Surviving Paranoid Schizophrenia

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Both Chinese studies found the point prevalence of schizophrenia in urban areas to be significantly higher than that for rural areas: in the urban point prevalence for persons 15 years of age or older was 6. There are several possible explanations for these differences. These results could be seen as a within -country confirmation of the International Pilot Project on Schizophrenia 7 findings that persons from less-developed countries are more likely to have a full recovery from a schizophrenic illness than persons from developed countries.

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Overall, the rural areas in China are much less developed than the urban areas, so a higher rate of full recovery in less-developed areas would lead to lower overall prevalence in the rural population assuming similar urban versus rural incidence. The tighter social networks and lower occupational demands in rural areas could result in a lower incidence of schizophrenia because fewer acute psychotic episodes progress to a chronic illness. Given that most rural patients do not receive treatment and most urban patients do receive treatment, higher urban prevalence could occur because involvement with the treatment system increases stigma, discrimination, and chronic social dysfunction.

There may be a higher rate of death among schizophrenic patients in rural areas than in urban areas. The differences may also be due to methodological problems in the studies. For example, the screening method using key informants and the examination method using a translated version of the PSE-9 may be less sensitive in rural areas where the level of illiteracy is much higher than in urban areas.

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Unlike the GBD estimates, both the and studies found that the point prevalence for schizophrenia was much higher in women. In , the point prevalence for women 15 years of age or older was 5. It is certainly possible that these surprising gender-based differences in rates are due to methodological problems. However, Chinese psychiatrists are convinced that this is a real difference, 8 so we must also consider other possible explanations for the higher rates in females: China-specific differences in the socioeconomic prospects of women and men particularly in the rural areas could, potentially, produce differences in the incidence and remission rates of the disorder by gender.

There are, moreover, other gender-specific characteristics of schizophrenia in China that differ from those in the West. For example, the long-held belief that males have an earlier age of onset 9 is not confirmed in some Chinese studies 10 and is also questioned in some studies in India Long-term follow-up studies of first-episode incident cases of psychoses in urban and rural areas are needed to fully understand the unique social epidemiology of schizophrenia in China. The formal diagnostic criteria currently employed by Chinese psychiatrists are those found in the Chinese Classification of Mental Disorders, third edition, revised CCMD-3 , which has just recently been published in April by the Chinese Society of Psychiatry.

Symptomatic criteria. In the Chinese system at least two out of the following nine groups of symptoms are required during the acute phase of the illness: repeated auditory hallucinations; thought disorder loosening of associations or poverty of thought ; thought insertion, withdrawal, or blocking; experiences of being controlled or of thought broadcasting; primary delusions; illogical thinking, symbolic thought, or neologisms; inappropriate affect or marked apathy; catatonic or bizarre behavior; and avolition.

The inclusion of inappropriate affect and the subdivision of delusions into three separate categories are two important differences between the Chinese and Western diagnostic symptoms. Severity criteria. Unlike other systems, the CCMD-3 requires loss of insight during the active phase of the illness and either significant social dysfunction or an inability to communicate effectively. Duration criteria. Previous versions of the Chinese diagnostic criteria required 3 months of continuous active symptoms longer than the 1 -month duration criteria of ICD and shorter than the 6-month duration criteria of DSM-IV , but the new version of the Chinese criteria now only requires 1 month of continuous active symptoms, similar to the ICD criteria.

The Chinese system does not consider prodromal or residual symptoms as part of the 1 -month duration criteria. Diagnostic subtypes. In the s, there was widespread overdiagnosis of schizophrenia in China 14 , 15 ; many patients who Western clinicians would consider as suffering from affective disorders were diagnosed as schizophrenic by their Chinese counterparts. In the s, the widespread promulgation of the formal Chinese diagnostic system largely eliminated this problem, 16 though it still occurs among poorly trained psychiatrists in smaller hospitals.

Despite the differences in the formal criteria, almost all patients diagnosed by well-trained psychiatrists as suffering from schizophrenia in China today would be readily identifiable as suffering from schizophrenia by Western clinicians. One important question is the extent to which cultural factors mold the expression of biologically based mental disorders such as schizophrenia. Chinese clinicians did not focus much attention on schizophrenic patients' negative symptoms until the late s and have only recently started to pay attention to cognitive symptoms.

