In the acute stage of the disease, schizophrenic people experience a multitude of characteristic disorders that affect almost all areas of inner experience and behavior, such as perception , thinking , emotional and emotional life , will formation , psychomotor skills and drive .
Frequently voices that are not actually present are heard (so-called voice hearing ). It can be delusional to be pursued, spied on or controlled. Furthermore, the feeling of being controlled externally can occur, e.g. B. by deprivation of thoughts or inspiration . Persistent hallucinations of any sensory modality are possible. Also, social withdrawal , apathy , lack of motivation , emotional shallowness and unhappiness are not rare. Depending on the predominant symptoms, several subgroups of schizophrenia are distinguished. Medical laypeople often mistakenly associate schizophrenia with the idea of a “ split personality ”, as the literal translation of the term (schizophrenia = “split soul”) seems to suggest this (see On the term schizophrenia ).
In most of the geographic cultures studied to date, about 0.5% to 1% of the population will develop schizophrenia at least once in their lifetime. The risk of disease is equally high for men and women, although statistically speaking, men are affected at a somewhat earlier age. Although diseases from the schizophrenic range have been described since ancient times, no single single responsible cause could be determined. Therefore, today (as of 2020) it is assumed that several triggering factors interact.
In many cases the symptoms disappear after the initial phase of the disease. Thereafter, further phases of the disease ( relapses ) can follow at irregular time intervals . In around a third of those affected, all symptoms regress completely at some point. About a further third have recurrences. In the last third there is a chronic course that leads to a permanent mental disability .
There is a whole range of treatment options, which often enable the sick to lead a largely symptom-free life. The focus here is on drug therapy with neuroleptics .
The term schizophrenia is derived from ancient Greek σχίζειν s'chizein = "split, split, split up" and φρήν PHREN = " spirit , soul , mind , diaphragmatic " from. In ancient Greece , the diaphragm was believed to be the seat of the soul, which is why the word “phren” (φρήν) stood for both terms. Until the middle of the 20th century, schizophrenia was literally translated as divisive insanity. This was intended to describe what was then seen as the core of the disease: the "loss of the inner connection between soul processes".
The term was first publicly presented on April 24, 1908 by the Swiss psychiatrist Eugen Bleuler at a meeting of the German Association for Psychiatry (DVP). In the same year Bleuler published the article The prognosis of the dementia praecox (schizophrenia group) in the general journal for psychiatry and psychological-judicial medicine and in 1911 the well-known text Dementia praecox or the group of schizophrenias . Bleuler's concept of schizophrenia competed with Emil Kraepelin's concept of dementia praecox (premature dementia) .
The first diagnoses with the designation “schizophrenia” were not made more frequently until 1921 and 1930.
In everyday clinical practice in psychiatric facilities, the term “Bleuler disease” used to be used during rounds and in doctor's letters in order to avoid the negative and stigmatizing term schizophrenia. In the past, schizophrenia and affective psychosis were summarized under the term endogenous psychosis .
Schizophrenia is associated with limitations in some intellectual abilities, but not with reduced intelligence , even if the historical term dementia praecox seems to confirm this error . It is the subject of scientific discussion whether schizophrenia is a single disease unit or a group of diseases - with different causes and courses.
Use of terms outside of technical language
By medical laypeople, schizophrenia is often confused with identity disorders ( dissociative identity disorder ), especially with the idea of a “split personality”. This has its cause in a too literal translation back of the two parts of the technical term, namely "split" and "spirit".
In addition, since the 1950s, “schizophrenic” established itself in colloquial language as a derogatory classification in the sense of “nonsensical, absurdly behaving, delusional, ambivalent”. The general term mental illness was also used earlier for schizophrenia.
The symptoms of schizophrenia are traditionally divided into two broad areas: positive symptoms and negative symptoms. In recent times, however, the cognitive symptoms of the disease have also received increasing attention and are seen as a separate third area.
