MY PROFESSION -
COMMUNITY PSYCHIATRIC NURSE

Sudha Chavda. Hillingdon
Part 6

Namaste folks! Hope you are all in splendid health. Sorry for the delay in preparing this issue. Sometimes we are not aware of the events, which life has lined up for us, which throws us off balance. As I mentioned in my last issue, it is time for us to be a little bit more knowledgeable on various mental illnesses. To start off with we will discuss the illness Schizophrenia.

Introduction
Schizophrenia is a mental illness that affects about one out of every hundred people. There are many popular myths and misunderstandings about it. That makes it all the more important to get the facts straight.

· What it is like to have schizophrenia
· What may cause it
· What can be done to help

The outlook today is much brighter than it used to be. There are now better ways of helping someone to cope with schizophrenia. Many people with schizophrenia live independently, and more and more are able to work and have family.

Basic facts

How common is it?
Schizophrenia affects one in every hundred people. This is about the same for many different places and peoples across the world. It seems to be more common in city areas.

Who does it affect?
Schizophrenia affects men and women equally. It rarely starts before the age of 15, but can develop at any time after this. Men with schizophrenia usually notice the first signs in their late teens or early twenties. Women are often first affected a little later, in their twenties or thirties.

What are the symptoms of schizophrenia
You may hear people talk about positive and negative symptoms of schizophrenia.

"POSITIVE" SYMPTOMS
These are the unusual experiences that are part of schizophrenia. They sometimes happen in other severe mental illnesses.

Hallucinations
A hallucination happens when you hear, smell, feel or see something when there isn't anything, or anybody, actually there to hear, smell feel or see. In schizophrenia, the commonest hallucination is hearing voices. The voices can sound so real that you become convinced they truly are coming from outside you. It may be hard to work out why other people can't hear them. They may seem to be coming out of thin air, or you may hear them coming from the television or some other object. You may try to find an explanation for them - that they are coming from hidden microphones, loudspeakers, or the spirit world. The voices can be so real that you find yourself talking back to them, or even shouting at them. You may feel that you have to do what they say, even if they are telling you to harm yourself. The voices are not imaginary, but they are created by our own minds. The brain mistakes our own thoughts for real experiences happening outside us.

People with other kinds of mental illness, such as severe depression, may also hear voices that talk directly to them. In schizophrenia, the voices seem to talk to each other, as well as talking to you. It can sound as if you are over-hearing a conversation, as though you can hear people talking about you. Visions and hallucinations of smell, taste or being touched can also happen - these are less common.

Delusions
A delusion is a particular kind of unusual belief. It can be unusual because it is uncommon or unknown in your culture. It can be unusual because you believe it very strongly without having any evidence to support it. Either way, other people find that they can't really discuss it with you. If someone asks you to explain why you've come to believe this, you can't say why, or your reasons don't make sense to him or her - you " just know".

How does it start? A delusion may sometimes come out of the blue, often after a few weeks or months when you have felt that there has been something strange going on that you couldn't explain. You may come to believe it by trying to explain hallucinations, or other strange experiences (see below). They feel so real that you have to find some reason for them.

People often talk about 'paranoid' delusions. 'Paranoid' is just another word for feeling persecuted or harassed. You may have ideas of persecution that, at first sight, seem quite reasonable. For example, you may start to believe your partner is unfaithful, even though other people can see nothing to suggest that this is true. On the other hand, you may have ideas that are more unusual, like feeling that MI5 or the government is spying on you. You may believe that you are being harassed by the neighbours who are using special rays, or that you are God's special messenger. Delusions of persecution can be especially upsetting for your family, if you see them as your persecutors.

Some people have "delusions of reference". This is where you start to see special meanings in ordinary, day-to-day events. You may find yourself believing that radio or TV programmes are about you, or that people are communicating with you through the colours of cars passing in the street.

It can be difficult to discuss your ideas with other people, because you realise that they won't understand. Often, delusions won't affect the way you behave. However, if you feel that other people are trying to harm or harass you, you may feel so threatened that you want to retaliate. More commonly, you will just keep away from other people.

Muddled Thinking (or "Thought Disorder")
You may find that it is becoming harder to concentrate - you can't finish an article in the newspaper or watch a TV programme to the end. If you are at college, you will find it difficult, or impossible, to keep up with your studies. If you are working, you just can't keep your mind on the job.

One of things that make it difficult to concentrate is the way that your thoughts connect with each other. They seem to wander off on their own. You can drift from one idea to another one that doesn't seem to have any connection with the first. After a minute or two you can't remember what you were originally trying to think about. Some people describe their thoughts as being "misty" or "hazy" when this is happening.

When your ideas are disconnected in this way, it can be hard for other people to understand you. You may notice that other people look a bit baffled when you are trying to tell them something.

