. Additionally, substance abuse, such as the use of cannabis, risks the development of schizophrenia. A significant number of people with schizophrenia abuse recreational substances such as excessive alcohol, marijuana, and nicotine. Recreation drugs, for instance, stimulants, including cocaine and amphetamine, result in a temporary psychosis stimulation relatable to schizophrenia. Substance abuse is also used to alleviate schizophrenia symptoms such as loneliness, anxiety, depression, and boredom. Although tobacco and cannabis use has not been associated with cognitive deficits development, drug abuse is lethal and escalates suicidal risks and inadequate treatment responses.
Notably, schizophrenia being a chronic condition with varied symptoms, early diagnosis is difficult. Schizophrenia diagnosis is attained via an evaluation of patient-specific symptoms as elucidated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This assessment criterion of schizophrenia, according to the DSM-5, follows the persistence of at least two of the active-phase symptoms that last for a minimum of one month. These active-phase symptoms include catatonic or grossly disorganized behavior, delusions, negative symptoms, disorganized speech, and hallucinations. Typically, disorganized speech, hallucinations, or delusions are the qualifying symptoms for schizophrenia diagnosis. Additionally, DSM-5 points out that schizophrenia diagnosis is effective when the patient exhibits a reduced functioning level associated with self-care, work, and interpersonal relationships. Besides, progressive schizophrenia signs must persist for a minimum of six months, including the active-phase symptoms month as previously noted. However, an intensive differential schizophrenia diagnosis is critical for differentiating the condition with other mental disorders, including advanced anxiety disorders with catatonic or psychotic traits, obsessive-compulsive disorder, post-traumatic stress disorder, and schizophreniform schizoaffective disorder, and body dysmorphic disorder. Therefore, schizophrenia is distinct for such conditions through a meticulous assessment of the illness duration, the timing of hallucinations or delusions, and the seriousness of manic or depressive symptoms. Moreover, mental health practitioners must assert that the exhibited symptoms are not associated with other medical conditions or substance abuse.
Regarding treatment, schizophrenia lacks a specific treatment; instead, treatment is symptom-based. The aim of treatment is to alleviate the symptoms, prevent relapse, and increase adaptive functioning, allowing for the ease of integration of the patient into the society. Often, people with schizophrenia hardly go back to their thresholds of adaptive functioning; thus, pharmacological and non-pharmacological medications should be used optimally for long-term changes. Pharmacological medication is the primary mode of treatment and management of schizophrenia. However, the persistence of the residual symptoms might be common. Therefore, a superimposition of non-pharmacological therapies, including psychotherapy, is also essential. Psychotherapeutics can be administered in three distinct ways; group, individual, and cognitive-behavioral. This treatment modulation includes mindfulness therapies, meta-cognitive facilitation, and narrative therapies. For efficacy, these modulations should be administered complementarily and not as the primary treatment for schizophrenia. Psychotherapeutics ensure that people with schizophrenia adhere to their medication. These non-pharmacological approaches, such as compliance therapy, cognitive behavioral therapy, and personal therapy, help educate people with schizophrenia on medication adherence. As a result, relapse and rehospitalization can be overcome.
Similarly, for effective therapy and rehabilitation, pharmacological treatment is crucial. There has been difficulty in rehabilitation approaches where antipsychotic drugs were exempted. The first-line treatment of schizophrenia is the use of second-generation antipsychotic agents. However, clozapine has been excluded because the drug can result in agranulocytosis. These antipsychotic agents (second-generation) have few cases of extrapyramidal effects compared to the first-generation antipsychotic agents. First-generation drugs inhibit dopamine neurotransmission by blocking the D2 receptors, whereas the second-gen antipsychotics influence serotonin neurotransmission. These drugs can improve anxiety symptoms in less than an hour after administration, but may last for weeks before realizing their optimal effect. However, these antipsychotics have little or no impact on cognitive and negative schizophrenia symptoms. The tolerance of these antipsychotics varies from individual to individual; therefore, there is no single first-line treatment for people with schizophrenia.
Furthermore, schizophrenia is believed to be only a human disorder. However, it can be stimulated pharmacologically in non-human models. Research is ongoing to decipher and determine the principal and effective treatment for schizophrenia. Antipsychotics have been of little effect on the negative schizophrenia symptoms. Nonetheless, various studies regarding anti-inflammatory medication, which build on the assertion that inflammation influences schizophrenia development, is progressive and promising. Alternatively, studies reveal that minocycline (antibiotic) has tentative effects on schizophrenia symptoms and can be used as an add-on medication. Research has further demonstrated the efficacy of minocycline in mitigating all the symptoms, besides its tolerance and safety. Despite the promising position of minocycline, further studies are essential. Moreover, other areas of exploration include the identification of biomarkers, which would, in turn, ease diagnosis approaches alongside prognosis and treatment. Several biomarkers have been identified, for instance, genetics, inflammation markers, BDNF, speech analysis, and neuroimaging. C-reactive proteins are invaluable in the detection of inflammation levels, which are implications in most of the mental conditions, although they lack specificity.
Being a complex disorder, schizophrenia calls for immediate medication in its initial episode of psychosis. The epidemiology of schizophrenia indicates a global distribution, and the condition is said to be the most common mental disorder. Accordingly, mental health practitioners should not overlook on adverse effects of treatment and non-adherence while considering a therapeutic approach. Despite the considerable efficacy of non-pharmacological and pharmacological therapies on adaptive functioning, further studies are needed to determine the possible cure and to counter the research gaps regarding schizophrenia.