A professor of Psychiatry in the Faculty of Medical Sciences, University of Nigeria, Nsukka, Jude Ohaeri, speaks with EMMANUEL OJO about the triggers factors and management of schizophrenia, commonly called madness
What is schizophrenia?
It is a severe mental disorder characterised by abnormal experiences such as hearing of strange voices or seeing things that others cannot see, what we call hallucination. Schizophrenia patients have an abnormal belief that people are trying to harm them; beliefs that are not normal to other people, abnormal behaviour and they lack awareness of being sick. They have no insight and lack the ability to carry on with their daily functions or activities. They also don’t take care of themselves, don’t have good personal hygiene and don’t relate well with others.
In order words, schizophrenia is what is typically referred to as madness. It is the prototype or the popular imagination of madness where someone is seen talking to themselves, pointing in the air and not caring about what others are saying to them and not being productive. They lack motivation to work and are socially isolated.
What triggers this condition?
The correct answer is that we don’t know. We don’t know in details but we have some ideas about it. It is a kind of interaction between genetic factors and environmental factors – in other words, what we call nature-nurture interactions. It means that it’s not only embedded in genetics but can be triggered by environmental factors too. It’s an interaction between the genes and environmental factors and the environmental factors are quite many, the most important one being the use and abuse of substances like cannabis, cocaine and so on. They trigger schizophrenia. Scientific finding has proven that these substances can cause schizophrenia.
Other factors like poor environmental conditions, living in very bad area of the city, social isolation can also trigger the condition. The nature of the genes that are involved are not clear. What is clear is that the gene still makes a contribution. People always assume that it is purely genetic but it is not true.
For a vast majority of people with schizophrenia, rarely can you find family members that have it, that’s the truth to say that even though genes are supposed to play a role but the majority of people who has it rarely would you find it with their family members.
It is over represented among families of those who have schizophrenia compared with the general population. That’s where you know that there’s a genetic basis, it is not in majority of cases that if someone has schizophrenia, there’s somebody having it in their family. It is not true that because someone has it, the children will now have it. It’s just that one in a family with a schizophrenia patient has a greater possibility of having it than for one not having it in the family. It is called risk factors.
It can be hereditary but it must not be. What is truer is that the person is at greater risk of having it than someone from another family where there’s nobody with it and it is not a 50-50 per cent thing. The risk is way lower than 50 per cent.
The children given birth to by women on the street are usually normal. They have nothing wrong with them. You see them running around and healthy. Although, there’s a suspicion that schizophrenia makes one less fertile but that’s a suspicion, it is not confirmed. It is just an observation, not a robust finding. The fact we can see is that schizophrenia patients all over the world get pregnant and give birth to children, that’s what we can see. If they were really less fertile, the number of schizophrenia patients in the world should be less per year but they are increasing. Their children are quite normal as we can see. What makes most of their children abnormal is not the schizophrenia itself but the condition in which the children are living in. The child is living on the streets, hungry, not bathing, not taken care of and so on. The child could even be abused and all that.
Apart from genes and environmental factors, child abuse is another risk factor. Children who are abused, especially sexually, are at risk of physical and mental disorders. To abuse children is a crime; it’s really a crime because it causes a lot of problems for the children in the future. It exposes them to risks of being sick in a number of ways.
How common is schizophrenia?
It depends on the angle you are coming from but what we say is that this condition is about one per cent prevalent in the population and that is the usual cliché from WHO but those statistics are shaky.
What are the complications?
The complications can be psychological, social, individual and communal. The individual is not able to relate well psychologically to the members of society. He is not able to relate with others. At the social level, one would find out that for reasons that are not very clear, these people who are schizophrenic tend to die earlier than people of their age. They have all sorts of sicknesses like cardiovascular diseases and diabetes. They always smoke and drink, so they damage their liver, kidney and heart and then their teeth because of their poor hygiene. Their physical life, both in terms of quality and lifespan, is highly compromised. Also, at the community level, these people, because they are non-conformists, are not productive, so, they are a nuisance. They are lost to society. Incidentally, at the individual level, it is thought that they are more likely to take their lives, that is, they have a suicidal tendency but that is what is said abroad. We don’t see that kind of picture here. That’s because they do a lot of drugs and drug addictions abroad and so they die from it and other reasons.
At the community level, they become a nuisance to society in the sense that they are not behaving properly, they are not obeying the rules. They roam the streets doing nothing. They can pose dangers to themselves and to other people and they are very liable to abuse, especially sexually. They are lost to productivity. Their contribution to national productivity is lost.
It’s not just schizophrenia that leaves the sufferers tattered but lack of social support. It’s not an inevitable situation, it’s because their families are not there or they are not capable. So, the patients you see on the streets are just as a result of lack of care or social support. They are humans and they come from a place but what is keeping them in the streets is that for whatever reasons, their relatives are not able to pay or take care of them and if anybody were to pay for their treatments, you will find out that just after a month, there will be a lot of difference. Bathe them, shave them and give them good meals, proper medication and they are on their way to recovering. To be schizophrenic is not to be on the streets. This is an illness that one needs families. It takes one’s insight, the ability for one to know that he is sick and something needs to be done. It robs one of his mind that something needs to be done.
