Relatives of schizophrenics face 10 times more risk

Schizophrenia is a mental disorder characterised by odd behaviour. The oddness may be noticeable in several domains: speech may be incoherent, illogical or rambling, and convey very little information; there may be complaints of hearing threatening voices, seeing scary visions or smelling bad odours; unrealistic beliefs about being controlled or persecuted may be held. There may be no interest in work or recreational activities, or in interacting with other people. When addressed, the patient’s response may be indifferent, with very little by way of facial expression and eye contact; you may get a sense of not being able to communicate with him.

The patient himself is unaware that the things he is saying and doing appear strange to people around him. His experience of reality is distorted and he does not have the insight to recognise that something is amiss.

A patient usually does not come to consult a doctor on his own. He is brought by a family member or friend who has noticed a change in him over several weeks or months. After relating the sequence of events that led to the visit, the accompanying person usually sums it up with, “he has changed a lot, doesn’t make sense when he talks . . . doesn’t seem to listen. . . I can’t get through to him. . .”

Often a patient is brought to a doctor only when he has had a breakdown characterised by sleeplessness, irrelevant talk and inappropriate behaviour. He may appear intensely fearful and agitated, or may be aggressive and violent.

This, in a nutshell, is schizophrenia: episodes of florid disturbance against a backdrop of profound difficulty in initiating and organising his activities.

What is the cause of the odd behaviour in schizophrenia?
The fundamental deficits are in two areas: the ability to pay attention and process information, ie thinking, or cognition, and the will to initiate action, or motivation. Parts of the frontal lobe and temporal lobe of the brain that are responsible for these processes are dysfunctional. This may explain the seeming indifference that he displays towards everything in his daily life.
Against this background, transient episodes of chaotic behaviour can occur due to increases in certain chemicals in some parts of the brain. These may be precipitated by missing doses of medicines, lack of sleep or by undue stress. For example, being at a noisy party where several people are talking at the same time would not affect normal people; to a person with schizophrenia it would be more than what his information-processing ability can handle, resulting in a breakdown, or psychotic episode.

Who is at risk?
There are some suspected risk factors:• Lifetime risk is about 1% in the general population.• The risk is 10% in first-degree relatives of patients.• A history of obstetric complications like prematurity, low birth weight and resuscitation at birth.• Abuse of ‘recreational’ drugs by someone who might have been prone to schizophrenia but never showed symptoms before.

What is the course of the illness?
About 50-75% reach a clinically stable state with no further deterioration. Of the rest, 15-20 % completely recover from the first episode, 20-25% experience multiple episodes but remain nearly normal between episodes and 20-25% develop severe and chronic schizophrenia. A subgroup of patients may recover with mild residual effects after decades of severe illness.

How do you deal with it?
Episodes of psychosis are brought under control using medicines, with regular monitoring by the treating psychiatrist for at least one year. The decision to continue medications after one year is also taken by the treating doctor, depending on the patient’s progress. The negative state, ie the lack of initiative and drive, is difficult to change though some patients respond to medications meant to increase their interest and involvement in life.

How can family and friends help?
Most patients who are almost back to normal can be trusted to take their medicines regularly. Still, it is better to have someone discreetly check that the medicines are being taken, as missed doses could mean another breakdown.
Critical comments and hostility towards the patient should be totally avoided as they increase the risk of relapse. Commenting patronisingly on his positive actions like “he had a bath today, he’s better”, are also better avoided.

Encouraging a patient to work or study is alright up to a point. If he is unable to drum up the enthusiasm to do anything, criticising, pushing or goading him to do so may be stressful, and may elicit violent reactions. If a patient who was stable has suddenly stopped going to work and appears troubled, this should be brought to the notice of his psychiatrist; a mental state examination and appropriate adjustment of dose may be all that is required.

— Dr Shyamala Vatsa is a consultant psychiatrist