Schizophrenia
Introduction
It has been said that schizophrenia is "arguably the worst disease affecting mankind, even AIDS not excepted." It is a disease that, if left untreated, can rob a person of his or her ability to function normally in society. Thankfully, advances in modern medicine have led to better diagnosis and treatment of this mental disorder.
What is it?
Schizophrenia is a severe and disabling mental illness that causes affected individuals to separate themselves from reality. It typically begins in late adolescence or early adulthood and is characterized by bizarre thoughts and behaviors, hallucinations, and disorganized speech. Schizophrenia is a chronic illness that can occur in episodic phases (referred to as acute psychosis) or in continuing and recurring patterns. While the onset of this illness can be either gradual or abrupt, often there is a period of time before the onset when the individual starts to withdraw from society, has diminished interest in work or school, experiences lapses in personal appearance and hygiene, and exhibits behavior that is out of the ordinary.
Different sub-types of schizophrenia exist; some examples are paranoid, catatonic, undifferentiated, disorganized, or residual schizophrenia. Each of these sub-types is associated with specific symptoms and features.
Some people mistakenly think that schizophrenia is the same as "split personality" disorder--like Dr. Jekyll and Mr. Hyde--but this is an incorrect belief. Split personality (or dissociative identity disorder) refers to a disorder in which parts of the person's personality split into distinct personalities. However, the split in schizophrenia (from its Greek root, "schizo,") refers to a split with reality.
What causes it?
The causes of schizophrenia are still not completely understood. Many theories, including hereditary factors, environmental factors, chemical imbalances in the brain, and physical brain development abnormalities, exist. Most likely, a combination of these factors leads to schizophrenia.
There is increasing evidence that schizophrenia is a genetic illness. It has long been known that the mental illness can run in families. It is not clear which genes are involved and how the genetic predisposition is transmitted. And, at this point, science cannot predict whether offspring or siblings of a person with schizophrenia will develop the mental illness.
Environmental factors are merely speculative and may include complications during pregnancy and birth. For instance, some studies have shown that offspring of women whose sixth or seventh month of pregnancy occurs during a flu epidemic are at increased risk for developing schizophrenia although other studies have refuted this. During the first trimester of pregnancy, maternal starvation or viral infection may lead to increased risk for schizophrenia development in the offspring. It has even been conjectured that babies born in the winter season are at higher risk for developing this mental illness in their early adulthood. These, however, are just theories that have not been proven.
Scientists are researching the possible role of chemical imbalances in the brain as a causative factor for schizophrenia. Although the roles of the chemicals are not completely known, scientists think that an imbalance of the neurotransmitters-- substances that allow communication between nerve cells--dopamine and glutamate may be a likely link to schizophrenia.
Finally, abnormalities in brain development may predispose an individual to developing schizophrenia. Scientists have performed brain-imaging scans in patients with schizophrenia and have found subtle abnormalities such as enlarged ventricles (natural fluid-filled spaces in the brain), decreased size of certain brain regions, and changes in the distribution and number of brain cells. Evidence also exists that schizophrenia may be a developmental disorder resulting from neurons (nerve cells) establishing inappropriate connections and abnormal brain circuits during fetal development.
Who has it?
Schizophrenia occurs in every culture and every nation. It does not differentiate between race, gender, or socioeconomic status. Approximately 1% of people worldwide will develop schizophrenia in their lifetime. More than 2.2 million Americans suffer from this mental illness. Schizophrenia is associated with marked social and occupational dysfunction; therefore, it is not hard to believe that some estimates have suggested that 33%-50% of homeless Americans have this mental illness.
Although the prevalence is equal between genders, males tend to develop schizophrenia earlier than females. The first signs of schizophrenia typically present in males in their late teens or early twenties; women usually present with symptoms in their late twenties or early thirties. While it can happen, schizophrenia rarely occurs before adolescence or after the age of 40 years.
What are the risk factors?
