Special Report – Schizophrenia by The Magazine Production Company

SPECIAL REPORT

Schizophrenia

The Psychiatry Research Trust Schizophrenia Bipolar Disorder Misrepresented and Misunderstood

Published by Global Business Media

The Psychiatry Research Trust Needs your help now. Childhood Autism and Hyperactivity, Eating Disorders, Alcohol and Drug Addiction, Depression, Bi-Polar Disorder, Motor Neurone Disease, Chronic Fatigue Syndrome, Alzheimer’s, Parkinson’s Disease or any of the many more conditions that affect individuals of all ages. They all cause profound distress not only to sufferers but also their families and friends. Mental illness and brain disease are more common than many assume – they are part of everyone’s life in some way. Here at The Psychiatry Research Trust our sole aim is to raise funds for mental health and brain disease research being carried out at the internationally renowned Institute of Psychiatry (KCL), and the Bethlem Royal and Maudsley hospitals. Our target is not just to find better treatments for sufferers but also to understand the underlying causes of mental illness and brain disease with the goal of finding means of preventions and cures for these illnesses.

For further information or to make a donation, contact: The Psychiatry Research Trust PO87, De Crespigny Park Denmark Hill, London SE5 8AF Telephone: 0207 703 6217 Web: www.psychiatryresearch.org.uk Email: psychiatry_research_trust@kcl.ac.uk or donate on line at www.justgiving.com/psychiatryresearchtrust/ Registered Charity Number 284286

SPECIAL REPORT: SCHIZOPHRENIA

SPECIAL REPORT

Schizophrenia

Contents FOREWORD

Martin Richards, Editor The Psychiatry Research Trust Schizophrenia Bipolar Disorder Misrepresented and Misunderstood

THE PSYCHIATRY RESEARCH TRUST

SCHIZOPHRENIA

Dr Julia Lappin, Lecturer, Division of Psychological Medicine, Institute of Psychiatry Published by Global Business Media

What is Schizophrenia? Published by Global Business Media

Symptoms

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Onset

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What Causes Schizophrenia?

Publisher Kevin Bell

Treatment

Business Development Director Marie-Anne Brooks Editor Martin Richards

Who Develops Schizophrenia? Brain Correlates Schizophrenia Through the Lifespan

BIPOLAR DISORDER

Written for the Psychiatry Research Trust by: Professor Jan Scott, Formerly Professor of Psychological

Senior Project Manager Steve Banks

Treatments Research Institute of Psychiatry at King’s College London

Advertising Executives Michael McCarthy Abigail Coombes

Dean Maudsley Hospital and institute of Psychiatry at King’s College London

Production Manager Paul Davies

Treatment

For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

Dr Vivienne Curtis, Consultant Psychiatrist, Senior Lecturer and Vice

What is Bipolar Disorder? Genetics of Bipolar Disorder

MISREPRESENTED AND MISUNDERSTOOD

John Hancock

Wide Variety of Possible Causes Symptoms – Positive and Negative Treatment in the Community Adjusting Lifestyle Help is at Hand

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SPECIAL REPORT: SCHIZOPHRENIA

Foreword

his Special Report looks at the mental illness, schizophrenia, which affects almost one person in every hundred, across the whole spectrum of social classes. The Report opens by reviewing the work of The Psychiatry Research Trust which, since its formation in 1982, has raised £6 Million to enable research to be carried out into all aspects of mental health conditions and brain disease. The next piece examines the symptoms of schizophrenia and their effect on the relatives of sufferers of the disease, and traces the offset of the illness and how the symptoms can be recognised. Further sections look at who develops schizophrenia and the various causes of the disease which may be congenital, brought on by pregnancy or birth complications, virus infection, drug abuse or stress. Schizophrenia can cause nerve cells in part of the brain to develop faulty connections with other cells. The Report explores this phenomenon and discusses the brain structure and brain chemistry abnormalities in schizophrenia sufferers. The third article looks at bipolar disorder and describes its symptoms and the various forms it can take. It goes on to look at treatment both through the use of drugs and by psychological methods, and examines the causes and genetics of the illness. In the final article, the common conceptions and misconceptions of schizophrenia are reviewed, and advice is given as to how help can be given to sufferers by family and friends as well as by the community at large. Martin Richards Editor

The Psychiatry Research Trust The Psychiatry Research Trust was formed in 1982 with the sole aim of raising funds for research into mental illness and brain disease. Since that date the Trust has raised in excess of £6 Million which has been used to fund: • • • • •

research projects covering a wide spectrum of mental health conditions and brain disease lectures in aspects of mental health bursaries to enable students to study and also to carry out research projects prizes to encourage excellence in research by trainee psychiatrists and basic scientists the purchase of essential research equipment

This work is vital not only because it is directed at securing better treatment for sufferers but also because it seeks to understand the underlying causes of mental illness and brain disease with the aim of finding means of prevention and cures for these illnesses.

