© Borgis - New Medicine 3/2010, s. 92-93
*Ewa Ogłodek, Aleksander Araszkiewicz
The First Episode of Schizophrenia
Chair and Clinic of Psychiatry of the Nicolaus Copernicus University Collegium Medicum in Bydgoszcz, Poland
Head of Clinic: Prof. Aleksander Araszkiewicz, MD, PhD
Summary
Schizophrenia is a mental disease which usually affects young people. More than half of cases begin before the age of 25. The first episode of schizophrenia is a difficult time for a patient and his family. During this period patients experience personality breakdown, their youthful ideals collapse, their dreams face reality. Sudden appearance of hallucinations causes alienation from society. A person diagnosed with schizophrenia may experience hallucinations, delusions and disorganized thinking and speech. The latter may range from loss of train of thought, to sentences only loosely connected in meaning, to incoherence known as word salad in severe cases. There is often an observable pattern of emotional difficulty, for example lack of responsiveness or motivation. During their first episode of schizophrenia patients need specific services that provide rapid and easy access to specialist assessments, swift initiation of treatment in a setting which does not have stigma attached to it, and comprehensive psychosocial interventions and support. The purpose of this study is to present the clinical picture, pathogenesis and ways of treatment of schizophrenia including its first episode. Currently in Poland and worldwide there is a trend to start treatment at the early stage of the disease and to put strong emphasis on breaking down barriers between sane people and those suffering from schizophrenia.
The term "schizophrenia" was introduced in 1911 by the Swiss psychiatrist Eugen Bleuler, pointing out that it covers a group of disorders of common characteristics, called axial symptoms, which occur in every case of schizophrenia. These symptoms, according to Bleuler, include: formal thinking disorders, affective disorders, ambivalence and autism (1, 2, 3). To diagnose schizophrenia using the ICD-10 classification, one has to observe for a month at least one of the typical symptoms: thought echo, imposition and taking away thoughts, as well as revealing thoughts; delusions of influence, impact or capture, delusional observations; commenting hallucination voices, pseudo-hallucinations discussing with one another; fixed delusions of other type, the content of which is bizarre, namely not adjusted culturally and completely unreal, or at least two of the following: fixed hallucinations, if accompanied by delusions or fixed hyperquantivalent thoughts; dissociation or failure to adjust statements, neologisms; catatonic behaviour; "negative" symptoms; significant, consistent and wide-ranging change of behaviour. In addition, after diagnosing the symptoms one has to make sure that they are not only the effect of mood disorders or determined by somatic factors (4, 5).
Epidemiology of schizophrenia
Schizophrenia can be considered as a social disease since it occurs relatively often. 400 000 Poles, i.e. 1% of the population, suffer from it. Incidence, dissemination and even intensification of schizophrenia are higher in cities than villages. Most commonly it affects people between puberty and full maturity, namely between 15 and 30 years of age. Death rate among people with schizophrenia is twice as high as in the general population. It is to a large extent associated with unnatural causes of death, first of all suicide (6, 7, 8).
Aetiology of schizophrenia
Currently the publications of many authors refer to the polygenic nature of developing schizophrenia - it is supposed that there are many contributory causes which, when reaching the pathogenic threshold, release a common pathomechanism of the disease. There is also speculation about infection factors, and minor brain damage in the perinatal period. One of the hypotheses concerning psychosis is the dopamine theory, concerning an increase in the level of dopamine in schizophrenia in the areas of the brain called the subcortical nuclei. This hypothesis is confirmed by the effectiveness of anti-psychotic drugs which block dopamine receptors. Apart from dopamine, regulation of other systems of neurotransmitters is disturbed in schizophrenia: gamma-aminobutyric acid (GABA), serotonin and glutamic acid. Another important factor in the development of schizophrenia is the occurrence of obstetric complications (especially related to injuries or hypoxia of the fetus/neonate), and viral infections during pregnancy (especially the 2nd trimester). They also lead, along with genetic predispositions, to disorders in the migration of neurons, physiological impairment, atrophy of neurons after birth and irregularities in synapse formation (9, 10, 11). The impact of psycho-social and biological factors on the development and course of psychosis is unquestionable. In addition, these factors may occur simultaneously. Their co-existence can be explained with the theory of vulnerability/ /sensitivity to injury, because in patients with schizophrenia one can observe so-called pre-disease sensitivity to injury. This personal characteristic, in psychiatry called vulnerability, involves a given person being particularly susceptible to stress and injury (12, 13). The most commonly observed prodromal symptoms in the first episode of schizophrenia, according to Yung and McGorry, include: depressive mood, impaired concentration, weakened drive and motivation (anergy), social withdrawal, sleep disorders, anxiety, suspicion, hypersensitivity, and impaired performance of roles (14, 15, 16).
