Bipolar disorder

Bipolar disorder, also known as manic-depressive psychosis, is a mental illness characterized by atypical mood changes, energy swings and the ability to function. Unlike normal mood changes, with their ups and downs that are common to everyone, the symptoms of bipolar disorder can lead to very serious consequences. They are able to destroy personal relationships, affect the quality of work or school performance, and even lead to suicide. Fortunately for us, bipolar disorder still gives in to treatment, and patients with this disease are able to lead a full and productive life.

Every year1 about 5.7 million adult Americans, or 2.6% of the population aged 18 and over, are diagnosed with “bipolar disorder.” Bipolar disorder is usually manifested in late adolescence or in early adulthood. However, in some cases, the first symptoms appear already in childhood, and in others – the symptomatology is revealed only at later stages of life. Quite often bipolar disorder can not be diagnosed, and people have to suffer for years before they are properly diagnosed and begin the necessary course of treatment. As well as diabetes or cardiovascular diseases, bipolar disorder is a chronic disease that must be closely monitored throughout life.

“Manic depression breaks the normal course of moods and thoughts, provokes inadequate behavior, undermines the foundations of rational thinking and quite often destroys the will and will to live. This disease, organic by its nature, in practice proceeds as a psychological disorder; it is unique in its ability to enthrall and bring pleasure, but the consequences of it bring unbearable suffering and often lead to suicide.

“I am happy that I managed to avoid death from this disease, I am happy that I was able to get the best medical help, as possible, I am happy that I have such friends, colleagues and, of course, my family.”

Kay Redfield Jamison, Ph.D. An Unquiet Mind, 1995, p. 6. (Published with permission of the publishing house “Alfred A. Knopf”, branch “Random House, Inc.”).

Symptoms of bipolar disorder

Bipolar disorder is the cause of a sudden change of mood – from extremely excited and / or irritable, to minor and hopelessly helpless, with a subsequent return to the original state and often with periods of normal mood in between. Such alternations of moods are often accompanied by significant changes in energy and behavior. The periods of the excited state and the passive state are called “episodes of mania and depression.”

Signs and symptoms of mania (or manic episode):

  • Increased energy, activity and anxiety
  • Incredible excitement, overly elated, euphoric mood
  • Increased irritability
  • The confusion of thoughts and the rapid pace of conversation, jumping from one idea to another
  • Distraction, inability to concentrate
  • Decreased need for sleep
  • Unreasonable confidence in their own abilities and abilities.
  • Inadequate assessment of the situation
  • Wastefulness, wretchedness
  • A long period when behavior is very different from normal
  • Increased sexual activity
  • Drug use, especially cocaine, alcohol and drugs for insomnia
  • Provocative, intrusive or aggressive behavior
  • Denial of the fact that something is wrong

A manic episode becomes a diagnosis if an excited condition, accompanied by three or more symptoms, lasts for most of the day, almost every day for a week or longer. For the final diagnosis of irritation, four additional symptoms are necessary.

Signs and symptoms of depression (or depressive episode):

  • A prolonged state of sadness, anxiety or emptiness.
  • Feeling of hopelessness or pessimism.
  • Feeling guilty, feeling worthless or helpless.
  • Loss of interest or pleasure from activities that used to be fun, including sex.
  • A lowered level of energy, a feeling of constant fatigue or “inhibition”.
  • Problems with concentration, difficulties with memorization or decision making.
  • Anxiety or irritability.
  • Increased drowsiness or insomnia.
  • Changes in appetite or / and unintended loss or weight gain.
  • Chronic pain or other persistent symptoms of poor health, not a result of physical illness or injury.
  • Thoughts of death or suicide, suicide attempts.

A depressive episode becomes a diagnosis if five or more symptoms manifest themselves throughout most of the day, almost every day for two or more weeks.

Hypomania is a weakened or moderately mild form of mania. A patient with signs of hypomania is able to feel good and even feel satisfaction from his own increased productivity and efficiency. Therefore, even if a family or friends are able to recognize that a bipolar disorder may be hidden behind a mood change, then the patient himself does not consider his condition abnormal. However, in the absence of proper treatment, hypomania is able to move into a heavier form of mania, and in some individuals may end with depression.

In some cases, a severe form of mania or depression is accompanied by symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (sound, visual or other sensations of the presence of things, which are not really present at the moment) and delusions (distorted, unconditionally believed representations that are not based on any logical grounds and are not based on a person’s cultural experience). In bipolar disorder, psychotic symptoms tend to reflect the extreme condition of the patient at a given time. For example, in the manic phase, delirium can be observed when a person is sure that he / she is a president or a person with power or wealth. During the period of depression, there can be delusions of guilt or worthlessness, when a person is convinced of his economic collapse and lack of money, or committing a serious crime. With this symptomatology, patients suffering from bipolar disorder can erroneously diagnose schizophrenia – another severe mental illness. The phases of bipolar disorder can be imagined in the form of a spectrum or a continuous scale. At one end of this scale – a severe form of depression, above it is a depression of moderate severity. Then follows the state of depression, which, in case of its short duration, many are called “melancholy”, but which is professionally defined as “dysthymia” if it becomes chronic.

Then comes a normal or balanced mood, followed by hypomania (a weak or moderate-moderate form of mania), and at the end – a severe form of mania.

However, in some patients, the symptoms of mania and depression can be observed simultaneously. This condition is called mixed bipolar disorder. With this type of bipolar disorder, the symptomatology often includes excitement, sleep disturbance, significant changes in appetite, psychosis, suicidal thoughts.

The patient is in a state of sadness and hopelessness, but at the same time feels an extraordinary burst of energy.

Bipolar disorder is not always associated with a mental illness, its causes can be the abuse of alcohol or drugs, poor academic progress or failures at work, strained personal relationships. All these problems, in fact, can be signs of a latent illness of disturbed mood.

Diagnosis of bipolar disorder

Like other mental illnesses, bipolar disorder can not be diagnosed with the help of physiological research methods, such as, for example, a blood test or a brain scan. Thus, the diagnosis of bipolar disorder is made on the basis of a symptomatic picture, a medical history and, if possible, a family history. The criteria for diagnosing bipolar disorder are described in the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders, fourth edition, DSM-IV.

Evidence from patients with bipolar disorder is a valuable source for understanding the various phases of mood swings associated with the disease:

Depression: “I absolutely do not believe in my ability to do anything right. It feels like the course of my thoughts is slowing down and slowing down until eventually it comes to a state of total stupor … [It] haunts … a feeling of complete, desperate helplessness from all this … Someone says it’s , they say, a temporary phenomenon, it will pass and you will get better, but they certainly do not have the faintest idea of ​​what I feel, although they flatter themselves with hope. If I can not feel, move, think or want, then why do I need all this? ”

Hypomania: “At first, when I’m excited, it’s amazing … ideas flicker one by one … as if watching the falling stars in anticipation of seeing the brightest … Shyness removes the hand, the right words and the necessary gestures are right there … uninteresting people and events suddenly acquire an incredible interest. You are overcome by irresistible desires, you want to be seduced and be seduced … You are full of feeling of lightness, strength, omnipotence, euphoria … you are capable of doing anything … but at one point it all ends … ”

Mania: “Thoughts flicker somehow too quickly and they become too much … the clarity of thoughts is replaced by a state of complete loss … you are unable to follow all this, begins to change memory … Your poisonous humor ceases to amuse. It becomes scary for friends … and you do not like everything yourself … everything literally annoys, angers, frightens you, you become uncontrollable and you feel trapped. ”

Suicide

Some patients with bipolar disorder are susceptible to suicide. Any person who thinks about suicide, needs immediate help, preferably a psychiatrist or a therapist. It is necessary to take seriously any person who speaks of suicide. The risk of suicide is much higher in the early stages of the disease. Thus, early diagnosis of bipolar disorder and the definition of effective methods of its treatment can reduce the risk of death from suicide.

The signs and symptoms of suicidal intent:

  • talk about suicidal intent or desire for death
  • feeling hopeless; feeling that nothing will ever change and it will not get better
  • feeling helpless: whatever a person does, nothing can help
  • feeling like a burden to family and friends
  • alcohol or drug abuse
  • bringing affairs to order (putting in order finances, distribution of personal property, ie preparation for death)
  • posthumous memorial
  • the desire to be in danger, to fall into situations in which there is a likelihood of dying

If you have suicidal intentions or you know someone who is in this condition:

  • immediately call a doctor, an ambulance, or “911” for emergency treatment
  • Do not stay alone or leave a person with suicidal intentions of one
  • make sure that there is no access to medicines, weapons or other things that can be used for self-harm

In some cases, suicide is planned thoroughly and in advance, while in others it is an impulsive and ill-conceived act. In any case, the measures proposed in the previous paragraph can be a long-term strategy for patients suffering from bipolar disorder. It should be remembered that suicidal intentions and suicide attempts are symptoms of a disease that can be treated. With proper treatment, you can get rid of suicidal intentions.