Contrary to what the term suggests, this does not mean deficits in intelligence , but rather a. Problems with attention , memory, and planning actions . The extent to which they are affected in these areas best predicts how well patients can cope with their everyday lives. Cognitive disorders of this type are a central symptom complex of schizophrenia. The thinking may be kurzschrittig, or multilayered relationships are not understood in their complexity. The linguistic expression is impoverished. In acute cases, perseveration (stereotypical repetition of a word or thought) or idiolalia (unintelligible sounds) can occur.
The severity of the symptoms depends in part on the personality of the person affected. The symptoms differ greatly between different people; however, the individual patients often retain their individual symptom pattern over long periods of time.
Positive symptoms (or plus symptoms ) describe excesses of normal experience and are therefore viewed as a kind of "excess" compared to the healthy state. This includes strong misconceptions of the reality experienced through to hallucinations and loss of reality . Schizophrenia with predominantly positive symptoms often start suddenly, and often there are no outwardly conspicuous features beforehand. The course of the disease is rather favorable here.
Characteristic positive symptoms are content-related thought disorders , ego disorders , hallucinations and inner restlessness . The formation of a delusion is typical for content-related thought disorders . Acoustic hallucinations ( acoasms ) often occur : About 84% of people with schizophrenic psychosis perceive thoughts that they think come from outside. You take e.g. B. Voices are true, which in rare cases also give orders. This is commonly referred to as “ hearing voices ”. Those affected often have the impression of being offended by strange voices. Such an experience can occur while being alone or in the midst of sentences that people around you say. Hallucinations of voices also occur in the deaf, even in those born deaf. In deaf people with a diagnosis of schizophrenia, however, visual and tactile hallucinations are significantly more common (in approx. 50% of people each) than in general in schizophrenia (approx. 15% and 5%, respectively).
The ego disorders include:
- Thought inspiration : experiencing one's own thoughts as imposed by others
- Thought spreading: the idea that others could "listen" to or "read along" your own thoughts
- Mind deprivation: feeling of loss that others are stealing or cutting off your own thoughts
- External control: feeling of being controlled by others like a remote-controlled robot.
Negative symptoms (or minus symptoms ) refer to limitations in normal experience and mental functions that were previously present but are reduced or completely absent due to the illness. These symptoms therefore represent a deficiency compared to the healthy state. The following table gives an overview of the negative symptoms:
|Affect flattening||Insufficient range of emotions in perception, experience and expression. The impoverishment of emotions ( affects ) manifests itself in a reduced ability to “participate emotionally”. Those affected only react to a limited extent to normally moving events and appear little affected by the pleasant and the unpleasant. The normal change between different affective states (joy, curiosity, sadness, anger, pride ...) is lost.|
|Alogy||Lack of verbal utterance with delayed, taciturn answers and poorly differentiated language|
|Antisociality||Lack of contact skills in the form of a lack of interest in dealing with other people, social withdrawal , few friends and few sexual interests (not to be confused with anti-social behavior )|
|Avolition||inability to start and maintain targeted behavior|
|Drive failure||reduced ability and will for targeted activity (lack of drive)|
|Abulie||Lack of willpower in the form of difficulty in making decisions|
|apathy||lack of excitability and insensitivity to external stimuli, which leads to indifference and disinterest|
|Anhedonia||lack of ability to experience joy and pleasure or enjoyment|
|"Dynamic emptying"||Lack of motivation for activities resulting in a lack of drive. Includes a lack of future planning, up to and including a lack of prospects.|
|motor deficits||Lack of facial expressions and gestures with reduced movement. These deficits often make the patient appear dismissive or disturbed. This distance can be bridged by affection, which is usually gratefully accepted by the sick, even if they cannot show this through facial expressions and gestures. The impoverishment of the psychomotor system makes the affective resonance appear more impaired than it is. If the patients are not addressed during a hardened state of madness, they are usually receptive to attention.|
Schizophrenias with pronounced negative symptoms often begin insidiously and the course of the disease is rather unfavorable. Negative symptoms can appear months or years before the acute psychotic symptoms ("kink in the life curve", "leading defect"). Sleep disorders and not infrequently also depressive symptoms appear as early symptoms . The negative symptoms usually worsen or solidify as the duration of the illness increases.