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SPECIAL REPORT: SCHIZOPHRENIA

Schizophrenia Dr Julia Lappin, Lecturer, Division of Psychological Medicine, Institute of Psychiatry

What is Schizophrenia? Schizophrenia is the most common of the severe mental illnesses, and affects almost one person in every hundred. People from all social classes and walks of life may develop the illness which can bring immense distress to both them and their families. Until recently, it was believed that the incidence of schizophrenia was similar throughout the world, but it has now been shown that rates vary substantially in different populations and different areas of countries. There is no cure for the condition at present. Treatments are aimed at reducing symptoms, and at improving the quality of life of sufferers and their carers.

Symptoms When unwell, people with schizophrenia may experience a collection of symptoms, which are typically considered as either positive or negative. Positive symptoms include delusions, hallucinations, disorganised speech or thinking, and confused or disorganised behaviour. Delusions are unusual beliefs that typically are based around a misinterpretation of perception or experience. These ideas may be paranoid, meaning there is a belief that others are conspiring against them, leading people to become suspicious, frightened and distressed. Hallucinations take various forms: hearing voices (auditory); seeing things (visual) or smelling

odours (olfactory) that are not truly there. Disorganised speech and thoughts (thought disorder) make the world around difficult to understand at times, and may prevent logical decision-making and effective communication. Negative symptoms refer to the loss of ability to function in everyday tasks, such as washing, cooking, and working that is so often seen in people with schizophrenia. They also include decreased sociability, a tendency to withdraw from society, self-neglect (not looking after cleanliness and grooming), and an apparent loss of emotions and emotional expression. Negative symptoms are less distressing than positive symptoms to the sufferer who may not even notice them. However, they are often very upsetting to relatives and may be misunderstood as laziness or rudeness, which can lead to conflict with carers and other people. Depression and anxiety, are frequently experienced by individuals with schizophrenia. Over half will experience a depressive syndrome at some point during the course of their illness. These symptoms are increasingly targeted with treatment. Cognitive impairment, as assessed by impaired performance on tests of IQ, reasoning, language, memory, etc., is a core feature of schizophrenic illness. It is hoped that these difficulties may also respond to effective treatments in the future.

The Psychiatry Research Trust Needs your help now. Here at The Psychiatry Research Trust our sole aim is to raise funds for mental health and brain disease research being carried out at the internationally renowned Institute of Psychiatry (KCL), and the Bethlem Royal and Maudsley hospitals. Our target is not just to find better treatments for sufferers but also to understand the underlying causes of mental illness and brain disease with the goal of finding means of preventions and cures for these illnesses.

For further information or to make a donation, contact: The Psychiatry Research Trust PO87, De Crespigny Park Denmark Hill, London SE5 8AF Telephone: 0207 703 6217 www.psychiatryresearch.org.uk psychiatry_research_trust@kcl.ac.uk or donate on line at www.justgiving. com/psychiatryresearchtrust/ Registered Charity Number 284286

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SPECIAL REPORT: SCHIZOPHRENIA

The more closely someone is related to a person who suffers from schizophrenia, the greater the chances of also developing the disease. Onset Most commonly, the illness starts when a person is between 20 and 30 years old, although it may begin in the teenage years. When the symptoms of schizophrenia first begin to develop, many people become preoccupied and seem to lose interest in their relationships, work and previously-enjoyed activities. They may act oddly and appear different to others. Symptoms may come and go for some time in the early stages of illness – often they’re first noticed by a person’s family or friends, while the person himself feels there is nothing wrong. Without treatment, most people become much more obviously ill, and this is what’s known as an acute episode, or a breakdown.

Who Develops Schizophrenia? Males have a significantly higher incidence of schizophrenia compared to females, and tend to be slightly younger at the time of their first illness. If someone in a family has schizophrenia, another member has an increased probability of developing it, though most people with schizophrenia have no affected relatives. Cityliving is a risk factor for schizophrenia: studies have shown that the incidence is higher among those brought up in urban areas, and that the larger the town, and the longer the individual has lived in the city, the greater the risk. Risk is also elevated among migrants, especially black migrants to European countries. A study of three English cities examined both of these effects, and showed that the incidence in South London was twice that in Nottingham and Bristol. Many of those with schizophrenia in London were of African-Caribbean origin. It is still not fully understood why this group is more susceptible to illness, but a current theory is that 4 | WWW.PRIMARYCAREREPORTS.CO.UK

if someone feels excluded from society, their risk of developing schizophrenia is greater. In South London the incidence of schizophrenia doubled between 1965 and 1997 – key factors responsible seem to be drug abuse and migration. Migrants appear to be especially vulnerable if they live in areas where they are relatively isolated and where few others from their ethnic group live.