Since the causes of schizophrenia are not fully understood, it is difficult to ascertain what factors can put a person at increased risk for the mental illness. Evidence points toward a genetic link for the illness. In fact, a child of a parent with schizophrenia has about a 10% chance of developing the mental illness and a 40% chance of developing it if both parents have schizophrenia. An identical twin of a person with schizophrenia is at the highest risk--a 40% to 50% chance of developing the illness.
What are the symptoms?
The first signs of schizophrenia can be highly variable but often appear as changes in behavior that are confusing, peculiar, and even shocking. A psychotic episode may occur suddenly but may be preceded by odd behaviors--the patient with schizophrenia may lose touch with reality, becoming withdrawn and very suspicious. Likewise, patients with schizophrenia may at times act completely normal. Symptoms of the mental illness fall into three categories:
Positive Symptoms:
Positive symptoms are behaviors that are not typically seen in healthy individuals. They are often easy to spot and may come and go.
Hallucinations and illusions are disturbances in the schizophrenic patient's perception of his/her surroundings. These can be visual, auditory (sound), tactile (touch), taste, or smell disturbances. Hearing voices is the most common hallucination in patients with schizophrenia. A slight difference exists between hallucinations and illusions--hallucinations are perceptions of something that is not there (for instance, seeing a person in the room when no one is present); illusions are perceptions of something that is there but is incorrectly interpreted by the patient with schizophrenia (such as perceiving that a chair is a dog).
Delusions are false beliefs that arise without a legitimate cause. Common delusions of patients with schizophrenia are belief of persecution or fear that they are being cheated, harassed, or conspired against. For instance, if a schizophrenic patient is delusional of being poisoned, he or she may refuse food or drink. Some delusions are bizarre, for instance, believing that the neighbor's cat is sending special messages or that the government is controlling his or her behavior through radio waves.
Distorted perceptions of reality are often apparent in these individuals, and understandably so, due to the hallucinations and delusions they may be experiencing. Schizophrenic patients can behave very differently at various times--they may at one point sit very rigidly, not moving a muscle or making a sound for hours; other times they may be constantly in motion, always vigilant, alert, and preoccupied with whatever distorted perception they are experiencing.
Disordered thinking is commonly seen in patients with schizophrenia. They may not be able to concentrate, may be easily distracted, and cannot always connect thoughts into logical sequences. This makes it difficult for a person with schizophrenia to carry on a rational conversation with others.
Disordered movements are often seen in patients with schizophrenia. They may seem uncoordinated and clumsy. They may repeat the same movements over and over. Some schizophrenic patients seem to have unusual involuntary movements.
Negative Symptoms:
Negative symptoms occur when there is a reduction in normal emotions and behaviors.
Lack of emotional expression refers to a change in how schizophrenic patients express emotions. They may lack motivation, show no facial expressions, show no emotional response, and speak with a monotone voice. They may lose pleasure in everyday life.
Cognitive Symptoms:
Cognitive symptoms often result in problems with thinking and decision-making. They are often very subtle and may only be detected through a test preformed by a health care professional,
Poor executive functioning refers to the inability to interpret information and poor decision making skills.
Impaired attentionis commonly seen in patients with schizophrenia making them unable to sustain attention.
Impaired working memory refers to the inability to retrieve recently learned information.
Schizophrenia is a chronic mental illness with intermittent episodes of acute psychosis. In between these episodes, the schizophrenic patient will typically have residual symptoms such as anxiety, suspicion, and lack of motivation. Most patients with schizophrenia have difficulty forming relationships and do not marry. They may have poor self-hygiene and are often unable to hold down employment. They don't learn from their mistakes and have a lack of judgment. They may not understand the importance of continuing medical treatment for their illness. While schizophrenic patients can live a long time with their illness, they most often lack the ability to function productively in society. Many end up on the streets, and it has been reported that up to 10% commit suicide.
For more information on how schizophrenia is diagnosed, click on the link below.
Making a Diagnosis of Schizophrenia
Doctors use the following criteria to diagnose schizophrenia. If you notice any of these symptoms, call a doctor promptly.
