II- Environmental factors:
As we mentioned previously, schizophrenia appears to be a complex
disturbance occurring at many levels in which biological factors are
essential and the environmental factors are necessary to precipitate or
maintain the disorder.
Anyhow, the environmental factors can be divided into social causes
(early life events and recent ones) and psychological causes
I-social causes
-Early Life Events :
If the father or especially the mother has schizoid traits, there may be
considerable effect (directly or indirectly) on their child or his
personality.
The following situation can be a good example:
If the parents punish their child for every large and small mistake (even
the trivial one), then the child may expect punishment whatever he does,
moreover he may expect punishment if he makes no choice and no action.
Here, the child will learn to avoid punishment by doing meaningless
remarks and the child begins to become abnormal in behavior and
personality.
- Recent Life Events
It had been found that the disorder "schizophrenia" can be triggered
off by a variety of life events such as moving house, loss of job,
operations, accidents, marriage, joining the army, …etc.
Note: These life events precipitate either the onset of first
schizophrenia symptoms or relapse of the disorder or remission,
and now, we deal with the scientists who made studies about the
effect of life events:
 Steinburg and durral (in America)
They studied the solders after joining the army and found that
relapse of schizophrenia occurs in the 1st month after army joining.
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 Brown and birely (1968)
They studied the (12 weeks) period the onset of schizophrenia of
50 patients and found that stressful life events are present in the 3
weeks period before episode (onset of schizophrenia). So life
events (specially recent ones ) have their effect in the etiology of
the disorder.
 Brown 1972
He studied the causes of relapse of schizophrenia in recent cases by
observation of the patient after remission from the acute phase for 12
months. He found that relapse rate was high in families making critical
moments on the patient's behavior (e. g. of family members who make
these comments are the father, the mother, the wife, …etc)
Note : the families with excess critical comments are called high
expressed emotional families.
He found also that relapse rate decreases by applying the
following:
A-drug therapy
B-the contact of the patient with the critical relative must not exceed
35 hours per week (5 hours daily), the relapse rate according to brown's
study was 58% in high expressed emotional families and only 16% in
families who don't comment on patient's behavior he found also that
relapse rate decreases more by antipsychotic drugs.
 Beblinton
This scientist studied high numbered of schizophrenia (1250) cases and
found that relapse rate was 50% in high capital EEF and only 21% in low
EEF.
2-Psychological causes
There are theories to explain the theories of schizophrenic patients
1. Filter theory of sensory input or overload:
In ordinary state we perceive only the wanted information's and neglect
the unwanted information but the schizophrenic patients is open to all
events of the environment and react with the events and conservation he
sees and hears in a manner as to be related to him.
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2. First theory
The negative symptoms of the schizophrenic patients is due to inability
of having spontaneous action (will) and some of the positive symptoms
like hallucination are due to the inability of the patients to make
intention of voluntary actions
‫ان المريض ال يمتلك تصميم لعمل ما النه يعتقد ان االمر النجاز عمل معين ياتي من الخارج‬
(passivity, thinking, emotion, delusion of action)
He doesn't know also the intention of other people acts and think
that these acts are done to hurt him (against him) but actually
these acts are carried out by others in no relation ship with the
patients so with the paranoid delusion develop.
‫ان المريض اليعرف النية الصحيحة لالعمال التي يقوم بها االخرون ولذلك يفسرها‬
‫بانها موجهة ضده بينما نجد هذه االعمال التي يقوم بها االخرون طبيعية دون ان تكون‬
‫لها اصال عالقة بالمريض‬
Summary
It had been found from the genetics, neuro-pathalogical,
immunological findings that schizophrenia is neurodevelopmental disorder.
The architecture of temporal lobe and hippocampus are abnormal
and the connection (as a whole or especially with temporal lobe)
is also abnormal.
The developmental disorders are either due to genetic factors
(Genetically determined) or due to injury to the developing brain
intrauterinaly (at the time of pregnancy or at birth) this explains
enlargement of the ventricular system, and the other changes like
abnormal behaviors during childhood.
The question is "why it does appear in adulthood?"
The answer is this is due to maturation changes (demyelination
of neurons, modification of synaptic regions) until adulthood.
Example
If a small monkey is traumatized in the frontal lobe, the
symptoms appear only at adulthood but not immediately.