In about two thirds of people with schizophrenia, the negative symptoms outlast the positive symptoms after an acute attack (“schizophrenic defect”, “residual state”, “residual symptoms”). These differently pronounced restrictions lead to contact disorders, social withdrawal and often also to disability . In a certain percentage of those suffering from schizophrenia, however, no residual symptoms remain (see residual symptoms ).
After an acute phase of illness with relapsing schizophrenia has subsided, a temporary depressive episode ("depressive fluctuation") occasionally follows . A distinction should be made between real negative symptoms and the side effects of therapy with a neuroleptic . The side effects of neuroleptics can be similar to negative symptoms.
A careful diagnosis is important , as all symptoms of schizophrenia (positive as well as negative symptoms) can also be caused by epilepsy or other diseases of the brain , metabolic disorders and by the consumption or withdrawal of drugs . A problem is that there can be a considerable period of time between the actual onset of the disease and its diagnosis. Studies show that the first changes can be described five years before the first acute psychosis. The first treatment takes place an average of two months after the start of the first acute phase. To shorten this time of the untreated disease, early detection centers have now been set up. a. can be researched on the Internet via the Schizophrenia Competence Network .
Due to the different definitions of the clinical picture in Europe and the USA, there were clear differences in the stated frequencies; only the introduction of a standardized diagnostic system ( ICD ) led to more standardized diagnostics. With regard to the criteria for schizophrenia, this system included both the symptoms of schizophrenia according to Schneider and the symptoms of schizophrenia according to Bleuler .
According to DSM-5
According to DSM-5, schizophrenia is characterized by five main characteristics that deviate from the norm:
- Delusion: The delusion describes a firm belief that, despite evidence to the contrary, cannot be changed. Delusions range from paranoia, relationship mania, body-related mania and religious mania to megalomania.
- Hallucinations: Hallucinations are perception-like experiences that occur without adequate external stimuli. Hallucinations appear unambiguous and clear to those affected, cannot be controlled by the person concerned, and occur with the same intensity and effect as normal perceptions.
- Disorganized thinking (disorganized language): Disorganized thinking ( formal thought disorder ) is usually inferred from the linguistic utterances of those affected. Affected people can jump from one thought to the next ("derailment" or "loosening of associations"). Answers can only be indirectly linked to the questions or not at all (“talking alongside”).
- Grossly disorganized behavior or impaired motor skills (including catatonia ): Grossly disorganized behavior can manifest itself in different ways, ranging from childish silliness to unpredictable restlessness. Problems can manifest themselves in any form of purposeful behavior and lead to difficulties in performing everyday activities.
- Negative symptoms: Negative symptoms explain a significant part of the morbidity in schizophrenia and are less pronounced in other psychotic diseases. Two areas of negative symptoms are particularly common in schizophrenia: decreased emotional expression and reduced willpower (avolition).
Diagnostic criteria in the DSM-5:
A.) Two (or more) of the following symptoms, each for a significant portion of a month-long period (or shorter if treated successfully). At least one of these symptoms must be (1), (2), or (3).
- Disorganized speech (e.g. frequent derailment or disorganization).
- grossly disorganized or catatonic behavior.
- Negative symptoms (e.g. decreased emotional expression or decreased willpower [avolition]).
B.) For a significant period of time since the onset of the disorder, one or more key functional areas, such as work, interpersonal relationships, or self-care, have been well below their pre-onset level.
C.) Signs of the disorder persist for at least six months.
According to ICD-10
The ICD-10 lists nine symptom groups ((a) - (i)). Of the symptoms observed, at least one clear symptom from groups (a) to (d) or symptoms from at least two of groups (e) to (h) must apply over a period of at least one month (almost continuously) . Group (i) is used to diagnose “schizophrenia simplex” (ICD-10 2014).