What Causes Schizophrenia? There is no one cause for schizophrenia; rather, people may become more susceptible to developing the illness if they have been exposed to a combination of risk factors – these may be psychological, biological or social. In the last few years significant progress has been made in understanding the aetiology and pathogenesis of schizophrenia. In particular, progress has been made towards identifying susceptibility genes for the disorder, environmental risk factors have been clarified, and we have developed a new understanding of how abnormal brain chemistry underlies the characteristic symptoms. Research has shown that a range of early environmental hazards can also impair the development of normal nerve cell networks in the brain and thus cause the later development of schizophrenia. Genes The more closely someone is related to a person who suffers from schizophrenia, the greater the chances of also developing the disease. No one inherits a certainty of developing schizophrenia but just as some families transmit an increased risk of heart disease or cancer, so some people inherit genes which make them particularly susceptible to developing schizophrenia.

SPECIAL REPORT: SCHIZOPHRENIA

Pregnancy and Birth Complications Schizophrenia is more common in those people who suffered severe complications during their mother ‘s pregnancy or their birth. Babies born prematurely or requiring resuscitation or prolonged care in an incubator at birth are particularly at risk, probably because the baby’s brain was slightly damaged by transient oxygen deprivation. Virus Infection People who develop schizophrenia are more likely to have been born between January and May than during the rest of the year. Viral infections are, of course, much more common in the winter months and recent research has shown that babies whose mothers were exposed to such viral infections during mid-pregnancy have an increased risk of later developing schizophrenia. A range of different brain infections or meningitis in early childhood may have a similar effect. Further research is required to elucidate these factors more clearly. Drug Abuse Recreational drugs such as LSD and amphetamines have long been known both to bring on the illness and to provoke a relapse in those who have recovered. We know that cannabis use is also harmful: heavy cannabis abuse can have a similar effect in those who are susceptible. Consistent evidence supports an association between cannabis use and schizophrenia: people who use cannabis are twice as likely to develop schizophrenia as those who don’t use it. The dangers of cannabis are particularly important in adolescents, as it appears that cannabis use predates the development of illness; rather than being something that people with schizophrenia use in larger quantities to selfmedicate their symptoms. Stress The biological factors, like genes and family history, noted above render the person vulnerable to schizophrenia, but it is often some stressful event which precipitates the breakdown. People with schizophrenia can be overwhelmed by stresses that the rest of us manage to cope with.

Brain Correlates In people with schizophrenia, nerve cells in part of the brain may develop faulty connections with other cells. This results in a picture which can be likened to a computer with a minor problem in its “hard-wiring”: the computer works well most of the time but when it is overloaded may malfunction. Similarly, when the person with schizophrenia is subject to stress such as examinations or family problems, one of their brain systems becomes

The Psychiatry Research Trust Needs your help now. overloaded, malfunctions, and fails to tell the difference between real and imaginary events. Just as crossed lines in a telephone exchange can cause one to overhear a conversation when dialling, so the misreading of signals within the brain can cause the person with schizophrenia to hear voices. Brain Structure Magnetic resonance imaging (MRI) studies have demonstrated abnormalities of brain structure in people with schizophrenia. These include a decrease in the grey matter (nerve cells) of the brain and an increase in the fluid-filled areas (ventricles) adjacent to the grey matter. But when do these abnormalities arise? This may vary from person to person, but it is likely that some abnormalities are the consequence of damage incurred around the time of birth. There is evidence to suggest that some structural changes in the brain also appear around the time of onset of psychosis. Brain Chemistry Abnormalities Various neurochemicals required for brain processing have been shown to be abnormal in people with schizophrenia, in particular, brain dopamine. People who are psychotically unwell release excessive dopamine in some brain regions, and the degree of dopamine release is related to the severity of positive symptoms displayed. The origins of schizophrenia do not necessarily lie in dopamine abnormalities but it is clear that these operate as the final common pathway underlying positive psychotic symptoms and may also play a role in negative and cognitive symptoms. Now we need to understand how genetic and environmental risk factors impact on the brain in such a way as to disturb the dopamine system.

Here at The Psychiatry Research Trust our sole aim is to raise funds for mental health and brain disease research being carried out at the internationally renowned Institute of Psychiatry (KCL), and the Bethlem Royal and Maudsley hospitals. Our target is not just to find better treatments for sufferers but also to understand the underlying causes of mental illness and brain disease with the goal of finding means of preventions and cures for these illnesses.