So the social, psychological factors,…etc precipitate the illness
by the presence of a biological basis.
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- Till now the exact etiology of
accurately known.
schizophrenia is not
The course of schizophrenia
Most of patient have a relapsing remission course and full
recovery is rare after the 1st episode. Other patients may enter the
chronic phase and about 80-90 % of previously patients entered
the chronic phase due to delayed diagnosis absence of effective
treatment (drug and psychotherapy). But nowadays, the picture
is different ;5-10% only enters the chronic phase because of
early diagnosis and successful treatment which prevents the
chronicity to be established.
Prognosis:
Previously, most of the schizophrenia were hebephrenic in type
(bad sign) but now days, most of them are paranoid
schizophrenia (better sign) because their personality is better
developed.
Better prognosis is suspected when the following signs are
present:
1- Delayed onset
2- Acute illness
3- Marriage
4- No schizoid personality
5- The patient completed his academic study before onset of the
disorder
6- Early diagnosis and treatment
7- Paranoid schizophrenia is of better prognosis than
hebephrenic schizophrenia
- While bad prognosis is suspected when:
1- Early onset
2- Insidious (with prodroma)
3- No marriage
4- Schizoid personality
5- The patient didn't complete his academic study
6- Late diagnosis and treatment
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7- Simple schizophrenia
Treatment of schizophrenia
In acute cases, admission to the hospital is necessary followed by
taking thorough history and the assessment is done for need of
any particular type of treatment
- Physical treatment (drugs, ECT)
- Psychotherapy
- Social support
The drugs are called (neuoleptics or antipsychotic or anti
schizophrenic drugs) and their act to control dopamine excess
(typical drugs) or by another mechanism (atypical drugs):
- Phenothaizine
group
:
chlorpromazine,
hioridazine,
trifluoperazine , fluphnazine
- Butyrophenones group : haloperidol
The drug most commonly used is chlorpromazine with a dose of
300 mg/day (could be 600 mg/day) but not more than 900
mg/day.
There will be a Sedative at the beginning and the therapeutic
effect start 2 weeks. The dose may be increased or decreased
accordingly.
The treatment is usually for 6-8 weeks after which the acute
schizophrenia symptoms disappear. After that, maintenance drug
therapy is continued with the patient.
Note: we can shift to another drug when the patient becomes
good and quit which is the trifluoperazine (5 mg 3 times/daily)
but without a sedative effect.
In western countries, the psychiatrist depend on the precipitating
psychological and social events in the treatment of
schizophrenia patients, but in addition to that , they prescribe
drugs( neuroleptics) for the patient to enhance a quick
improvement. On the other hand, the psychiatrist in our country
depend mainly on drugs prescription rather than discovering or
understanding the underlying precipitating factor.
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It's very easy to prescribe drugs but it's hard to understand
the patient's complaints and feelings.
Anyway, the treatment of psychiatrist is not to include sedation
of the patient by the use of drugs but the purpose of treatment is
to treat the psychopathological symptoms of the patient
(delusions, hallucinations and thought disorders,.. etc) which is
usually carried out by the combination of drugs and
psychotherapy, industrial therapy, occupational therapy, ..etc.
In acute schizophrenia, it's advised to admit the patient to the
hospital followed by taking a complete history of the patient.
Then the assessment is done for the need of any particular
intervention. Inside the hospital, the patient receives 2 types of
therapy: physical therapy, and non physical therapy
(psychotherapy, occupational therapy, industrial therapy,…. etc)
I-Physical therapy
A-drugs: The drugs used are called neuroleptic or antipsychotic
or antischizophrenic drugs. They act mainly to control the excess
of dopamine hormone in certain region of the brain (mainly the
limbic region). These drugs are classified into typical and a
typical drugs. The main drug used is the chloropromazine
(largictil) with its therapeutic antipsychotic effect, tranquillizing
effect and sedative effect so, if the patient is aggressive and
violent then chloropromazine is used. But in quiet patients
trifluoperazine is preferred rather than chloropromazine.
However, the chloropromazine is used in the acute stage
(phase) schizophrenia in a dose of (100-200 mg 3 times daily )
and the dose can be increased but not more than 900 mg daily.
