Schizophrenia

Schizophrenia is a chronic, severe, and disabling mental illness. It affects men and women with equal frequency. People suffering from schizophrenia may have the following symptoms:

• Delusions, false personal beliefs held with conviction in spite of reason or evidence to the contrary, not explained by that person's cultural context 
  
  
• Hallucinations, perceptions (can be sound, sight, touch, smell, or taste) that occur in the absence of an actual external stimulus (Auditory hallucinations, those of voice or other sounds, are the most common type of hallucinations in schizophrenia.)
  
  
• Disorganized thoughts and behaviors
  
  
• Disorganized speech
  
  
• Catatonic behavior, in which the affected person's body may be rigid and the person may be unresponsive 

The term schizophrenia is Greek in origin, and in the Greek meant "split mind." This is not an accurate medical term. In Western culture, some people have come to believe that schizophrenia refers to a split-personality disorder. These are two very different disorders, and people with schizophrenia do not have separate personalities.

Schizophrenia and other mental health disorders have fairly strict criteria for diagnosis. Time of onset as well as length and characteristics of symptoms are all factors. The active symptoms of schizophrenia must be present at least 6 months, or only 1 month if treated.

• Who is affected?

• Estimates of how many people are diagnosed with this disorder vary. The illness affects about 1% of the population. More than 2 million Americans suffer from schizophrenia at any given time, and 100,000-200,000 people are newly diagnosed every year. Fifty percent of people in hospital psychiatric care have schizophrenia.

• Schizophrenia is usually diagnosed in people aged 17-35 years. The illness appears earlier in men (in the late teens or early twenties) than in women (who are affected in the twenties to early thirties). Many of them are disabled. They may not be able to hold down jobs or even perform tasks as simple as conversations. Some may be so incapacitated that they are unable to do activities most people take for granted, such as showering or preparing a meal. Many are homeless. Some recover enough to live a life relatively free from assistance.

The causes of schizophrenia are not known. However, an interplay of genetic, biological, environmental, and psychological factors are thought to be involved. We do not yet understand all the causes and other issues involved, but current research is making steady progress towards elucidating and defining causes of schizophrenia. 

In biological models of schizophrenia, genetic (familial) predisposition, infectious agents, allergies, and disturbances in metabolism have all been investigated.

Schizophrenia is known to run in families. Thus, the risk of illness in an identical twin of a person with schizophrenia is 40-50%. A child of a parent suffering from schizophrenia has a 10% chance of developing the illness. The risk of schizophrenia in the general population is about 1%.

The current concept is that multiple genes are involved in the development of schizophrenia and that factors such as prenatal (intrauterine), perinatal, and nonspecific stressors are involved in creating a disposition or vulnerability to develop the illness. Neurotransmitters (chemicals allowing the communication between nerve cells) have also been implicated in the development of schizophrenia. The list of neurotransmitters under scrutiny is long, but special attention has been given to dopamine, serotonin, and glutamate.

Also, recent studies have identified subtle changes in brain structure and function, indicating that, at least in part, schizophrenia could be a disorder of the development of the brain.

It is important for doctors to investigate all reasonable medical causes for any acute change in someone’s mental health or behavior. Sometimes a medical condition that might be treated easily, if diagnosed, is responsible for symptoms that resemble those of schizophrenia.

Usually with schizophrenia, the person's inner world and behavior change notably. Behavior changes might include the following:

• Social withdrawal
  
  
• Depersonalization (intense anxiety and a feeling of being unreal)
  
  
• Loss of appetite
  
  
• Loss of hygiene
  
  
• Delusions
  
  
• Hallucinations (eg, hearing things not actually present)
  
  
• The sense of being controlled by outside forces

A person with schizophrenia may not have any outward appearance of being ill. In other cases, the illness may be more apparent, causing bizarre behaviors. For example, a person with schizophrenia may wear aluminum foil in the belief that it will stop one's thoughts from being broadcasted and protect against malicious waves entering the brain.

People with schizophrenia vary widely in their behavior as they struggle with an illness beyond their control. In active stages, those affected may ramble in illogical sentences or react with uncontrolled anger or violence to a perceived threat. People with schizophrenia may also experience relatively passive phases of the illness in which they seem to lack personality, movement, and emotion (also called a flat affect). People with schizophrenia may alternate in these extremes. Their behavior may or may not be predictable.