How is bipolar disorder?

Episodes of mania and depression usually repeat throughout life. In the intervals between the episodes, most patients with bipolar disorder do not have symptoms, however, about a third of patients have residual symptoms. A small proportion of patients experience chronic continuous bipolar disorder symptoms despite treatment.3

The classical form of this disease, in which episodes of mania and depression regularly recur, was called type I bipolar disorder. Some patients do not have a severe form of mania, but there are mild episodes of hypomania, alternating with depression.

This type of bipolar disorder is called type II bipolar disorder. If within a period of twelve months the patient has four or more episodes, then they speak of a rapidly circulating bipolar disorder. In some patients, episodes are repeated repeatedly for one week or even one day. Rapidly circulating bipolar disorder usually develops at a late stage of the disease and is more common in women than in men.

In case of effective treatment, patients with bipolar disorder are able to live a healthy and productive life. However, without treatment, the natural course of the disease tends to deteriorate. Over time, episodes of mania and depression in the patient become more frequent (faster circulation) and become more severe than at an early stage of the disease.4 But in most cases, proper treatment can reduce the frequency and severity of episodes and help patients with bipolar disorder live a full and happy life.

Is there bipolar disorder in children and adolescents?

Bipolar disorder can be in children and adolescents. Children at greatest risk are those whose parents suffer from this disease.

Unlike adult patients with bipolar disorder, whose episodes are quite clearly delineated, children and adolescents with this disease have an incredibly fast mood change from depression to mania, several times a day. 5 In children, mania often manifests itself in irritability and outbursts of anger, and not in euphoria and excitement, as in adults. Mixed symptoms are also quite common in young people with bipolar disorder. Those who are ill in late adolescence, episodes and symptoms are more classic, inherent in adults, the character.

In children and adolescents, it is difficult to distinguish bipolar disorder from other problems that may occur in this age group. For example, irritability and aggressiveness are characteristic of bipolar disorder, but at the same time they may be symptoms of attention deficit hyperactivity disorder, behavioral disorder, opposition-causing disorders, or other types of serious mental illness more characteristic of adults, such as depression or schizophrenia. Drug abuse also provokes such symptoms.

However, with any disease, the key to success depends on the correct diagnosis. Children and adolescents with emotional or behavioral problems should be checked by a psychiatrist. To every child or adolescent with suicidal tendencies that speaks of suicide or attempts to commit suicide, one must be taken very seriously and immediately provide him / her with professional help from a psychiatrist or psychologist.

Causes of bipolar disorder

On the example of numerous studies, scientists are trying to understand the causes of bipolar disorder. At present, most of them have come to the conclusion that bipolar disorder does not have one single reason. Most likely, many factors play a role here.

Because bipolar disorder tends to repeat in the family, scientists are trying to detect specific genes (microscopic “building blocks” of DNA inside each cell, responsible for the development and growth of the body and psyche) transmitted from generation to generation that can increase the chance of the disease. However, it’s not just the genes. The study of identical twins, having an identical genetic structure, shows that both genes and other factors play an important role in the onset of bipolar disorder. If the cause of bipolar disorder was only in the genetic code, then in the case of a twin disease, the second twin would also always be sick. However, the results of the studies indicate otherwise. Although, if one of the twins develops a bipolar disorder, the chances of a twin from another twin are much higher than those of other siblings.

In addition, it should be noted that the results of genetic studies show that the cause of bipolar disorder, like any other mental illness, is not in one single gene. 7 Apparently, bipolar disorder is the result of joint actions of numerous genes in combination with other individual human factors and environmental factors. Discover these genes, each of which makes its small contribution to the development of predisposition to bipolar disorder, is extremely difficult. But scientists hope that the recently introduced new research methodologies will open this mystery and lead to the development of more effective treatment of bipolar disorder.

Studies of the brain with the use of its images help scientists understand what disruptions in brain activity provoke the development of bipolar disorder and other mental illnesses. 8.9 New technologies allow scientists to obtain images of a live working brain, thus enabling them to study its structure and activity without the need for surgical or any other intervention. These technologies include a magnetic resonance imaging (MRI), positron emission tomography (PET), and a functional magnetic resonance imaging (MRI). There is sufficient evidence obtained on the basis of brain research that the brain of patients with bipolar disorder differs from the brain of a healthy person. In the course of further research, scientists will be able to make a clearer picture of the differences and understand the cause of this disease, which in the end will enable them to find the most effective ways of treatment.

How is bipolar disorder treated?

Due to correctly selected treatment, in most patients with bipolar disorder – even in its most severe forms – it is possible to stabilize mood changes and other symptoms of the disease. Since bipolar disorder occurs with relapses, preventive measures of treatment are not only shown, but are strongly recommended. Treatment combining drugs and psychotherapy is optimal to keep the disease under control.

In most cases, bipolar disorder is controlled much more effectively if the patient does not interrupt treatment, but constantly follows it. But even in these cases, episodes of mood change are quite likely. In such cases, you must always inform the attending physician. A timely change in the doctor’s course of treatment can prevent a full-scale episode.

Treatment will be more effective if you openly discuss with your doctor all doubts and proposed treatment options.

In addition, if the patient and his loved ones fill in the daily schedule of symptoms of mood, medication, sleep patterns, day events, they begin to better understand the disease. Such graphics also help the treating physician to monitor the progress of the disease and treatment more effectively.

Medications

Drugs for the treatment of bipolar disorder are prescribed by certified psychiatrists-MDs (MD), specialists in the diagnosis and treatment of mental illness. Although the therapist can also prescribe medication, nevertheless the patient with bipolar disorder is strongly recommended to be observed and treated by a psychiatrist.

In bipolar disorder, as a rule, prescribe the so-called “mood stabilizers.” 10 There are several types. Usually patients with bipolar disorder continue to take mood stabilizers for a long period of time (years). Other drugs are administered additionally as needed, usually for a shorter period of time, to relieve episodes of mania or depression that may occur periodically, even with mood stabilizers.

  • Lithium is the first of mood-stabilizing drugs allowed by the US Food and Drug Administration (FDA) to treat mania. This medicine is an effective means of controlling mania or preventing relapses of both manic and depressive episodes
  • Anticonvulsants such as valproate (Depakote®) or carbamazepine (Tegretol®) also have a mood stabilizing effect and can be used in particularly difficult to treat cases of bipolar disorder. The FDA authorized the use of valproate for the treatment of mania in 1995
  • New anticonvulsants, such as lamotrigine (Lamictal®), gabapentin (Neurontin®), and topiramate (Topamax®), are under study to determine how well they affect the stabilization of mood cycles
  • To achieve maximum effect, several anticonvulsants can be prescribed at once or they can be used in combination with lithium
  • Children and adolescents with bipolar disorder are usually treated with lithium, but valproate and carbamazepine are also used. Scientists find out the safety and effectiveness of the use of these and other psychotropic drugs for children and adolescents. According to studies, valproate can lead to hormonal changes in adolescent girls and polycystic ovary syndrome in young women who started taking this drug before the age of 13. 13 Therefore, young patients taking valproate should certainly be under close medical supervision .
  • Patients with bipolar disorder who want to become pregnant or are already pregnant face a difficult choice, as mood stabilizers can have a negative effect on the fetus or on a breast-fed baby.14 Thus, before taking a responsible decision, it is necessary to discuss with the expert all the pros and cons “Against” all possible ways of treatment. Currently, at the testing stage are new drugs that significantly reduce the risk during pregnancy or lactation.

Treatment of bipolar disorder

According to the results of the study, patients with bipolar disorder undergoing treatment with antidepressants are at risk of developing mania, hypomania or a rapidly circulating form of the disease. 15 In order to protect patients with bipolar disorder from such effects, it is usually necessary to use mood-stabilizing drugs, either in combination with antidepressants, or by themselves. At present, lithium and valproate are the most common drugs that stabilize the mood. Nevertheless, experiments are continuing to evaluate the effectiveness of the use of new medications for mood stabilization.

  • Atypical antipsychotics, including clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Rispendal®), quetipine (Seroquel®), and ziprasidone (Geodon®) are being studied for possible use in the treatment of bipolar disorder. There is reason to believe that the use of clozapine can help patients who do not respond to lithium or anticonvulsant drugs.

Other studies have confirmed that olanzapine is effective in acute mania, and has recently been approved for use in this capacity by the FDA. Olanzapine also helps in the treatment of psychotic depression.