Symptom groups according to ICD-10 :
- (a) Giving up thoughts, inputting or withdrawing thoughts, spreading thoughts
- (b) Mania for control, mania for influence, feeling of what has been made, delusions
- (c) commentary or dialogical voices
- (d) persistent, culturally inappropriate, and totally unrealistic delusion
- (e) persistent hallucinations of any sensory modality accompanied by fleeting delusions or over-valued ideas
- (f) Gedankenabreißen or insertions in the flow of thought leading to incoherence, addition speeches or Neologismen leads
- (g) catatonic symptoms such as excitement, postural stereotypes, waxy flexibility, negativism, silence ( mutism ) or rigidity ( stupor )
- (h) "negative" symptoms such as noticeable apathy, shallow or inadequate affects
- (i) clear and constant change in personal behavior (loss of interest, aimlessness, idleness, social withdrawal)
Origin and course
Schizophrenia in adults
Schizophrenia can be both intermittent and chronic, with the intermittent form being more common. A relapse, i.e. an acute phase of illness, can last several weeks to months. Then the disease disappears more or less completely, until a new flare-up occurs after months or years. It is seldom a single episode.
Symptoms may completely regress ( remission ) between the individual attacks . Usually, however, the acute phase is followed by a phase with residual symptoms (residual phase) from the group of negative symptoms. Such symptoms are, for example, severely restricted social skills , impairment of personal hygiene, conspicuous language patterns (speech impoverishment), depression or lack of drive. With some courses the residual symptoms remain stable, with others they get worse after each attack. The first flare-up typically begins between puberty and the age of thirty. In women, the first schizophrenic episode usually starts a little later than in men (around five years). Late schizophrenia (first flare-up after the age of 40) occurs more frequently in women than in men. Reasons for this gender-specific difference are not yet known (as of 2018).
Factors ( predictors ) for a more favorable outcome are inconspicuous primary personality , higher level of education, good social adjustment, undisturbed family relationships, acute onset of illness, recognizable psychosocial trigger factors and pronounced affective and paranoid symptoms. Factors for a rather unfavorable outcome are: social isolation, prolonged duration of the episode before treatment, previous psychiatric treatments, previous behavioral problems (such as ADHD ) and a lack of employment.
The risk of suicide is significantly higher: around 5% of all sick people die by suicide . This most commonly affects younger men.
Schizophrenia in children
In rare cases, forms of schizophrenic psychosis can occur in children. The most important symptoms are decay of speech, loss of contact and mood disorders. Schizophrenia in children before school age cannot be diagnosed because the symptoms presuppose impairment of thinking , speaking , perception and the world of emotions and these skills are not yet sufficiently developed at this age. A distinction must be made between childhood autism ( Kanner syndrome and Asperger syndrome ) from childhood schizophrenia, which must be understood as a sudden kink in a previously normal development . This is evident from birth or from crawling age .
Estimates of the lifetime prevalence of schizophrenia vary widely . The mean statistical value ( median ) is around 0.5 percent. Geographical and cultural influences on frequency cannot be reliably described so far (as of 2018) due to the variety of investigation methods and the wide range of results.
The explanatory model for the causation ( etiology ) of schizophrenic psychoses is currently based on a multifactorial interplay of biological (e.g. genetic, infectious, metabolic ) and psychosocial (e.g. social environment, psychological stress in the biography) causes. According to this, several of these factors in combination can trigger schizophrenia - as shown in the vulnerability-stress model . Exceeding a stress threshold is considered to be the triggering factor that causes psychosis to break out in a biologically susceptible ( vulnerable ) person. A faulty regulation of information processing is seen as central.
The closer you are to someone with schizophrenia, the more likely you are to have your own illness. For parents with schizophrenia it is five to ten percent, for sick siblings eight to ten percent, for identical twins 45% and about 21% for dizygoti. If schizophrenia were a purely genetic disease, it should be 100% in identical twins.
In the context of gene-environment interaction, for example, birth complications such as oxygen deficiency, infection or stress on the mother increase the risk of developing schizophrenia. Another example of a possible gene-environment interaction is the interaction of genetic susceptibility and infection , especially during early childhood. Biographical, psychological and social influencing factors can also be largely responsible for the development of schizophrenia if there is a genetic vulnerability.
