Schizophrenia

By Sabry Fattah

Are you looking for an in-depth exploration of schizophrenia from an expert who has worked in psychiatry and treated patients with mental illness for over 40 years? Written by an expert in the psychiatry who has conducted research on the subject, this book is your one-stop resource. Learn about the history of schizophrenia, early signs, types, diagnosis, risk factors, causes and neurobiology. Plus get insight into how it's treated and strategies for coping with it as a patient or carer. Get all this information plus more! With practical advice on how to cope with schizophrenia and strategies for recovery included too – this book is essential reading for anyone affected by the condition, his family or carers. Discover how it is treated and what physical problems people with schizophrenia may face. Get strategies to cope with the disorder and find out about its outcome and course. Everything you need to know about schizophrenia is here! This book is a must-read! 

• Language: English
• Publisher: Dr Sabry Fattah
• Release date: Feb 18, 2023
• ISBN: 9798215444535

Sabry Fattah

د. صبري عبد الفتاح يعمل استشاري للطب النفسي في انجلترا . تدرب ومارس الطب النفسي بإنجلترا منذ عام1990 وحصل على زمالة الكلية الملكية البريطانية للأطباء النفسيين ودرس بجامعة لندن وأجري ونشرأبحاث بجامعة ادنبره باسكتلندا وهو حاليا مقيم بالمملكة المتحدة.

Book preview

What Is Schizophrenia?

Misconceptions about schizophrenia are everywhere, with some people believing it is the same as having a split personality. However, this is not true - dual personality (also known as dissociative identity disorder) is an entirely different condition and not as severe as schizophrenia. Dual personality involves a disruption in consciousness so that the person exhibits behaviour or qualities which contrast with their usual character - think of Dr Jekyll and Mr Hyde, for example. In reality, cases of dual personalities are rarer than they appear in literature or on screen.

Two renowned figures in the history of schizophrenia have left a mark on our understanding of the condition. German scientist Emil Kraepelin (1856–1926) suggested that mental illness is caused by an impairment in brain function, possibly due to genetic factors. Swiss doctor Eugene Bleuler (1857–1939) gave the disorder its famous name: schizophrenia.

Before them, a French psychiatrist named Morel described an illness that affects youth and begins in adolescence as an early form of dementia, which he called démence précoce. Dementia is usually associated with the elderly, but this particular disease appears to start earlier.

Kraepelin, a German psychiatrist, was the first to distinguish schizophrenia from manic-depressive psychosis (now known as bipolar disorder). He used the Latin term 'dementia praecox to describe what we now call schizophrenia. Kraepelin noted that delusions and hallucinations characterize this condition which dominates the patient's thoughts so that he cannot get rid of them. In contrast, people with manic-depressive psychosis experience episodes of depression or mania but can eventually return to normality between them.

An individual suffering from hallucinations may experience sights, sounds and sensations that do not exist in the real world. For example, they might hear a voice telling them to do something even though no one is present. In addition, German psychiatrist Emil Kraepelin differentiated between schizophrenia and paranoia, which he describes as a persistent belief of being persecuted or harmed without any accompanying hallucination or deterioration of personality. Unlike manic-depressive psychosis, which has alternating episodes of illness and recovery, this condition does not have these cycles.

The Swiss psychiatrist Dr Eugene Bleuler has given a new name to that mental illness: Schizophrenia, which comes from two Latin words meaning split or dissociation of the mind. Dr Bleuler was the first to point out that this is not just a single disorder but rather a group of related illnesses known as Schizophrenia.

Bleuler used the term schizophrenia to express the split of aspects of mental activity in thinking, feelings and behaviour. His view of the disease differed from Kraepelin's.

Dr Bleuler proposed that four main signs characterize schizophrenia. He argued that the disorder affects the way people think and communicate in four distinct ways: 

First, a disconnection has occurred between the elements of thinking, leading to disorganized and irrational thoughts. The relationship between one thought and another is weak or non-existent, resulting in speech and thought processes that are hard to comprehend or make sense of.

The second is the split of feelings so that people can detach feeling from their ideas. Even if a person is thinking of something sad, it doesn't necessarily make them feel sadness; similarly, fearful thoughts don't always cause fear, and happiness doesn't need to come with an explanation. For example, someone starts laughing for no reason or becomes angry without provocation.