Assessment of Chinese inpatients' symptoms 17 has found that negative symptoms are largely independent of positive symptoms and that the interrelationship of positive and negative symptoms is quite similar to that reported for Western patients. This does not, however, mean that culture plays no role in the patterning of symptoms in schizophrenia.

The content of the delusions experienced by schizophrenic patients in China has changed over time in parallel with social changes. In China, as in many developing countries, the primary responsibility for interpreting the bizarre symptoms of schizophrenia and for managing a schizophrenic illness falls on the family, not on the individual, the health care system, or the society as a whole. Psychiatric hospital beds are limited 1.

With the exception of serious forensic cases eg, murder or arson , there is no formal commitment procedure for mentally ill patients; the family decides when the patient is admitted typically to a locked inpatient facility and has the power to discharge the patient at any time. Very few patients with schizophrenia in China or their family members consider biological factors important causes of the problem. The family's hierarchy of resort to care providers is determined by their beliefs about the causes of the problem and the availability and cost of different types of providers.

There are many possible choices: specialist psychiatrists almost all of whom are situated in urban psychiatric hospitals , Western-style general physicians, traditional Chinese medicine TCM physicians, herbalists, acupuncturists, Buddhist monks, shamanistic healers, and others. Chinese families are very pragmatic in their utilization of services; they often try a variety of modalities either sequentially or concurrently to find the method that generates the most desirable outcome.

In the Chinese worldview, schizophrenic patients' occasional disruption of social order and their failure to act in ways that promote social harmony are considered serious transgressions of social norms. Given the public's fear of the mentally ill and of their potentially disruptive effects, the community approach to the mentally ill is primarily focused on control and only secondarily on treatment.

These beliefs make it extremely difficult for persons who suffer from a serious mental illness to obtain a job or get married, and so most patients remain dependent on family members for their entire life. Thus, it is not surprising that family members often delay necessary treatment for fear of being stigmatized and frequently go to extreme lengths to prevent neighbors and other acquaintances from discovering the family secret.

In most cases, the secret eventually comes out, resulting in severe negative consequences for the individual and the family. The economic and emotional burden of caring for a schizophrenic family member in China is quite high.

The turning tide

The ability of this measure to predict subsequent relapse in China has not yet been fully assessed. As would be expected, families with a schizophrenic family member in China have higher levels of conflict, lower cohesion, and lower adaptability than matched control families. With a few exceptions, there are no psychiatric wards in general hospitals and general physicians do not provide basic mental health services, and so almost all formal treatment services provided for schizophrenic patients are provided from specialized psychiatric hospitals, most of which are situated in large urban centers.

In , there were an estimated psychiatric hospitals in the country with a total of about beds, 34 a national average of about 1. The relative cost of psychiatric hospitalization has increased rapidly over the last 15 years, more than twice as fast as the rise in incomes. Many families pay for the first hospitalization in the hope that the treatment will be curative; if the patient relapses they are reluctant or unable to make the financial sacrifice a second time, and so they may try to manage the patient at home.

One solution would be to decrease the mean length of stay, but hospitals arc reluctant to do this because this would further reduce revenues and because there are no community services to provide the intense level of posthospitalization care needed after a brief hospitalization. The cornerstone of the inpatient treatment of schizophrenia in China, like elsewhere, is antipsychotic medication. Medication usage varies somewhat from region to region and has changed over time; Table I shows the antipsychotic usage at the Beijing Hui Long Guan Hospital over the last decade.

Delusions in Schizophrenia - Fact Sheet - Mental Illness Policy Org

Almost all inpatients on antipsychotic medication have a diagnosis of schizophrenia, and so the pattern of antipsychotic usage among inpatients mirrors the pharmacological treatment of schizophrenia. Despite reports that Asian patients require significantly lower antipsychotic dosages to achieve the same plasma concentrations as Caucasians, 36 the acute treatment dosages administered to Chinese inpatients are similar to or, in the case of the high-potency neuroleptics, somewhat higher than those used in the West. The quality of the inpatient management of antipsychotic medications varies widely, depending on the level of training of the clinician; in some of the smaller hospitals polypharmacy with multiple antipsychotics remains a serious problem.