  • Aripiprazole (Abilify®) is another atypical antipsychotic drug used to treat the symptoms of schizophrenia and manic or mixed (manic and depressive) episodes of type I bipolar disorder. It is available in tablets and in liquid form. Injections are used to treat symptoms of excitement in schizophrenia and manic or mixed episodes of type I bipolar disorder.
  • If there is a problem of insomnia, high-performance benzodiazepine drugs, such as clonazepam (Klonopin®) or lorazepam (Ativan®), can help. However, since these drugs are addictive, they are prescribed only for a short time. Instead, in some cases, they are prescribed soothing, such as zolpidem (Ambien®).
  • During the course of treatment of bipolar disorder, it is necessary to repeatedly change medicines for the purpose of the most effective treatment. All drug changes and changes in drug doses should occur according to the prescription of the treating psychiatrist.
  • Do not forget to tell your psychiatrist about all your medications, including over-the-counter medications, homeopathic remedies, vitamins and other supplements. This is very important, as some drugs and supplements are incompatible and can cause adverse reactions.
  • To avoid relapse or a new episode, you must strictly adhere to the treatment plan. Discuss with the attending physician all the questions about the medicines.

Thyroid function

In patients with bipolar disorder, thyroid dysfunction is often observed. Increased or decreased levels of thyroid hormones in itself can affect mood changes and energy levels. Therefore, it is very important that the thyroid parameters are under constant monitoring by the attending physician.

The rapidly circulating form of bipolar disorder is often accompanied by diseases of the thyroid gland. In such cases, along with medications for bipolar disorder, it is necessary to take medications to treat the thyroid gland. It should also be borne in mind that in some patients, lithium can cause a decrease in thyroid activity. In this case, in the course of treatment, it is necessary to introduce medications to regulate thyroid function.

Side effects of drugs

Before you start taking new medications, always consult a treating psychiatrist and / or a pharmacist about possible side effects. Depending on the drug, side effects can be expressed in the addition of weight, nausea, tremor, decreased sexual activity or possibility, anxiety, hair loss, difficult movements and dry mouth. Be sure to tell your doctor about all side effects that occurred during the taking of a medicine. To remove or reduce side effects, the doctor can change the dosage of the drug or change it to another. Do not change medication or stop taking them without consulting a psychiatrist.

Psychosocial methods

Along with medical treatment, the use of psychosocial methods is recommended, including certain forms of psychotherapy (or “colloquial” therapy). Such methods help patients with bipolar disorder and their families understand the specificity of the disease and obtain the necessary information. The results of the research showed that psychosocial therapy helps to stabilize the mood, reduce the number of hospitalizations and improve the vital activity in various spheres of human activity.12 As a rule, licensed psychologists and social workers are engaged in such therapy, coordinating their actions with the attending psychiatrist and jointly monitoring the progress in state of health of the patient. The number of sessions, their frequency and duration depend on the individual needs of each patient.

Among the psychosocial methods used in bipolar disorder include cognitive behavioral therapy, psychological education, family therapy and a new technique – interpersonal and socio-rhythmic therapy. Researchers at the National Institute for Mental Health (NIMH) study and compare the effectiveness of these methods in combination with various drugs for the treatment of bipolar disorder:

  • Cognitive-behavioral therapy helps patients with bipolar disorder understand and change negative or distorted patterns of thinking and behavior associated with the disease.
  • Psychological education introduces patients to information about the disease and methods of its treatment, and also helps to learn to recognize the signs of relapse, which allows you to seek help in advance and prevent the onset of a full-scale episode. Mental education is also useful for family members of the patient.
  • Family therapy uses a strategy of lowering the level of tension in the family, which can aggravate the symptoms of the disease or caused them.
  • Interpersonal and socio-rhythmic therapy helps patients with bipolar disorder improve interpersonal relationships and organize their daily routine. A regular schedule and an orderly sleep regime help prevent manic episodes.
  • As with medical treatment, in order to achieve successful results of psychosocial therapy, it is necessary to strictly follow the prescribed course of treatment.

Other treatments

  • Electroconvulsive therapy (ECT / ECT) is used when medication, psychosocial therapy, or a combination of these drugs do not have the desired effect or are too slow to stop serious symptoms such as psychosis or suicidal manifestations. The use of ECT can also help during acute episodes when the physical condition of the patient (including pregnancy) does not allow the use of medications. ECT is a highly effective treatment for severe depression, manic and / or mixed episodes. The possibility of long-term memory problems resulting from ECT, which until recently was a serious cause for concern, has now been significantly reduced by the latest ECT methods.

Nevertheless, it is necessary to discuss in advance all the pros and cons of using ECT and other alternative therapies with the patient himself, and, if necessary, with family members or friends.

  • Medicinal herbs and natural supplements, such as Hypericum perforatum (Hypericum perforatum), have not been studied enough, and the specialists have little information about their effect on bipolar disorder. Since FDA regulation rules do not apply to such products, different manufacturers of these additives use different amounts of active ingredients. Before you start taking herbs or natural supplements, you should consult your doctor. There is evidence that St. John’s wort can lower the effectiveness of certain drugs (see: www.nimh.nih.gov/events/stjohnwort.cfm) leaving the OMH site. 20 In addition, like prescription antidepressants, in some patients with bipolar disorder, St. John’s wort may provoke mania, especially in cases where the patient does not take mood stabilizers.
  • Studies are under way on the effectiveness of use in the treatment of bipolar disorder Omega-3 (contained in fish oil fatty acids) in combination with traditional medicines or separately.

Chronic disease, which is treated very effectively

Although episodes of mania and depression are in the habit of appearing and disappearing, it must always be remembered that bipolar disorder is a chronic disease that is not currently cured. The only way to keep this disease under control is to constantly take medication, even during periods when you are feeling well. Only in this case it is possible to reduce the chance of relapse and deterioration of the condition.

Accompanying illnesses

Among patients with bipolar disorder, alcoholism and drug addiction are very common. Studies have shown that there are a number of reasons for this, including self-medication, a change in mood from alcohol or drug abuse, and risk factors that affect both the development of bipolar disorder and drug dependence. 23 Treatment of alcoholism or drug addiction is an important part of the overall course of treatment.

Anxiety disorders, such as post-traumatic stress or obsessive-compulsive disorder (obsessive-compulsive disorder), are also common in bipolar disorder. 24, 25 Concomitant anxiety disorders can sometimes be controlled by the same means as bipolar disorder, but in some cases special treatment is required. For detailed information on anxiety disorders, contact NIMH (see below).

Helping patients with bipolar disorder and their families

Patients with bipolar disorder should lead an experienced psychiatrist, specializing in the diagnosis and treatment of this disease. Psychologists, social psychiatric service workers and nurses of psychiatric clinics help to provide various aspects of treatment and care for patients and their families.

You can get help in the following places:

  • Treatment programs at universities or medical institutes
  • In psychiatric departments of hospitals
  • In private psychiatric offices and clinics
  • In health care organizations (HMOs)
  • In the offices of district or children’s doctors
  • In community mental health centers

Patients with bipolar disorder may need help to get help

  • Patients with bipolar disorder often do not realize how sick they are, or they see the cause of their illnesses not in a mental disorder, but in something else.
  • To seek help from a doctor, patients with bipolar disorder may need encouragement and support from the family and friends. The therapist can play an important role, insisting on consultation with a psychiatrist.
  • Sometimes it is necessary that a family member or friend accompany a patient with bipolar disorder to see a doctor and be treated.
  • Sometimes a patient who is in a stage of acute attack should be hospitalized for his / her own safety and to provide the necessary treatment. In some cases it is necessary to hospitalize the patient against his / her will and without consent.
  • It is necessary to constantly support and encourage the patient, after the start of treatment, because in some cases it may take quite a long time to find the right course of treatment.
  • In some cases, patients with bipolar disorder during the period of remission can specify a plan of action in the event of a future manic or depressive relapse.
  • Like other serious diseases, bipolar disorder severely affects spouses, family members, friends and employers.
  • Family members of a patient with bipolar disorder often have to deal with serious problems in their behavior, such as unrestrained waste of money during episodes of mania, or withdrawal into themselves during depression, and the long-term consequences of such behavior.
  • Many supportive bipolar disorders are supported by support groups supported by various organizations, such as the National Association for the Study of Depressive and Manic-Depressive Disorders (NDMDA), the National Alliance for the Treatment of the Mind Indigent (NAMI), and the National Association for Mental Health (NMHA). Such support groups also help families and friends of patients with bipolar disorder. The coordinates of these organizations can be found in the “Useful Information” section of our brochure.

Clinical studies on bipolar disorder

Some patients with bipolar disorder receive medication and / or psychosocial therapy if they agree to participate in clinical trials (clinical trials). During these tests, scientific studies of the disease and the ways of its treatment involving people are conducted. Clinical trials in psychiatry provide information on the effectiveness of a drug or a combination of several drugs, the benefits of behavioral therapy or psychotherapy, the reliability of a diagnostic procedure, or the success of a preventive method. Clinical trials help scientists to follow the course of the disease: how it starts, progresses, goes on recession, how it affects the body and mind. Thanks to information obtained during clinical trials, millions of Americans with mental illness today live a normal and productive life. However, not everyone can take part in such trials. Before deciding to participate in the study, each person should weigh the pros and cons.

