Schizophrenia – The “psycho” disorder?!

Schizophrenia

What is Schizophrenia?

Schizophrenia is a complex brain disorder, with its pathogenesis in neurodevelopmental anomalies. The 5 domains of schizophrenia include:

  • Positive symptoms (delusions, hallucinations).
  • Negative symptoms.
  • Ubiquitous cognitive deficits
  • Motor symptoms (dyskinesias).
  • Deficits in social cognition, or socio-occupational functioning.
Negative Symptoms: 

Negative symptoms include blunted affect, alogia, avolition, asociality, amotivation, anhedonia, ideational constriction, apathy or inertia, and abulia.

  • Blunted affect: This refers to the decreased intensity and repertoire of emotional expressions.
  • Alogia: This refers to the paucity in the speech content that is evident in patients of schizophrenia.
  • Avolition: This refers to the deficits in initiation and maintenance of goal-directed behaviors.
  • Anhedonia: This is the decreased ability to experience and anticipate pleasure, or pleasurable emotions. Recent studies have pointed out that patients with schizophrenia have the ablility to enjoy the pleasurable experience. However, they display a lack of wanting to experience these pleasurable pursuits or enjoyable experiences. Consummatory hedonia is the ability to experience an emotion. Also, anticipatory hedonia is the want to experience a pleasurable pursuit. Patients with schizophrenia display anticipatory anhedonia. However, negative symptoms have not been unique to schizophrenia alone.
Classification of Negative Symptoms:

Deficits in the brain circuitry concerning reward (nucleus accumbens), motivation and pleasure are the reason for negative symptoms.

Negative symptoms are further classified into:

  • Enduring Primary Negative Symptoms: The enduring primary negative symptoms can consistently present over long periods of time, despite fluctuations in other aspects of the disease. These enduring primary negative symptoms constitute what is called the deficit syndrome in schizophrenia.
  • Transitory Secondary Negative Symptoms: Secondary negative symptoms can occur transitory in nature, fluctuate largely over the course of the illness, and abate with reduction in the other aspects of the disease.
What Causes Secondary Negative Symptoms?
  • These are secondary to positive symptoms. That is, if a patient hears voices commanding him not to venture out of his home, lest he is attacked by his arch nemesis, such an individual is bound to stay at home for the fear of being attacked. Such an individual will also limit his social interaction, and display paucity in his speech content. People mistake this for apathy and alogia. However, in fact it is a reflection of the aftermath of auditory hallucinations, a positive symptom.
  • Secondary negative symptoms are attributable to chronic social deprivation. This is evident in patients who are chronically institutionalized in asylums. Such long bouts of social isolation serve to remove all motivation in these individuals to interact with the outside world, especially at a time when they are overwhelmed by their illness, and are unable to integrate their inner perceptual experiences. Chronic institutionalization comes across as a severely under-stimulating environment. 
  • Lastly secondary negative symptoms may be due to medications themselves. In medical terms, it is called neuroleptic-induced dysphoria. The medications which are used to treat a psychotic breakdown cause a reduction in the levels of the happy hormone serotonin, and this may produce a depression like picture. However, this is not to be confused with the post-psychotic depression that is commonly seen after a psychotic episode. Although the treatment does not differ in both these scenarios, recognition of the individual clinical scenario has important prognostic ramifications. In theory, risk of exacerbation of the psychotic symptoms exists, when the post-psychotic depression is treated with antidepressants.
Deficit Syndrome:
  • Indeed, deficit syndrome or a clustering of these negative symptoms entails a poor quality of life, and impaired socio-occupational functioning.
  • Subsequently, individuals become unproductive, and lead a life of social isolation and deprivation.
  • The motivation to go out and do something beautiful, achieve a target, strive towards betterment of oneself diminishes and stops. Also, work towards a greater good of one’s community, all day to day goals in the lives of a regular individual, cease to exist.
Degree of Future Negative Symptoms:
  • Firstly, Among the strongest predictors of the degree of future negative symptoms is Duration of Untreated Psychosis, or DUP.
  • Thus, DUP refers to the time lag between the appearance of the first psychotic symptoms, and the treatment sought for these symptoms.
  • However, greater the duration of the untreated psychosis, greater is the future occurence of negative symptoms and cognitive deficits.
  • Indeed, an individual with a substantial cognitive reserve offers some protection against the cognitive deficits in schizophrenia, and dementia.
  • Since the nature of these cognitive deficits is ubiquitous, these may be evident as early as the prodromal phase of schizophrenia.
  • Indeed, greater the volume of grey matter loss, greater is the cognitive deficit syndrome. Also, greater the duration of untreated psychosis, greater is the grey matter volume loss.

Treatment:

Factoring in all these points, it becomes imperative to seek comprehensive professional psychiatric help early in the course of the illness. The prodromal phase of schizophrenia presents with memory disturbances, vague anxiety and depressive symptoms, progressive social withdrawal, before the positive symptoms set in. This prodrome can last as long as 5 years before the onset of core psychotic symptoms, like delusions and hallucinations.