The therapeutic effect is expected to appear in the 2nd week of
drug intake onset (10-14)days and the drug must be taken for (68) weeks after which complete improvement of the patient's is
expected.
After remission of acute schizophrenia symptoms, maintenance
drug course is usually started to prevent relapse of the disorder.
The same drug of acute phase is usually used but in (1/3-1/2) the
dose that had been used in the acute phase. The maintenance
period is usually long and continues for about one year.
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After one year , assessment is done to decide whether to stop or
continue the medication. This depends on certain factors:
1. Severity and symptoms
2. The response of the family (i.e. if the family is high EEF,
continuity of drug is preferred while in low EEF, the drug
treatment can be stopped)
There are patient who have poor compliance with the drug
treatment (stop the drug treatment) because they think:
1. The drug is burdensome
2. They dislike the routine intake of drug treatment
3. The drug is expensive
4. They don't want the schizophrenia symptoms
(hallucinations, ..etc) to disappear because the sounds that
talk or comment with the patient are their only friends
In these cases, it's advisable to use long acting injections of
neuroleptics (depot) such as fluphenazine decanoate, flupenthixol
and haloperidol decanoate and others….
Note : these drugs (neuroleptics) are used in combination with
anticholinergics (procyclidine, benzhexol, others) when extra
pyramidal size effects appear at any stage of treatment course
Note : the dose of drug during the (6-8 weeks) period can be
increased or decreased according to the patient's requirements.
Note : after about (10-14 days), therapeutic effect is expected to
appear, but not immediately.
Chronic schizophrenia patients are also treated by neuroleptics
(like chloropromazine), but the effect on the negative symptoms is
usually weak
B- Electro Convulsive Therapy (ECT) :
Here, the patient receives electricity (e. g. 100v) for a very short
period of time. This induces instant loss of consciousness
followed by convulsion (grand-mal epilepsy) in the following
steps:
- Tonic
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- Clonic
- Recovery
Nowadays , modification has been achieved of ECT by the use of
intravenous anesthesia to prevent the complication of the patient
which can lead to a lot of unwanted results and for other causes
this is to say:
IV anesthesia+ ECT applied
The fit that occurs after the application of ECT is not a side
effect ; actually, it is the effect that must be occur to be a
successful therapy.
The ECT has indications to be used which are:
1. In catatonic behaviors in which the patient refuses to eat
and drinks and this needs to decrease the No. of medical
emergencies.
2. 2nd line treatment after failure of drug therapy.
3. In post natal psychosis
4. In depression- schizophrenic has a suicidal attempt (10% oc
cases due to severe depression that may associate with it).
5. In case were primary treatment was not effective very well
(i.e. no significant improvement)
In addition to that ,ECT has also contraindication (e.g. organic
psychosis, ..etc) and many side effects that are sometimes harmful
to the patients.
After demonstration of drugs and ECT as a subdivision of
physical therapy, we will deal with other types of treatment.
II- Non physical therapy
Here, we try to strengthen the patient's ties reality and we try also
to increase the self confidence of the patient. This purpose is
usually reached by the applicaton of " rehabilitation" which is one
of the most important treatments in psychiatry. It starts from the
first day of patient admission into the hospital with drug therapy.
Rehabilitation helps the patient to know how to live, drink, eat,
and others so that the patients return as one of the members of
society with acceptable behavior
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A-Occupational therapy:
Here the patients learned either a new job (task) or refurbish old
ones (i.e. either acquiring new skills or continue on the same and
old skills) there are a lot of example sewing, carpet making, or
working as smith or carpenter. It has been found that the
occupational therapy clams the anxious patients. Occupational
therapy prevents worsening of patient's state and has a role in
remission. Here, the patient avoids the boring routine day life
because he needs a balance environment. If there is high
stimulation, relax may occurs and if the day life passes without
events (no excitement) then chronicity will be established.
So the patient in need to suitable environment where no high
stimulation, routine day life and neglection present.
B-psychotherapy: there are 2 types of psychotherapy which are
the supportive and analytic psychotherapy. In addition there are
individual and group psychotherapy; however the schizophrenia
patients are treated by supportive psychotherapy in which the
patient is encouraged to talk freely about himself and his
symptoms and problems without exploring his unconscious
mental life. On the other hand the psychiatrist must give an
attention to the patient and listen carefully. The psychiatrist or any
other member of psychiatric medical staff can add possible
solutions of the patient's problem in a gentle manner.