In recent years, the NIMH has introduced a new generation of clinical trials, so-called real-world research. They received their name for several reasons. Unlike traditional clinical trials, they offer many different types of treatment and treatment combinations. In addition, they try to involve as many mentally ill people from different regions of the United States and treated in various health facilities as possible. To participate in these trials, they try to attract patients suffering from several mental illnesses simultaneously, as well as those who have concomitant physical ailments. The main objective of research in the real world is to improve the methods and improve the results of treatment for all those suffering from mental disorders. Apart from the fact that these studies record the dynamics of the symptoms of the disease, they also collect information on how treatment affects other important aspects of the “real world”, such as the quality of life, the ability to work and function in society. In the course of research, the effectiveness of costs for different types of treatment is also studied and factors that affect how patients adhere to the prescribed course of treatment are analyzed.

Quetiapine (seroquel) and biopsychosocial approach in schizophrenia

Schizophrenia as a biopsychosocial phenomenon requires long-term combined drug and psychosocial treatment. With adequate care, the clinical and functional outcome of schizophrenia is no less favorable than in a number of diseases requiring conservative or surgical treatment (arthroplasty, coronary bypass) [2]. Psychopharmacotherapy is an integral part of the biopsychosocial treatment of a patient with schizophrenia. The clinical efficacy (in daily practice) of typical neuroleptics (TN) and atypical antipsychotics (AA) is composed of interrelated safety indicators (individual tolerability), satisfaction with treatment, compliance of patients. A scientifically justified choice of VT or AA is determined by the best risk ratio (early and delayed adverse effects) / benefit (clinical effect) of therapy and the preferences of the patient and his loved ones. The choice of the drug is dominated by a precautionary principle: minimizing the risk of unwanted actions, taking into account the patient’s suspected sensitivity and in the context of his professional and daily activities (for example, small finger tremor is a tragedy for a musician). The effect of a TH or AA is predicted by the doctor, based on the experience of treating the patient or his blood relatives (incidentally, their awareness of the details of treatment and the need for information is revealed). The selling price of AA (seroquel) is two orders of magnitude higher than the TN in terms of the daily dose, but pharmacoeconomic studies indicate that the former has an illusory-objective value in formulating the form and choosing a doctor. After all, the cost of antibiotics and immunosuppressants is not less, but priority in financing health care. The resource-saving potential of AA manifests itself fully in their rational choice and application [2]. The position of the national clinical guidelines [6] is consistent with the recommendations for the treatment of schizophrenia in a number of European countries: AA is shown in the absence of the expected (acceptable for the doctor, patient, his loved ones) clinical response and / or high risk or development of undetectable undesirable effects of TN in a minimal therapeutic dose , causing significant distress in the patient and reducing his social functioning and quality of life. This step-by-step approach is a proven cost-effective strategy in the face of a scarcity of medical resources [2]. The criterion for deciding on the choice of AA was the ethical principle of justice – a non-discriminatory, reasonable, differentiated distribution of limited medical resources for the treatment of certain groups of patients with limited therapeutic options in comparison with the population of schizophrenia. The success of the treatment is facilitated by the productive union of the patient, his relatives with the doctor-adviser (members of the multidisciplinary team), joint planning of treatment for the consistent resolution of the patient’s personally significant problems (from getting rid of blasphemous “voices” before returning to the profession), forming the responsibility of the patient and his relatives for the result of treatment. The strategic goal of biopsychosocial treatment is unchanged: improving the clinical and functional outcomes of schizophrenia, alleviating its multiple burdens for the patient and his loved ones, psychiatric and general medical services, society as a whole. However, the tasks of therapy change in connection with the phase of the disorder [6, 9, 25, 26].

Acute (stop) treatment of patients in the first episode, relapse or exacerbation of schizophrenia is aimed at the early stabilization of psychotic disorders; identification of individual psychosocial triggers of an acute condition; prevention of prolonged social disadaptation of the patient. The purpose of treatment of paroxysmal forms: the achievement of the deepest remission, continuous forms – compensation of psychotic disorders within the framework of therapeutic remission. Explanatory work with the patient (the meaning of treatment to alleviate the most disturbing symptoms, an individual prognosis, preferably in an optimistic manner) strengthens the setting for treatment during the “latent” period of the drug. Education of close, active participants in the process of therapy is important in the formation of a protective and protective environment. It is important to “imprints” (imprinting) positive events in acute treatment, and negative impressions result in the rejection of subsequent treatment, distress. When hospitalization should be avoided whenever possible physically constraining the patient, prolonged isolation in the monitoring room. Disturbance of patients, lack of exercise and lack of employment, roughness, internal conflicts of personnel are risk factors for the patient’s aggression in the hospital department even against the background of “good medicine”. It is preferable to take drugs inside and only if necessary to resort to parenteral administration. However, some physicians are inclined to start acute treatment with intramuscular forms of VT, or, more rarely, AA, unreasonably believing that this method is more effective [2].

However, no more than 10% of patients require parenteral administration of the drug in connection with the rejection of tableted forms. A number of patients perceive injections as a repressive measure, evidence of a particular danger of their condition. In addition, injections are painful (especially for patients with a reduced pain threshold), are costly and fraught with complications (respiratory depression, infiltrates).

Seroquel in connection with its safety can be appointed until the results of laboratory tests are obtained; in urgent cases, when the patient resists examination (but not taking the medicine) – until a complete medical examination. Probably a trial 48-hour treatment with trial doses of seroquel (50-100 mg) to identify the individual sensitivity of the patient with an assessment of his subjective reaction [16]. Seroquel less often than TN, causes dysphoria, emotional indifference. Such an unpleasant and memorable early symptomatology, which outstrips the therapeutic effect, often leads to the rejection of further treatment. Hypotension (it is important to prevent the patient, especially the elderly, not to stand up sharply, avoid dehydration, especially in summer) and dry mouth (good rinse, chewing gum without sugar) are usually reduced as they adapt to seroquel, like most of the early “general toxic” actions of neuroleptics [ 1].

In psychogerontological practice, the risk of orthostatic hypotension (to prevent abrupt rising from bed) and dizziness
(with possible falls), tachycardia in the initial stage of treatment (the initial dose of seroquel should not be more than 25 mg, the slower the dose, the better the drug is tolerated). The risk of ventricular tachyarrhythmia in the treatment with seroquel (10%) corresponds to that in the treatment with tableted haloperidol and 1.5 times less than when treated with risperidone [22]. In acute treatment, the speed of the drug is important. Olanzapine inside (including the resorption form) requires 5-8 hours for its concentration in the blood plasma to peak, oral haloperidol – 4 hours, risperidone and seroquel – 2 hours. It is possible to increase the dose of quetiapine to 800-1000 mg for a 3- 5 days (200 mg / day) with asymmetric two-time appointment of most of the drug at night, if necessary in combination with high-potency tranquilizers (lorazepam, phenazepam). The non-specific calming effect of seroquel without hypersedition (the need for tranquilizers is reduced) is useful for prompt, within 5-7 days, arresting the agitation and hostility of patients [8], is positively perceived by patients, does not interfere with detailed somatoneurological evaluation and early psychosocial interventions. While the risk / benefit ratio of quetiapine is above the recommended threshold, little is known about it, but within the therapeutic range, with the selection of seroquel (up to 750 mg / day), psychotic anxiety decreases within a week [12].

Gradual build-up of doses (up to 400 mg / day for 5 days) is shown elderly and with liver diseases. Doses of seroquel 450 mg / day, approximately equivalent to 8 mg of haloperidol, are usually sufficient for patients in the first episode of schizophrenia. The efficacy (in RCTs) of acute treatment with seroquel (400-800 mg / day), olanzapine (10-20 mg / day) and risperidone (4-8 mg / day) is similar [3]. The antipsychotic effect of seroquel is most pronounced to the 8th-12th week in 50-85% of patients [15]. Seroquel monotherapy avoids the risk of pharmacokinetic interactions and a complex treatment regimen for the patient and medical staff. A smaller need for anticholinergic correctors (cyclodole), exacerbating and prolonging psychosis, having the potential of dependence and aggravating cognitive frustration of schizophrenia, contributes to the optimization of therapy in the choice of seroquel. The widespread combination of seroquel with VT and other AAs in everyday practice (up to 40%) is associated with the doctor’s impatience , not taking into account the risk of treatment at its rise in price, blurring the clinical picture [2]. In acute treatment, patients prefer seroquel to a number of other AA and TN [7], especially those who avoid taking medication because of increased sensitivity to neurological and metabolic (obesity, hyperprolactinemia) side effects, such as in the first episode of schizophrenia [3] . Thus, weight gain causes no less distress than acute neurological disorders, especially in young girls (at risk), which is important when choosing an antipsychotic to avoid a later break even of successful clinical therapy. The risk of weight gain (in 25% of patients, usually not more than 4 kg for the first 12 weeks with subsequent access to the plateau for a one-year treatment) in seroquel is lower than in a number of AA [3].

