Schizophrenia

The idea of caring for people with mental disorders, rather than simply keeping them, did not emerge again until the 18th century. Psychology had been left to philosophers, and the laws of the behavioral sciences had not even been thought of. Physicians were confined to the use of physical and chemical remedies that they knew from empirical application in the treatment of other diseases.

The therapeutic armamentarium of these early physicians was actually restricted for centuries to a few standard procedures, such as blood letting, purging, and the administration of emetics. There existed a fantastic pharmacopoeia, which owed many of its principles to the medieval alchemists.

Convulsions produced by camphor and anesthesia produced by ether were also employed occasionally.
Shock treatment in the 18th and 19th centuries consisted of twirling the patient on a stool until he lost consciousness or dropping him through a strap door into an icy lake. This early shock treatment, with its emphasis on producing fear and discomfort in the patient, is directly opposed to modern, physiological shock therapy, where every effort is made to eliminate psychological trauma.

Animal magnetism, or Mesmerism, which became the fashion for a brief period in the late 18th and early 19th centuries, was probably not used frequently for the treatment of psychotics. However, moral treatment, applied widely to hospitalized psychotics in the United States during the middle 19th century, resembled in many aspects today's milieu therapy and other social therapies and was probably an effective therapeutic approach to schizophrenic patients at that time.

With the advent of huge mental hospitals in which a personal approach was impossible, moral treatment and its therapeutic gains were lost. A therapeutic vacuum persisted for half a century until the development in the middle 1930's of Sakel's hypoglycemic coma treatment and Meduna's convulsive therapy.

The neuroleptic drugs in the 1950's brought important further gains, particularly in the sustained control of schizophrenic manifestations. And despite Freud's firm belief, shared by most early psychoanalysts, that psychotherapy could not be effective in the treatment of schizophrenia, it has been demonstrated over the past few decades that not only is psychotherapy of schizophrenia feasible and frequently effective but it can also provide vitally important new insights into the complex psychopathology of the schizophrenic patient. Nevertheless, there still is no succeeded in isolating its basic causes.

Conventional neuroleptic drugs

The conventional neuroleptic drugs were the foundation of pharmacological treatment in schizophrenia, beginning in 1952, when chlorpromazine was introduced, until the early 1990s. These drugs have been found to be effective in treating the positive symptoms of schizophrenia, enabling patients to remain out of hospital and to function in the community. Although all typical antipsychotic agents are effective in acute and maintenance treatment of schizophrenia, they have several therapeutic limitations. They have a limited range of efficacy, being mainly effective against positive symptoms (such as hallucinations, delusions, or mood swings), and relatively ineffective against negative (affecting skills and abilities the patient used to have) and affective symptoms and neurocognitive deficits (related to concentration, the ability to plan and to solve problems, to memory, etc.). In addition, 30 to 60% of patients have no response or only a partial response to conventional agents. Finally, conventional antipsychotic agents may not effectively alter the course of the illness sufficiently to minimize the occurrence of other health problems over the course of the patient's lifetime. Consequently, conventional antipsychotics are no longer regarded as a first-line option for most patients with schizophrenia.

Side effects of treatment with conventional agents

Conventional neuroleptic drugs are also associated with a high incidence of side effects. This both limits the drugs' effectiveness and reduces their acceptability to patients. Some patients may need to take additional medication as treatment for the side effects. However, many patients discontinue their medication because they find the side effects unacceptable. Patients who do discontinue their antipsychotic medication are highly likely to see their psychotic symptoms relapse.

The major side effects associated with conventional antipsychotic drugs relate to the occurrence of extrapyramidal symptoms (EPS, including the parkinsonian symptoms of tremor and rigidity), tardive dyskinesia (abnormal movements, particularly of the mouth and facial muscles, which are severely incapacitating and which can become irreversible) and akathisia (motor restlessness, which is extremely distressing and often the reason for non-adhesion to treatment rules and withdrawal of treatment). Because of their mechanism of action on the brain, more than 50% of patients receiving conventional antipsychotic agents experience side effects.

Atypical/novel antipsychotic drugs

The introduction of the first atypical antipsychotic drug, clozapine, in 1990 was a landmark event, not only because it was found to be effective in patients who were not responding to treatment with conventional neuroleptics, and also in reducing negative symptoms, but also because it was associated with a reduced risk of Parkinson symptoms. The list of novel antipsychotic drugs also includes risperidone, olanzapine, quetiapine, and ziprasidone. As a group, the newer agents have for the first time provided improvements in negative symptoms, affecting (and reducing) skills and abilities the patient used to have (such as socialization, energy, or interest in other peoples). They are therefore proving to be at least as efficacious and more tolerable than the conventional drugs, and hold the expectation of a more favorable clinical course for patients with schizophrenia.

Side effects of treatment with novel agents

While the atypical neuroleptics are generally better tolerated than the conventional drugs, the adverse-effect profiles of the atypical agents vary, and these differences may affect patient adhesion to treatment schedule. Thus, side effects such as dry mouth, blurred vision, constipation, and confusion can be observed. Atypical neuroleptics are also associated with sedation, drowsiness, appetite stimulation and weight gain, together with blood pressure and cardiac rhythm alterations, and dizziness.

Among the possible neurological side effects associated with neuroleptic drugs are neuroleptic malignant syndrome (NMS), seizures, and adverse effects on cognition, including sedation. The risk of seizures is low in patients receiving atypical antipsychotic medications.

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armamentarium : the equipment and methods used especially in medicine

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emetics : agents that induce vomiting

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camphor : a tough gummy volatile aromatic crystalline compound C10H16O obtained especially from the wood and bark of the camphor tree and used as a liniment and mild topical analgesic in medicine, as a plasticizer, and as an insect repellent; also : any of several similar compounds (as some terpene alcohols and ketones)

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What is schizophrenia? | What are the causes? | What are the treatments?