Acute episode of schizophrenia
Schizophrenia may start suddenly, dramatically, without any doubts that this is a mental disease, or in a hidden form. In the first case, a sudden change in behaviour is most prominent. It can be a rage attack - strong excitement with usually predominant feelings of anxiety, stupor, acute condition of trouble, queerness, non-systematized delusions, hallucinations, escape, dissociation, suicide or self-mutilation attempts.
Subacute episode of schizophrenia
In the latter case, the ill person seemingly does not change, works, still maintains social relations. However, something strange can be sensed in his or her behaviour. The person becomes distant, as if absent, something imperceptible divides him or her from close friends and relatives. Sometimes such a person reveals his or her bizarre thoughts or delusional suspicions, makes people wonder about too frequent exclusion from the course of conversation, strange facial expression, desire to be alone, neglecting daily routines. Sometimes the beginning of the disease follows a sudden event several weeks or months earlier. The patient's behaviour is incomprehensible with regard to the previous life, and does not fit his or her life pattern (17, 18).
Paragnomen
This kind of incident has been called paragnomen, namely a type of behaviour beyond the boundaries of predictability, in the opinion of both the person's associates and the person displaying the behaviour. Such behaviour should be distinguished from impulsive behaviours which, after rejecting social inhibitions, are predictable (19, 20). Care of schizophrenic patients should be based on the treatment of psychopathological symptoms, reduction of unfitness in psychosocial functioning, allowing patients to play significant roles in life (as a parent, partner, employee), and developing the proper attitude of patients and the social environment towards psychosis.
Piśmiennictwo
1. Schennach-Wolff R et al.: An early improvement threshold to predict response and remission in first-episode schizophrenia. Br J Psychiatry 2010; 196(6): 460-6. 2. Murphy BP: Beyond the first episode: candidate factors for a risk prediction model of schizophrenia. Int Rev Psychiatry 2010; 22(2): 202-23. 3. Agius M et al.: The staging model in schizophrenia, and its clinical implications. Psychiatr Danub 2010; 22(2): 211-20. 4. Meister K et al.: Dual diagnosis psychosis and substance use disorders in adolescents - part 1. Fortschr Neurol Psychiatr 2010; 78(2): 81-89. 5. Romm KL et al.: Depression and depressive symptoms in first episode psychosis. J Nerv Ment Dis 2010; 198(1): 67-71. 6. Puri BK: Progressive structural brain changes in schizophrenia. Expert Rev Neurother 2010; 10(1): 33-42. 7. Becker HE et al.: Verbal fluency as a possible predictor for psychosis. Eur Psychiatry 2010; 25(2): 105-10. 8. Falcone T et al.: Suicidal behavior in adolescents with first-episode psychosis. Clin Schizophr Relat Psychoses 2010; 4(1): 34-40. 9. Passerieux C, Caroli F, Giraud-Baro E: Persons suffering from schizophrenia and relapses. Encephale 2009; 35(6): 586-94. 10. Roesch-Ely D et al.: Context representation and thought disorder in schizophrenia. Psychopathology 2010; 43(5): 275-84. 11. van Veelen NM et al.: Left dorsolateral prefrontal cortex dysfunction in medication-naive schizophrenia. Schizophr Res 2010; 123(1): 22-9. 12. Romano DM et al.: Reshaping an enduring sense of self: the process of recovery from a first episode of schizophrenia. Early Interv Psychiatry 2010; 4(3): 243-50. 13. Montreuil T et al.: Social cognitive markers of short-term clinical outcome in first-episode psychosis. Clin Schizophr Relat Psychoses 2010; 4(2): 105-14. 14. Agius M et al.: The staging model in schizophrenia, and its clinical implications. Psychiatr Danub 2010; 22(2): 211-20. 15. Luck D et al.: Disrupted integrity of the fornix in first-episode schizophrenia. Schizophr Res 2010; 119(1-3): 61-4. 16. Schultz CC et al.: Increased parahippocampal and lingual gyrification in first-episode schizophrenia. Schizophr Res 2010; 123(2-3): 137-44. 17. Franz L et al.: Stigma and treatment delay in first-episode psychosis: a grounded theory study. Early Interv Psychiatry 2010; 4(1): 47-56. 18. Jahshan C et al.: Course of neurocognitive deficits in the prodrome and first episode of schizophrenia. Neuropsychology 2010; 24(1): 109-20. 19. Shrivastava A et al.: Persistent suicide risk in clinically improved schizophrenia patients: challenge of the suicidal dimension. Neuropsychiatr Dis Treat 2010; 6: 633-8. 20. Andreasen NC: The lifetime trajectory of schizophrenia and the concept of neurodevelopment. Dialogues Clin Neurosci 2010; 12(3): 409-15.