Against the background of seroquel, the initially increased weight may even decrease. In everyday practice, however, the majority of patients are treated with a combination of drugs, including a high risk of weight gain (for example, “classical” tricyclic antidepressants, lithium), and the beneficial effect of seroquel against polypharmacy may be lost. Therefore, it is important to teach the patient the skills of a healthy lifestyle (exercise, low-calorie diet). Ineffectiveness of treatment is noted in the absence of positive dynamics in the clinical and functional areas of assessment, including the subjective – the patient himself, within 3-8 weeks after reaching the therapeutic dose of seroquel; with a partial response, treatment should be continued for another 4-10 weeks.

With ineffective treatment, a reassessment of the patient’s mental and physical condition is necessary (revealing hidden organic inferiority, substance abuse, affective disorders, compliance problems, chronic psychosocial distress, increased emotional experience in the family). It is possible to increase the dose of quetiapine after 6-8 weeks of treatment, but ultrahigh doses should be avoided. The practice of premature replacement of quetiapine with another drug or polyneurosis leads to the fact that the cause for improvement of the patient’s condition and undesirable actions remains unclear for the doctor. The transition to seroquel is logical in the case of uncontrolled undesirable phenomena of VT (for example, acute extrapyramidal disorders) or other AA, with the exception of clozapine (for example, obesity). A method of cross-titration that minimizes the risk of symptoms of “ricochet”, sometimes interpreted by a physician, as undesirable actions of a new treatment is desirable (Table 1).

The orderly behavior of the effect of seroquel with the “distancing” of the personality from the remaining psychotic experiences makes it possible to start individual and then group psychosocial interventions (training in management of the disease and its treatment) at the early stages of hospital treatment, continuing at discharge. Therapy includes a number of components:
• detection and prevention of relapse factors, active control of the “early” symptoms of worsening;
• urgent treatment when they are identified by a joint crisis plan worked out jointly with the doctor and close (management of distress, intensification of observation and treatment, strengthening of informal support);
• training in effective coping skills with symptoms and family (family) distress, drawing on the positive experience of group members and behavioral techniques, learning to solve common problems and social skills in the organization of treatment (seeking help, alliance with loved ones and professionals);
• Individual or group family therapy for emotional support, learning to cope with the illness of a loved one through understanding the active role in treatment, reducing excessive emotions as triggers of relapse, and prevention of distress.

As the patient’s condition is stabilized, it is necessary to switch to a treatment that is effective for acute treatment with a drug (seroquel) to prevent early relapses and exacerbations, to strengthen and consolidate the success of therapy. As remission deepens, the patient increasingly acts as a subject of treatment on the principles of partnership. The psychiatrist (social worker, clinical psychologist) focuses on the patient’s problems outside the protected environment of the hospital (day hospital): limits unrealistic expectations and requirements for the functioning of the patient in his family. It is necessary to balance the stimulation of patient responsibility for the result of treatment and the provision of emotional and social protection. It is important to save the patient and his loved ones from the fatalistic expectation of a return of psychosis, orient them to a healthy lifestyle. The management of the patient is focused on evaluating, supporting, explaining, strengthening the sense of reality, changes in his behavior. Relief of psychotic symptoms in the treatment of seroquel allows you to indirectly master (restore) social skills. Group psychosocial therapy is used to develop skills for management of illness and treatment, it is useful to involve the patient and his relatives in the activities of the self-help society in the community (an important part of the treatment plan). Improvement of symptoms outstrips the improvement of social and labor functioning. The nature and extent of disability is a more relevant and real measure of the outcome of schizophrenia treatment than a change in the clinical picture (“target syndrome”). A clear sign of a patient’s social recovery is a return to an occupation appropriate to age. When persistent symptoms need to strengthen psychosocial treatment (cognitive-behavioral therapy).

Pharmaco-dependent remissions with “blurred” symptoms, which are actualized with the abolition or reduction of doses of TN or AA in more than 60% of patients with schizophrenia, determine the continuation of treatment with total (unchanged) doses of quetiapine by the majority of community-acquired patients. The treatment regimen should correspond to the daily functioning of the patient, and it should be simplified, which will improve compliance and facilitate its monitoring by trained relatives. It is advisable to “asymmetric” the reception of most of the seroquel in the evening, since the drug in medium doses is prescribed twice a day, but the clinical effect in patients receiving the drug once a day is similar [13]. When revealing the early symptoms of relapse (the topic of psychoobrazovaniya) may increase the dose of seroquel by 100-200 mg with a temporary attachment of tranquilizers.

Clinical problems in the development of remission. Experiencing a state of “awakening”, that is, a pronounced and rapid clinical improvement in the treatment with seroquel, patients reveal a wide range of reactions (alienation of the disease, reactive depression), disrupt the treatment regimen and therefore require intensive emotional support, since their “I” did not have time to adapt to new ones social problems, and the family of the patient is not always able to perceive with understanding the new role of the patient, more habitual in the inhibited state. The condition is transient, it is possible to appoint tranquilizers for up to a week. Negative disorders, their severity (buildup) is difficult to detect in an acute period. It is necessary to distinguish caused, for example, TH, akinesia, as well as depressive anhedonia, paranoid asociality, impoverishment of speech in thinking disorders from primary negative symptoms. It should be explained to the close nature of the patient’s changes (not “laziness”), cautiously prepare them for the idea that patients may not return to a painful condition, and for improvement, not only medication but psycho-social effects are required. The negative disorders that come to the forefront are the basis for choosing seroquel, if it has not already been assigned, keeping in mind its possible antidecitant and cognitive-impairing effects (at least, it does not exacerbate their undesirable actions), but it’s worthwhile to set up the family not to rely on the fast ” miracle “(to determine the effectiveness of treatment requires at least six months) and call for active cooperation in the case of resocialization of the patient. After all, the “defect” of the patient in many respects is his personal compensatory reaction to the neglect of others, and “learned helplessness” is a consequence of understated requirements in the hospital and community settings. Therefore, the heaviest patients should be sent as soon as possible to the rehabilitation department to develop (restore) social skills, in more light cases – in the day hospital for the continuation of the rehabilitation program or home to the care of relatives with compulsory communication with social services. An unpublished extract from the hospital is fraught with an increase in the burden of schizophrenia for the family and the rapid deterioration of the patient’s condition. Post-schizophrenic depression is possible in 50% of patients, although in the majority (up to 60-80%) of cases active treatment of TN or AA (seroquel) and intensive psychological support in the acute period contribute to resolving depression within the psychosis. In case of depression, the doctor will have to eliminate the previously unrecognized organic disease and schizoaffective disorder, the distress after the previous psychosis, the prolongation of a new episode, treat any concomitant medical illnesses, exclude substance misuse and neurological undesirable actions (akinesia, akathisia can not be ruled out in the treatment of any TN or AA) , to reveal the psychotraumatic situation that is persisting or brought by the illness in the family or at work. A necessary condition for treatment is the information of relatives about the risk of suicidal tendencies in the patient, creating an atmosphere of reasonably weighed optimism. It can be assumed that the harmonious effect of quetiapine on all components of an acute attack will allow for a deeper remission (including a decrease in the frequency of post-schizophrenic depression). With depression in the background of seroquel, treatment with antidepressants of the new generation is shown for at least 6 months [9, 26]. With the difficulty of distinguishing between depressive symptoms and negative, a trial course of antidepressant therapy is shown. The appointment of antidepressants without seroquel can exacerbate psychosis.

Non-compliance with treatment regimens. Good tolerance of seroquel does not guarantee continuation of treatment without systematic psychosocial work with the patient and his relatives, since the main causes of long-term compliance problems are the internal picture of the disease (the patient does not need treatment, he is actively opposed to medicines), an unsatisfactory therapeutic alliance with a doctor , disinterest of the family in the results of treatment. At least 50% of patients lose their relationship with HDPE in the first months after discharge from the hospital. A number of patients, stopping treatment on their own, note that they feel good after 3-4 weeks. It is necessary to take into account the incompletely formed reaction to the acute period, the patient’s vulnerability to psychosocial stresses, possible undesirable actions of therapy, to explain to the patient and his family that the risk of deterioration is high and he is delayed in time, and the path to recovery is long, but “the path will master the going.”