Schizophrenia is the most devastating disease of mankind. It’s most devastating because it robs one of the mind, which is the essence of being a human. Cancer is terrible but at least if one has cancer, one is aware that he is sick and would seek medical help but in the case of schizophrenia, the person doesn’t want to be cared for, they don’t agree that they are sick and don’t want anyone to even help them. It robs one of his humanity and that’s why it’s regarded as the most devastating disease of mankind. It strips one of the uniqueness of being a human, which is the mind. Schizophrenia does not kill soon as cancer does but degrades one’s quality of life. It’s really a terrible condition to suffer from but the good news is that, it is treatable, very treatable. It’s treatable but the problem is adhering to the treatment. In the majority of cases, they respond to treatment but in the minority of cases, they respond only partially but they are okay.
What are the risk factors?
Infections of the brain, like viruses attacking the brain, what is called encephalitis. Generally, things that affect the integrity of the brain. They make one liable of developing mental disorders in which schizophrenia is one of them.
Also, poor living conditions and poor quality of living. It is also seen in populations that are migrants, people that left home and are now in a place where they are not living well. Foreigners that are not documented, living from hand to mouth, hiding from the immigration officers and all that. Facing harsh conditions of life, including rascism. These are all risk factors.
The principal risk factor is drug addiction like cannabis and cocaine. All those things are very dangerous to use. Abuse, especial sexually, will not only cause a mental damage but also physical damage.
How is the condition diagnosed?
There is usually no blood test like you have for malaria and other ailments. They are basically diagnosed through the symptoms which are hallucinations, abnormal behaviours and so on. It can also be seen from socially disabled and unproductive life. Inability to take care of oneself and family or actually go to school or work. This is what is called the diagnostic criteria.
How can it be managed?
It is treatable and we should re-emphasise that. The problem with schizophrenia is that people are not brought to hospital on time. They make the sickness become more chronic before they bring them. Those brought in time responds faster and better. It is better to talk about it as treatment because when someone goes mad, the first reaction of those around is that it’s a spirit that is disturbing the person and they take the person to spiritual home. It’s not true to say that it is demonic attack. Those are archaic ideas which are not true.
When they bring them to us in the psychiatric hospitals, we treat with anti-psychotic drugs and they are available. They are very effective to the majority of the patients. Some patients don’t respond quickly and fully but they still respond.
The first thing we usually do is to calm the patients down because they are usually very aggressive and not cooperative. That’s usually the general scenario. In order to make them to calm down, we talk to them and let them know that we just want to help them and we are not against them. Then, injections can be administered on them which helps them to sleep.
Lack of sleep is also one of the major symptoms. They make noise in the night, they cry, they laugh and all. After they have woken up, they are taken for a bath and well taken care of.
Medication is important but there are other parts of treatments like counseling and psychotherapy. We try to look at the risk factors too and find out what could have caused the condition; what is sustaining it or causing a relapse. The basic nature of the illness is that it is a relapsing illness. It is not true that when schizophrenia patient is seen to have recovered, then, the person is well for life. It is not true. If they don’t take their tablets they will relapse. We usually tell them to come for their appointments and take their tablets but they usually ignore this instruction which usually causes a relapse. We also help them to socialise within the hospital and when facilities are available, we teach them skills. It is called occupational therapy. You can treat people by helping them to work or teaching them new skills. Then, you can think of rehabilitation.
The patients usually get better between four to six weeks and are ready to go home but that’s also a challenge because many leave the hospital and because they are getting better or seem to be fine, they stop taking their medications and stop keeping medical appointments. We usually advise that there should be someone in the family who will agree to stay and care for the person.
The treatment is both inpatient and outpatient follow-up. The treatment might be for life. There must be a constant follow-up and the treatment is usually a life-long one. Educating the family caregivers is also part of the treatment.
There’s a myth that when a mad person bites one, the bitten gets mad. What can you say about that?
That’s not true. The mad person could transfer some other diseases like HIV and so many others that are infectious if the person has but not schizophrenia. It is not a communicable disease. Those are myths we were told as children, maybe to scare us off. There is no truth in that.
How can it be prevented?
Prevention is always better than cure. Knowing if someone is at risk is important. Are there family members who have the disease and so on. Taking of substances like cannabis, cocaine and so on should be avoided. Also, one should be mild with alcohol and avoid smoking. Live life moderately. Don’t overwork yourself. Don’t be socially isolated. Live with other people and have a good mind. Try to manage stress. Also, get your mind totally occupied with good thoughts.
What are the early warning signs?
Early warning sign is insomnia (sleeplessness). Nobody is to go for three days without sleep continuously. Secondly, when someone looks distressed and is gradually becoming socially isolated and not playing their usual roles, it could just be an early sign.Thirdly, it can also be seen with less productivity at work, coupled with strange behaviours.
Is the condition possible in children?
Usually, schizophrenia sets in at adolescence. Rarely can it be seen in children of less than 10 years. It’s rare and could be devastating. The commonest time is adolescence up to young adulthood and it takes about 45 years of age. Beyond 45, it’s not common at all, so, it’s a disease of young people.
Are there side effects that come with the treatment?
Yes. All medications have side effects but they have their antidotes, meaning there are drugs that help manage the side effects.