Management of Negative Symptoms:
Non-pharmacological Management:
  1. Psychosocial interventions: Indeed, this is as important as psychopharmacological interventions. Thus, forming support groups, and meeting at regular intervals of these groups is important. Nevertheless, these group meetings give voice to individual experiences and problems. So, thereapists give encouragement to client participation. Assessment is done of the progress so far. Therapists also ascertain the goals for the future.
  2. Cognitive Behavioral Therapy (CBT): Therapists aid the clients in recognizing cognitive distortions. Subsequently, they help in unlearning older maladaptive behaviors, and focusing on learning newer adaptive ones. Individualized therapy is suitable. Because, there is no one-size-fits-all treatment. Studies consistently show that individual therapy is better than group therapy in the treatment of negative symptoms.
  3. Cognitive remediation therapy for cognitive deficits: This includes pencil-paper tasks, sudoku, crossword, computer exercises. Therapists tailor some of the exercises to focus on deficits in individual domains like attention, speed of thought processing, verbal working memory, reasoning, and social cognition.
  4. Others: Thus, aerobic exercises help in neurogenesis, synaptogenesis, and modulate neuroplasticity. 
Pharmacological Management:
  1. In fact, Amisulpiride and Fluoxetine treat the negative symptoms. Amisulpride increases levels of the hormone prolactin in the long run. Hyperprolactinaemia can set the precedent for osteoporosis.
  2. However, recent studies have shown that Clozapine has the highest level of evidence in the management of negative symptoms.  With Clozapine, the improvements can be visible even after 6 months of initiation of treatment. 
  3. Moreover, Clozapine trial requires regular monitoring of the White Blood Cell counts, and causes constipation, weight gain, salivation, postural hypotension, and palpitations as common side effects.

Brain Stimulation Techniques:

  1. Transcranial Magnetic Stimulation (TMS). Firstly, TMS of the dorsolateral prefrontal cortex (DLPFC) has proven to be very effective in the treatment of negative symptoms.
  2. Electroconvulsive therapy (ECT). However, it is not as effective for negative symptoms, as it is for depression and positive symptoms.

Novel Treatment Approaches:

  • Emerging molecular targets – These include GABAergic modulation, targeting oxytocin receptors (implicated in the social cognition deficits in schizophrenia, along with mirror neurons). Also, countering neuroinflammation by using cyclo-oxygenase inhibitors like Rofecoxib. Others include – NMDA (N-Methyl-D-Aspartate) antagonists like Memantine, Glycine-reuptake inhibitors like Bitopetrin, and Metabotropic Glutamate Receptor 2/3 agonists like Pomaglumetad. Memantine, Bitopetrin and Pomaglumetad come under the purview of glutamatergic modulation.

There is definitely hope for those afflicted with the deficit syndrome, with researchers identifying a plethora of molecular targets.

Hallucinations Delusions Schizophrenia ?

hallucinations delusions schizophrenia

Weird, Bizarre, Incoherent – Hallucinations Delusions Schizophrenia ?! Serious Mental Illnesses (SMIs) and side effects to varied medicines may cause hallucinations in many individuals. Psychosis and Schizophrenia are the most commonly known causes that may cause this condition. Hallucinations are sensations and feelings that may appear as real to the patient. Thus, convincing him or her of the occurrence of things that are not really happening in reality. Hearing voices, seeing people, and experiencing things that no one else can, are some of the ways in which hallucinations work.

Let us find out the varied signs and symptoms of this condition.

Hearing Voices: One of the most common signs of hallucinations includes hearing voices. You may hear voices from people who cannot be seen or heard by other people around you. In such cases, you may have the distinct feeling of hearing these voices from within. However, this could also be from a source outside your own mind and body. In many cases, you may feel like these voices are trying to talk to you or give you a certain message. Ringing of the ears on a persistent basis may also be experienced in such cases.

Visual Hallucinations: Such hallucinations will make the patient see things. In such cases, the patient may be witness to a scene that cannot be seen by anyone else. Essentially, it is a scene that may not be happening in reality. In visual hallucinations, the patient may also see people that other people in the room or the area cannot see. The patient may also see objects and other creatures. For example, insects crawling across his or her hand. Subsequently, the patient reacts with fear or anxiety, when in reality, no such scene may be happening. These kind of hallucinations also cause occipital seizures where the patient will see spots, shapes and rings of brightly coloured lights. They may be coming towards him or her, or even encircle him or her.

Other kinds of hallucinations

Tactile Hallucinations: In this kind of hallucinations will make the patient feel things that may not really be happening. For example, these hallucinations will make the patient feel hot during winters. They may also feel a blast of air even when there has been none.

Taste Hallucinations: In these hallucinations, the patient may get a salty taste from sweet food, or vice versa. Such hallucinations make the patient imagine that he or she tastes a certain flavor when in reality, this is not true. They are also called gustatory hallucinations.

Olfactory Hallucinations: These hallucinations have to do with odd smells that the patient may get a whiff of. In these hallucinations, the patient imagines certain smells like burning, or other odours. Patients may also feel that their own bodies are letting out certain odours which may not be the actual case.  

Delusion vs. Hallucination

A delusion is a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes. This is also despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture For example, it is not an article of religious faith.