Antiretpressive (maintenance) therapy reduces the risk of recurrences (exacerbations) of schizophrenia and, apparently, slows down the rate of its progression. Treatment is necessary as long as the underlying pathology persists, and does not imply that the risk of relapse is reduced after discontinuation of medication and that in the future it will not need its renewal. Secondary prevention is more important than the risk of unwanted effects of drugs, since most of them are reversible, and the consequences of relapse can be fatal. Adequate pharmacotherapy (“the right medicine for the right patient”) allows to improve, consolidate the achieved therapeutic results with the least risk of undesirable actions. In connection with the unclear prediction of the cessation of activity of the painful process, supportive treatment is indicated to all patients. For patients who have undergone the first episode and are fully remorted within a year, gradual withdrawal of seroquel treatment within one to two years is possible [6, 9, 26]. At least 5 years to be treated in the absence of psychotic symptoms to patients with repeated attacks. Preventive treatment during life is shown by a third of chronic patients, especially dangerous for themselves and others in an acute period (or if repeated psychoses differed in duration and did not respond well to therapy). For many patients, a psychiatrist becomes a general practitioner. He should pay more attention to the state of physical health and well-being of patients, dynamically controlling the possible undesirable effects of prolonged therapy. In this regard, low risk of unwanted effects of seroquel with long-term use [3] is important, for example, tardive dyskinesia, a scourge of maintenance therapy for TH or obesity in the treatment of a number of AA. The choice of seroquel is indicated by the stabilized symptomatically ill, but experiencing these side effects that are not otherwise corrected. Reduction of seroquel dose due to good tolerability and low risk of dose-dependent adverse effects is not useful in patients with pharmacologically dependent remission; in others, it is possible (if the risk / benefit ratio is re-evaluated) not earlier than 6-12 months of stable relief of symptoms of paroxysmal schizophrenia, control. The minimum therapeutic dose of seroquel is determined by physicians after trial and error. With insufficient doses of quetiapine, relapses (exacerbations) may be delayed for several months, and therefore serve as an unreliable indicator. Good tolerability of seroquel in combination with its high antiresidivnoy efficiency contributes to the satisfaction of patients with long-term treatment [11, 14, 17, 21, 24]. However, discontinuation of AA therapy (ziprasidone, quetiapine, olanzapine, risperidone) in chronic patients reaches 75% within 18 months, and is only slightly determined by drug intolerance [18]. Screenings in seroquel treatment are 80% within three years [22], which emphasizes the danger of neglecting psychosocial work to strengthen and control long-term compliance of patients.

So, in the first months of treatment with seroquel, the main efforts are aimed at reducing psychotic symptoms with minimal risk of unwanted effects of therapy. After 3-12 months, the emphasis is shifted to preventing relapses (exacerbations), maintaining and monitoring compliance by the patient, reducing the risk of medical complications of therapy, social and labor engagement and meeting the changing needs of the patient and his family. After a year, the therapy focuses on ensuring an independent and happy life for most patients, regardless of the “length of service” of their disorder.

The symptomatic effect, social functioning and quality of life of a patient with schizophrenia when treated with seroquel will be higher with coordinated interprofessional and interagency interventions (Table 2).

Seroquel opens the locks of early rehabilitation (due to the ordering action); contributes to the establishment of a stable full-fledged remission (antipsychotic and antiresidivnye effects), as the basis of social recovery [4]. A “patient-friendly” seroquel with a close to optimal ratio of risk / benefit therapy is the first choice drug at successive stages of systematic biopsychosocial treatment of schizophrenia.

Literature

1. Gurovich I.Ya. Side effects and complications in neuroleptic therapy / Diss. Doct. honey. sciences. – M., 1971. – 443 p.
2. Gurovich I.Ya., Lyubov E.B. Pharmacoepidemiology and pharmacoeconomics in psychiatry. – M .: Medpraktika, 2003. – 264 p.
3. Gurovich I.Ya., Lyubov E.B. Seroquel in a number of other antipsychotics in the treatment of patients with schizophrenia / / Russian Medical Journal. – 2008. – T. 16, № 12. – С. 1705-1710.
4. Gurovich I.Ya., Lyubov EB, Storozhakova Ya.A. Recovery in schizophrenia: The concept of “recovery” / / Social and clinical psychiatry. – 2008. – Vol. 18. – Issue. 2. – P. 7-14.

What is schizophrenia?

Schizophrenia is a severe, chronic, disabling mental disorder known to mankind throughout its history. About 1% of Americans suffer from schizophrenia.1

People with schizophrenia hear voices that other people do not hear; they are certain that someone is reading and controlling their thoughts or is plotting a plot to harm them. These experiences inspire horror in them, giving rise to feelings of fear, severe anxiety or isolation. People with schizophrenia say nonsense, they can sit still and silent for hours, or they seem absolutely normal until they start talking about what they really think. Since many people with schizophrenia find it difficult to work or take care of themselves, the disease is a heavy burden on their families and society.

The methods of treatment available in the arsenal of today’s medicine can weaken many of the symptoms of the disease, but in most cases, schizophrenic patients are forced to live with some residual symptoms of the disease for life. And yet, our time is a time of hope for schizophrenic patients and their families. Today many patients lead a worthy and meaningful life. Scientists are developing more effective drugs and using new tools and methods of research, are looking for the causes of schizophrenia and ways to prevent and treat the disease.

This brochure contains information on the symptoms of schizophrenia, when they appear, about the course of the disease, the current methods of treatment, about the support of patients and their loved ones, and about new areas of research.

Symptoms of schizophrenia

Symptoms of schizophrenia are divided into three categories:

  • Positive symptoms. These include abnormal thoughts and judgments, including hallucinations, delusions, thinking disorders, and motor disorders.
  • Negative symptoms that are expressed in the loss or decline of the ability to plan, express themselves, express emotions or enjoy everyday life. These symptoms are more difficult to recognize as manifestations of schizophrenia, they can be mistaken for being lazy or depressed.
  • Cognitive symptoms (or cognitive impairments) are problems with concentration and attention, certain types of memory and controlling functions responsible for our ability to plan and organize. Cognitive impairment is also difficult to recognize as a symptom of the disease, but it has the greatest impact on the ability to lead a normal lifestyle.

Positive symptoms

Positive symptoms are easily recognizable behaviors that are not common to healthy people and are associated, usually with a loss of connection with reality. These include hallucinations, delusions, mental disorders and movement disorders. Positive symptoms may appear and disappear. Sometimes they are manifested in severe form, and sometimes hardly noticeable – it all depends on whether the person is treated or not.

Hallucinations. Hallucinations are a phenomenon when a person sees, hears, smells or feels something that no one but him can see, hear, smell or feel. “Voices” is the most common form of hallucinations in schizophrenia. Many patients hear voices that comment on their behavior, order them to do something, warn about imminent danger, or talk with each other (usually about the patient). Sufferers of schizophrenia can hear such voices for a long time before relatives or friends notice something is amiss. Other kinds of hallucinations include visions of non-existent people or objects; smell of odors, which no one else feels (although this may also be a symptom of some brain tumors); and imaginary tactile sensations (for example, touching invisible fingers to the patient’s body when no one is around).

Rave. Delusions are false representations of a person who do not have roots in his cultural experience and remain unshakable, even when other people give evidence that these representations are incorrect and illogical. In patients with schizophrenia, absolutely abnormal delusions can be observed, for example, they are sure that neighbors control their behavior with the help of magnetic waves, people on television broadcast special messages to them, or that radio stations in their broadcasts voice their thoughts to other people. They can also develop delirium grandeur and the belief that they are famous historical figures. People with paranoid schizophrenia may think that others intentionally deceive them, mock them, try to poison them, spy on them or plot against them and their close people. Such representations are called delusions of persecution.

Disorder of thinking. In patients with schizophrenia, abnormal forms of the mental process are often observed. One of the most significant is disorganized thinking, in which it is difficult for a person to systematize his thoughts or logically connect them. The speech may be incoherent or difficult to understand. Another form is a “delay in thinking,” in which a person stops suddenly in the middle of a thought. If you ask why he stopped, then a person can answer that he seemed to have taken the thought out of his head. Finally, a person can create incomprehensible words or “neologisms”.

Movement disorders. Patients with schizophrenia can experience awkward, uncoordinated and involuntary movements, grimaces, or strange mannerisms. They can repeat certain movements again and again or fall into a catatonic state – a state of immobility and immunity. Catatonic syndrome was more common when there was no treatment for schizophrenia; now, fortunately, this symptom is rare.2

Negative symptoms

The term “negative symptoms” means a decrease in the normal emotional potential and level of behavior:

  • flattened affect (fixed expression, monotonous voice),
  • inability to enjoy in everyday life,
  • weakened ability to plan and carry out the assigned tasks, and
  • sluggish and poor speech, even if you need to communicate.

Patients with schizophrenia often disregard the rules of basic hygiene and in everyday life need outside help. Since it is not obvious that negative symptoms are manifestations of mental illness, schizophrenia patients are often considered simply lazy and unwilling to improve their lives by people.

Cognitive symptoms

Cognitive symptoms are invisible and are often detected only as a result of neuropsychological tests. Cognitive symptoms include:

  • the weakness of “managing functions” (the ability to absorb and process information and make decisions based on this information),
  • inability to focus attention, and
  • problems with “working memory” (the ability to remember recently received information and immediately apply it)

Cognitive impairment often prevents a patient from living normally and supporting himself. They can cause severe emotional distress.

When is schizophrenia manifested and who is sick?

