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Mental Illness Guide: Care, Support, and Education
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Why after Puberty?

Why does schizophrenia begin after puberty?

Schizophrenia researchers have long been puzzled about why the illness normally begins in adolescence when important risk factors, such as genetic loading and neonatal brain damage, are present from birth or sooner. Many believe that the answer to this puzzle could tell us a lot about the cause of the illness. We now have some good clues to this mystery.

We know, for example, that normal brain development leads to the loss of 30 to 40 percent of the connections (synapses) between brain cells during the developmental period from early life to adolescence. Brain cells themselves do not diminish in number during this period, only their connectivity. It appears that we may need a high degree of connectivity between brain cells in infancy to enhance our ability to learn language rapidly (toddlers learn as many as twelve new words a day). The loss of neurons during later childhood and adolescence, however, improves our "working memory" and our efficiency to process complex linguistic information. When we are listening to someone talking, for example, and we miss part of a phrase or sentence because someone nearby coughs or sneezes, our working memory allows us to fill in the blank, using a memory store of similar familiar phrases we have heard before.

We now know that, for people with schizophrenia, this normally useful process of synaptic pruning has been carried too far, leaving fewer synapses in the frontal lobes and medial temporal cortex. In consequence, there are deficits in the interaction between these two areas of the brain in schizophrenia which reduce the adequacy of working memory. One intriguing computer modeling exercise suggests that decreasing synaptic connections and eroding working memory in this way not only leads to abnormalities in the ability to recognize meaning when stimuli are ambiguous but also to the development of auditory hallucinations.

It is possible, therefore, that this natural and adaptive process of synaptic elimination in childhood, if carried too far, could lead to the development of schizophrenia. If true, this would help explain why schizophrenia persists among humans despite its obvious functional disadvantages and its association with reduced fertility. The genes for synaptic pruning may help us refine our capacity to comprehend speech and other complex stimuli, but, when complicated by environmental assaults resulting in brain injury, the result could be symptoms of psychosis. As yet, this formulation is speculative, but it allows us to see more clearly how the environment may interact with our innate qualities to increase our predisposition to schizophrenia.

What works?

There is more agreement now about what is important in the treatment of schizophrenia than ever before. In a recent global project designed to combat the stigma of schizophrenia, prominent psychiatrists from around the world agreed on the following principles:

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People with schizophrenia can be treated effectively in a variety of settings. These days the use of hospitals is mainly reserved for those in an acute relapse. Outside of the hospital, a range of alternative treatment settings have been devised which provide supervision and support and are less alienating and coercive than the hospital.

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Family involvement can improve the effectiveness of treatment. A solid body of research has demonstrated that relapse in schizophrenia is much less frequent when families are provided with support and education about schizophrenia.

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Medications are an important part of treatment but they are only part of the answer. They can reduce or eliminate positive symptoms but they have a negligible effect on negative symptoms. Fortunately, modern, novel antipsychotic medications, introduced in the past few years, can provide benefits while causing less severe side effects than the standard antipsychotic drugs which were introduced in the mid-1950s.

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Treatment should include social rehabilitation. People with schizophrenia usually need help to improve their functioning in the community. This can include training in basic living skills; assistance with a host of day-to-day tasks; and job training, job placement, and work support.

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Work helps people recover from schizophrenia. Productive activity is basic to a person's sense of identity and worth. The availability of work in a subsistence economy may be one the main reasons that outcome from schizophrenia is so much better in Third World villages. Given training and support, most people with schizophrenia can work.

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People with schizophrenia can get worse if treated punitively or confined unnecessarily. Extended hospital stays are rarely necessary if good community treatment is available. Jail or prison are not appropriate places of care. Yet, around the world, large numbers of people with schizophrenia are housed in prison cells, usually charged with minor crimes, largely because of the lack of adequate community treatment.

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People with schizophrenia and their family members should help plan and even deliver treatment. Consumers of mental health services can be successfully employed in treatment programs, and when they help train treatment staff, professional attitudes and patient outcome both improve.

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People's responses towards someone with schizophrenia influence the person's course of illness and quality of life. Negative attitudes can push people with schizophrenia and their families into hiding the illness and drive them away from help. If people with schizophrenia are shunned and feared they cannot be genuine members of their own community. They become isolated and victims of discrimination in employment, accommodation and education.