It is known from imaging techniques that in the case of schizophrenia, the brain exhibits multiple deviations in anatomy and physiology . It is the subject of more recent research (as of 2018) to elucidate the connection between certain deviations and the expected course of the disease.
Schizophrenic psychosis is also associated with biochemical changes in the brain. It is also known from imaging methods that in schizophrenia the signal transmission between the nerve cells in the brain with regard to the neurotransmitter systems that work with dopamine , GABA or glutamate deviates from their normal functioning.
In general, it can be stated that substances that alter your mind strongly promote the onset of schizophrenia. General statements cannot be made; it depends on the genetic disposition as well as the respective personality. Psychotropic substances such as alcohol , amphetamines , cocaine and phencyclidine can trigger substance-induced psychoses . It is also known that non-mind-altering substances such as B. steroids can cause psychosis. Observations in experimentally generated psychoses , such as B. induced by hallucinogens , it can be concluded that the experimentally generated psychosis is a useful model for acute schizophrenic psychoses (relapses).
There have been signs for many decades that estrogens have an influence on the risk of the disease and the severity of symptoms. More recently (2018) it has been shown that in addition to normal drug treatment, selective estrogen receptor modulators such as raloxifene can slightly reduce the symptoms of schizophrenia and can also be used over longer periods of time, both in women and in men .
The earlier assumption of a family milieu that triggers schizophrenia (especially the “ schizophrenogenic mother ”) is considered outdated. This also applies to the long popular double bond theory . Deficits in ego development or serious neglect in the first years of life, on the other hand, can be factors that lead to greater susceptibility to disease (vulnerability). According to Josef Bäuml , the importance of psychosocial influences was clearly overestimated in the 1950s and 1960s. Today we know that this area is less of a cause than of importance for the further course of the disease.
A comprehensive follow-up study ( prospective study ) showed that children of mothers who had described their child as "unwanted" in late pregnancy were more than twice as likely to develop schizophrenia in the course of their lives as a control group. In the opinion of the authors, the results led to the conclusion that either psychosocial stress during pregnancy or a particular tendency in the mother's general behavior was associated with an increased risk. A meta-analysis from 2012 confirmed that the risk of developing schizophrenia increased with the size of the place of residence, up to a factor of 2.37 when comparing the most rural and the most urbanized areas. When assessing this result, the authors emphasized that both special influences of the urban environment and special family or personal factors that influenced the choice of place of residence were possible causes.
According to reviews from 2006 and 2016 and a meta-analysis from 2012, there were indications that the incidence of childhood trauma in the biography of people with schizophrenia is statistically increased.
A meta-analysis from 2011 showed that the risk of developing schizophrenia is increased in immigrants and their subsequent generation: in the first generation by a factor of 2.3 and in the second generation by a factor of 2.1. The authors viewed the results as an indication that, because of the effect in the second generation, the influences from the period after immigration were greater than the influences from the period before immigration. The differences found between the individual studies were associated with possible influences of the various social environments.
The following sub-forms of schizophrenia are not an exhaustive list. Frequently, a psychosis from the schizophrenic group of forms cannot be clearly assigned to any of these forms, as there are many mixed forms and overlaps. The following subtypes describe more symptomatic emphases within the schizophrenic psychoses. In the DSM-5 , the division into subgroups has been abandoned.
This is the most common form of schizophrenia (approx. 60%). Essential characteristics of paranoid schizophrenia are delusions and delusions (hallucinations). Also I disorders are common. The delusional experiences often lead to great fear and strong distrust.
Hebephrenia, also called disintegrative schizophrenia , describes a small group of forms of schizophrenic psychosis that begin in adolescence . Here affective changes (i.e. abnormalities in the emotional and emotional life and mood ), disorganized behavior and thought disorders are in the foreground. Those affected are often described as emotionally flattened or impoverished. A developmental kink can often be observed: a sudden drop in performance at school , a break in social relationships, noticeable listlessness or isolation . Because of these symptoms, it is not easy to differentiate hebephrenia from normal, non-pathological puberty difficulties. Delusions and hallucinations are only fragmentary. Hebephrenic schizophrenia has a rather unfavorable prognosis in the ICD-10 .