In order to better understand schizophrenia, the concept of clusters of symptoms is often used. Thus, people with schizophrenia can experience symptoms that may be grouped under the following categories:

• Positive symptoms - Hearing voices, suspiciousness, feeling under constant surveillance, delusions, or making up words without a meaning (neologisms).
  
  
• Negative (or deficit) symptoms - Social withdrawal, difficulty in expressing emotions (in extreme cases called blunted affect), difficulty in taking care of themselves, inability to feel pleasure (These symptoms cause severe impairment and are often mistaken for laziness.)
  
  
• Cognitive symptoms - Difficulties attending to and processing of information, in understanding the environment, and in remembering simple tasks
  
  
• Affective (or mood) symptoms - Most notably depression, accounting for a very high rate of attempted suicide in people suffering from schizophrenia

Helpful definitions in understanding schizophrenia include the following:

• Psychosis: Psychosis is defined as being out of touch with reality. During this phase, one can experience delusions or prominent hallucinations. People with psychoses are not aware that what they are experiencing or some of the things that they believe are not real. Psychosis is a prominent feature of schizophrenia but is not unique to this illness.
  
  
• Schizoid: This term is often used to describe a personality disorder characterized by almost complete lack of interest in social relationships and a restricted range of expression of emotions in interpersonal settings, making a person with this disorder appear cold and aloof.
  
  
• Schizotypal: This term defines a more severe personality disorder characterized by acute discomfort with close relationships as well as disturbances of perception and bizarre behaviors, making people with schizophrenia seem odd and eccentric because of unusual mannerisms.
  
  
• Hallucinations: A person with schizophrenia may have strong sensations of objects or events that are real only to him or her. These may be in the form of things that they believe strongly that they see, hear, smell, taste, or touch. Hallucinations have no outside source, and are sometimes described as "the person's mind playing tricks" on him or her.
  
  
• Illusion: An illusion is a mistaken perception for which there is an actual external stimulus. For example, a visual illusion might be seeing a shadow and misinterpreting it as a person. The words "illusion" and "hallucination" are sometimes confused with each other.
  
  
• Delusion: A person with a delusion has a strong belief about something despite evidence that the belief is false. For instance, a person may listen to a radio and believe the radio is giving a coded message about an impending extraterrestrial invasion. All of the other people who listen to the same radio program would hear, for example, a feature story about road repair work taking place in the area.

Types of schizophrenia are as follows:

• Paranoid-type schizophrenia is characterized by delusions and auditory hallucinations but relatively normal intellectual functioning and expression of affect. The delusions can often be about being persecuted unfairly or being some other person who is famous. People with paranoid-type schizophrenia can exhibit anger, aloofness, anxiety, and argumentativeness.
  
  
• Disorganized-type schizophrenia is characterized by speech and behavior that are disorganized or difficult to understand, and flattening or inappropriate emotions. People with disorganized-type schizophrenia may laugh at the changing color of a traffic light or at something not closely related to what they are saying or doing. Their disorganized behavior may disrupt normal activities, such as showering, dressing, and preparing meals.
  
  
• Catatonic-type schizophrenia is characterized by disturbances of movement. People with catatonic-type schizophrenia may keep themselves completely immobile or move all over the place. They may not say anything for hours, or they may repeat anything you say or do senselessly. Either way, the behavior is putting these people at high risk because it impairs their ability to take care of themselves.
  
  
• Undifferentiated-type schizophrenia is characterized by some symptoms seen in all of the above types but not enough of any one of them to define it as another particular type of schizophrenia.
  
  
• Residual-type schizophrenia is characterized by a past history of at least one episode of schizophrenia, but the person currently has no positive symptoms (delusions, hallucinations, disorganized speech or behavior). It may represent a transition between a full-blown episode and complete remission, or it may continue for years without any further psychotic episodes.

If someone who has been diagnosed with schizophrenia has any behavior change that might indicate treatment is not working, it is best to call the doctor. If the family, friends, or guardians of a person with schizophrenia believe symptoms are increasing, a doctor should be called as well. Do not overlook the possibility of another medical problem in addition to the schizophrenia.  

• On a general level, anyone with an acute change in mental status (a noticeable change in behavior), whether diagnosed with schizophrenia or not, should be taken to a hospital or a physician for evaluation. The behavior change may indicate a readily treatable medical illness that, if not treated early, can cause permanent physical damage.
  