Psychotic symptoms (such as hallucinations and delusions) usually occur in men during late adolescence and up to 25 years, and in women aged 25-35 years. They occasionally occur after 45 years and very rarely until puberty, although there are described cases of schizophrenia in children 5 years of age. The first signs in adolescents can be: a change of friends, a decrease in academic performance, problems with sleep, irritability. Since the same features of behavior are common to many mentally normal adolescents, it is difficult to diagnose at this stage. In young people with schizophrenia, this period is called “prodromal.”

As research has shown, schizophrenia is equally susceptible to both men and women, and the incidence rate is the same among all ethnic groups worldwide.3

Are patients schizophrenic aggressive?

Patients with schizophrenia are not particularly prone to violence and often prefer to be left alone. According to the research, if a person is not criminally responsible for violence before the illness and does not use psychoactive substances (drugs, alcohol, etc.), he / she is unlikely to commit a crime even after getting sick. Most violent crimes are committed not by patients with schizophrenia, and most patients with schizophrenia do not commit violent crimes. The use of psychoactive substances always increases the aggressiveness of behavior, regardless of the presence of schizophrenia (see the inset on page 4). If someone who is paranoid schizophrenic is aggressive, then most often it is directed at family members and manifests in a home environment.

Substance Abuse

Symptoms similar to those of schizophrenia may appear in drug users, so schizophrenic patients may be mistaken for people who are under the influence of drugs. While researchers do not believe that substance abuse is the cause of schizophrenia, the evidence suggests that patients with schizophrenia abuse alcohol and / or drugs more often than non-schizophrenics.

The use of psychoactive substances in schizophrenia can reduce the effectiveness of treatment. Stimulants (such as amphetamines or cocaine), phenylcyclidine and marijuana can worsen the symptoms of schizophrenia. In addition, people who use psychoactive substances most likely will not adhere to the treatment plan.

Schizophrenia and nicotine

The most common form of substance abuse among patients with schizophrenia is an addiction to nicotine. Nicotine dependence among them is three times higher than among the general population (the ratio of 75% -90% to 25% -30% per cent).

As a result of research, a complex relationship between smoking and schizophrenia has been revealed. Patients with schizophrenia smoking attracts and lures, and researchers are studying whether there are biological prerequisites for this need. In addition to the well-known fact that smoking harms health, a number of studies have found that smoking weakens the effect of antipsychotics. If a schizophrenic patient smokes, he may need a higher dose of medication.

Patients with schizophrenia are particularly difficult to quit smoking, as stopping the consumption of nicotine can cause a temporary worsening of the psychotic symptoms. Better tolerated smoking cessation methods, including nicotine-substituting drugs. If a patient with schizophrenia decides to start or stop smoking, the attending physician should carefully monitor the effects of antipsychotics.

Schizophrenia and suicide

Patients with schizophrenia commit suicide attempts much more often than representatives of the rest of the population. In 104, 5 percent of cases (especially among young men) these attempts reach the goal. It is difficult to predict who from schizophrenic patients is prone to suicide, so if someone talks about suicide or attempts, you should immediately contact a specialist for help.

The causes of schizophrenia

It is believed that, like many other diseases, schizophrenia is the result of a combination of environmental and genetic factors. To search for the causes of schizophrenia, the whole arsenal of modern science is involved.

Is schizophrenia inherited?

Scientists have long known that schizophrenia is hereditary. This disease affects 1% of the world’s population, but it occurs in 10% of people whose closest relatives (one parent, brother or sister) suffer from schizophrenia. People whose relatives of the second degree of kinship (aunts, uncles, grandparents or cousins) are schizophrenic are also more likely to suffer from this disease than the rest of the population. In a pair of odnoyaytsovyh twins, where one is sick with schizophrenia, the risk of falling ill with the second – the highest: 40% – 65% .7

Our genes are located on 23 pairs of chromosomes, which are in the nucleus of each human cell. We inherit two copies of each gene – one from each of the parents. It is assumed that some genes are associated with an increased risk of developing schizophrenia, but scientists believe that a single gene has very little impact and in itself can not be the cause of the disease. To date, it is still impossible to predict who will fall ill, based on genetic material.

In the presence of genetic prerequisites for schizophrenia, it is unlikely that genes themselves are a sufficient basis for the development of the disease. There is a point of view that schizophrenia is the result of a certain interaction of genes and objective factors of the external world. For example, risk factors include the effect on the fetus of viral diseases and the lack of vitamins in the mother during pregnancy, complications during childbirth, and psychosocial factors such as stressful conditions.

Patients with schizophrenia are impaired chemical processes of the brain?

It is likely that an imbalance in the complex of interrelated chemical brain reactions involving dopamine and glutamate neurotransmitters (and possibly others) plays a role in the development of schizophrenia. Neurotransmitters are substances that allow brain cells to communicate with each other. Basic knowledge of the chemical processes of the brain and their relationship with schizophrenia are rapidly expanding and are a promising direction of scientific research.

Is the brain of a schizophrenic patient different?

The brain of a schizophrenic patient is slightly different from the brain of a healthy person, but these differences are small. Sometimes, in patients with schizophrenia, fluid-filled cavities of the central part of the brain (the so-called ventricles) are larger; the amount of gray matter is generally smaller; and in some areas of the brain, metabolism is slowed or vice versa accelerated.3 Posthumous studies under the microscope of brain tissues of schizophrenic patients also show small changes in the distribution and characteristics of brain cells. It turns out that many of these changes are prenatal, since they are not surrounded by glial cells, necessarily present if the brain damage occurred after birth.

According to one of the theories, complications during the formation of the fetal brain cause a disruption of the connection, which does not appear until pubertal age. During adolescence, the human brain undergoes significant changes that can trigger the development of psychotic symptoms.

To answer the questions posed here and many other questions about schizophrenia, further research is required. Scientists of the United States and around the world are studying schizophrenia and are trying to develop new methods for its prevention and treatment.

Treatment of schizophrenia

Since the causes of schizophrenia are still unknown, existing methods of treatment are aimed at combating the symptoms of the disease.

Antipsychotics

Antipsychotic drugs appeared in the mid-1950s. They effectively reduce the positive symptoms of schizophrenia. And although these drugs significantly improve the lives of many patients, they do not cure schizophrenia.

Everyone reacts differently to antipsychotic medications. Sometimes, in order to choose the right medicine, you have to try several different drugs. The joint efforts of the patient and the attending physician are required in order to select the medicines that control the symptoms best and with the least side effects.

The drugs of an earlier generation include chlorpromazine (Thorazine ©), haloperidol (Haldol ©), perphenazine (Etrafon ©, Trilafon ©), and fluphenazine (Prolixin ©). These drugs can cause extrapyramidal side effects, such as muscle numbness, persistent muscle spasms, tremors, and excitement.

In the 1990s, new drugs were created, the so-called atypical antipsychotics, which practically do not give these side effects. The first such drug was clozapine (Clozaril ©). It effectively affects psychotic symptoms even in those patients who do not respond to other drugs, but it can cause a serious complication – agranulocytosis – a reduction in the number of white blood cells (leukocytes) that protect the body from infections. Therefore, patients taking clozapine should check the level of leukocytes in the blood every week or every two weeks. The inconveniences caused by the need for frequent tests, and the high cost of the blood test and the drug itself, are an obstacle for many in the treatment of clozapine. Nevertheless, this medicine is the best choice for those whose symptoms do not respond to other antipsychotics, both the first generation and the new ones.

Some of the drugs developed after clozapine, such as risperidone (Risperdal ©), olanzapine (Zyprexa ©), quetiapine (Seroquel ©), sertindole (Serdolect ©) and ziprasidone (Geodon ©) are effective and rarely provoke extrapyramidal phenomena or agranulocytosis. However, they can cause weight gain and metabolic changes, which increases the risk of increased cholesterol and diabetes.

Aripiprazole (Abilify) is another atypical antipsychotic drug used to treat the symptoms of schizophrenia and manic or mixed (manic and depressive) episodes of type I bipolar affective disorder.

Patients respond differently to antipsychotic drugs, although phenomena such as excitement and hallucinations usually normalize in a few days, and delusions – for several weeks. In many patients, there is a significant improvement in both types of symptoms at the sixth week of taking the drug. Nobody can say in advance exactly how the medicine will affect a particular person, and sometimes you need to try several drugs until the right one is selected.

At first, after starting taking atypical antipsychotics, patients may experience drowsiness, dizziness when the body position changes, blurred vision, rapid heartbeat, problems with the menstrual cycle, sensitivity to sunlight or skin rash. Many of these symptoms disappear within a few days after the start of treatment, but patients taking atypical antipsychotics should not drive vehicles until they get used to the new drug.

If a patient with schizophrenia develops depression, then to the treatment scheme, you may need to add an antidepressant.