In catatonic schizophrenia, psychomotor symptoms shape the appearance. For example, postural stereotypes can arise (strange postures are adopted and maintained over a long period of time). In the catatonic stupor , the patient is motionless with fully preserved consciousness: he is frozen and does not speak. A sub-form of stupor is catalepsy , in which the patient can be moved like a jointed doll . In the catatonic excitation ( raptus ) there is strong motor restlessness ("movement storm"). Arousal and stupor can change suddenly.
The concept of this sub-form of schizophrenia has been heavily criticized since 2010 at the latest. Catatonia and schizophrenia are fundamentally different syndromes that can be easily distinguished by certain drug tests and that also require completely different treatment.
This rather rare sub-form was first described by Otto Diem in 1903 . Here the disease sets in slowly and insidiously in adulthood, whereby the striking hallucinatory and paranoid symptoms are absent. Therefore it is also referred to as a rather harmless ( bland ) psychosis. Those affected are easily perceived as "strange" or "cranky" by their environment and withdraw more and more.
Eugen Bleuler wrote about schizophrenia simplex: “... is a creeping form of schizophrenia, which over the years has been characterized by increasing, incomprehensible social failure in people who were previously healthy (...). If the sick come for a medical examination years after this failure has started, no eye-catching, dramatic psychotic signs are found. But soon you notice their unclear, eccentric language; on closer examination it reveals the hallmarks of schizophrenic disunity. However, the autism of such patients is usually even more noticeable: They live without worrying too much about healthy goals in life, about their professional advancement, their relatives and their future. "
In general, this disorder is considered difficult to diagnose, among other things because of strong definition overlaps with the schizotypic disorder . In DSM-IV, schizophrenia simplex is not defined as a clinical diagnosis, but is included in Appendix B as a research category.
Schizophrenia must be differentiated from other mental disorders , e.g. B. from:
- Autism (both early childhood autism and Asperger's syndrome ) and other pervasive developmental disorders such as Heller's dementia
- Dissociative Identity Disorder
- Psychotic or delusional depression
- Injuries and tumors in the brain
- Different forms of dementia
- Post- stroke conditions
- States of confusion and disorientation
- the psychotic states in borderline personality disorder
- and schizoid and schizotypic personality disorder
- Obsessive thoughts
- Pernicious anemia (vitamin B 12 deficiency)
Often times, schizophrenia is misdiagnosed in people with dissociative identity disorder (DID). One of the reasons for this is that Schneider's first-rate symptoms are more common in patients with DID than in schizophrenic patients themselves, and are therefore more characteristic of dissociative identity disorder.
To date, schizophrenic disorders are not considered to be “curable” in the true sense of the word. With the introduction of neuroleptics, the previously practiced “hard cures” such as malaria therapy , insulin shock or lobotomy (operations on the patient's frontal lobe ) disappeared . Today there is a whole range of treatment options that often enable the sick to lead a largely symptom-free life.
In an acute phase, drug treatment is in the foreground and remains the basis of therapy throughout the treatment. First and foremost, antipsychotics (also: neuroleptics ) are used, which have a specific effect on psychotic symptoms (positive symptoms, such as hallucinations). They influence the signal transmission through neurotransmitters in the brain and can often relieve or eliminate the acute symptoms relatively quickly. Neuroleptics do not induce habituation or dependence. In a meta-analysis from 2017 it was found that the mortality rate of schizophrenia patients was almost halved by medication with neuroleptics.
Older neuroleptics (also: typical neuroleptics or neuroleptics of the first generation ) mainly influence the signal transmission through dopamine . Since dopamine has, among other things, important functions in movement control, there are sometimes serious side effects in this area, so-called extrapyramidal motor side effects ( tardive dyskinesia ) with movement disorders , mainly in the facial area and on the extremities, symptoms similar to Parkinson's and agonizing agitation ( akathisia ). Tardive dyskinesias are particularly problematic here, which only occur after a long period of ingestion and sometimes persist after the medication has been discontinued. Classic neuroleptics can lead to an increase in the level of prolactin in the blood ( hyperprolactinemia ), and this in turn can cause a suppression of estradiol production . This means that long-term consequences such as emotional instability, osteoporosis , an increase in cardiovascular risk and cognitive disorders are believed to be possible. Therefore, an estrogen substitution is often carried out.