  
• Someone with schizophrenia should be taken to the hospital if medical illness is suspected. People with schizophrenia may or may not be able to communicate their symptoms in the same way as someone who does not have schizophrenia. This situation requires a doctor for diagnosis and treatment. Moreover, medical illness can aggravate schizophrenia.

Take your loved one with schizophrenia immediately to the hospital and/or call "911;" if he or she is in danger of self-harm or harming others. People with schizophrenia are much more likely than the general population to commit suicide.

• A quick way to assess whether someone is suicidal or homicidal is to ask the questions: "Do you want to hurt or kill yourself?" "Do you want to hurt or kill anyone?" "Are you hearing any voices?" and "What are the voices telling you?" People will tell you what is on their mind and should be taken seriously when they verbalize these thoughts.

Many families fear abusing the emergency medical system when these and similar issues arise. However, if you have any doubts, go to the emergency department. Don't worry about whether the visit should be made. If, afterward, the health concern is found not to be an emergency problem, then everyone is relieved. Likewise, if a medical emergency is found, you have made the right decision. The medical professionals can reassure you that you made the right decision in the face of unknown medical questions about someone else’s health.

To diagnose schizophrenia, one has first to rule out any medical illness that may be the actual cause of the behavioral changes. Once medical causes have been looked for and not found, a psychotic illness such as schizophrenia could be considered. The diagnosis will best be made by a licensed mental health professional (preferably a psychiatrist) who can evaluate the patient and carefully sort through a variety of mental illnesses that might look alike at the initial examination.

• The doctor will examine someone in whom schizophrenia is suspected either in an office or in the emergency department. The doctor's role is to ensure that the patient doesn't have any medical problems. The doctor takes the patient's history and performs a physical examination. Laboratory and other tests, sometimes including a computerized tomography (CT) scan of the brain, are performed. Physical findings can relate to the symptoms associated with schizophrenia or to the medications the person may be taking.

• People with schizophrenia can exhibit a mild confusion or clumsiness.

• Subtle minor physical features, such as highly arched palate or wide or narrow set eyes, have been described, but none of these findings alone allow the physician to make the diagnosis.

• Most symptoms found are related to movement (motor symptoms). Some of these can be side effects of prescribed medications. Medications may, for example, cause dry mouth, constipation, drowsiness, stiffness on one side of the neck or jaw, restlessness, tremors of the hands and feet, and slurred speech.

• Tardive dyskinesia is one of the most serious side effects of medications used to treat schizophrenia. It is usually seen in older people and involves facial twitching, jerking and twisting of the limbs or trunk of the body, or both. It is a less common side effect with the newer generation of medications used to treat schizophrenia. It does not always go away, even when the medicine that caused it is discontinued.

• A rare, but life-threatening complication resulting from the use of neuroleptic (antipsychotic, tranquilizing) medications is neuroleptic malignant syndrome (NMS). It involves extreme muscle rigidity, sweatiness, salivation, and fever. If this is suspected, it should be treated as an emergency.

• Generally, results are normal in schizophrenia for the lab tests and imaging studies available to most doctors. If the person has a particular behavior as part of their mental disorder, such as drinking too much water, then this might show as a metabolic abnormality in the person's laboratory results. Some medications can trigger a decreased immune response, reflected by a low number of white blood cells in the blood. Likewise, in people with NMS, metabolism may be abnormal.

• Family members or friends of the person with schizophrenia can help by giving the doctor a detailed history and information about the patient, including behavioral changes, previous level of social functioning, history of mental illness in the family, past medical and psychiatric problems, medications, and allergies (to foods and medications), as well as the person's previous physicians and psychiatrists. A history of hospitalizations is also helpful so that old records at these facilities might be obtained and reviewed.

|Self-Care at Home|

Home care for a person with schizophrenia depends on how ill the person is and on the family or guardian's ability to care for the person. The ability to care for a person with schizophrenia is tied closely to time, emotional strength, and financial reserves.

In spite of these possible barriers, basic issues to address with people with schizophrenia, include the following:

• First, ensure that your loved one is taking prescribed medications. One of the most common reasons that people with schizophrenia relapse into a new episode is that they quit taking medication. Family members might see much improvement and mistakenly assume medications may no longer be needed. That is a disastrous assumption. A later psychotic outbreak will likely happen.