Clozapine, which has been produced generically in China since , is currently the most commonly used antipsychotic medication at Beijing Hui Long Guan Hospital Table I , as it is in many other parts of the country. It is now occasionally used as a first-line drug and is fairly frequently given during the first admission of a patient if the first drug administered usually perphenazine or chlorpromazine is not rapidly effective or has bothersome side effects. The most common reasons for terminating treatment with clozapine are sedation and hypersalivation.

Blood monitoring for potential agranulocytosis was erratic in the early years of use, but, by the beginning of the s, monitoring became more systematic; white blood counts with differentials are now done on inpatients taking clozapine weekly during the first 3 months of treatment and then monthly thereafter. A review of Chinese publications about clozapine from to identified 29 deaths due to clozapine and a combined rate of agranulocytosis of 0. Risperidone, unlike olanzapine, is covered by government-based health insurance, and is thus being used in a small proportion of patients.

Other biological treatments are employed less frequently. Acupuncture is occasionally used to treat psychotic symptoms. Insulin shock therapy was used fairly commonly until the mids, but is now largely outdated. Almost all acute-care wards in Chinese psychiatric hospitals arc single -sex locked wards in which patients wear hospital garb, so psychosocial interventions are important in preventing the sensory deprivation that often accompanies hospitalization.

Similarly, some chronic care wards are little more than warehouses for the severely mentally ill and the severely mentally retarded, but the better chronic care wards have an open-door policy, allow patients to wear their own clothes, and provide a variety of structured activity programs. Like everywhere else in the world, economic factors influence the treatment schizophrenic patients receive in China.

Insured schizophrenic patients - primarily urban residents who work for government-supported industries - receive inpatient treatment 2. Almost all outpatient psychiatric services for schizophrenic patients are provided in the outpatient departments of psychiatric hospitals: there are very few freestanding community psychiatric clinics, the psychological clinics that have opened in some general hospitals over the last few years rarely provide services for schizophrenic patients, and the number of private psychiatrists mostly physicians who have retired from the hospital system is extremely small.

There are no data available on the pattern of antipsychotic usage in outpatient settings, but it is probably quite similar to that for inpatients Table I , though the dosages used are somewhat lower. Most patients are unwilling to take depot medications so their use in outpatient settings is somewhat less than in the West the most commonly used depot medications are haloperidol decanoate and fluphenazine decanoate. Nonadherence is even more of a problem in China than in the West; very few patients remain on medication for more than 1 year after an initial admission. As part of the new reform era that started in , hospitals in China have been forced to become economically self-sufficient; the state is no longer willing to pay for services that arc not profitable.

This change has decreased the willingness of hospital administrators to expend personnel and resources to provide cost-effective but n unprofitable community services. Similarly, family therapy for schizophrenia 47 , 48 and group psych oeducati on for relatives of schizophrenic patients 49 are cost-effective ways of reducing rehospitalization in China, but psychiatric hospitals the only source of the personnel who could provide these services are reluctant to employ family therapy methods in their outpatient departments because this change would reduce overall hospital revenues.

Social welfare services for disabled persons in China experienced a renaissance during the s, largely initiated and sustained by the efforts of the All China Disabled Persons' Federation under the direction of Deng Pufang, Deng Xiaoping's disabled son. A comprehensive range of legislation during this period recognized the extent of the problem of the disabled in the country, established the rights of the disabled and the responsibility of the state to provide for their care and employment, and set out a plan for their rehabilitation.

Surviving Paranoid Schizophrenia

In the absence of a culture-specific theory of psychiatric rehabilitation, the indigenous models that evolved over this period were based on vague notions about the benefits of repetitive practice and social support; they involved collective activities rather than individualized assessment and skills-training.

Most models were small-scale, hospital -based experiments that never generalized to the community because of a lack of trained personnel in the community, limited funding, and lukewarm support from local officials. Some smallscale community-based models were quite successful, particularly the comprehensive service network developed in the Zhengyang district of Shenyang a large industrial city in northern China. The Yantai model provided basic mental health services to the 6. The All China Disabled Persons' Federation promoted the generalization of a slightly revised version of the Shanghai model to 64 sites around the country as part of their Eighth Five-Year National Development Plan and to urban and rural communities as part of their Ninth Five-Year National Development Plan However, sustaining and generalizing these excellent models of care delivery in the s has proven difficult, largely because the economic reforms have changed the socioeconomic factors that made the models possible in the first place.

