State Psychiatric Hospital - Tserova Koria

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What is the prevalance of schizophrenia?

Most epidemiological studies have shown that approximately one percent of people are affected by schizophrenia during their lifetimes. The point prevalence is typically smaller and in most studies it rarely exceeds 0.5%. In Bulgaria there are about 40 000 people with schizophrenia. The prevalence of the disease among men and women is equal. Typically schizophrenia is developed in adolescence or in young adulthood, most often in the second or third decade of life.

What are the symptoms of the disease?

Schizophrenia is a disorder that affects the basic mental functions that give the normal person a feeling of individuality, uniqueness and autonomy. Distortions of self-experience such as feeling as if one's thoughts or feelings are not really one's own to believing thoughts are being inserted into one's mind, sometimes termed passivity phenomena, are also common.The disease often causes abnormal behavior and disturb the normal social functioning. The most common symptoms of schizophrenia during the acute phase of the disease are delusions and hallucinations. Delusions are found in 90% of the patients and they are the most common symptoms.

What are delusions?

Delusions are false beliefs that are not based on real life experience or other evidence and are inconsistent with the known laws of nature and the facts established by science. I.e. delusions are irrational beliefs. By their nature they are assumptions have become firm convictions for the patients, without reliable facts and evidences. Delusions cannot be influenced by the arguments of common sense, so the patients cannot be dissuaded. An important condition for an irrational belief to be qualified as a delusion, i.e. a symptom of mental illness, it has to be very unusual and strange to the origins of the patient. In other words, delusions are erroneous beliefs that have an absurd content, i.e. they sound amazing and are defined as impossible.

The essence of delusions is not specific for the disease and it depends much on the origins of the patient and his personal life story. The specific content of the delusions can be anything and the only limitations are those of the human imagination. Throughout the development of human civilization the content of the delusional beliefs of patients with schizophrenia have been constantly changing, by insertion of modern scientific discoveries and technological achievements and intertwining them with archaic beliefs.

The most common delusions of schizophrenia are delusions of persecution (paranoid delusions) and the impact from a distance. A typical example of the delusional belief is firm conviction for exposure to cosmic rays by aliens or the belief that one's thoughts can be heard or they "put" others’ thoughts in their own mind from a distance, by the usage of a special technique or by people with special telepathic skills or they believe that the body and its actions are controlled by external supernatural force. In the early formation phase of the delusions of persecution patients may have diffuse experience for hazards or to feel that daily ordinary situations have a special, usually sinister meaning, intended only for them, or they begin to perceive reality as strangely changed, different and unusual. These feelings cause patients to develop delusional beliefs that certain events are staged that segments of the real world are altered or even replaced by their similarities (such as stage decors) to be deceived, misled or manipulated by unseen foes and enemies. This feeling can be projected even on people in the close circle - parents, for example, can be perceived as replaced – they look the same people, but are felt by the patient as others entirely different beings. Patients may feel that the regular events are intentionally directed towards them. They might also misunderstand the (e.g they  might think that the normal look of a passerby  is a mocking act or an evil one), i.e they often believe in a meaningless, abnormal, self-directed meaning.

What are hallucinations?

Hallucinations are false sensory perception, i.e. experience of perception without any stimulus or source of this feeling. In this sense, hallucinations are false perception of reality. A typical example of hallucination is "hearing" sounds or speech without any source of these sounds near to the patient. The feeling can be so vivid and so strongly resembles the real perception that patients are turning to see the source of the sound or speech. Therefore, the occurrence of hallucinatory perception first reaction usually is a reaction of disbelief as the source of perception cannot be identified under the original expectation of patients. Later delusional patients develop different interpretations of this discrepancy with reality. Besides hearing, there might be hallucinatory perceptions in each sensory area. For example hallucinations can be visual when patients "see" images or objects that do not exist in the physical reality of their immediate surroundings or they can perceive odors without any source of these odors; they can have a sense of touch, without a physical stimulus to the skin.