• The family should provide a caring, safe environment that allows for as much freedom of action as is appropriate at the time. Any hostility in the environment should be reduced or eliminated. Likewise, any criticism should be reduced.

|Medical Treatment|

This is a time of hope for people with schizophrenia as well as for their families. New and safer medications are constantly being discovered, thus making it possible not only to treat symptoms otherwise resistant to treatment (such as negative or cognitive symptoms), but to considerably diminish the side-effect burden and to improve the quality and enjoyment of life.

In patients experiencing acutely psychotic episodes in which they are obviously a danger to themselves and others, due to either suicidal or homicidal ideation, or inability to take care of their basic needs, hospitalization and antipsychotic medications are the treatments of choice. Hospitalization is essential.

|Medications|

Antipsychotic medications are proven effective in treating acute psychosis and reducing the risk of future psychotic episodes. The treatment of schizophrenia thus has two main phases: an acute phase, when higher doses might be necessary in order to treat psychotic symptoms, followed by a maintenance phase, which could be life-long. During the maintenance phase, dosage is gradually reduced to the minimum required to prevent further episodes. If symptoms reappear on a lower dosage, a temporary increase in dosage may help prevent a relapse.

Even with continued treatment, some patients experience relapses. By far, though, the highest relapse rates are seen when medication is discontinued.

The large majority of patients experience substantial improvement when treated with antipsychotic agents. Some patients, however, do not respond to medications, and a few may seem not to need them.

Since it is difficult to predict which patients will fall into what groups, it is essential to have long-term follow-up, so that the treatment can be adjusted and any problems addressed promptly.

Antipsychotic medications are the cornerstone in the management of schizophrenia. They have been available since the mid-1950s, and although antipsychotics do not cure the illness, they greatly reduce the symptoms and allow the patient to function better, have better quality of life, and enjoy an improved outlook. The choice and dosage of medication is individualized and is best done by a physician who is well trained and experienced in treating severe mental illness.

The first antipsychotic was discovered by accident and then used for schizophrenia. This was chlorpromazine (Thorazine), which was soon followed by medications such as haloperidol (Haldol), fluphenazine (Prolixin), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). These medications have become known as "neuroleptics" because, although effective in treating positive symptoms (ie, acute symptoms such as hallucinations, delusions, thought disorder, loose associations, ambivalence, or emotional lability), they cause side effects, many of which affect the neurologic (nervous) system. These older medications are not as effective against symptoms such as decreased motivation and lack of emotional expressiveness.

Since 1989, a new class of antipsychotics (atypical antipsychotics) has been introduced. At clinically effective doses, no (or very few) of these neurological side effects, which often affect the extrapyramidal nerve tracts (which control such things as muscular rigidity, painful spasms, restlessness, or tremors) are observed.

The first of the new class, clozapine (Clozaril) is the only agent that has been shown to be effective where other antipsychotics have failed. Its use is not associated with extrapyramidal side effects, but it does produce other side effects, including possible decrease in the number of white cells, so the blood needs to be monitored every week during the first 6 months of treatment and then every 2 weeks to catch this side effect early if it occurs.

Other atypical antipsychotics include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify). The use of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizophrenia.

Although more effective and better tolerated, the use of these agents is also associated with side effects, and current medical practice is developing better ways of understanding these effects, identifying people at risk, and monitoring for the emergence of complications.

Most of these medications take 2-4 weeks to take effect. Patience is required if the dose needs to be adjusted, the specific medication changed, and another medication added. In order to be able to determine whether an antipsychotic is effective or not, it should be tried for at least 6-8 weeks (or even longer with clozapine).

Because the risk of relapse of illness is higher when antipsychotic medications are taken irregularly or discontinued, it is important that people with schizophrenia follow a treatment plan developed in collaboration with their doctors and with their families. The treatment plan will involve taking the prescribed medication in the correct amount and at the times recommended, attending follow-up appointments, and following other treatment recommendations.

People with schizophrenia often do not believe that they are ill or that they need treatment. Other possible things that may interfere with the treatment plan include side effects from medications, substance abuse, negative attitudes towards treatment from families and friends, or even unrealistic expectations. When present, these issues need to be acknowledged and addressed for the treatment to be successful.

|Other Therapy|

Psychosocial treatments

In spite of successful antipsychotic treatment, many patients with schizophrenia have difficulty with motivation, activities of daily living, relationships, and communication skills. Also, since the illness typically begins during the years critical to education and professional training, these patients lack social and work skills and experience. In these cases, the psychosocial treatments help most, and many useful treatment approaches have been developed to assist people suffering from schizophrenia.