With the introduction of clozapine in 1972 there was a preparation that showed none of the extrapyramidal side effects while having a superior effect. The antipsychotics introduced afterwards are attempts to achieve this superior effect without having to accept the side effects that occur with clozapine, especially changes in the blood count.
Extrapyramidal motor side effects also exist with the newer atypical neuroleptics. However, they are usually lower here and differ depending on the preparation, previous treatment and the patient's personal constitution.
Treatment during pregnancy
A 2016 meta-analysis of longitudinal studies on the effects of neuroleptics during pregnancy showed that continued medication during pregnancy did not entail any greater risks for mother and child than discontinuing medication before pregnancy.
New and alternative approaches
In a meta-analysis from 2012, the possible influence of eicosapentaenoic acid from the group of omega-3 fatty acids as an addition to the treatment of schizophrenia was examined. With established schizophrenia there was no effect. However, conclusions about a possible effect in relapse prevention or in the early phase of the disease were not possible.
Electroconvulsive therapy (ECT)
Another treatment method is electroconvulsive therapy (ECT), in which a brief neuronal overexcitation in the brain is triggered by means of electrical impulses on the skull under general anesthesia. This is observed by the doctor electroencephalographically (EEG). There are recommendations for use in catatonic and drug-resistant schizophrenia. Therapeutic effects have been proven, but usually only last temporarily. Unwanted side effects such as partial and usually temporary memory loss have been demonstrated.
Complementary treatment measures
Psychoeducation is sometimes recommended as an essential preparation for the trusting cooperation between patient and therapist . Based on this, the actual therapies follow:
- Sociotherapy , occupational therapy , occupational therapy and supported employment can help to establish a daily structure after it has been shown that it has a psychologically stabilizing effect. Possibly these measures can also aim at maintaining or regaining a job, which in turn is also psychologically stabilizing and can counteract the considerable risk of social decline.
- Physical activity has been shown to improve clinical symptoms, quality of life, general level of functioning, and reduce depressive symptoms in schizophrenics.
- Psychotherapy : The aim of psychotherapy for schizophrenic illnesses is to alleviate unfavorable influences from external stress factors as well as to improve the quality of life and to promote abilities to cope with illnesses ( supportive psychotherapy ). Family therapy has proven its worth not only for those suffering from schizophrenia, but also for their relatives ; because it turned out that negative attitudes in the environment mean an additional risk of relapse.
- Metacognitive training : Against the background of a large number of scientific findings that people with schizophrenia have problems assessing their own thought processes ( metacognition ), metacognitive training (MCT) is increasingly being used as an additional treatment. A meta-analysis published in 2018 reported a significant superiority of MCT compared to control interventions in the weak to medium effect size range.
- Soteria is an alternative milieu therapeutic inpatient treatment for people in psychotic crises. This will u. a. Achieved through close, supportive therapeutic accompaniment in a manageable, comfortable environment that is poor in stimuli.
- Neurofeedback , a special form of biofeedback , gives the patient an active feedback on his current brain activities. For example, therapy-resistant acoustic hallucinations can be influenced as a result.
Early detection and prognosis
In about 75% of patients, there is a preliminary phase ( prodromal phase ) before the onset of the first psychotic symptoms , which can last several years. During this lead time, there are often unspecific (unclear) negative and depressive symptoms. Since these usually have negative social consequences and therefore increase the risk of schizophrenia, early detection of a possible preliminary phase is of great importance and is suitable for noticeably improving the prognosis for the course of the disease.
