Schizophrenia (skit-zo-free-nia) is a term coined by the famous Swiss Psychiatrist, Eugene Bleuler [1857 – 1939] in the year 1911 which was accepted later worldwide. It denotes a severe and complex mental illness wherein the patient loses the ability to think, feel or behave in a normal way. The patient perceives adistorted reality but is usually unaware that he is ill. Patients also suffer from delusions ie. firmly held but false beliefs and begin to act on them. As a result of their faulty thinking and perception, their behavior becomes abnormal. Nearly  6 – 7 million Indians suffer from this disorder variously described as the “Cancer of the mind” and the “Greatest disabler of youth”. It starts in the most productive period of life 15 - 45 years and is cosmopolitan in its occurrence. It cuts across barriers of gender, educational and social classes. It is now widely recognized that Schizophrenia is a brain disorder.

How is it caused?

The exact cause of the illness is not known as yet. Research into the illness continues; what has emerged in recent years is a bio psychosocial model of the illness.

The Biological aspect:
Research indicates that schizophrenia is a disorder of the brain with a tendency to run in families. A certain vulnerability to the  illness is transmitted genetically; a person whose family records other cases of schizophrenia is more likely to be afflicted than one without such a history. The children of a schizophrenic parent. for example, each have about a 10% chance of developing schizophrenia as compared with 1% chance in the general population. Most scientists agree that a vulnerability to the illness is inherited, a potential that, given a certain set of factors, can lead it schizophrenia.

The Psycho-social aspect:
It is generally seen that among genetically vulnerable individuals, those who are exposed to a highly critical or stressful environment are more likely to succumb to schizophrenia than those who are not. The onset of the illness itself is often triggered by a traumatic event in the person's life. The death of a loved one, some deeply-felt failure, rejection or disappointment can lead to schizophrenia in a susceptible individual.

It can be seen therefore that while schizophrenia is related to biochemical irregularities in the brain, external stress, family and social pressures, if intense, can work on a vulnerable individual and lead to schizophrenia. Families carrying a genetic record of past illness are especially susceptible.

How can you identify Schizophrenia?

The onset of schizophrenia is gradual and not dramatic. However there are a few common symptoms which mark the illness.

Loss of interest and social withdrawal:
The person starts losing interest in his work, studies, family and friends. He is unable to concentrate, is irritable or looks vacant when questioned, stops going to work, often spends time wandering aimlessly or doing nothing, looking  preoccupied or lost in thought. This is usually accompanied by a sharp fall in academic or work performance, disturbed sleep patterns and loss of appetite. The individual also begins to withdraw into  himself, to shun company and social interaction of any sort.

Delusions:
Sometimes schizophrenia is identified by the patient's  fixed belief in something that is obviously untrue.  He may believe that he is being persecuted, that people are conspiring against him at work; he may suspect his spouse's fidelity and many take to watching her constantly; he may believe his thoughts are being controlled by some external force for instance, that a radio receiver is planted in his head. These beliefs will not be shaken  by attempts to reason with him.

Hallucinations:
During the 'acute' phase of the illness the patient often hears voices in his head and begins responding to them. He is seen apparently talking to himself but in a disjointed way, often laughing, gesturing ,smiling.
Sometime the patient sees frightening figures, in his fear he may become uncontrollable and be driven to violence, even attempting suicide.

Disinterest in personal hygiene:
In the later stages, the patient refuses to bathe or keep himself clean, loses interest in his physical appearance and that of his surroundings.

Inability to express emotion:
The patient becomes emotionally 'blunted' - he is unable to express appropriate emotion and does not appear to be in touch with outer reality. It is not often that all the symptoms listed appear in any one individual. But if any of these symptoms can be identified, then it is imperative that the First Step be taken.

What is the First Step?