• Individual psychotherapy: This involves regular sessions between just the patient and a therapist focused on past or current problems, thoughts, feelings, or relationships. Thus, via contact with a trained professional, people with schizophrenia become able to understand more about the illness, to learn about themselves and to better handle the problems of their daily lives. They become better able to differentiate between what is real and, by contrast, what is not and can acquire beneficial problem-solving skills.
  
  
• Rehabilitation: Rehabilitation may include job and vocational counseling, problem solving, social skills training, and education in money management. Thus, patients learn skills required for successful reintegration into their community following discharge from the hospital.
  
  
• Family education: Research has consistently shown that people with schizophrenia who have involved families fare better than those who battle the condition alone. Insofar as possible, all family members should be involved in the care of your loved one.
  
  
• Self-help groups: Outside support for family members of those with schizophrenia is necessary and desirable. The National Alliance for the Mentally Ill (NAMI) is an in-depth resource. This outreach organization offers information on all treatments for schizophrenia, including home care.

|Follow-up|

Follow-up after an initial stay in the hospital is absolutely essential if the person with schizophrenia is to continue to improve and recover. It is especially important to take any medications as prescribed and to go to therapy sessions.

|Prevention|

Not enough is known, as yet, about the causes of schizophrenia to determine practical preventive measures. However, research in this area is very active, and it may be possible to offer some useful suggestions regarding prevention in the not-too-distant future.

|Outlook|

This is a time of hope for people with schizophrenia. New antipsychotics are currently under investigation, and brain research is progressing towards understanding the molecular and neuronal underpinnings of the illness. Currently, schizophrenia cannot be cured but the outlook for people suffering from this illness is constantly improving. Here are a few predictors of outcome worth mentioning: 

• How well the person with schizophrenia functioned in society and at work prior to onset of the mental illness will be important in determining the long-term outcome.

• The amount of time that lapses from onset of symptoms to diagnosis and treatment can often help to predict outcome as well. The sooner someone is treated for schizophrenia once symptoms begin, the better the overall likelihood for improvement and recovery. However, at this time, the average length of time between the onset of psychosis and first treatment is 6-7 years.

• Schizophrenia can be treated using multiple methods, including medication, psychotherapy, and behavioral therapy. Psychiatrists, primary care physicians, psychologists, social workers, and other mental health professionals are pivotal in helping people with schizophrenia and their families explore available resources that lead to complete treatment. Many people with schizophrenia recover to the point of living functional and rewarding lives in their communities.

|Support Groups and Counseling|

Self help groups: Schizophrenics Anonymous is an organization devoted to support of the person with schizophrenia. 

Outside support for family members of those with schizophrenia is necessary and desirable. The National Alliance for the Mentally Ill (NAMI) is an in-depth resource. This outreach organization offers information on all treatments for schizophrenia, including home care.

Another organization that can be useful for both people with schizophrenia and their families is the National Mental Health Association or one of its state or county chapters.

|Web Links|

National Alliance for the Mentally Ill (NAMI)

schizophrenic, psychosis, psychotic, dementia, delusional, delusions, hallucinations, illusions, split mind, mental health disorder, schizoid, paranoid-type schizophrenia, disorganized-type schizophrenia, residual-type schizophrenia, undifferentiated-type schizophrenia, catatonic-type schizophrenia, mental illness, tardive dyskinesia, neuroleptic malignant syndrome, NMS, antipsychotics, atypical antipsychotics, psychosocial treatments, rehabilitation, schizophrenia

Author: Cristinel M Coconcea, MD, Assistant Professor, Department of Psychiatry, Case University School of Medicine; Director of Schizophrenia and Psychotic Disorders Program, University Hospitals of Cleveland.

Coauthor(s): David E Ramos, MD, Staff Physician, Department of Emergency Medicine, Salinas Valley Memorial Hospital.

Editors: Ronald C Albucher, MD, Assistant Chief, Psychiatry Service, VA Ann Arbor Healthcare System; Clinical Assistant Professor, Department of Psychiatry, University of Michigan School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Alan D Schmetzer, MD, Professor and Assistant Chair for Education, Department of Psychiatry, Indiana University School of Medicine.