Community volunteers are much harder to find because more retired persons are now involved in income-generating activities, so guardianship networks are difficult to develop and maintain. Many factories are laying off workers and trying to improve their efficiency, and so they no longer have piece-work to give to the sheltered workshops; without revenue producing work, many workshops have had to close because they arc no longer economically viable.

Moreover, many local governments are trying to reduce their expenditures, and are thus reluctant to support any expansion of health and welfare services. Overall, community-based services for schizophrenic patients are still primarily limited to the large cities and, even there, the services are patchy; medium-size cities rarely have more than token services; and throughout most of the countryside there arc no mental health services whatsoever. Schizophrenia is a serious public health problem for China that the mental health care system and the social welfare system are not, as yet, adequately addressing.

The socioeconomic factors that are influencing the development of health services in China are quite different from those in other countries, and so the challenges and opportunities for providing comprehensive services to persons suffering from schizophrenia are, to some extent, unique. General physicians and other health workers are unable and often unwilling to provide basic psychiatric services because they have little or no training in mental health, and so almost all professional services for schizophrenic patients are provided from urban psychiatric hospitals.

Many schizophrenic patients and their family members cannot afford inpatient care or the new antipsychotic medications. The current economic incentives require psychiatric hospitals to maintain high occupancy, and so there is no motivation to provide high-quality outpatient or community -based care that would reduce hospitalization rates. There ere arc no occupational therapists, psychiatric social workers, or community psychiatric nurses, and so the community-based services that are available are primarily provided by nonprofessionals with little or no training in mental health.

Lack of knowledge about mental illnesses and the stigmatization of the mentally ill limits use of the services that are available and greatly magnifies the burden experienced by schizophrenic patients and their family members. There is no organized family movement that could lobby for the provision of family-based services. The rapid increases in the costs of inpatient care are making community -based alternatives to inpatient care more and more cost-effective.

The Ministry of Health and the powerful All China Disabled Persons' Federation are actively promoting the development of high-quality community-based mental health services.


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Public awareness of the importance of psychological factors to overall health is gradually increasing, particularly in urban areas. As China moves forward in the development of its mental health care system, it will have many lessons to learn from the West. However, the West also has many lessons to learn from China. Detailed, long-term assessments of the onset and course of schizophrenia in urban and rural China - with a particular emphasis on those aspects that are different from the West - will help clarify the complex interaction between biological and socioeconomic factors.

These important theoretical issues must be resolved before we can translate the new biological findings into better outcomes for the large numbers of untreated or poorly treated patients suffering from schizophrenia. National Center for Biotechnology Information , U.


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  7. Journal List Dialogues Clin Neurosci v. Dialogues Clin Neurosci. Michael R. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract Assessment of differences in the characteristics, experience, and treatment of schizophrenia between China and the West highlights the importance of the interaction of biological and sociocultural factors in the onset and course of the disorder.

    Keywords: China , epidemiology , nosology , rehabilitation , schizophrenia , treatment. Characteristics of schizophrenia in China Epidemiology The Global Burden of Disease GBD study 1 - 2 used the best available epidemiological data and sophisticated projection methods to estimate the prevalence of schizophrenia in eight regions around the world. Chinese diagnostic criteria The formal diagnostic criteria currently employed by Chinese psychiatrists are those found in the Chinese Classification of Mental Disorders, third edition, revised CCMD-3 , which has just recently been published in April by the Chinese Society of Psychiatry.

    Symptomatology One important question is the extent to which cultural factors mold the expression of biologically based mental disorders such as schizophrenia. The experience of schizophrenia in China In China, as in many developing countries, the primary responsibility for interpreting the bizarre symptoms of schizophrenia and for managing a schizophrenic illness falls on the family, not on the individual, the health care system, or the society as a whole.

    Beliefs about causes and health care seeking Very few patients with schizophrenia in China or their family members consider biological factors important causes of the problem. Stigma In the Chinese worldview, schizophrenic patients' occasional disruption of social order and their failure to act in ways that promote social harmony are considered serious transgressions of social norms. Family burden The economic and emotional burden of caring for a schizophrenic family member in China is quite high. Treatment and rehabilitation of schizophrenia in China With a few exceptions, there are no psychiatric wards in general hospitals and general physicians do not provide basic mental health services, and so almost all formal treatment services provided for schizophrenic patients are provided from specialized psychiatric hospitals, most of which are situated in large urban centers.