Take the patient to a psychiatrist. The importance of this step cannot be over-emphasized.
The sooner the illness is identified and treated for, the greater are the chances of recovery.
If schizophrenia is left untreated, it can become chronic- and then it will be too late to effect anything bur the most minimal improvement. Simply labeling the patient as 'slow-minded', 'lazy' or 'pretending ' does not solve the problem. It must be accepted that there is a problem and the sooner it is treated for, the better.

How is Schizophrenia treated ?

It has been found that the best approach to treating schizophrenia is a broad-based one -comprising  Medical Treatment, Psychotherapy and Social Rehabilitation.

Medical Treatment:
Medical Treatment is the most important part of the program and must be adhered to strictly if the patient is to show consistent improvement. The antipsychotic drugs prescribed aim at controlling the acute symptoms of the illness and suppressing distortions in perception. Sometime ECT-Electro convulsive therapy or  shock treatment - is advised during a schizophrenic episode but usually in conjunction  with the drugs.

How important is medication?

Medication is vital because it aims at restoring the normal functioning of the brain. Once the illness has been identified and the patient is started on a program of drug treatment, it as vital that he keeps to it.
These drugs are the product of years of research and are found to have a definite beneficial effect on the patient. If they are stopped for any length of time, the disease will inevitably proceed on its course, causing a relapse. Until recovery has been effected, the drugs should not be stopped, Some times treatment with drugs will have to be continued for years.

Is the treatment safe?

Yes.
Administration of drugs and giving ECT or shock treatment is completely safe in expert hands and does not cause damage to the patient's  mind or body. These drugs do not causes additction and there are no bad effects after they are stopped ,as for instance, in the case of alcohol.  In some patients however, the drugs produce certain side effects-like excessive lethargy, stiffness of limbs, drooling of saliva or fixing of eyeballs in one position. These effects can be removed by counter-active drugs. So patients showing such reactions will have to take a combination of antipsychotic drugs and the counter-active drugs.

Psycho-therapy:
Very often the sever loss of self-esteem and depression suffered by the patient can be countered only by effective psychotherapy - sessions of counseling, encouragement and extension of positive support to the patient by friends and family. Supportive individual talks on a regular basis with mental health professional such as a psychiatrist or psychologist helps the patient to talk freely about his perceptions, problems and experiences. Sympathetic counseling enables him to learn to distinguish the real from the unreal and distorted, and gradually to understand more about his illness and himself. Very often he learns to live with symptoms which cannot be completely eradicated.

Social Rehabilitation:
In order that the patient may function normally and become a productive member of society social rehabilitation becomes essential. One aspect of rehabilitation is Occupational therapy which aims at the acquisition of simple social and trade skill in keeping with the patient's  capabilities so that he may be gainfully employed and resettled in life. A second aspect is Group Therapy by which means a patient is enabled to interact freely with others and thus to regain and strengthen his inter personal skills and his self-confidence.
An important feature of this efforts to rehabilitate the  patient is Family Counseling where the family can discuss the patient, his problems and theirs with a professional psychiatrist and be given guidance on how to treat the patient and how best to aid the recovery process.
All aspects of this program are important although it must be emphasized that medication, as prescribed, should never be neglected, even in case of substantial improvement, since that may lead to a relapse . The overall result of such a comprehensive approach to the treatment of schizophrenia is that the patient not only improves as a result of medication, but as he becomes proficient at some trade and continues his counseling  sessions, also recovers his self-esteem and  become more confident of his place in society.

In India, we now have Clozapine and Risperidone and Olanzapine is expected to be introduced shortly.

What is the extent of recovery possible ?

The extent of recovery possible is dependent to a great extent on the stage at which treatment is begun. This underlines the necessity for  early identification and early treatment.
It is possible in may cases to fully rehabilitate the patient with medication and psycho-social therapy- if the illness had been identified in the early stage. However, even if the patient has returned to normal functioning, a periodic check-up with a psychiatrist is advised.
Current figures show that:
About 30-40% register complete recovery
About 30-40% are seen to be partially recovered' (This means they will improve but need continuous medication) and about 20-30% become chronic.(They may improve but never be fully recovered.)