The most common hallucinations are the auditory hallucinations. They are one of the most common symptoms in schizophrenia. When auditory hallucinations are very strong, patient behavior changes in a characteristic way - they can try to find the source of sounds or voices, or to speak to invisible interlocutors, sometimes they might clog their ears, if the content of the hallucinations is uncomfortable, or they smile if it is enjoyable. The combination of two types of hallucinations is very typical – the first type with a pleasant content, the other with objectionable content, the first type advises and guides, while the other curses and threatens the patient. These hallucinations are responsible for generating a very high level of anxiety and confusion for the patients. Sometimes hallucinations may have an imperative nature - patients hear voices that order them to do something. In less severe cases, patients manage to resist, and in the worst they feel incapable of it. Therefore these types of hallucinations are among the most severe symptoms - in this case, under the influence of delusions, patients can do something dangerous or even a suicide. Although frequent, auditory hallucinations are not mandatory for the diagnosis. Approximately half of the patients with schizophrenia have auditory hallucinations. Far more rare are visual hallucinations (occurs in approximately 15% of patients). Even more rare are the olfactory, tactile and body hallucinations ( e.g a sense of oscillation, of vibrations, a sense of electricity, passing through the body, sense of brain burning, bones softening, of shrinkage or enlargement of the body parts etc. Typically, these false sensations, are always accompanied by more or less bizarre delusions that patients develop in an effort to explain their nature.

Other symptoms of schizophrenia

Emotional disorders are common in patients with schizophrenia. Some of them are non-specific and are found in many other mental disorders, while others are relatively typical of the disease. The most common nonspecific emotional disorder is the strong pathological fear. This fear is not caused by the shock of a dangerous event, but it is a result of unusual, strange sensations that patients have and as a result of erroneous interpretations that they make as an effort to explain what is happening. Another frequent emotional problem in patients with schizophrenia is the depressed mood; it often occurs as a natural psychological reaction of awareness of the disease after resolution of the acute attack. Despair and hopelessness experience, respectively the feeling of incurability, are one of the reasons for the frequent suicide attempts among the patients with schizophrenia. Among the relatively more specific emotional disorders stands the emotional incongruity. It makes the patients to have an emotional reaction that is deeply inconsonant with their internal experiences or with the stimuli of the environment. For example, patients can smile without any apparent reason for this, and when asked whether they are happy, they respond negatively or even that they experience the opposite emotion of the event, for example fear. Often in such moments it is very difficult, even impossible, to establish an emotional connection with the patients.

The troubled thinking is another common symptom of schizophrenia. Besides the delusions, the troubled thinking can occur as confused, illogical (not related) statements. Often the confusion thinking  is so strong that others cannot perceive any logic in the statements of the patients.

Catatonia is a specific disorder, which occurs in a relatively small percentage of the patients with schizophrenia. Most often it manifests with muscle stiffness and rigid posture, patients do not respond to external stimuli, no adequate facial expression, they are frozen and it is impossible to establish a connection with them. In severe cases the patients cease to eat and/or even drink water. This final condition it is called a catatonic stupor. In some stupor cases the patients hear and perceive what is happening around them, but they cannot respond. This condition is especially painful for them. In other cases patients are preoccupied with pathological experiences (intense hallucinations) and their whole attention is directed into them. Catatonic stupor is a medical emergency and always needs an intensive specialized treatment in a medical institution. This is primarily related to the refusal of the patients in a state of stupor to take food and water by mouth.

What does it feel like to have schizophrenia?

Schizophrenia causes an immense suffering for those affected. In the prevalence of cases, patients with schizophrenia experience strong fears. Most often these fears are related to the experience of persecution and negative effects from a distance and fear, as well as fear of losing control over their own feelings, thoughts and behavior. Often people suffering from schizophrenia have a diffuse feeling that something fatal and inexplicable will happen in moment and it will make them cease to exist, disappear, or fall apart. This feeling causes deep primary existential fear that could grow into panic, respectively in a disorganized behavior. Patients often believe that other people or invisible forces are trying to destroy them. These beliefs are formed by patients in their attempt to explain their abnormal feelings.