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SPECIAL REPORT: SCHIZOPHRENIA

Many adults with schizophrenia have had subtle, and previously unappreciated, problems in childhood long before the onset of their illness.

Schizophrenia Through the Lifespan The Early Years Schizophrenia is believed to be a neurodevelopmental illness, meaning that there are factors present even in early life and childhood that affect how the mind and brain develop, and predispose a person to developing schizophrenia at a later stage. Many adults with schizophrenia have had subtle, and previously unappreciated, problems in childhood long before the onset of their illness. Children destined to develop schizophrenia are more likely to have problems playing with other children. They also tend to show unusual emotional expression, anxiety, impaired intellectual function and odd movements. It is important to remember though that many people who develop the illness describe normal childhoods. Life Course In people with schizophrenia, life expectancy is shorter by an average of 15 years. This is due to higher rates of accidental deaths and suicide, as well as to increased risk of cardiovascular and infectious diseases. Sadly, around a third of people with schizophrenia will make some attempt on their own life, and about 5% eventually commit suicide, making it the most common cause of death in this population. Preventing suicide in schizophrenia is a major area of concern. Research efforts are being aimed at identifying and minimising risks for suicide and natural disorders such as diabetes and heart disease. Quality of Life Having a mental disorder like schizophrenia impacts on all aspects of life: from work to social life and relationships, general well-being and satisfaction with health to participation in leisure activities. Women who are unmarried, older and with less education seem to fare worse in terms of quality of life over time, and so it is important to assist them in maintaining or improving their benefits/income, friendships and social circles. A feeling of improved quality of life is attained through regular discussion between clinicians and patients, in order to provide care aimed at improving emotional well-being and self-esteem. Violence Most people diagnosed with schizophrenia donâ&#x20AC;&#x2122;t commit violent crimes, though newspapers and TV often suggest otherwise. The truth is that some individuals with schizophrenia are at increased risk, compared with the general population, of committing both non-violent and violent offences. Thus there appears to be a subgroup

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of people who may become violent. Factors which contribute to this risk include antisocial behaviour in childhood, not taking medication, and drug and alcohol abuse. It is hoped that through better understanding of these risk factors, treatments may be developed to be delivered at an early stage of illness in order to prevent violent acts, which can lead to a vicious cycle of isolation and discrimination.

Treatment Although schizophrenia is a serious illness there are many ways to help and many people get better, sometimes for good. The aims of treatment have evolved over time: previously, most emphasis was given to relieving positive symptoms, but a more comprehensive approach now aims also to treat negative, cognitive and affective symptoms. In so doing it is hoped that people with schizophrenia will experience improvement in their social and occupational functioning and in their quality of life. A key focus recently has been early intervention in schizophrenia to prevent relapse and maintain as high a level of functioning as possible. It is hoped that by treating early it may be possible to reduce or prevent subsequent hospital admissions and loss of social and work skills. Antipsychotics Antipsychotic (neuroleptic) drugs are the first line in schizophrenia treatment. Older (typical) drugs such as chlorpromazine and haloperidol work, but at higher doses can cause unpleasant side-effects, including sedation and movement disorders (extra-pyramidal side effects or EPSEs). Over the past 20 years newer treatments, such as olanzapine and risperidone, have been developed. These drugs, known as atypical or second-generation antipsychotics, represent an advance in treatment, because they cause fewer EPSEs. However, they can give rise to a different profile of side effects, including weight gain and a tendency to develop diabetes. Antipsychotics come in tablet, syrup or injectable (depot) form, and may be taken daily, weekly, fortnightly or monthly. For some time the atypical drugs have proven popular and been prescribed more frequently than the older typical drugs, because of beliefs that atypicals are better able to treat negative symptoms and to improve cognitive abilities. Recently, this has been thrown into question: research has shown there is no great advantage in terms of quality of life or symptom control when the newer treatments are used, compared with the older ones. One exception to this is the atypical drug clozapine, which is the most efficacious of all antipsychotics. The use