    Inpatient treatment The cornerstone of the inpatient treatment of schizophrenia in China, like elsewhere, is antipsychotic medication. Open in a separate window. Outpatient treatment Almost all outpatient psychiatric services for schizophrenic patients are provided in the outpatient departments of psychiatric hospitals: there are very few freestanding community psychiatric clinics, the psychological clinics that have opened in some general hospitals over the last few years rarely provide services for schizophrenic patients, and the number of private psychiatrists mostly physicians who have retired from the hospital system is extremely small.

    We now know that Krapelin was wrong: that most people with schizophrenia will improve over time and that if they pursue a recovery based approach to their life, with good adherence to medication and a healthy lifestyle, they will live long and happy lives. However we also know that people living with schizophrenia have a shorter life expectancy by about 8 to 10 years than average. Well there are a variety of reasons. One reason is that people with schizophrenia have more accidents than other people. Even though they are less likely to drive they are involved in more traffic accidents.

    This may be simply because under the influence of positive symptoms like hallucinations and delusions they are less likely to take basic care in their everyday life. Some people with schizophrenia have reported how they would walk out in front of traffic without looking because they thought they were being protected by angels and were invulnerable 2. Sadly many people with schizophrenia in the UK still end up living on the streets or in prison.

    Image: Photographee. Another reason is that people with schizophrenia suffer more from conditions like heart diseases and diabetes. This may be linked to problems of weight gain and also to the higher incidence of smoking amongst people with schizophrenia. Weight gain can be a side effect of many antipsychotic medicines and it can also be caused by a poor diet and lack of exercise.

    There is also evidence that people with schizophrenia are less likely to seek help with physical conditions such as cancer early on and that when they do present with physical conditions they may not receive appropriate help as quickly as those who do not have mental illness.

    There is also of course the problem that significant numbers of people with schizophrenia are homeless and consequently living in risky and unhealthy conditions 7. People with schizophrenia tend to suffer more form physical conditions such as cancer partly because they are often reluctant to approach their doctor.

    It should be emphasised that the chances of recovery are very much improved if a recovery strategy aimed at managing symptoms, improving quality of life, reducing stress and self monitoring to identify early signs of relapse is adopted. See our information sheet on recovery strategies for more on this. Whilst any recovery process can be seen as a continuous movement along a path from severe disability to wellness there are a number of markers which help to signpost progress along the route.

    Accepting your schizophrenia. You will not be able to recover from your schizophrenia until you have accepted that you have got a problem and that that problem is a mental illness. A diagnosis enables you to attach a label to your problems, to be able to explain all of your bizarre and distressing experiences and provides a starting point for your recovery. Managing your symptoms. In this complex illness rehabilitation can only really begin when treatment with appropriate drugs and talking therapies has achieved a reasonable level of functioning and residual symptoms have been reduced to the point that they no longer interfere with every day life.

    Recovery of basic social skills. An episode of schizophrenia often involves the loss of basic skills involved in running your life such as personal hygiene and grooming, budgeting and time management. Recovering these basic skills is both an indicator of your wellness and a toolkit to help make further progress. Occupation is an essential part of your recovery at every stage but later in the recovery process will come a time when you will want to occupy your time with more than simply household chores or light entertainment and at this point the prospect of study, volunteering or part-time work will be a real option.

    In coping with schizophrenia some people advocate taking one day at a time. Whilst this may be useful when you are in crisis, a successful recovery involves identifying goals and working towards them. By identifying simple goals such as those listed above and using proven strategies for achieving them, a higher quality of life can be attained. Living with schizophrenia was set up by people who have direct personal experience of the condition using their own personal funds and relies on donations to continue its work.

    We do not get grants from any public body or commercial organisation: we rely on people like you supporting our work. All rights reserved. Web Design by Priority Pixels. Terms of use , Privacy and Cookie Policy , Website acceptable use policy. Home What is Schizophrenia? Facts and Figures Myths. Information Sheets About schizophrenia Schizophrenia and dangerous behaviour How is schizophrenia diagnosed?

    A brief history of schizophrenia Recovery from schizophrenia Recovery strategies Disclosure — telling other people about your schizophrenia Can you recover from schizophrenia?