Shunning the Stigma of Schizophrenia
Iris C F Gomes
Like all mental illnesses, schizophrenia carries with it stigma that can stand in the way of the patient’s treatment and ability to lead a relatively normal life. 24th May was World Schizophrenia Day, which was celebrated by the COOJ Mental Health Foundation by hosting a variety of programmes during the week leading up to the day. This was an attempt to educate people and remove the stigma attached to the disease.
Dr Peter Castelino, psychiatrist and founder of COOJ (Cause of Our Joy), explained in a discussion on World Schizophrenia Day how schizophrenia affects its sufferers. This chronic neuro-psychiatric condition affects thinking. In short it is the distortion of thoughts. Unlike bipolar disorder, which is a mood disorder, schizophrenia is a thought disorder. One can have a combination of mood and thought disorder symptoms such as schizoaffective disorder. The disease also affects perception, emotions, language and behaviour. Student and work life are affected adversely by the deficits in concentration and memory that schizophrenia causes.
Hallucinations (a person may begin to see, hear or feel things that are not present) and/or delusions (fixed thoughts or beliefs that do not have a place in reality) are common with schizophrenia. Delusions can be implausible, such as aliens landing on the planet, or plausible, such as the belief that someone is following you, which are more of a problem. The person can have disorganised speech, where he/she may intend to say something but the structure of the sentence will be jumbled up, and disorganised behaviour, such as looking blankly at somewhere or throwing stones aimlessly. All these come under positive cognitive symptoms.
Flattened affect, ie lack of facial expression to convey emotion, is one of the negative cognitive symptoms. There is a loss of taking pleasure in anything, or anhedonia. Speech becomes flat and there is a complete lack of ability to motivate oneself. Schizophrenics find it difficult to plan or structure activities. Another negative cognitive symptom is the lack of insight which separates a psychotic illness from a neurotic one. This lack of insight convinces the patient that his/her delusions and hallucinations are true.
Catatonia is another characteristic of schizophrenia. Here patients can experience stupor that lasts for long periods of time. They may move limbs in an odd manner repetitively and sit in a strange position. Schizophrenics sometimes exhibit echolalia, another catatonic behaviour, where they repeat words spoken to them by another person.
The onset of schizophrenia is usually during late adolescence and early adulthood, but children have also been diagnosed with the disease. The symptoms are the same as in older individuals. The earlier the disease is diagnosed and treated, the better it is to preserve the person’s cognitive functions and avoid disabilities, since there can be permanent damage to these if caught at a later stage. A combination of genetic and environmental factors can cause schizophrenia.
Brain scans show that there is reduction in the grey matter of the brain of a schizophrenia patient as the illness progresses, which leads to symptoms mimicking dementia. This is the reason why, early on, schizophrenia was called dementia praecox, or a precursor to dementia.
So what causes the symptoms of schizophrenia? There are neurochemicals in the brain, which help relay messages from one neuron to another, like dopamine, gamma-aminobutyric acid (GABA), serotonin, glutamate, and acetylcholine. The way these work together affects patients of schizophrenia. For example if the dopamine levels begin to rise in certain parts of the brain, it could lead to positive symptoms as mentioned above. When serotonin levels go down, schizophrenics experience depression and apathy. Medicine attempts to restore the right balance of these neurochemicals.
The different types of schizophrenia are paranoid schizophrenia (more positive symptoms), disorganised schizophrenia (more disorganised behaviour), catatonic schizophrenia (more catatonic behaviour), undifferentiated schizophrenia (when the schizophrenia cannot be strictly categorised) and residual schizophrenia (when symptoms begin to subside). Many chronic schizophrenics are mainly in the residual phase.
The Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V) is one of the tools used to diagnose schizophrenia. Symptoms must be prevalent for six months and two or more of the symptoms must persist significantly (affecting your social, academic or work life) for at least a month for the person to be diagnosed with schizophrenia.
The condition can be stabilised with medicines (typical and atypical antipsychotics) and psychotherapy. The psychotherapy is geared towards the cognitive rehabilitation of the person. Electroconvulsive therapy (ECT) is another form of treatment that is employed when treatment needs to be immediate (as in the case of suicide risk) and there is not enough time to have medication work. It can be used in conjunction with medication to enhance its effectiveness. It is given under anaesthesia and is safe for the patient despite the negative notions that most people hold about ECT. There is ongoing research in the field of neuroscience to find new treatment for schizophrenia.
Some of the challenges of treating mental illness are the stigma attached to it, which prevents individuals from seeking help from a doctor, and keeping patients on a course of medication, where they sometimes cannot deal with the side effects of the medication or do not have the frame of mind to maintain a routine. Medication and rehabilitation can be prohibitive economically. The government (in Goa) does provide free medicines but does not cover the cost of rehabilitation.
About a third of schizophrenia patients manage to lead a fairly normal life, even holding good jobs. One third continue to have symptoms, but they do not disrupt their lives drastically. And another one third has considerable trouble with the symptoms and do not respond to treatment and medication.
Neetha Mascarenhas, the coordinator of the rehabilitation programme at COOJ, went on to talk about rehabilitation at the non-profit. When a client comes to COOJ, Mental Status Exam (MSE) and other tests are administered, and a case history is recorded. Based on these, a psychological report is formed and goals are formulated along with a treatment plan, using a holistic approach while taking the strengths and weaknesses of the client into consideration. The family is involved in the treatment process by giving them information and awareness regarding the illness. The COOJ team consists of a psychiatrist, clinical psychologist, counselling psychologist, psychiatric social workers and various therapists (expression therapy, etc).
Vocational therapy at COOJ is directed at helping clients get back to some sort of work situation. The clients at COOJ make all kinds of products like cards, paper bags, paintings, decorative items, etc. Cognitive remediation helps clients improve functions such as memory, attention, concentration, decision making, problem solving, etc. Group sessions are held where two or more people help each other achieve goals. There are also psychotherapy groups. Aside from this, COOJ has newspaper and book reading, meditation, music therapy, singing, gardening and other activities for its clients. Clients have the Friends Club where they have varied activities such as outings, movie screenings, workshops, etc.
Dylan Arthur’s testimony about the improvement he felt in his own mental health after seeking treatment at COOJ, is proof enough of the good work that the NGO is carrying out. COOJ not only aids mental health patients but is instrumental in providing a new lease of life to the elderly through its programmes for seniors.