Sometimes when the suffering becomes unbearable, some patients take extreme actions. Some patients attempt suicide in order to escape from the unbearable torment. Some try to escape from their "persecutors", they might leave their homes, without informing anybody of their location and can be missing for a long time. Some take self-defensive actions as they often submit complaints to various institutions, sometimes because of the desperation, they become aggressive to the people they consider as their persecutors. Some patients have a behavior that can be qualified as dangerous as a result of imperative auditory hallucinations. These are false perceptions of hearing voices that order the patients to perform specific actions. In the vast majority of the cases, patients manage to resist them. In some cases, however, patients lose their self-control ability, they feel as if an invisible force is obsessed with their body and manipulate their actions. In such cases, it is better if the patients are moved or placed in a specialized compartment where they can receive a timely and adequate treatment.

Despite the widely held view that the patients with schizophrenia are dangerous to others, it appears that the opposite is quite true - patients with schizophrenia are more dangerous to themselves. Approximately 50% of the patients with schizophrenia attempt suicide at least once in their lives, and between 10% and 15% of the patients die as a result of a successful suicide attempt. There is no other disease where the risk of suicide is as big as at schizophrenia.

What are the first signs of the disease?

As the disease usually occurs for the first time in adolescence, sometimes it is difficult its early symptoms to be distinguished from the abnormal behavior associated with the crisis of puberty. Some of the first signs of the disease before it has manifested in its characteristic clinical appearance can be: attention disturbance, distractibility and decreased concentration, decreased initiative and spontaneity, limited interests and leisure activities, lack of motivation, isolation and spending too much time alone, termination of the social life, depressed mood, sleep disturbances, reduced success in school and/or increased absenteeism from school, neglect of care of their appearance or excessive squinting and anxiety about their appearance about their health, loss of trust in friends, excessive suspiciousness, regarding the motives and intentions of others, anxiety, unexplained irritability, temper or impulsive behavior, confused thoughts and statements, strange experiences and ideas, giving an unusual illogical interpretation to the actions of others or to their own actions, stereotyped behavior or thinking, strange rituals, or compulsions grimaces, an impaired abstract thinking or understanding and use of metaphors. Usually the change in behavior is noticed first by parents, relatives, teachers or friends, this change cannot or can hardly be explained by certain life circumstances.

What are the harbingers of a worse condition?

In most cases, schizophrenia occurs with episodes of deterioration (relapses) and episodes of improvement (remissions). Also, in most cases deterioration occurs gradually - within a few days or weeks the condition gradually deteriorated until the disease begin to manifest in the behavior of the patient. Usually these are the moments when the patient seeks a medical attention. However, when the deterioration has already occurred, the treatment is more difficult, it requires more time, mobilizing more resources and people, and sometimes a hospitalization is required in order the acute condition to be managed. When patients have already experienced one or more episodes relapses, they may find that the crisis is preceded by milder symptoms, which are called precursors. Such are sleep disturbances, increased anxiety or irritability, increased suspicion in relation to others, coffee, cigarettes abuse and others. It is important each patient to identify those sensations that preceded the deteriorations of the disease because it would allow him to take timely measures that would reduce the risk of a relapse. Such measures usually involve frequent consultations with a psychiatrist, optimization of the treatment regimen or a change in the environment for a short period of time.

What causes schizophrenia?

Yet, modern science has failed to find the reasons for the development of the disease. However, over the past two decades a significant progress in the control of the symptoms of schizophrenia was made. So the practical success in the treatment of schizophrenia has been achieved empirically and it has got ahead of the scientific discoveries about the detection of the initial mechanisms and development of this disease.

Can schizophrenia be inherited?