In large clinical trials funded by the National Institute for Mental Health (NIMH) and known as CATIE (Clinical Studies on the Effectiveness of Antipsychotic Treatment), the efficacy and side effects of five (both new and old antipsychotics) used in the treatment of schizophrenic patients . For more information about CATIE, visit: www.nimh.nih.gov/healthinformation/catie.cfm

Duration of treatment. Like diabetes or high blood pressure, schizophrenia is a chronic disease that needs constant treatment. To date, schizophrenia is incurable, but, thanks to treatment, the frequency of psychotic episodes can be significantly reduced. Although everyone responds differently to treatment, most patients with schizophrenia should take medication throughout life, as well as use other means, for example, supporting or rehabilitation therapy.

Relapses often occur when patients feeling better, stop taking antipsychotics or take them irregularly, because they forget or do not consider it important. It is very important for patients with schizophrenia to take medicines systematically and for a period of time prescribed by the doctor. If they follow these rules, they will attenuate the psychotic symptoms.

You can not stop taking antipsychotics without consulting a doctor and always gradually. To cancel a medicine it is necessary under observation of the doctor, gradually reducing a dose, instead of sharply stopping reception.

There are many reasons why patients with schizophrenia do not adhere to the prescribed treatment. If they do not believe that they are sick, they do not believe that they need any kind of treatment. If their thinking is too disorganized, they may forget to take medication every day. If they do not like the side effects of the drug, they may stop taking it, not wanting to try another. Substance abuse can also affect the effectiveness of treatment. The attending physicians should ask the patients about the regularity of taking their medications and be sympathetic to the patient’s request to change the dosage or to try other medications to get rid of unwanted side effects.

There are many ways to help patients with schizophrenia take regular medications. There are long-acting drugs in the form of injections, which, unlike tablets, do not need to be taken on a daily basis. Medical calendars and boxes for tablets, with the days of the week indicated on them, can help patients not to forget about taking medications, and caring for them – to control whether the patient has taken the pill. To help patients comply with the medication regimen, electronic clock timers can be programmed for the time of taking the tablets or timed to everyday activities (such as eating, for example).

Interaction of drugs. The combination of antipsychotics with certain other drugs can cause unpleasant or dangerous side effects. For this reason, the doctor who prescribes antipsychotics must report all medications (prescription and over-the-counter), vitamins, minerals and herbal supplements the patient takes. It should also discuss the use of alcohol or other drugs.

Psychosocial therapy

Numerous studies show that psychosocial therapy can help patients with stabilized antipsychotic drugs to resolve a number of social aspects of schizophrenia, such as communication difficulties, motivation, self-service, work, tying and maintaining relationships with others. Studying and using the mechanisms of psychological adaptation to solve these problems allows schizophrenic patients to attend school, work and communicate. Patients who regularly undergo psychosocial therapy better adhere to the medication regimen, they have fewer relapses and less likely to go to hospital. A good relationship with a psychologist or social worker serves the patient as a reliable source of information, empathy, support and hope – all those that play a crucial role in fighting the disease. Informing patients about the causes of the disease, the common symptoms or problems they may face, and the importance of continuing the use of medications, the therapist can help them better understand the disease and learn how to live with schizophrenia.

How to take the disease under control. Patients with schizophrenia can play an active role in the fight against their disease. Having become acquainted with the basic information about schizophrenia and the principles of its treatment, they can make a measured decision regarding medical supervision. Having learned to recognize the early symptoms of relapses and how to respond to them, they can learn to prevent them. You can train patients and effective skills on how to cope with persistent symptoms.

Complex treatment with concomitant substance abuse.

Abuse of psychoactive substances is the most common concomitant phenomenon in patients with schizophrenia, but the usual programs for the treatment of drug dependence, as a rule, do not take into account the specific needs of this part of the population. Combining programs to treat schizophrenia and drug addiction gives the best results.

Rehabilitation. By focusing on social and vocational training, rehabilitation contributes to the more successful life of patients with schizophrenia. Since schizophrenia often begins at a crucial age for development of career (from 18 to 35 years) and often prevents normal cognitive functioning, most patients do not have the necessary preparation for skilled work. Rehabilitation programs include vocational guidance, vocational training; consultations on the management of money and the use of public transport, as well as provide an opportunity to gain skills in social behavior and working relationships.

Sanitary-educational work with the family. Patients with schizophrenia are often discharged from the hospital in the care of their family, so to prevent relapse it is very important that relatives know as much as possible about the disease. To help his sick relative effectively fight the disease, family members must have different ways of helping the patient adhere to the prescribed course of treatment; they should be armed with a full arsenal of methods of psycho-physiological adaptation and have the skills to solve problems. It is also very important to know where the outpatient and family care services are providing support to schizophrenic patients and those who care for them.

Cognitive-behavioral therapy. Cognitive-behavioral therapy is applicable in the treatment of patients whose symptoms persist even when taking medication. A specialist in cognitive therapy teaches patients with schizophrenia how to check whether the realities correspond to their thoughts and feelings, how to “not listen” to voices and how to shake off their apathy. This treatment effectively relieves symptoms and reduces the risk of relapse.

Mutual help groups. Self-help groups for schizophrenic patients and their families are becoming more common. Although these groups do not include professional psychologists, the members of the group themselves are a constant source of mutual support and comfort, which also has a therapeutic effect. In self-help groups, people begin to realize that others have the same problems as they do, and cease to feel isolated because of illness or illness of their loved ones. The ties and acquaintances established in mutual aid groups contribute to social initiatives. Working together, families of patients can fight for scientific research, for increasing the number of hospitals and public care programs for patients; and patients with joint efforts can draw public attention to the discrimination still existing in the modern world of people with mental illnesses.

Both support groups and initiative groups are an excellent means of early recovery for people suffering from various kinds of mental disorders.

What is the role of the patient care system?

Help to mentally ill people is provided by families, professional nurses and caregivers at home or in day hospitals, friends or neighbors, graduated social workers, as well as all others who care about their destiny. Patients with schizophrenia quite often need the help of other people.

How to achieve treatment. Patients with schizophrenia often resist treatment, believing that their delusions and hallucinations are actually real and that they do not need any psychiatric help. Family and friends should take measures to save their native people at a critical time.

Any attempt at compulsory treatment causes problems with civil rights. The laws protecting patients from compulsory treatment have become tougher and help to a mentally ill person can be very difficult. Laws vary from state to state, but in general, if, due to a mental disorder, people pose a danger to themselves or others and refuse medical help, family members or friends can call the police to take the patient to the hospital. In the admission department, a psychiatrist assessing the patient’s condition will determine whether voluntary or involuntary hospitalization is required.

Those who do not want to be treated mentally ill can hide strange behavior and ideas from the psychiatrist, so family members and friends should ask the doctor who conducts the examination of the patient, talking privately and telling him what happened at home. After this, the psychiatrist will be able to interview the patient and see for himself the deformity of his thinking. Specialists are required to personally verify abnormal behavior and personally hear crazy thoughts before they can legitimately recommend forced hospitalization, and family members and friends can provide the information necessary for this.

Care for the sick. It is very important that after discharge from the hospital, schizophrenic patients continue to be treated and take medicine. If patients stop taking medication or stop seeing a doctor, the psychotic symptoms will appear again. If these symptoms become severe, patients may not be able to take care of themselves, being unable to take care of food, clothing and shelter, neglecting personal hygiene, facing the threat of being in the street or in a prison where they are unlikely to find the help they need .

Family and friends can help patients learn to set realistic goals for a return to life in society. The entire process should be broken down into small stages, each of which is absolutely achievable, and each step of the patient along this path should be provided with support. Mentally ill people, experiencing pressure and being criticized, usually regress and their symptoms worsen. To focus their attention on what they are doing right is the best way to help them move forward.

How should one respond if a schizophrenic patient says something strange or obviously abnormal? Since abnormal beliefs or hallucinations are absolutely real for the patient, attempts to dissuade him, assuring that these thoughts and visions are wrong or a figment of the imagination, will not be of use. Agree with delirium – is also not an option. It’s best to say calmly that you look at things differently, but you recognize the right of every person to his own opinion. Polite, well-disposed and kind attitude, while not tolerating dangerous or inappropriate behavior, is the most appropriate approach to people suffering from this disease.

Forecasts and prospects for the future

Over the past 30 years, predictions for patients with schizophrenia have improved. And although this disease is still incurable, effective treatment has been developed and the condition of many patients is improved so much that they can live an independent and full-blooded life.

Scientific research in the field of schizophrenia is going through very interesting times today. Rapid development of knowledge in genetics, neurology and behavioral studies will allow us to better understand the causes of the disease, to find ways to prevent it, and to develop new methods of treatment that will allow schizophrenic patients to realize their potential to the fullest.

How can I become a participant of experienced research on schizophrenia?

Scientists all over the world are engaged in the study of schizophrenia to find new methods of preventing and treating the disease. The only way to understand the disease is to investigate how it proceeds in the patients themselves. That’s why a lot of different studies are conducted. To participate in some of them it is necessary to change medicines, for others, as, for example, for genetic studies, drugs need not be changed.

To get information about public and private studies of schizophrenia, go to ClinicalTrials.gov. The received information should be discussed with the attending physician and follow his recommendations.