Feelings of Being Controlled
When this happens, it can feel as though someone is taking thoughts out of your mind, or putting their thoughts into it. It can feel as though someone is trying to take you over or control you - this is extremely unpleasant and disturbing. You may feel as though your body is being taken over, or that you are being controlled like a puppet or a robot. It may get to the point where your whole personality seems under the influence of an alien force or spirit. This is a terrifying experience, which people explain in different ways. In 'high-tech' societies, people tend to blame radio, television or laser beams, or believe someone has installed computer chip in their brain. In traditional and religious communities, people may blame witchcraft, angry spirits, God or the Devil.

"NEGATIVE" SYMPTOMS
"Negative symptoms" are less obvious than positive symptoms.
Your interest in life, energy, emotions and 'get-up-and-go' just seem to drain away. It's more difficult to feel excited or enthusiastic about anything. You can't concentrate. You may not bother to get up or go out of the house. It can be difficult to wash or tidy up, or to keep your clothes clean. You may feel more uncomfortable with people, and feel that you have nothing to say.

Other people can find it hard to understand that negative symptoms are actually symptoms, and that you are not just being lazy. This can be upsetting, both for the family and for someone with schizophrenia. The family can feel that you just need to pull yourself together. You can't explain that you can't.

It can seem to them as if you have changed, you don't seem like the same person anymore. It is important for the family to understand that this is as much a part of a crippling illness as are any delusions and hallucinations. Negative symptoms are much less dramatic than positive symptoms, but they can be just as troublesome.

Does everyone with schizophrenia have all these symptoms?
No. someone can hear voices and have negative symptoms, but may not have thought disorder. Some people with delusional ideas seem to have very few negative symptoms. If someone has mainly thought disorder and negative symptoms, the problem may not be recognised for years.

What causes schizophrenia?
We don't yet know for sure what causes schizophrenia. It is likely to be a combination of several different factors, which may be different for different people.

Genes
About one in ten people with schizophrenia have a parent with the illness. If neither of your parents has schizophrenia, your chance of developing it is more like one in a hundred. This difference is probably caused by heredity (genes), not upbringing.

For example, identical twins have exactly the same genetic make-up as each other, down to the last molecule of DNA. If one identical twin has schizophrenia, the brother or sister has about a 50:50 chance of having it too, even if they are brought up in different families.

Non-identical twins don't have the same genetic make-up as each other. If one of them has schizophrenia, the risk to the other twin is just slightly greater than for any other brother or sister. Research suggests that heredity provides about half the explanation of the illness. We have not yet discovered the gene, or combination of genes, responsible for schizophrenia.

Brain Damage
New ways of producing pictures of the brain show that some people with schizophrenia have larger spaces in the brain than people who don't suffer from the illness. This suggests that some parts of the brain may not have developed quite normally. Problems during birth might be responsible - these can affect the supply of oxygen to the baby's brain. It is also possible that, during the early months of pregnancy, virus infections can cause subtle brain damage.

Stress
Stress often seems to happen shortly before an episode of schizophrenia. This could be a sudden event like a car accident, bereavement or moving home. It can be part of everyday problems, such as difficulty with work or studies. Stress is not the cause of schizophrenia, but it may help to bring it on in someone who is vulnerable. Long-term stress, such as family tensions, can also make it worse.

Street Drugs and Alcohol
Sometimes, the use of street drugs like ecstasy (e), LSD (acid), amphetamines (speed), and cannabis (hash, marijuana, pot, ganja, skunk, dope, spliffs, joints) seems to bring on schizophrenia. We know that amphetamines can bring on symptoms just like those of schizophrenia, but they usually stop when you stop taking the amphetamines. We don't yet know whether these drugs can trigger off a long-term illness but they may do in someone with a predisposition. It does seem that using street drugs and alcohol can make matters worse in some people who already suffer from the illness. Many people use street drugs or alcohol to cope with their symptoms or, sometimes, the side effects of anti-psychotic medication as a form of self-medication.

Family Problems - At one time, it was fashionable to believe that schizophrenia was caused by problems within the family. There is no evidence to support this idea. However, if you already have schizophrenia, family tensions can make it worse.

What is the outlook? Schizophrenia can make it hard for someone to work, to study, and to get on with other people. It can make it hard to live an independent life, and it can cause a lot of distress in families, BUT:

Treatment and help for schizophrenia are much better today. Before 1950, many people with schizophrenia spent most of their lives in mental hospitals. Now, many people with schizophrenia never have to go into hospital.

Many people who suffer from it are eventually able to settle down, work and make lasting relationships. New treatments and ways of helping schizophrenia mean that the outlook is now much brighter.

In the long term:
1 in 4 people will get better within five years of their first episode of schizophrenia.
2 out of 3 will get better, but will still have some symptoms. They will have times when their symptoms get worse.
Around 1 in 5 will have troublesome symptoms that will continue to interfere with their lives.

The longer schizophrenia is left untreated, the greater its impact on your life. The sooner it is noticed and you get help for it, the better.