A hallucination occurs when environmental, emotional, or physical factors such as stress, medication, or extreme fatigue. In a mental illness the mechanism within the brain that helps to distinguish conscious perceptions from internal, memory-based perceptions misfire. As a result, hallucinations occur during periods of consciousness. They can appear in the form of visions, voices or sounds, tactile feelings (known as haptic hallucinations), smells, or tastes.

Delusions are a common symptom of several mood and personality-related mental illnesses. These include schizoaffective disorder, schizophrenia, shared psychotic disorder, major depressive disorder, and bipolar disorder. They are also the major feature of delusional disorder. Individuals with delusional disorder suffer from long-term, complex delusions that fall into one of six categories. They are persecutory, grandiose, jealousy, erotomanic, somatic, or mixed.

So… are all hallucinations delusions schizophrenia ?! If you notice any of the above, it may be time to consult a neuropsychiatrist OR visit your nearest doctor to find out more.

Sexual Intercourse or… simply Sex

Sexual Intercourse or Simply Sex

When a man and a woman have sexual intercourse or simply sex – where a man’s penis enters the woman’s vagina – it is called vaginal sex. Find out more about what it is, why people do it and how to do it safely. Sleep Hygiene has a lot to do with Sexual Health.

Should I have vaginal sex?

Deciding whether to have sex is a very personal thing and there is no rule to say whether you ‘should’. The main things to consider are whether it feels right, and whether you and your partner are both sure. 

Vaginal sexual intercourse or simply sex, usually starts when a man and a woman are getting sexually excited from kissing, stroking, caressing, rubbing and touching each other. You’ll often know you’re getting aroused (which means your body is preparing itself for sexual intercourse) from certain physical signs:

  • for women, the vagina (the sexual opening between the legs) begins to moisten
  • men get an erection, which means their penis will get bigger and harden.
The importance of foreplay

Try not to rush things. The best approach is to enjoy each other’s bodies and make sure you’re relaxed with one another – this is called ‘foreplay’ and it’s an equally important part of sex as intercourse itself. It’s also perfectly ok not to go any further than this stage. Many couples enjoy having foreplay for a long time before they move on to having vaginal sex.

If you are both ready to have vaginal sex, it’s important that foreplay lasts for long enough. If the woman is not sexually excited enough, then her vagina will not become lubricated and it will be difficult for the man’s penis to enter.

How does vaginal sex work?

When you are both aroused and ready to have sex it helps if one of you uses your hand to guide the penis into the vagina. Take your time, and don’t worry if it takes a few goes to guide it in properly – this is very normal, especially when you are both getting used to each other’s bodies.

Once the penis is inside, you can move your bodies so that the penis pushes into the vagina and then pulls partly out again. Do what comes naturally and feels good – being slow and gentle is a good idea to start with as you can both make sure one another is comfortable.

What about different positions?

One common position involves the woman lying down, with the man lying or sitting on top (also called the ‘missionary position’). Alternatively, the woman can be on top – or you can both lie on your sides. It is probably easiest to choose one of these positions if you are having sexual intercourse for the first time. As you get to know each other’s bodies better you can experiment with different positions that work for you both.

After a while you might find certain movements, positions and ways of touching that lead to one or both of you having an orgasm. This is also called ‘coming’ or ‘climaxing’. Don’t be too concerned if this doesn’t happen straight away or at all. It takes time to get to know what works for you sexually. And for your partner as well. And sex can be enjoyable whether you climax or not.

Will it hurt – and will the woman bleed?

It can take a bit of time to get used to the sensation of sex. And, some women can find it a little uncomfortable or painful at first. Taking things slowly and using a good water-based lubrication can help.

If it’s a woman’s first time having sex she may bleed a little. This is generally nothing to worry about. Since, it’s a sign that her hymen (a very thin piece of skin that partially covers the entrance to the vagina) has broken. Sometimes, a woman’s hymen will have been broken through activities. For example, horse riding or through using tampons. So, not all virgins bleed the first time they have sex.

If you continue to bleed everytime you have sex then it’s a good idea to speak to a healthcare professional. This is for reassurance and to check it’s nothing to worry about.

Being safe and sure

Knowing how sex works can help you to feel more relaxed and ready to have sex. However, being clued up about contraception and protection is just as important. If you aren’t, you will put yourself (and your partner) at risk. This includes unwanted pregnancy, sexually transmitted infections (STIs) and HIV.

There are many STIs that you can get through unprotected vaginal sex. These are chlamydia, herpes or HIV and it can happen as a result of just having sex once. Using condoms is the only way to be sure that you’re both properly protected is to always.

If you’ve had unprotected sex make sure you seek healthcare advice as soon as possible. This is to access emergency contraception to prevent unwanted pregnancy, and perhaps post-exposure prophylaxis (PEP) to prevent HIV infection. 

Talking to your partner about protection before you start having sex will help things go more smoothly. This can be embarrassing, but it’s an important part of having sex. Additionally, if you find it difficult to discuss then it is a sign you aren’t ready to start having sex yet. That’s fine. However, remember that there are lots of ways to enjoy being together and to explore your sexual feelings until the time is right.