Scientific studies have shown that schizophrenia is not a typical hereditary disease. It is believed that the not the disease is inherited, but the predisposition to it. I.e. children of patients with schizophrenia inherit an increased vulnerability to non-specific environmental factors with a negative impact (stress) which may favor the triggering of the disease. Unfortunately, these factors have not yet been established firmly enough. If a person, suffering from schizophrenia, builds a family, the probability of children to develop schizophrenia is 12%. If both parents suffer from schizophrenia, the risk their children to trigger the disease, at some point in their lives, is more than 25%. Therefore, the efforts of patients with schizophrenia to build a family and have children should not be restricted. The only reasonable condition which must be set, is the presence of a complete remission, which would enable them to adequately fulfill their role as parents. The presence of symptoms is a circumstance which would seriously damage their ability to complete parenting and raise healthy and harmonious children. It is an ethical obligation of the people, suffering from schizophrenia, to inform future spouses for the presence of the disease and the risk of developing the disease in their offspring.

What are the consequences of the disease?

Consequences associated with the development of the disease

The course of schizophrenia is not inevitable, chronic and it does not necessarily lead to a decline in functioning. Approximately 25% of sufferers recover completely after a first psychotic episode, which might remain as the only one. In about 50% of cases, the disease occurs with repeating episodes of deterioration, and there is a recovery that can be observed to some extent between the intervals. When the disease becomes chronic, it can lead to a so-called residual condition. This condition is observed in the later stages of the disease process, usually after a long course. For a description of the symptoms of this condition, experts often use the term "negative symptoms", it marks the manifestations of deficiency of mental and social functioning. Negative symptoms include apathy or lack of adequate emotional reaction, indifference and emotionless, poor facial expression and gestures, passivity, limited initiative and spontaneity, unwillingness to communicate, loss of interest, poverty of speech, impaired abstract thinking, self-neglect.

Consequences associated with negative attitudes of others

One of the worst consequences of schizophrenia is not because of the disease itself, but the negative attitude of others to those who suffer from schizophrenia. Patients often become victims of prejudices. Many people associate schizophrenia with unpredictable and aggressive behavior. Andthough sometimes similar behavioral abnormalities might be observed during the exacerbation of the disease, the majority of patients with schizophrenia are quiet, closed in themselves and distant from public life. However, they are often shunned by acquaintances, neighbors and even by close relatives, just because of prejudices. This attribution of negative qualities to a certain kind of social group is defined by the term stigma. Stigma to the patients with schizophrenia is strong and it disables those, affected by the disease, because the negative attitudes hinder their social development. They are systematically ignored, spurned, stigmatized. These negative attitudes are usually activated when patients inform people about their suffering or that they have suffered from schizophrenia. The word schizophrenia is being perceived by others, and by those, suffering as a shameful stigma. Often people use the word schizophrenia to condemn and disqualify a person that they do not understand. Therefore, patients are ashamed of their diagnosis, they try to keep it secret, and often deny even to themselves, that they are sick. This phenomenon has many negative effects, the most dangerous among them is the reluctance to seek medical help or to carry out treatment for fear that it would reveal the secret of their illness.

Can patients with schizophrenia work?

Yes. Schizophrenia rarely takes the full working capacity of the patients. However, they might not be able to perform work under emotional stress, for example in a very dynamic and stressful environment. It may turn out that the working process with clear and stable tasks and operations, in a friendly environment, is more appropriate. Work associated with intensive communications or in a very dynamic, tense or hostile environment may lead to an increased emotional stress and to exacerbation of the disease. LEDC figure out what kind of work is appropriate for each individual patient and what is not.