Social interaction with the sick
time of the nationalsocialism
In the time of National Socialism , schizophrenia was considered a "hereditary disease" and, according to the law for the prevention of genetically ill offspring (GezVeN) of July 14, 1933, a diagnosis was made which resulted in "sterility" - i.e. forced sterilization or forced castration . In the case of systematic mass killings (→ Aktion T4 , Aktion 14f13 and Aktion Brandt ), schizophrenia was one of the criteria for the murder known as euphemistic euthanasia . Between 220,000 and 269,500 people with schizophrenia were sterilized or killed. That is 73 to 100% of all those suffering from schizophrenia in Germany between 1939 and 1945. The murder of psychiatric patients is considered to be the greatest crime in the history of psychiatry.
Even outside the sphere of influence of National Socialism, there were many countries in which legally regulated forced sterilization of schizophrenia patients was practiced. For example, in Switzerland, with the significant participation of the Swiss psychiatrist Eugen Bleuler and his son Manfred, forced sterilizations and forced castrations were propagated and carried out on schizophrenic patients.
The possible lack of understanding in the patient's social environment about the disease and its symptoms can easily lead to exclusion ( stigmatization ). Careful attention to this risk is a particular challenge for everyone involved.
Criticism of the concept of disease
The concept of the disease has been criticized in many ways , especially from the ranks of antipsychiatry, since around the 1960s . One of the most frequent points of criticism is that schizophrenia as a disease, like many other mental illnesses, is a historically conditioned concept that emerged as a result of social and political processes and serves to maintain the power of the existing social system .
The thinking and trading patterns of a person associated with schizophrenia are rather based on axes along which each individual varies, and the diagnosis “schizophrenia” on a culturally shaped and historically contingent separation of the areas of these axes into “healthy” and “sick” “Based. From the point of view of some authors, this thesis would be supported by the high prevalence of delusional thoughts and other psychotic symptoms in the general population. One of the main proponents of the continuum model of psychoses (Jim van Os) pointed out in a later review article (2010) that, in addition to the indications for supporting the continuum model, there were also indications of categorical differences between the sick and the non-sick give this area.
People with an opinion that deviates from the majority opinion or a different perception of the world would be labeled as "sick" with the help of the scientifically legitimized instrument of psychiatry and thus excluded from the social discourse ( e.g. Michel Foucault ), see for example the controversial diagnosis of as Politically motivated terrorist Ted Kaczynski known as “Unabomber” as “schizophrenic”. There is a risk of political abuse and human rights violations, especially when people are locked up and forcibly treated as a result of the diagnosis, although the designation of the institution as a “clinic” instead of a “prison” makes it difficult for the victim to take legal action, for a limited time Unrestricted lock-up enables and discredits the person and their ideas.
Schizophrenia in literature and film
Some of the literary works depicting schizophrenia include a. Georg Büchner's novella Lenz (1835) and his dramatic fragment Woyzeck (1836–1837), Hannah Green's book I never promised you a rose garden (1964), Unica Zürn's novel Der Mann im Jasmin (1977), Heinar Kipphardt's play March, an artist's life ( 1980), Dorothea Buck's autobiographical novel On the Trail of the Morning Star - Psychosis as Self-Discovery (1990), Ruth White's novel Helle Sonne, darker shadow (2000), Renate Klöppel's novel Die Schattseite des Mondes (2004) and Henri Loevenbruck's novel The Copernicus Syndrome (Le Syndrome Copernic) (2008).
Schizophrenia is also an occasional central theme in feature films, e.g. B. in Wie in einer Spiegel (1961), Identikit (1974), I never promised you a rose garden (1977) and Woyzeck (1979) according to the above-mentioned book or drama fragment, Clean, Shaven (1993), Angel Baby ( 1995), Shine - Der Weg ins Licht (1996) about the life of the pianist David Helfgott , Benny and Joon (1993), Forever Lulu (2000), The white noise (2001), A Beautiful Mind (2001), Donnie Darko ( 2001), Der Solist (2009) Take Shelter (2011) and Hirngespinster (2014). Schizophrenia is also treated in the US series Perception (2012), in which Dr. Daniel Pierce, a college professor of neuromedicine, through his schizophrenia, helps the FBI solve difficult cases.
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