A. Symptoms*: For a significant portion of at least 1 month, the individual must show two or more of the following:
- Delusions
- Hallucinations
- Disorganized speech
- Disorganized or catatonic behavior
- Lack of pleasure in acts that are normally pleasurable; lack of will or motivation; lack of emotions
*Note: If delusions are bizarre, if hallucinations consist of a voice keeping a running commentary of the person's behavior, or if hallucinations consist of two or more voices having a conversation with each other, then a diagnosis can be made based on any of these alone.
B. Social and occupational dysfunction: For a significant proportion of the time since the onset of the disorder, one or more major areas of functioning such as work, self-care, or interpersonal relationships are significantly below the level prior to onset.
C. Duration: Continuous signs of the mental illness for at least 6 months--this must include at least 1 month of the symptoms fulfilling Criterion A above (unless the individual has been successfully treated). This 6-month time frame may include the period of time before the psychotic episode when the individual starts acting peculiar and the period of time following the psychotic episode when the individual may experience lingering symptoms.
D. Other mood disorders have been excluded from the diagnosis.
E. The disorder is not due to substance abuse or a general medical condition.
F. If a history of a persistent developmental disorder such as autism is present, the additional diagnosis of schizophrenia can be made only if prominent delusions or hallucinations are also present for at least 1 month.
These criteria are adapted from: Schizophrenia and other psychotic disorders. In: Diagnostic & Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington DC, American Psychiatric Association. 1994: 273-290.
How is it treated?
The good news about schizophrenia is that although there is no cure, it can be treated effectively with prescription medications. In the past decade, several new antipsychotic medications ("atypical antipsychotics") have been developed that have fewer side effects than older medications ("typical antipsychotics").
Medication therapies as well as numerous psychological rehabilitation programs are the mainstays of treatment. To learn more about non-drug therapies, click on the "Helping Yourself" button at the top of this page. Goals of therapy are to reduce schizophrenic symptoms, prevent return of symptoms, minimize side effects from medications, and help the individual function more normally in society.
Initial drug treatment should include use of one of the atypical antipsychotic medications--such as olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), or aripiprazole (Abilify). If no response is seen within 3 to 4 weeks, then addition of a second atypical antipsychotic is warranted. If no response is evident while on two atypical antipsychotics, then addition of a third atypical can be tried. If schizophrenic symptoms are still present after trying three atypical antipsychotics, a typical antipsychotic medication--for instance, chlorpromazine, fluphenazine, and haloperidol--should be initiated. Clozapine (Clozaril), an atypical antipsychotic, is usually left as a last-line therapy because of its potential for serious side effects. In most medication-resistant patients, however, clozapine can be used with mood stabilizers (such as lithium), antidepressants, other atypical antipsychotics, typical antipsychotics, or electroconvulsive therapy (ECT). If noncompliance with a medication regimen is suspected, some typical antipsychotics are available in long-acting, injectable forms--for example, haloperidol decanoate or fluphenazine decanoate.
After treating the first psychotic episode, most schizophrenic patients should continue treatment for at least 1 year. If the individual has multiple psychotic episodes, then treatment should last for at least 5 years. Patients with schizophrenia should be evaluated at least annually to determine the need to continue medication. Continuing antipsychotic medications indefinitely should be considered for patients with a history of serious suicide attempts or violent, aggressive behavior.
Helping Yourself
Although medicinal therapy is essential for controlling psychotic symptoms, psychosocial therapy can be helpful with the behavioral aspects of the illness such as improving communication skills, self-care, and work skills. There are numerous forms of psychosocial therapy and which of these programs you use often depends on what's offered in your community or local medical center.
Rehabilitation programs are numerous and can help prepare a person with schizophrenia to re-enter society in a functional capacity. These programs may include job training, money-management skills, social skills, basic living skills, supported housing, and even instruction on how to use public transportation.
Psychotherapy is essential for recovery and maintenance of recovery. Every patient with schizophrenia should have regular counseling sessions with a psychiatrist, psychiatric nurse, or social worker to help deal with the mental illness and to adapt to a more normal life.
Self-help groups are becoming more popular not only for patients with schizophrenia, but for family members as well. These groups may be helpful for support, understanding, and friendship.
