What is the norm and what is pathology?

Schizophrenia is a disorder from the group of so-called psychotic, that is, manifested by states of psychosis, that is, states of loss of contact with current reality.

Such a state could be compared to a situation in which the mind acts as if it loses a stable, current link with reality. Disturbances appear in the connection, making it difficult to realistically perceive the environment, and there is an inadequate, distorted perception and interpretation of incoming stimuli, i.e. events or other people’s behavior. The result of this distorted perception of reality is often what loved ones and those around the person struggling with this disorder begin to observe, namely inadequate to the situation, increasingly bizarre behavior and increasing difficulties in finding their way in relationships with others and at work. A patient in a state of psychosis has no access to critical, i.e. realistic perception, of his surroundings and relationships with others.

The onset of schizophrenia can be sudden, with symptoms developing in a matter of days or weeks, or they can escalate gradually over months or even years.

If the disorder develops slowly, it is difficult for the patient’s loved ones and himself to notice the first symptoms. A person struggling with the disorder may gradually withdraw from usual activities, become increasingly suspicious, distrustful, may avoid contact with people and even stop leaving the house periodically. The development of the disease (not just schizophrenia) may be indicated by the so-called breakdown of a person’s life line. In the case of schizophrenia, we often observe a significant change in the habitual functioning (note, this is important!) of this particular person. The patient begins to behave differently in relations with people, for example, relatives often say that he used to be reasonably sociable, but now completely avoids acquaintances, or that he looks as if he has become indifferent to the events around him and the experiences of loved ones, he very often withdraws somewhere inside himself, becomes increasingly isolated, or comments on various current affairs in a manner that is increasingly bizarre and uncharacteristic for him.

Over time, the patient begins to find it increasingly difficult to fulfill his existing social roles, such as continuing his education or fulfilling his responsibilities at work, or being in a satisfying relationship with his partner or children. The reason for the increasing withdrawal from social life is usually the experiencing of increasingly severe anxiety and, in general, the increasing focus on one’s own difficult experiences with the environment, which are the result of the worsening disease.

Symptoms today are most often put into three categories:

• positive
• negative
• symptoms of disorganization

At the same time, the terms “positive”/”negative” are not assessments of how well the patient feels, but medical terms.

Positive, or productive, symptoms are those during which there is some excess, additional activity of the body in relation to the norm, and negative symptoms are those during which there is some lack, deficiency of activity.

Among the positive ones, delusions and hallucinations are most often observed. Delusions are distortions of thinking that cause an inadequate perception of what is happening around the patient. The sick person may be convinced that he or she is constantly being watched by others and groped, does not believe the explanations of relatives or doctors that this is not the case, and begins to perceive them as enemies (so-called xobic delusions: e.g., the patient often has the impression that everyone is watching and laughing at him or her, or when he or she sees people talking in the hallway believes that they are definitely talking about him or her and plotting against him or her). The patient may often have the impression that he is being followed, overheard, or that those around him want to harm or even kill him (so-called persecutory delusions). He may also have the impression that his thoughts, emotions and body are controlled, influenced by other people or things, and that he has no control over them (known as influence/affect delusions).

Hallucinations (hallucinations), on the other hand, are distortions of perception through the senses (the most common are auditory, but can also involve sight, smell, taste, touch). They involve the realistic perception of a sensory experience despite the absence of a stimulus in the environment that could have triggered it. In the case of auditory hallucinations, the patient often hears the voice of a person who is not in the environment, or various murmurs, knocking noises, etc. The people he hears most often comment on his behavior critically, sometimes aggressively, or require him to perform specific actions. In the case of visual hallucinations – the person struggling with the disorder sees shapes or figures that are not present in reality.

The main difficulty lies, among other things, in the fact that, contrary to the common perceptions of healthy people, a person struggling with this disorder in its emission (i.e. active) phase is unable to verify the reality of what he hears, sees, or is convinced of. Voices or sounds and other sensory impressions sound and are experienced as very realistic. The movie “A Beautiful Mind”, among others, can help to better understand this type of struggle.

Negative symptoms, on the other hand, include isolation and withdrawal from previous activities, loss of interest in the outside world, often emotional indifference (the patient, in response to questions about preferences, increasingly repeats that it’s all the same to him), as well as so-called shallow/pale affect (lack of visible emotions), weaker gesticulation, less clear facial expressions, increasingly perfunctory and poor speech. Over time, the person increasingly withdraws from all activities, does not initiate any activities, and even begins to neglect daily personal hygiene.

Among the symptoms of so-called disorganization, the most common are disorganization in speech or behavior. Speech disorganization manifests itself, for example, in so-called thought slips – a person struggling with the disorder speaks in a way that is difficult to understand, as if there were new plots all the time, jagged, unrelated, or bizarre word combinations or neologisms. Disorganization of behavior manifests itself, for example, in inadequate clothing for the weather or the situation, or repeated non-standard or chaotic reactions to the old norm (that person’s norm) to the environment at work or school, causing loved ones to say that this person “is not himself.” Exacerbation of symptoms may be accompanied by mood disorders: lack of joie de vivre, increasing sadness, anxiety, or inadequate, excessive cheerfulness in response to difficult situations. In the acute course, catatonic behavior can occur, a behavioral disorder involving freezing in a stupor (stupor) for some time, sometimes even in bizarre positions. After the acute symptoms of psychosis have subsided, the so-called post-psychotic depression may appear: sadness, indifference, exhaustion, loss of interests (it is very important to observe whether suicidal thoughts appear during this period).

The course of active relapses can nowadays be significantly alleviated with medications. And the frequency or severity of relapses can be reduced with prophylaxis during periods of remission. Therefore, it is worth looking at schizophrenia as a chronic disease, the treatment of which must be carried out for the rest of life, including during periods of remission.

The disease often manifests itself before the age of 30, often after puberty and in young adults. In women it can also reveal itself later, studies show that in some women it reveals itself around age 40 or later around age 60.

It is very important to consult a psychiatrist if the symptoms mentioned above occur and persist for more than two weeks or a month. Early detection of the disorder, adjustment of a permanent treatment program and inclusion of the family in the therapy process can significantly help return to a satisfying active life.

Compiled from, among others, DSM-V and Butcher et al, Psychology of Disorders, 2017.

Author: Justyna Bąba

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