Psychosis is a term that many people have heard of, yet few can adequately define; the same could be said of schizophrenia. Psychosis can be considered, loosely, as detachment from reality which is frequently characterised by reality distortion along with a reduction of intrapersonal and interpersonal functioning. The presence of hallucinatory phenomena, with auditory hallucinations being most common, may occur– either synchronously or asynchronously – with the development of false belief systems. These false belief systems are often firmly and rigidly held in conviction and can be referred to as delusions. It is stated that this clinical syndrome, if recurrent or prolonged, can lead to the chronic condition schizophrenia; which follows a relapse course. But, there are some significant aspects to explore before concluding that prolonged psychosis equates with schizophrenia.
The signs and symptoms of psychosis can be divided, broadly, into positive and negative categories. Positive symptoms are referred as such, not because these are associated with a ‘positive’ contribution to one’s life, but because these experiences are additional to, or outside of, the usual range of experiences. Examples of positive symptoms include disordered thinking, hallucinations, and delusions; as well as disturbed self-presence (ipseity disturbance). Conversely, negative symptoms represent a departure from the usual level of functionality and self; with examples including poverty of thought or speech, lack of motivation, or a lack of enjoyment and pleasure. Further clinical features related to cognition and mood may also present, and these may be difficult to differentiate from negative symptoms on occasion. It is very often the case that it is the negative symptoms, that can be long-lasting in nature, which have the most significant impact upon an individual’s quality of life; and it is also these symptoms which are the most difficult for clinicians to manage effectively.
Considering the significant, and often chronic, implications of these negative symptoms, it remains a little surprising that most laypeople (and some professionals) most frequently cite hallucinations as being the primary indicator of schizophrenia; however, this may well be an erroneous position to occupy.
Let me explain why: firstly, it is entirely possible for healthy individuals to experience hallucinations, and there is likely a phenomenological continuum of sensory experiences which we all traverse. Secondly, there is a significant body of evidence to propose that hallucinations are not uncommon features within several, non-schizophrenia related, conditions (both ‘mental’ and ‘physical’ health conditions- once more, I use these terms with caution for fear of perpetuating Cartesianism). These conditions include endocrinological, metabolic, autoimmune, degenerative and demyelinating disorders, to list but a few. It may be that the focus upon hallucinations – and ‘voices’ specifically – within the public understanding of schizophrenia, misrepresents the very essence of the condition; as well as minimising the negative features which often have the most significant impact upon the individuals living with a diagnosis of schizophrenia.
So, if hearing voices and developing irrational beliefs are not the defining features of schizophrenia, what is? In its most basic form, schizophrenia is related to loss.
A sense of loss that is pervasive, and influences everything in one’s life; ranging from relationships, determination, aspirations, hobbies, hopes, and interests. This loss, which may or may not be recognised by the individual, can be immense; both for the individual and those close to them. These features may present as a reduced ability to care for oneself, or even a reduced sense of the need to care for oneself. In addition, there will likely be the presence of associated cognitive features; such as inattentiveness, poor memory or impaired recall. This persistent loss, or diminution, of self can lead to profound and chronic disability with poor functional outcomes.
The clinical features of schizophrenia are currently managed using antipsychotic medications, in partnership with psychological therapies and social interventions that improve an individual’s ability to recover from, or manage, these symptoms in both the short and in the longer term. However, while antipsychotic medications are effective in managing the positive symptoms, the negative symptoms (or negative syndrome) often persists. These negative symptoms – which can be chronic in nature- can, sometimes, be secondary to the primary condition or its treatment. This again can cross multiple domains – including ‘physical’ and ‘mental’ comorbidities, as well as adverse effects to treatment and environmental factors. However, it is more common that these are associated directly with the underlying pathophysiology of schizophrenia. Whilst secondary negative symptoms are more responsive to treatment options, primary negative syndromic features continue to pose difficulties for those living with a diagnosis of schizophrenia and also in relation to their clinical management. These prolonged negative symptoms are associated with both greater risk of relapse and poorer outcomes in the longer term.
Psychopharmacological management for the primary negative syndrome is somewhat limited. However, there is some evidence for the effectiveness of amisulpride, which has been licensed for schizophrenia with prominent primary negative symptoms. This medication is a second-generation (or atypical) antipsychotic; therefore, this is responsible for the blockade of both dopamine and serotonin and is evidenced to assist in the reduction of both positive and negative symptoms. There is further evidence to suggest that there may be times when clinically indicated, that augmenting existing treatment with antidepressant medication remains a valuable treatment option when seeking to reduce negative symptoms.
In accordance with national and international guidance, these interventions should be utilised in partnership with both psychological and social interventions. The role of cognitive behaviour therapy (CBT) for the management of negative symptoms has been a topic of discussion for many years- while there is evidence for CBT and social skills training in the amelioration of negative symptoms, there remains a need to expand upon current psychological therapies. The need for further research within this area appears to reflect the need for advances in relation to psychopharmacology regarding the management of negative symptoms. Thankfully, research is continuing in the critical area with some fascinating concepts; including the potential use of sodium nitroprusside – an antihypertensive medication and a donor of nitric oxide, a gaseous neurotransmitter, that appears to have some impressive outcomes during research trials. Furthermore, the potential of utilising cannabidiol, a phytocannabinoid found within the cannabis sativa, appears to also be offering some promising outcomes; as well as exploring repurposing existing anti-inflammatory medications may also offer some hope of new therapeutics in the not too distant future.
While our knowledge of schizophrenia and its treatment is continuing to expand, it may be that better understanding of the condition in the first instance could be one of the best current options for the benefit of those currently living with the condition.
Joel Petch is a Senior Lecturer in Mental Health and Clinical Science at Canterbury Christ Church University. Joel tweets @joelpetch
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