The third is the split from the real world so that the patient lives in his world, isolated from others. This split from reality means that the person's imagination is not held back by what is considered possible and reasonable within the real world.

The fourth is the defect of the will and lack of determination to act. When the will to initiate actions is lost, the schizophrenia patient thinks forces outside his mind drive his actions. He believes these are automatic actions, like a machine controlled by evil powers. 

These four characteristic features are called the four As about the first letters in the four defects:

Association Disturbance: lack of connections between ideas.

Association Disturbance: lack of connections between ideas.

Affective Disturbance: lack of connections between ideas and emotions.

Autism: Withdrawal from reality.

Ambivalence: lack of will to act and passive feeling of control.

Bleuler added to these essential four features what he called secondary signs that Kraepelin considered the main manifestations of his Dementia Praecox, namely hallucinations and delusions.

Kurt Schneider, a German scientist, who lived from 1887-1967, was interested in defining the symptoms to help diagnose schizophrenia. He believed that if these signs were not present, though not necessarily, it would mean the patient was free of schizophrenia. Most psychiatrists agree these are key indicators for diagnosing this mental illness. If they are absent, it is unlikely the person has it. They are known as First-Rank Symptoms of schizophrenia.

The first-degree signs of schizophrenia:

According to Schneider, these signs are:

- The patient hears his thoughts as a clear voice, coming from outside his ears as if a such voice is calling from outside his head.

- The patient hears voices discussing and fighting about him and arguing about what he thinks or does.

- The patient hears these voices commenting on his actions, moment by moment.

- The patient's sensations and movements are controlled by external forces that move and control him against his will.

- The patient feels that his thoughts are not his own, ideas are pulled out from his head or instilled within his brain, they do not belong to him and he did not think about them.

- His thoughts are broadcast in public so that all people know them, perhaps by a hidden device or a hellish tool installed in his head. He feels spied upon from a distance by a machine that picks up what he thinks.

- That there are ideas that suddenly appear in his mind while unaware of where they come from. For example, he may suddenly receive a revelation of a bright undeniable truth, which he did not know anything about before without evidence to support it.

- What he wants or desires is not his wishes and motives, but strange and alien to him.

Secondary signs

Most of these symptoms represent a serious disintegration of will, thinking and feelings, which means the split and dissociation of the components of mental functions. Schneider advised against using these symptoms for diagnosis routinely without taking into account other signs as well, which he called secondary signs and he believed they might confirm the diagnosis:

The secondary signs are:

Most of these symptoms represent a serious disintegration of will, thinking and feelings, which means the split and dissociation of the components of mental functions. Schneider advised against using these symptoms for diagnosis routinely without taking into account other signs as well, which he called secondary signs and believed might confirm the diagnosis:

The secondary signs are:

- The emergence of misrepresentations, delusions and misconceptions suddenly and without premises or comprehensible explanation.

- Feeling bewildered and perplexed. 

- The patient's mood changes between depression, sadness, joy and euphoria. 

- Loss of feelings and emotional blunting. 

- Hallucinations and multiple other sensory illusions.

Ernest Kretschmer, a psychiatrist, has been exploring the potential link between body shape and mental illness. He observed that people with schizophrenia are usually thin, tall and less muscular compared to those who are more stocky, round or plump - typically diagnosed as manic-depressive or bipolar patients. While this does not necessarily confirm or deny any diagnoses made by psychiatrists about their schizophrenia patients, it is an interesting observation nonetheless.

Karl Jaspers (1883-1969), a German philosopher and psychiatrist, made a significant contribution to our understanding of schizophrenia symptoms. His detailed descriptions of the inner thoughts and feelings of those suffering from psychosis were based on phenomenology; an existential study which examines human experience as separate from objective reality. His book General Psychopathology is considered a classic in psychiatric literature today.

Karl Jaspers has shifted his focus from the content of a patient's experience to its form. For example, when a person with mental health issues sees visual hallucinations, it is not necessary to explain what they are seeing - rather that something is seen that does not exist in reality. This helps us define what are visual hallucinations ?: perceptions without any external stimuli present.