What can the family do to help ?

The family is in the best position to provide a helpful and supportive atmosphere for the patient. The first step is to recognize that the patient is ill and nor being lazy, stubborn or anti-social. Once the illness is identified and being treated fore the family should encourage the patient in every way possible.

What the family can do:

Follow the treatment:
See to it that the patient takes his prescribed dosage of medication regularly. Failure to keep to the dosage may lead to a relapse.

Take an interest:
Talk to the patient and show an interest in what he is doing as part of his treatment program. Continue to be interested in what he is doing even if it sounds dull and repetitious to you. Simple routine tasks ate important for the schizophrenic to master first.

Assign small responsibilities:
As the patient improves, it helps to bolster his sense of worth by getting him to perform simple tasks around the house. Keep these tasks small and uncomplicated, do not push him, for 'over-loading' will only tire and confuse him. Let him feel that he is as valuable and productive a member of the family as any other.

Encourage and support the patient:
The most important thing a relative can do is to let the person concerned know that there is a future  for him - far though it may be from what was originally hoped for. A person with schizophrenia is very vulnerable - he desperately needs assurance of his worth, is very sensitive and needs people to believe in him.

Supervise:
The need for supervision varies. Patients who are chronically ill or who express suicidal thoughts and seem very depressed need constant supervision. Those undergoing treatment must be supervised periodically in order to ensure that drugs are taken. Personal hygiene is looked after and that  there is no return to depression. As patients improve. The need for supervision will slowly decrease as the patient becomes self-sufficient and can be trusted to function safely alone.

Appreciate:
Appreciate of the smallest task is important Until a person's abilities and efforts are recognized and appreciated, his self-confidence is severely limited. As far as possible ignore deluded or abnormal talk. Show interest and try to prolong normal talk and conversation.

Do not ignore:
Ignoring the patient's attempts to regain his self-esteem, his smallest achievement or his desire to talk or discuss his future can have serious effects on the patient, Be patient and do not ignore him.

Do not criticize:
Derogatory criticism, taunting or disbelief can have a very traumatic effect on the schizophrenic who is in a very sensitive state and easily hurt Haranguing and  harassing the patient only adds to the stress and may lead to a return of the acute symptoms.

Do not exert social pressure:
Trying to make the schizophrenic aware of his social and financial responsibilities while he is undergoing  treatment is the wrong thing to do, for now, just show him that you believe in him and him that you believe in him and aim at self-sufficiency. As the patient improves, he himself should be allowed to grow slowly into a realization of his own abilities and responsibilities.

Refrain from over involvement:
Sometimes the patient may interpret interest and support as interference and 'meddling'.  In that case it is better to back off and stand by in case of need, rather than involve yourself actively.  But do not ignore him altogether.  It is important to strike the right balance between a caring involvement and constant intrusion.

Remember he is still intelligent:
Do not write off the patient as mentally deficient.  Aside from distortions in thought and perception, he is still an aware and sensitive individual.  Insensitive discussions of his condition or his future while he is present could prove to be very harmful.

Watch for a Relapse:
Patients may sometimes suffer a relapse for no obvious reason.  Watch out for early signs of this such as sleeplessness, increased restlessness, irritability and a return of hallucinations.   Take the patient immediately to a psychiatrist, so that medication may be adjusted and a relapse prevented.

Maintain a check:
Even after a patient is rehabilitated and goes back to work or study, it is important to check regularly on his progress in order to prevent a sudden, unforeseen relapse.  If the patient leaves to work in another city, be sure to stay in touch with someone - a friend or relative - who can give you periodic reports of the patient's progress.

Accept him as he is:
It is very important for families to realize the limitations and weaknesses of the patient.  You can minimize your own frustrations by learning not to expect the impossible from him.  The patient's condition can be made to improve - but slowly.  The best thing you can do to set him speedily and surely on the road to recovery is to refrain from rejection and to accept him wholeheartedly as he is.