SPECIAL REPORT: SCHIZOPHRENIA

of clozapine must be restricted to people who have treatment-resistant schizophrenia because of a rare but serious side effect known as agranulocytosis (a sudden reduction of white blood cells). This side-effect is closely monitored by regular blood testing in people who take the drug. It may take trial and error to find the drug to which a given person responds best. Some people stop taking treatment because of the side effects, but the danger of this is that there is an increased risk of further illness episodes if antipsychotic treatment is not taken regularly, even in the early stages. Over time, if people with schizophrenia are functioning well, the need for treatment may become less. Other people may benefit from long-term treatment. For these people, staying on the lowest effective dose of the drug helps to lessen side effects while also treating the symptoms. Talking Treatments Psychological Treatments Psychological treatments, or talking therapies, can help people to deal with the symptoms and problems that are part of schizophrenic illness. Different therapies include psychotherapy, counselling, family therapy and cognitive behaviour therapy (CBT). The style of therapy differs, but the aims are similar: to recognise problems, deal with their consequences, develop coping strategies and learn to predict and prevent crisis situations. Governmental (NICE) guidelines for the treatment of schizophrenia emphasise the benefit of both CBT and family therapy. Unfortunately, not all NHS services have the resources to provide these treatments but some local voluntary groups, such as Mind and Hearing Voices, can offer them free. Community Care Mental health care was once provided in asylums and hospitals isolated from wider society. There has been a steady shift towards community care over the past 50 years, beginning with the abolition of asylums in the early 1960’s. Instead, psychiatric wards were included in general hospitals, and out-patient services and outreach teams were developed to enable people to be cared for in their homes. In the main this is better, because people with mental illness are not excluded from society, but the downside is that carers often carry an unacknowledged burden. A further adverse consequence of the shift to community care is the sad reality that many people with schizophrenia become homeless and uncared for. Community Mental Health Teams (CMHT’s) coordinate care in the community. These teams are made up of a number of specialist workers, such as community psychiatric nurses (CPN’s), social workers and a psychiatrist. They act as care co-

ordinators whose role it is to design and oversee care plans that enable independent living, and to assist in practical issues, such as applying for welfare benefits and housing. They may also help individuals to access other facilities, such as day centres, drop-in centres, further education colleges, or return-to-work initiatives. Sadly, community teams are often under-resourced, meaning that they can not always provide optimal care despite the best efforts of the staff. Everyone referred to psychiatric services should have a thorough assessment of their health and social care needs, resulting in the development of a care plan aimed at addressing those needs. This is the Care Programme Approach (CPA), part of the government’s National Service Framework for Mental Health. Individuals with schizophrenia and their carers are encouraged to be actively involved in the development of their care plan, which is reviewed on a regular basis.

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Typically, bipolar disorder develops for the first time in the

Bipolar Disorder Professor Jan Scott Formerly Professor of Psychological Treatments Research Institute of Psychiatry at King’s College London Dr Vivienne Curtis Consultant Psychiatrist, Senior Lecturer and Vice Dean Maudsley Hospital

early 20s and affects

and institute of Psychiatry at King’s College London

men and women with equal frequency.

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What is Bipolar Disorder? The old name for bipolar disorder was manic depressive illness. Both terms refer to the mood swings of mania and depression that characterise the illness; the two “poles” of the disorder. The disorder is episodic. Bouts of mania or hypomania, are interspersed with periods of depression, and in between times the individual is completely well and neither depressed or manic. The illness affects approximately 1:200 of the general population, and can range in severity from 1-2 episodes of mania or depression throughout a life-time, to a severe and disabling illness with several episodes of mania or depression occurring within a single year. In mania or hypomania, the mood is often elevated and the individual feels very good about themselves. Sometimes, however, instead of mood elevation, irritability occurs. Associated with elevated or irritable moods are over-activity, an incoherent flow of ideas, rapid speech, loss of judgement, excessive spending, an exaggerated idea of the individual’s own abilities and sometimes sexual indiscretions. Although an individual in a manic phase of bipolar disorder has many ideas or schemes, and the energy to undertake them, the proposals are usually impractical and seldom sustained. In practice the person is quite inefﬁcient and unable to carry out their grandiose plans. Over-activity and lack of sleep can also lead to physical and mental exhaustion and sometimes the grandiose ideas become delusional, with the manic person typically believing that they have special gifts from God, or are God’s chosen messenger. Hallucinatory voices may also tell them this. At the other extreme (or depressed “pole’) of bipolar disorder, there is profound low mood, feelings of hopelessness, apathy, guilt, worthlessness and a slowing of thoughts and movements. In addition there may be loss of concentration, appetite and memory, as well as poor sleep. Suicidal thoughts and attempts may also occur during episodes of depression.

Typically, bipolar disorder develops for the first time in the early 20s and affects men and women with equal frequency. The diagnosis of bipolar disorder can only be made once the individual has had a manic or hypomanic episode, even if this is only brief. As mentioned above the illness can vary considerably in its severity. At the mild end of the spectrum, treatment is only required during the acute phases. Between episodes the individual remains quite well and is able to return to their normal occupational and social life, with no permanent changes or damage to personality or cognitive abilities.