What treatments are available?
If you have the symptoms of schizophrenia for the first time, you may need to stay in hospital for a while for thorough assessment and treatment. However, if the illness is caught early enough, this may not be necessary. You would need to see a psychiatrist because schizophrenia needs expert help. Even if you do have to come into hospital, it will usually be for only a few weeks. Afterwards, any help or treatment you need can be given at home.

Medications help the most disturbing symptoms of the illness. However, they do not provide a complete answer. Medication is an important first step, which makes it possible for other kinds of help to work.

Support from families and friends, other forms of treatment and services such as supported housing, day care and employment schemes also play a vital part in getting better.

Medication - "Typical" Antipsychotics
In the mid - 1950s, several drugs appeared that could reduce the symptoms of schizophrenia. They became known as "antipsychotic" medications. These older drugs are called "typical" antipsychotics. They work by reducing the action of a particular chemical messenger in the brain called dopamine.

They usually weaken delusions and hallucinations gradually over a period of a few weeks. If you have had thought disorder, you may find that you are able to think more clearly.

Side Effects
The most common are stiffness and shakiness, like Parkinson's disease. Giving anti-Parkinsonian drugs can reduce these. These "typical" anti-schizophrenia medications may make people slow and sleepy, and overweight. An uncomfortable restlessness can be caused by these medications, and they can interfere with your sex life. Perhaps the worst side effect is permanent movements of the mouth and tongue . This affects about 1 in 20 people every year who are taking these medications.

"Atypical" Antipsychotics
Over the last 10 years, several newer medications have appeared. They work on a wider range of chemical messengers in the brain and are called "atypical" anti-psychotics. They are less likely to cause Parkinsonian side effects, although they may cause weight gain and some cause problems with sexual function. They may also help the negative symptoms, on which the older drugs have very little effect. Many people who use these newer medications have found the side effects much less troublesome than those of the older medications.

How well does mediation work?
These medications, although they work well for many people, are NOT a cure. The symptoms of schizophrenia often come back. This is much less likely to happen if you carry on taking medication even when you feel well. This is why a psychiatrist will usually suggest that you take medication for a long time. If you want to stop your medication, you need to discuss this with your doctor, family or friends.

How is it Taken?
Medication for schizophrenia comes as tablets, capsules, and syrup. We can all find it hard to remember to take tablets several times a day, so there are now some that you only need to take once a day.

If you find it hard to take tablets every day, you may find it easier to take anti-psychotic medication as an injection. These are called depot injections and are given weekly or every 2,3 or 4 weeks. On the other hand, taking tablets gives you more control over your medication and its effects.

What happens if you stop medications?
The symptoms of schizophrenia will usually come back - not immediately, but usually within 6 months.

Getting back to normal
What happens after your positive symptoms have been controlled? Schizophrenia can make it difficult to deal with the demands of everyday life. Sometimes this is because of the symptoms. Sometimes, the illness may have gone on for so long that you may just have got out of the habit of doing things for yourself. Ordinary things - washing, answering the door, shopping, making a phone call or chatting with a friend - can seem very difficult.

Medication can help up to a point but you need to be able to get other types of help to have the best chance of getting better. Your local mental health team, social services and voluntary organisations in your area should provide these.

The family
You may find it hard to understand what is happening if your son or daughter, husband or wife, brother or sister develops schizophrenia. They may have become odd, distant or just different from how they used to be. They may be avoiding contact with people and may seem to be less active. If they have delusional ideas, they may well keep quiet about them. If they are hearing voices, they may suddenly look away from you as if they are listening to something else. When you speak to them, they may say little, or be difficult to understand. Their sleep pattern may change so that they stay up all night and sleep during the day.

Sometimes, no one realises what is happening. You may wonder if this behaviour is just rebellious or perverse. It can happen so slowly that, only when you look back, can you see when it started. It can be particularly difficult to recognise these changes if the illness develops during teenage years. This is a time when young people are changing anyway, and often experimenting with new freedoms and lifestyles.

If you do realise that schizophrenia is the problem, you may start to blame yourself and wonder 'Was it my fault?' You may wonder if anyone else in the family is going to be affected, what the future holds or how they can get the best help.

Families need as much help and information as possible from the psychiatric team. They also need advice. What do they need to do? Someone with schizophrenia will be more sensitive to stress, so it is helpful to avoid arguments and keep calm - perhaps easier said than done! The psychiatric team needs to listen to the worries and concerns of families. It can advise on drugs and their side effects, as well as suggesting small manageable tasks that may help recovery.

Compulsory treatment
Someone with schizophrenia may not always realise they are ill. They may refuse treatment when they badly need it. the Mental Health Act(in England and Wales) and similar legal arrangements in other countries, allow a person to be admitted to hospital against their will. This is only used if someone needs assessment or treatment, and they cannot or will not accept it, and:

· their health is at risk or
· they are a danger to themselves or
· they are a danger to other people

I hope the information provided is useful. For more material please download from the website - www.rcpsych.ac.uk

Sudha Chavda



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