Employers should be more flexible when they schedule the job description of the employees with this disease. The part-time or the flexible work schedule for the use of annual leave might be more appropriate. Another possibility is the appointment of a mentor, who for a long period of time, supports and encourages the employee with schizophrenia. What patients should do when they are searching or about to start working, is to inform their employers about the disease, this way he will be able to take the necessary measures and to establish appropriate working conditions. Although many employers also have biased and discriminatory attitude towards people suffering from schizophrenia, hiding and keeping secret the disease creates prerequisites for exacerbation of the disease due to the appointment of unsuitable work or inadequate conditions, which may reinforce the negative attitudes and beliefs of employers. Therefore keeping the disease in secret can provide you with an easy beginning, but in in the future it might do much more harm than help, as the damage from it spreads to all people with schizophrenia.

Is it curable?

Yes. Schizophrenia is a treatable disease. Modern Clinical Psychiatry has highly efficient and safe medicines which relieve the symptoms of schizophrenia. Classic treatments that had been widely used in the past (such as the insulin shock therapy, for example) remain in the past. The electroconvulsive therapy is very limited as well, although it remains as a method of treatment in certain forms of the disease. There is no radical treatment of the disease, due to the fact, that the cause for the initiation and development of schizophrenia is not yet known. Therefore there is a tendency the term “treatment” to be replaced by “controlling” or “relieving” the symptoms.

Opportunities for drug control of the symptoms continuously growing. Medicines that are used to treat the symptoms of schizophrenia are called antipsychotics. The new drugs that are distinguished by their greater efficacy and safety compared to the conventional medications have been continuously developed and marketed since the early 90s. These new generation drugs are indicated by common name or new atypical or new antipsychotics. Atypical antipsychotics are suitable for the symptoms control during exacerbation of the disease and for preventing further deterioration (relapses), and also for long-term control of the symptoms (maintenance). Studies have shown that some of the new antipsychotics are effective in terms of negative symptoms in the residual stages of the disease.

Besides medication, the psychological support, the involvement in various programs for psychosocial rehabilitation, the psychological counseling and mental training, the cognitive psychotherapy and the support for the patients’ families are an important and integral part of the individual treatment plan. Often interventions, related to a support that aims to ensure an adequate job or other opportunity for the patient to participate fully in the community life, can play a key role for the full recovery of patient. The ultimate goal of the treatment of schizophrenia should not be limited to the removal or reduction of the psychotic symptoms (delusions, hallucinations, confusion thinking etc. It should be directed at restoring the social functioning of the patients to a level as close to normal as possible, while also achieving a high satisfaction and quality of life. The way of the achievement of this goal is called generalized psychosocial rehabilitation. It includes various activities aimed at satisfying the basic needs of the patients, related to: providing sufficient income, to provide opportunities and support for adequate employment, providing adequate housing, the possibility of full social participation, training in various skills and personal development etc.

An important prerequisite for the successful treatment of the disease is to build a relationship of trust with the patient. Trust is built on the basis of experience, empathy, respect and support of the assisting professionals and relatives. It is necessary the attitude of the whole society to those suffering from schizophrenia to be changed in order the patients with schizophrenia to be able to seek more actively a professional psychiatric help, without being ashamed of it.

How long should be the treatment?

Most experts and researchers recommend the medication after the first psychotic episode to last a minimum of 1 year. After a second psychotic episode this period increases to five years, then after third episode the treatment should be for life. It has been found that a significant proportion of the patients discontinued prematurely their assigned treatment or medications. This kind of behavior is referred to as bad assistance of treatment. This is one of the reasons for the severe course of the disease. Therefore, you should pay attention to the attitude with which patients receive recommendations for long-term medical treatment. The attitude is often negative and associated with irrational expectations about addiction or developing drug dependence. It is important the antipsychotic medications typically do not create addictive effects.

Recovery tips!

 One reason for the poor assistance to the treatment may be the presence of side effects from the drugs or lack of a pleasant treatment effect. If this happens or if you have symptoms that you associate with the medications, talk to your treating psychiatrist, who may recommend one or more of the following strategies:

  • he may change the dosage of the medicaments
  • he may change the drug intake pattern
  • replacing the drug with another
  • adding a second medicament to neutralize the undesirable effects or to enhance the therapeutic effect of the main drug.