Treatment Drug Treatment: Medicines which are available to treat Bipolar Disorder fall within the following classes: a. Mood Stabilisers: The class of medications includes Lithium and medicines such as Sodium Valproate and Carbamazepine (which are also used as anti-epileptic medications). b. Antipsychotic Medications: Although both the older antipsychotics (such as Haloperidol) and the newer second generation antipsychotics (olanzapine, risperidone and quetiapine) were first used to treat patients suffering from Schizophrenia they are also used to help patients with Bipolar Disorder. Studies have shown that these medicines are not just useful against symptoms such as hearing voices but can also help with symptoms of both mania and depression. c. Antidepressant Medication: Depression can be a huge burden for Bipolar patients and studies have shown patients can spend up to one third of their lives depressed. However, antidepressant medications should be prescribed with caution as they can cause a switch from a depressed to a manic state. Mood stabilizing or antipsychotic medications can also be used in Bipolar Depression. d. Calming medications: Medications such as benzodiazepines can be of great use in the

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short term if patients are suffering from sleep disturbance. For many patients treatments which are started in an acute episode of illness need to be continued in order to provide ongoing maintenance of their well being and reduce the risk of relapse. Some patients will require treatment with only one medication, but combinations of medication (particularly of mood stabilisers and antipsychotics) may be required both in the short and the long term. While long term use of medication may seem to be a burden, it has been shown to be associated with decreased rates of relapse, improvements in occupational and social functioning and a reduction in rates of suicide. Within the IOP many studies take place looking at medications in Bipolar Disorder so that we can learn which drug treatments are the most effective and how to optimise their use.

Psychological Treatments: There are a number of brief therapies that in combination with medication have been shown to be effective in accelerating recovery from depressive episodes, reducing the risk of relapse into mania or depression and improving day to day functioning in individuals with bipolar disorders. The four best known approaches are Interpersonal Social Rhythms Therapy (IPSRT), Cognitive Behaviour Therapy (CBT), Family Focused Therapy (FFT) and Group Psychoeducation. Each of these talking treatments comprise a course of about 22 one-hour sessions held over 6 months. All the approaches include similar core elements that (i) help the individual understand bipolar disorder and adjust to the problem, (ii) monitor their day to day life style and introduce more stable patterns of social activities (social rhythms), (iii) enhance their engagement with treatment services and their adherence to medication and (iv) learn to recognize and manage the possible triggers and early warning symptoms that indicate increased periods of risk of manic or depressive relapses and to learn how to act or cope in such circumstances. Which therapy to use will depend partly on the preferences of the patient and partly on whether a trained therapist is available to provide a particular therapy. The results of large scale therapy trials in Britain, Europe and the USA all suggest that, when added to medication and usual psychiatric care, all the therapies noted can reduce the risk of relapse by about 50% over two years, and recent findings suggest that there is some sustained benefit for as long as 5 years. Further research is now being undertaken to determine which individuals with Bipolar Disorders most benefit from therapies plus medication so that these interventions can be targeted at specific patient subgroups.

What Causes Bipolar Disorder? The precise cause of bipolar disorder is unknown, but it is clear that the disorder does tend to run in some families. This familiality is now known to be due to genetic risk factors, and a brief review of genetic studies carried out throughout the world, is given below. However, although genes are important in causing bipolar disorder, there are clearly other factors which are often termed â&#x20AC;&#x153;environmentalâ&#x20AC;?, such as life events or aspects of early development which are important risk factors.

Genetics of Bipolar Disorder Genes for rare genetic disorders are being cloned at an astonishing rate since the first achievements in the 1980s. The same cannot be said for traits which are inherited in a more complex fashion. Most common disorders have an extremely complex pattern of inheritance. In no field has the difficulty been more frustrating than in the field of psychiatric genetics. At first glance manic depressive illness might appear an easier target for molecular biologists. The illness is diagnosed fairly unambiguously in people who suffer episodes of depression and of elated mood. It has a strong genetic component and multiply affected families should not be that difficult to find. However, the history of genetic linkage findings in manic depression has been similar to the course of the illness itself: moments of euphoria after initial reports, have been followed by gloomy periods of non-replication of findings. The main research effort has been concentrated on genetic linkage studies. Such studies examine whether a genetic marker is transmitted down the generations in a family together with the occurrence of the illness. If it is, it is likely that the disease gene is localised somewhere near that marker. The standard statistical measure used in genetic linkage studies is the Lod score method. A lod score is the Logarithm of the Odds ratio comparing the likelihood that apparent co-segregation of marker and illness is due to linkage, with the likelihood that the apparent co-segregation is due to chance. The accepted significance threshold is a lod score of 3 or higher. The region with the oldest history is Chromosome Xq28, starting in 1969 and being followed up by other positive reports. These early studies relied on phenotypic markers such as colour-blindness and G6PD deficiency as the currently used highly polymorphic DNA markers were not yet available. Some of the lod scores were truly impressive and should not have left any doubt that the linkage was true. Not so if the illness studied is manic depression. Unfortunately, these reports have been followed up by non-replications

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The precise cause of bipolar disorder is unknown, but it is clear that the disorder does tend to run in some families.