C- Family therapy:
Here we have to teach the members of the family to be merciful
with the patients and to avoid commenting continuously on his
behavior. They must also give attention to the presence of the
patients as a human being, who may carry thoughts that are of
benefit in solving certain issues.
‫يجب على افراد االسرة التعاون معه في اجتياز المرحلة الصعبة التي يمر بها حيث‬
‫يكون باشد الحاجة الى العطف والحنان الذي يمكن ان يقدم له عن طريق العبارات‬
.‫اللطيفة او شراء هدايا له‬
‫وكذلك فان االسرة يجب ان تكون صبورة مع التصرفات الخاطئة التي يقوم بها‬
‫ وايضا‬...‫المريض وغض النظر عنها حيث ال يجب ان تعلق على هذه التصرفات‬
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‫عليهم ان يعتبروا المريض انسان له استقالليته وافكاره الخاصة ويمكن استشارته في‬
.‫بعض االحيان بخصوص مسائل معينة لتعزيز ثقته بنفسه‬
D-Community therapy:
The patient is admitted into the hospital for a long time during
which the patient is exposed to a new environment. It is advisable
to make a free communication between the patient and the
psychiatric medical staff, thus removing meaningless barriers
between them. In addition the patient need color, activity and
hope so that they can adapt quickly to hospital environment.
E-behavior therapy:
This term is applied to a variety of psychiatric treatment in which
the patient are re-educated away from abnormal behavior. There
are several methods of behavioral therapy e. g. over practice , here
the patient is entered into a large room in which many blankets,
pillows and carpets are present. The patient who has a desire to
arrange these things continuously will lose this desire due to the
present of these things in high number.
‫المريض الذي لديه رغبة مستمرة في ترتيب الفراشات والبطانيات والمخدات يفقد هذه‬
!!‫الرغبة بعد وضعه داخل قاعه كبيرة مليئة بالبطانيات والفراشات‬
Another example is positive reinforcement; here the patient is
given a gift or money when he carries out the desired task or
behavior.
F-Industrial therapy:
Here, certain jobs are provided for schizophrenic patients
specially the chronic cases, in fact, the type of work chosen for
them must be suitable associated with encouragement and
supervision.
Note: The jobs are usually practiced outside the hospital (e.g.
factories)
Then the patient is shift to a "day hospital" in which the patient
spends several hours during the day without remaining in it at
night because it is a day hospital as we mentioned.
Here, the patient eats, learn music and does other activities and
hobbies. This hospital is a transient stage between the hospital and
the community to which the patient will return as a normal
member of it with an acceptable behavior.
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Note: treatment of schizophrenia is difficult and hard and needs
cooperation and patience of both the doctor and the patient
‫التقسيم التالي لعالج الشيزوفرينيا‬
I-physical therapy (drugs and ECT)
II- Non physical therapy: (rehabilitation)
(Occupational therapy, psychotherapy, family therapy,
community therapy, behavior therapy, industrial therapy)
Now after demonstration the lines of treatment of schizophrenia
we will deal with the anti-psychotic drugs (narcoleptics) and their
classification.
Q/ Mention the antipsychotic drugs and their side effects?
A/ these drugs are classified into typical and a typical drugs
according to the mechanism of action:
1-Typical anti-psychotic drugs:
a- Phenothiazines: which include:
1-chlopromazine
2-thioridazine
3-trifluoperazine
4-fluphenazine hydrochloride
5-fluphenazine decanoate
6-fluphenazine ethanol
7-perphenazine
8-mesonidazine
9-Acetophenazine maleate
B- butyrophenones which include:
1-halperidol
2-droperidol
3-haloperidol decanoate
C- thioxanthenes: which include:
1- Flupenthixol
2- Clopenthixol
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3- Zuclopenthixol
D- Diphenylbutylpiperidines: pimozide
E- Dibenzoxazines: oxapine succinate
F-Indole derivatives: molindole hydrochloride
2- A typical antipsychotic drugs:
A-Benzisoheterazoles : risperidone, zeprasidone
B-Dibenzodiazepines : clozapine , quetiapine fumarate
C-Thiolobenzodiazepines: olanzapine
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