Use meetings with the attending psychiatrist to ask any questions related to your designated treatment. You can control the symptoms of your illness with medications more successfully if you have informed your psychiatrist about all effects you feel. Never change your designated treatment without consulting specialist and without being fully informed of the possible consequences and risks of such change. Find information on the Internet. If you have persistent doubts about the advice of your doctor, seek a second, independent opinion from another doctor.

Advices for relatives!

Patients can sometimes require assistance in carrying out their treatment, for example, always remind for the intake of the medications. To be effective in an effort to help, you need to follow a few basic rules.

Some of them are:

Before you take an action always ask your sick relative if he/she needs help. Even the best intentions can be perceived as an intrusion into privacy (such as psychological violence!) and as a disregard, if you have not received a permission of the patient. When inform patients about your intentions towards their disease, you can get consent in a silent way (absence of active denial and opposition may be an expression of consent for assistance). If you have not received consent naturally then you should expect opposition and an arising conflict.

You should never secretly treat your loved ones - do not put drugs secretly in food or beverages. Even if there is an improvement, caused by such treatment, patients are deprived of the opportunity to understand that the improvement in their condition is not accidental, but it was due to the impact of the drug. Thus, in the next episode of deterioration patients will refuse the medical treatment, arguing that the previous exacerbation of the disease was resolved without drugs. Although this method of treatment avoids confrontation with patients and achieves good short-term results, in the long term it is extremely harmful for them, because it deprives them of the opportunity to acquire skills for self-control of the symptoms through an adequate medical treatment. If there is an exacerbation of the disease and the patient refuses to consult a doctor, you should consult a psychiatrist and ask for the possible strategies and approaches to treatment. The compulsory treatment, set by a decision of an independent authorized statutory body (court), it may be much less traumatic for the patients than the effects of the secret drugs you put in the food.

Remember that the illness of your relative is not your fault. It's not known what causes schizophrenia, although many studies have been trying to establish what is the impact of the relationships in the family and whether it contributes to the cause of the disease, a pattern has not yet been found. Therefore you should not blame yourself. In addition, the change, caused by the disease, in the behavior of your close one may require a corresponding change in your own behavior towards him. In any case, it is better to send clear and unambiguous messages to avoid ambiguity and sophisms in the communication with the patient. Be open and consistent. Do not be too insistent in your demands of the patients. Do not you bad remarks and negative comments. Do not confront with zany beliefs of the patient during exacerbation of the disease. Whenever you require something from the patient, for example to drink drugs regularly, offer something in return, such as more personal freedom in other areas of his/her life. Do not criticize his/her behavior. Instead you can just inform them of the impression they have created in you. If the behavior of the patient scares you, tell him! Do not pretend that everything is fine when it is obviously not. Be honest, concerned and friendly. Be interested in the details of his experiences. This will help you better understand the patient and gain his/her trust again. The trust is the foundation of every kind of help or assistance.

Try to overcome the feeling of shame, associated with the disease of your close one. Remember that schizophrenia is an illness like any other and it is not a sign of bad character, bad parenting or education. Do not try to hide the disease from your relatives or neighbors - sooner or later they will learn, regardless of your efforts to keep it secret. Deciding to hide the truth about the disease of your close one, adds another problem to the disease. This often requires a lot of effort. You could not announce the official medical diagnosis, but should not hide the existence of the health problems, especially when the disease is manifested by abnormal behavior or communication. The more people know about the suffering of your close one, the more support he/she and your family will get. Share your worries with your relatives and friends. Contact other relatives of patients with schizophrenia, share your experiences with them and support each other. It is impossible for a person to deal with the disease without an additional support. Of utmost importance is the presence of positive attitude from the environment - relatives, neighbors, colleagues, friends and others. Hiding and keeping the disease secret, talking about the disease with a parable and riddles only mystifies the topic of schizophrenia in society and prevents the formation of rational attitude towards the patients. This can seriously impede the recovery.