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and one study was later reanalysed with DNA markers, leading to a diminution of the linkage evidence. Still, it might appear that the linkage result on the X-chromosome has received enough replications. However, the results implicate a very large area of the chromosome, making it extremely unlikely that the same gene is causing all these results. Still the evidence supports the view that the short arm of the X-chromosome harbours at least one (possibly rare) gene of major effect. The year 1987 witnessed another promising study (Egeland et al) on the short arm of chromosome 11 (llpl5), claiming a Lod score of 4.9 (well above the accepted significance level of 3.0). This team had investigated a large pedigree from the Old Order Amish community, a genetically isolated population. The feeling at that time was that the gene for manic depressive illness had been found. But the report was soon followed by a number of nonreplications. And even worse was to follow. An additional analysis of the same family diminished the results to non-significance. The following few years were a gloomy period for geneticists working on manic depression. However during this time clinicians accumulated a large number of new families. Thousands of highly polymorphic genetic markers were developed which spanned the whole human genome at dense intervals and made a total genome scan a feasible task. More recently, semi-automated methods for genotyping were developed, and we now have available the first total genome scan results on some very large family samples. These latest results have not yet produced any definitive findings but they are promising and have certainly improved our understanding of the genetics of manic depression. Some are so important that we will consider them in more detail. In June 1994 the results on chromosome 18 from one of the large collection of families were published. These are 22 large pedigrees consisting of 365 individuals, 159 of whom are affected. There were no overall positive lod scores but affected sibling pair and affected pedigree member analysis yielded evidence for linkage. These, so-called non-parametric methods of analysis can detect smaller genetic contributions, which can be missed by the Lod score method. This report prompted a number of teams to analyse their samples of families for markers in this region. While some results were negative, others supported the finding; but the implicated region is still too large to allow any firm conclusions.

SPECIAL REPORT: SCHIZOPHRENIA

Misrepresented and Misunderstood John Hancock

Mental illness makes people behave differently so is often misunderstood or, worse still, misrepresented. That is certainly true for schizophrenia: two of the most common misconceptions are that schizophrenia sufferers experience a split or dual personality and that they are violent. People with schizophrenia can experience episodes of dysfunction and disorder in their minds but that is not the same as a split or duel personality. Equally, while there is a link between violence and schizophrenia, it is not to anything like the degree or the scale that the media sometimes suggest. Indeed, some consider the term schizophrenia unscientific; stigmatising sufferers but not really throwing any light on the roots of the condition. Statistically, alcohol and substance abuse are more likely to be associated with violent crime while people with schizophrenia are more likely to be victims than aggressors. Moreover, while people with schizophrenia do sometimes ‘hear’ voices, those voices are often harshly critical of the sufferer and will more likely tell them to harm themselves than to harm others. Sadly about one in 10 people with schizophrenia commits suicide. In a sentence, the NHS defies schizophrenia as ‘a long-term mental health condition that causes a range of different psychological symptoms.’ Schizophrenia develops in about one in 100 people and can occur in men or women usually in the age ranges of 15 to 25 for men and 25 to 35 for women.

Wide Variety of Possible Causes There are a number of causes and triggers that may generate schizophrenia symptoms. The condition seems to run in families but no individual gene has been identified as being responsible until a recent discovery by a research group, led by the University of California, San Diego with Trinity College Dublin, identified a gene mutation that may be linked to schizophrenia and which might make a target for new drug therapies. But genetics is not the only factor. A brain disorder can cause schizophrenia and, more specifically, there is a connection between neurotransmitters (the chemicals that carry messages between

brain cells) and the condition; or at least it is known that drugs that act on neurotransmitters can be linked to schizophrenia or the relief of its symptoms. Other possible causes include a viral infection during the mother’s pregnancy or in early childhood, a lack of oxygen at the time of birth, stress (such as may be generated by relationship problems, financial difficulties, social isolation or bereavement) and other personal difficulties. Illegal drugs are linked to the condition in some people and studies suggest that heavy cannabis users are six times more likely to develop schizophrenia than non-users: other drugs such as marijuana, amphetamines cocaine, ketamine and LSD can also cause schizophrenia symptoms.