In the 20th century, theories on social and psychological aspects were at the forefront of studying schizophrenia. Some psychiatrists thought it wasn't a medical condition but just a label for people who acted differently. However, their legacy has been disregarded or forgotten as research into biological factors has advanced significantly in recent years.

Recent studies in the biological, genetic, neurochemical and clinical aspects of schizophrenia have provided a greater understanding of mental illness in general and schizophrenia specifically. Thanks to new drugs, patients with this condition can live within their community while receiving little or reasonable support. In the following chapters, we will explore how our knowledge of this disorder has evolved.

History of Schizophrenia

Mental illness has been known throughout history, with many famous figures considered mad. For example, in the Greek play Oedipus Rex, Oedipus is portrayed as unable to control his emotions and thoughts. Ulysses referred to this condition in the drama as a kind of brain fever. King George I of England is another notable figure who was said to be as mad as a loon. Mental health issues have been around for centuries and continue today.

In Ancient Egypt and the Near East, people believed in the magical forces of evil gods are the cause of mental illness. Priests were used as therapists, using religious and magical rituals to counter these forces. After Christianity began, these gods became known as demons. Belief in them fluctuated over time in many societies around the world.

The writings of the Greek physician Hippocrates, who lived from 460 to 370 BC, suggest that four essential humors: phlegm, yellow bile, black bile and blood determine mental health. These substances he thought are secreted by different organs in the body and can vary depending on the season. The balance between these four humors brings about proper brain functioning.

If there were large amounts of any one humor present in an individual, it could cause an ailment: dementia (phlegm), manic rage (yellow bile) or melancholia (black bile). Little excesses of each humor also affected personality; too much phlegm made them phlegmatic (lacking in response, interest and emotions), while an abundance of yellow or black biles created choleric (unreasonably aggressive) or sanguine (cheerful energetic and optimistic) personalities, respectively. This theory marks the first attempt at explaining differences in temperaments and personalities among people.

The Hippocratic authors were the first to rationally describe and classify such diseases as epilepsy, mania, paranoia, organic toxic delirium, postpartum psychosis, phobias, and hysteria. Hysteria, they named from the Greek word for womb. They believed it is confined to women and its cause is a wandering uterus. They associated melancholia with an aversion to food, despondency, sleeplessness, irritability, and restlessness, and they believed that personal hygiene, bathing, and dieting were essential to keep the humors in balance. In cases of insanity, they tried to eliminate excess humors by purgatives, cathartics, and (if necessary) bleeding.

Plato, a philosopher who lived between 427 and 347 BC, proposed that the soul is composed of three parts: rational, appetitive (strong desires and urges) and spirited-affective (mood and emotions). He suggested that either the cause of madness is an imbalance of these components, or divine forces acted upon them to create inspired or destructive behaviour. To treat disease, he recommended verbal therapy between patient and doctor - similar to modern psychotherapy - through questions being asked back and forth for the patient to gain knowledge which would help alleviate their illness.

Aristotle (384-322 BC), Plato's student, is credited as the first to accurately describe a range of emotions such as desire, anger, fear, courage and envy. He believed that the cause of the mental illness is a change in temperament and levels of black bile in the soul. Aristotle also highlighted joy, hatred and pity, among other feelings, associated with mental health issues.

In addition to Hippocratic somatic and medical treatments, the Greeks developed three psychological treatments: methods of inducing sleep, interpreting dreams (often performed by priests in temples, most notably those of Aesculapius, the God of healing), and using words to persuade, console, and gain knowledge of an illness (e.g., when using Plato's dialectics).

Roman Psychiatry

The Romans adopted the psychiatric teachings of the Greeks. According to these beliefs, passions and unsatisfied desires can lead to mental illnesses, which can be controlled through arguments and reasoning to achieve a state of ataraxia - or calmness and lack of worry and perturbation. Some modern tranquillizers have been classified as ataractics due to their ability to induce this same sense of tranquillity.

The great Roman physician Galen (130 to 200 AD) consolidated and augmented Greek medical and psychological thinking. He conceptualized that the humors exist in normal and abnormal forms, and those four qualities: hot, cold, dry, and moisture, are essential in forming human temperaments. He added the concepts of natural spirits and animal spirits to the previous concept of pneuma (a vital spirit). He divided the soul into three parts: reason and intellect, courage and anger, and