Family Support and Education is important because schizophrenic patients are often released from the hospital to be cared for by family members. Family caregivers need to learn and understand the mental illness in order to deal with the problems and difficulties faced by a patient with schizophrenia.
For more information on various support programs, visit any of the following Web sites:
National Mental Health Association: http://www.nmha.org
National Mental Health Consumers' Self-Help Clearinghouse: http://www.mhselfhelp.org
What is on the horizon?
Much is happening on the research front. Researchers at Yale University are studying a possible new medication treatment for schizophrenia. This drug (called LY354740) blocks the release of a chemical called glutamate, reversing the effects of another drug (PCP), which causes a psychosis that resembles schizophrenia. Not all studies focus on new medications, however. Researchers are also currently investigating medications that are typically used to treat other, non-related health conditions, such as atomoxetine, dipyridamole and others, to see how they affect the positive, negative and cognitive symptoms of schizophrenia.
Some symptoms of schizophrenia (for example, lack of motivation and social withdrawal) are inadequately treated with available medications. Studies are being conducted to gain a better understanding of how available medications and investigational medications affect specific neurotransmitters (substances that allow communication between nerve cells) in the brain. These studies should help scientists determine which drugs work best for which people.
Scientists are further investigating the possible causes and risk factors of schizophrenia. Investigators are using more sophisticated imaging techniques to study the living brain. Through this research, scientists have found evidence that early biochemical changes may precede the onset of schizophrenia.
Researchers at Columbia University are conducting neuroimaging studies on chronic abusers of PCP ("angel dust") in order to examine abnormalities of brain function that might be similar to those observed in schizophrenia. In addition, investigators at the University of California, San Francisco are seeking to identify brain physiology changes associated with the emergence of hallucinations due to schizophrenia and are trying to determine if reversing those changes may alleviate hallucinations.
These studies and numerous others are underway.
Researchers at the University of California, San Francisco are seeking to identify brain physiology changes associated with the emergence of schizophrenic hallucinations and are try to determine if reversing those changes may alleviate hallucinations.
These studies and numerous others are underway.
References
National Alliance for Research on Schizophrenia and Depression. Available at URL: http://www.narsad.org/. Accessed November 2007.
Black DW, Andreasen NC. Schizophrenia, Schizophreniform Disorder, and Delusional (Paranoid) Disorders. In: Hales Re, Yudofsky ST, Talbott JA, eds. Textbook of Psychiatry. 3rd ed. Washington DC. American Psychiatric Press. 1999: 425-477.
Carpenter WT, Conley RR, Buchanan RW. Schizophrenia. In: Enna SJ, Coyle JT, eds. Pharmacological Management of Neurological and Psychiatric Disorders. U.S. McGraw-Hill. 1998: 27-51.
Carpenter WT, Buchanan RW. Schizophrenia. New England Journal of Medicine. 1994; 330 (10): 681-690.
Crismon ML, Dorson PG. Schizophrenia. In: DiPiro JT, Talbert RL, Yee GC, and others, eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York. McGraw-Hill; 2005:1209-1233.
Kane JM. Schizophrenia. New England Journal of Medicine. 1996; 334 (1): 34-41.
Practice guideline for the treatment of patients with schizophrenia. American Psychiatric Association. American Journal of Psychiatry. 1997; 154(4 Suppl): 1-63. (Revised 2000.)
Schizophrenia. National Institute of Mental Health. Available at: http://www.nimh.nih.gov/publicat/schizoph.cfm Accessed: November 2007.
Schizophrenia Research at the National Institute of Mental Health. Available at: http://www.nimh.nih.gov/publicat/schizresfact.cfm Accessed: November 2007.
When Someone has Schizophrenia. National Institute of Mental Health. Available at: http://www.nimh.nih.gov/publicat/schizsoms.cfm Accessed: November 2003 and June 3, 2006.
Clinicaltrials.gov. Schizophrenia. Avaliable at: www.clinicaltrials.gov Accessed: October 16, 2007
Schizophrenia Health Condition Last Updated: December 2007
Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.