Schizophrenia

Schizophrenia is a serious and chronic mental illness that impairs a person's thoughts and behavior, and if untreated, can include psychosis. 

Definition

Schizophrenia is a disabling mental illness that affects more than 1 percent of the world's population. Individuals afflicted with this thought disorder experience hallucinations, disorganized thinking, and are prone to false and paranoid beliefs. These and other symptoms often render the individual fearful, withdrawn, or difficult to interact with. 

Schizophrenia takes an enormous toll on afflicted families. Many people with schizophrenia have difficulty maintaining a job or living independently, though it is important to recognize that treatment, especially at the onset of symptoms, allows individuals with a diagnosis of schizophrenia to lead meaningful, productive lives. 

Schizophrenia afflicts men and women in equal numbers and is found in similar rates in all ethnic groups around the world. The symptom presentation and age of onset do differ between the sexes, however. Men present with more negative symptoms (see below) and become symptomatic at a younger age. The peak age for onset in men is between ages 21 and 25. Women are more likely to be diagnosed between ages 25 and 30, and again after age 45. In women with late onset, hormonal changes associated with perimenopause or menopause are thought to be a contributing factor but the mechanism is unclear and has been a source of debate within the field of psychiatry. 

Schizophrenia rarely occurs in children, but awareness of childhood-onset schizophrenia is increasing. It can be difficult to diagnose schizophrenia in teens because the first signs of the illness can include withdrawal from friends, a drop in grades, sleep problems, and irritability—common adolescent behaviors. The period prior to acute onset is known as the prodromal period and often includes withdrawing from others, and an increase in unusual thoughts and suspicions. It is critical to seek a professional opinion if a prodromal period is suspected because early intervention (prior to or just following a first psychotic episode) can greatly minimize symptoms and alter the course of the disease, leading to much higher lifetime functioning.

People with schizophrenia may display hostility or aggression. It should be noted, however, that the vast majority of people with schizophrenia are not aggressive and pose much more danger to themselves than to others. 

Schizophrenia is typically a chronic condition and people with this diagnosis cope with symptoms throughout life. However, many people with schizophrenia lead rewarding and meaningful lives in their communities.  

Symptoms

The symptoms of schizophrenia are classified by the DSM-5 as positive and negative, each of which includes a suite of behaviors. There may also be cognitive symptoms, which are harder to detect because functioning is already impaired. For a diagnosis to be made, acute symptoms must be present for a one-month period, and continuous signs of a disturbance must be present for at least six months. Despite the severity of their symptoms, many people diagnosed with schizophrenia are unaware that they have an illness.

Positive Symptoms

Positive symptoms refer to the presence of psychotic behaviors not seen in healthy people. People with positive symptoms often "lose touch" with reality. Positive symptoms include the following:

  • