Schizophrenia treatment according to the practicing psychiatrist
According to the definitions of international classifications of mental disorders, schizophrenia is a disease characterized by positive symptoms, which include delusions, hallucinations, and certain behaviors, as well as impaired memory, attention and thinking, apathy, decreased emotional background, and more.
Seeing the variety of symptoms and forms of schizophrenia, even a non-specialist has a question: is it really the same disease? This question remains open in modern science.
Short information about schizophrenia
Is schizophrenia a single disease?
As of today, no single cause of schizophrenia is identified, and there are many theories that try to explain why it occurs. Some of the researchers, for instance, the American scientist R. Yolken, believe that schizophrenia is associated with infectious agents (viruses or bacteria).
There is an autoimmune theory of the development of schizophrenia, according to which, brain damage in disease occurs due to abnormal activity of the immune system. After studying NMDA encephalitis and other types of autoimmune encephalitis, this theory received a new impetus.
Genetic studies indicate that there are many genes (about 120 mutations), including genes associated with the structure of neurons, neurotransmitter receptors, as well as genes of the immune system associated with the development of schizophrenia.
Today it is generally accepted that psychosis, an exacerbation of schizophrenia, is caused by an imbalance in neurotransmitters, primarily dopamine, and glutamate.
This point of view gained popularity among practicing psychiatrists, since they consider antipsychotics, i.e. drugs that affect dopamine, to be the most effective for the treatment of psychosis. However, in our experience, some psychoses are caused by disorders of other mediators, for which antipsychotics are only partially or indirectly effective but can contribute to the occurrence of side effects.
International studies show, in particular, the involvement of glutamate and serotonin in the development of psychosis.
Thus, there is likely not a single type of schizophrenia, but a group of diseases with different causes, the treatment of which should be different.
Finally, schizophrenia is often confused with similar symptomatic conditions that occur due to organic brain damage, for example, in cysts and brain tumors, with structural brain abnormalities, as the consequences of neuro infections or epilepsy, etc.
Today, the diagnosis of schizophrenia is made only on the basis of the presence of symptoms, observing the behavior and statements of the patient, which, in my opinion, is wrong.
Most patients with a presumptive diagnosis do not even get examined using an MRI or EEG, let alone other more complex examinations. That is why, for example, psychoses in epilepsy are confused with schizophrenia very often. You cannot diagnose schizophrenia without MRI and EEG data. Keep this in mind if you or someone from your family is diagnosed with this mental disorder.
For the optimal prescription of treatment, other studies may be required - genetic (allow doctors to understand which mutations are related to the risk of schizophrenia, and which drugs are best for treatment), DTI or tractography (allows to see violations of connections between brain structures, it is especially important for hallucinations and delirium), neuro test (shows which neurotransmitter systems are involved in the disease), hormonal and immunological tests.
Drugs for the treatment of schizophrenia
In my practice, I constantly encounter patients who have more negative effects from psychotropic drugs than positive ones. It does not mean that medications should not be used at all, but it is important to choose the right drug based on the tests and symptoms, start the therapy with the low dosage and increase it gradually with regard to drug tolerance, and so on.
Typical antipsychotics in high dosages are still widely prescribed, despite the obvious harm from side effects. These drugs were in use 50-60 years ago, since then science has stepped forward, and gave us a wide selection of new and safer drugs such as, for instance, Olanzapine.
Frequently, doctors prescribe two or more antipsychotic drugs, which is permissible in rare cases and for a short time when monotherapy (treatment with one drug) did not work. Other than summing up the side effects, such combinations do little. If you are prescribed several antipsychotics, in most cases it is worth trying to replace them with one. Dosages of drugs are selected as a rough guess, although today you can find out the concentration of a drug in the blood by a simple test, ask your doctor about this test when you they are choosing your therapy.
Unfortunately, in my practice, I frequently meet new patients with a dangerous overdose of drugs. The principles of personalized medicine say that each patient has their own drug in individual dosage. We are all individuals, so guessing with the drug and the dose is like going to the store, grabbing the first pair of shoes that come across and expecting it to fit without trying it on. Today, there is a pharmacogenetic analysis that allows determining which drug will be more effective in a particular patient, what side effects it can give, and in what dosage it should be taken.
How long drugs for schizophrenia should be taken? This is another frequent question. Standard recommendations say that they should be used continuously for years. In my opinion, the situation depends on the patient's condition. If all the research results say that the brain has recovered, it is worth starting to reduce the dosage of drugs, but this should only be done under the supervision of a doctor. Unfortunately, in psychiatry, it is easier to prescribe drugs than to withdraw. About a third of our patients successfully stop taking psychotropic drugs.
Other treatments for schizophrenia
Besides drugs for schizophrenia, biophysical treatments are available, such as TMS (transcranial magnetic stimulation), which is recommended for auditory hallucinations, tDCS and tACS (stimulation of certain brain structures with alternating and direct current of small amplitude).
In addition, we widely use drugs of other classes for the treatment of schizophrenia - mood stabilizers, drugs that affect glutamate receptors and the so-called complementary medicine. We also conduct specialized meta-cognitive trainings adapted by us from the works of the German psychiatrist-psychotherapist T. Moritz to restore the patient's thinking.
If a neuroviral infection or hormonal disorders are detected, appropriate treatment is prescribed.
Many relatives of patients and patients themselves are afraid of inpatient treatment, considering it the last resort. This approach is both right and wrong. Yes, it is more comfortable for the patient to be treated at home. But the hospital provides the opportunity for accurate diagnosis, round-the-clock monitoring and continuous treatment, ranging from monitoring the safety of drug therapy, physiotherapy, to daily work with psychologists. The hospital is especially important during the period of exacerbation and when changing drugs.
Sometimes a sick person does not realize that they are sick and does not want to be treated in a hospital. In such cases, involuntary hospitalization is necessary if the patient poses a danger to themselves or others, or failure to provide them with timely assistance leads to a deterioration in their health. Parents of patients often ask how involuntary hospitalization can ruin the relationship with the patient, usually, this does not happen with the correct and qualified work of doctors and psychologists. Involuntary hospitalization is an extreme but in some cases a necessary measure to stop a disease that destroys the patient's brain and consciousness. During the days of involuntary hospitalization, a psychologist and a doctor work with the patient, explain their disease, and begin therapy. In our practice, more than 95% of patients remain to be treated with us and give voluntary consent for further treatment.
Medical, psychological and social rehabilitation
This is the most underestimated stage in the recovery of the patient's health and social status. After the drugs and physical methods of treatment have given the desired effect, psychologists have improved memory, attention and thinking, worked with delirium, the patient needs to return to normal life. If the illness has lasted for a long time, it can be a difficult process. On the one hand, the patient's condition is still far from optimal, there are cognitive impairments and sometimes residual symptoms of psychosis, on the other hand, there may be fear of going into life, school or work. In such situations, it important to use rehabilitation programs that help to gradually, step by step, move towards a more independent life. In some cases, overprotection, unfounded fears and excessive emotionality on the part of relatives only exacerbate the problem, therefore, family therapy is often necessary.
Forecast - what will happen next?
The answer to this question depends on the specific case, and the research results, cooperation with the patient and the qualifications of the doctor. Do not focus on the diagnosis and think that schizophrenia is incurable. Many of our patients are grateful to us for the successful restoration of their health, stop taking antipsychotics and other drugs, and forget about their disorder like a nightmare. The remaining patients are stabilized with various types of treatment. Poor prognosis is made in about 15% of patients, usually, with advanced cases, mainly with serious abnormalities on MRI, which today we can only partially change.
Post by: Elizabeth Agrer, clinical pshychiatrist, Copenhagen, Denmark
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