Symptoms – Positive and Negative Symptoms are grouped into positive and negative. Positive symptoms are things that do happen, such as hallucinations, delusions, thought disorder and changes in behaviour or unpredictability. Negative symptoms, on the other hand, are things that don’t happen, such as loss of interest in life & relationships, lack of motivation, lack of concentration, not wishing to leave the house or mix with other people and, when having to do so, finding it difficult and uncomfortable. Schizophrenics often display flat or inappropriate emotions and may appear quite inexpressive with few facial expressions and little tonal variation in their speech. Taken together these symptoms are quite affective and sufferers often speak of feeling lonely, isolated or unable to communicate their thoughts. As with most conditions, the earlier schizophrenia can be diagnosed and treatment started, the more successful is likely to be the outcome. But a diagnosis of schizophrenia can, of itself, generate a degree of anxiety; so it is important that sufferers are quickly put in touch with one of the many support programmes available. And there are other mental disorders related to and not dissimilar from schizophrenia. For instance bipolar disorder (manic depression) can display many of the

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SPECIAL REPORT: SCHIZOPHRENIA

Rates of smoking in people with schizophrenia are three

symptoms of schizophrenia but is distinguishable by the extremes of mood from highly elevated, excited and driven behaviour to deep depression. Schizoaffective disorder, a mental illness in its own right, is also often triggered by stress but often occurs just once in a lifetime.

Treatment in the Community

times higher than in the general population; so stopping smoking is not only good for the condition itself but, again, will deliver other short and long-term health benefits.

Most people with schizophrenia can be treated in the community by community mental health teams (CMHTs) of social workers, mental health nurses, pharmacists, counsellors and psycho therapists; usually led by a psychologist and/or psychiatrist. The team helps with treatment, dayto-day support and guidance on drug regimens to ensure that sufferers lead as independent life as possible. When first diagnosed it may be necessary to admit a schizophrenia sufferer to hospital for a short time in order to quickly start the treatment and, in cases where the condition and symptoms become severe, sufferers may need to spend long spells in hospital or secure accommodation. Wherever possible, schizophrenia sufferersâ&#x20AC;&#x2122; families should be involved in their care. Medication usually consists of antipsychotics or neuroleptics which relieve the symptoms by altering neurotransmitters: however, drugs tend to work better with positive symptoms while psychological treatments and therapies are more effective at dealing with negative symptoms. A treatment development still at the research stage is transcranial magnetic stimulation (TMS), a non-invasive procedure using magnetic impulses to stimulate the frontal regions of the brain. It seems to help people with mainly negative symptoms and in dealing with auditory hallucinations (voices).

Adjusting Lifestyle Importantly, there are lifestyle choices that schizophrenia sufferers can make to help themselves. They should avoid stress (even to the extent of changing their work to a less stressful job), ensure that they get a plenty of sleep, and eat a balanced diet with plenty of fruit and vegetables. Regular exercise is recommended by the NHS and can also reduce the risk of developing cardiovascular disease or diabetes which can be a side-effect of the drugs and the listlessness that sufferers may experience. Some recent studies suggest that schizophrenia sufferers can derive particular benefits from EPArich fish oils such as can be found in sardines pilchards and supplements. Rates of smoking in people with schizophrenia are three times higher than in the general population; so stopping smoking is not only good for the condition itself but, again, will deliver other short- and long-term health benefits. 12 | WWW.PRIMARYCAREREPORTS.CO.UK

Help is at Hand There are charities and support groups to help people with schizophrenia cope and live with their condition, and projects to help them get back to work and independent lives. Relationships with friends, relatives and partners are vital in helping recovery and in reducing the risk of relapse. Most sufferers experience recurring episodes of symptoms (relapses) with varying frequencies and, while some people recover completely between relapses, others never fully recover. Around two in 10 sufferers are not greatly assisted by treatment and may need long-term dependent care in secure accommodation. And with up to one-third of people with schizophrenia involved with alcohol and/or illegal drug abuse, helping or treating such people can be difficult. Also, sufferers sometimes do not recognise their problem and need outside intervention to ensure adherence to their treatment programme. Most people diagnosed with schizophrenia recover: a third have only one experience with a further third suffering only occasional episodes. And even among those who live with schizophrenia, to varying degrees, throughout their lives there are a range of options available. Most sufferers can, with assistance, live with schizophrenia.

USEFUL ORGANISATIONS Rethink T: 0845 456 0455 W: http://www.rethink.org

MIND T: 0845 766 0163 W: http://www.mind.org.uk

SANE T: 0845 767 8000 W: http://www.sane.org.uk

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