Rethinking Schizophrenia – The need of the hour

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I recently came across an article which emphasized the need to re-conceptualize “schizophrenia”. Schizophrenia is one of the most well known yet least understood mental illnesses. The wide range of  clinical presentations, and a wide  variety of pathological findings, an even wider variety of treatment responses raise a lot of questions.

It is quite surprising that the name “schizophrenia” has stuck with us for so long, and it is quite possible that the existence of schizophrenia as a single diagnostic entity has impeded meaningful research into what could very well be distinct disease entities. Despite attempts in the past like Crow’s two syndrome hypothesis and Liddle’s three syndrome hypothesis, schizophrenia remains one single diagnosis.

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The pre-DSM 5 subtypes seem to have better diagnostic validity, at-least at the ground level. Per DSM-5 anyone with 2 or more of the following –  delusions, hallucinations, disorganized speech, disorganized behavior or negative symptoms can be diagnosed with schizophrenia, if the symptoms are active for a month with disturbances lasting at least 6 months. Schizophrenia is almost always seen as a lifetime diagnosis, which implies that the sufferer needs to be on anti psychotic medications for the rest of their lives.

A number of groups have  criticized the use of the term schizophrenia, which is 110 years . The International Society for the Psychological Treatments of Psychosis has criticized the term, arguing that the concept  has no real current scientific foundation, while it does have great power to stigmatize people so diagnosed. This criticism has been echoed by  radical voices  such as Peter Breggin and Peter C. Gotzsche, or Allen Frances and others who have strongly opposed the approach of the DSM 5.

Here are a myths about schizophrenia – 

Myth : Once a schizophrenic always a schizophrenic. 

Reality: A wide variety of treatment responses and even spontaneous remissions are not unknown. Once a schizophrenic should ideally remain once a schizophrenic.

Myth :  A schizophrenic is a schizophrenic.

Reality There is a lot variance in terms of symptoms, severity, treatment response and prognosis among people suffering from schizophrenia. Some people tend to do very well and develop insight early on, whereas others have long standing difficulties.

Myth : Schizophrenia not treatable and is a sentence for life.

Reality: Schizophrenia isn’t “curable” . It is however, very treatable. Medical treatment is progressively  becoming safer and more effective. Psychothereapeutic measures are also gaining a rapid evidence base. For a large section of the population, schizophrenia could just be an interruption in life and not a barrier.

Myth :  Psychotherapy has no role in schizophrenia.

Reality: Techniques like CBT-P (cognitive behavioral therapy for psychosis) have been proven to be useful in the management of schizophrenia and other psychoses. Supportive psychotherapy is crucial in crisis intervention and help overcome acute disturbances.

Myth : Patients must be on medication for the rest of their lives.

Reality: Most guidelines suggest high relapse rates when anti psychotics are withdrawn, however a proportion of patients do eventually go off the medications. Compliance with medication and therapy are of prime importance.

Myth : People with schizophrenia have to be restricted to to low-level jobs.

Reality: When symptoms are under control, nothing restricts one suffering from schizophrenia from performing adequately in any job situation.

Myth : Rehabilitation can be provided only after stabilization.

Reality: Rehabilitation should begin one day one, with recovery and rehab being one of the primary goals of treatment, not just an absence of symptoms.

Myth : Families are etiological agents.

Reality: Families can help in identifying early signs, decrease severity of illness and help greatly in the provision of care for those suffering from schizophrenia.

Myth : Pessimism –  A tendency to see the worst aspect of things or believe that the worst will happen.

Reality : Optimism – Hopefulness and confidence about the future or the success of something.

This short writeup was based on – Rethinking Schizophrenia in the Light of New Evidence:Thirty Years after the Vermont Longitudinal Study of Persons with Severe Mental Illness
Alberto Fergusson , Miguel Gutiérrez-Peláez
 

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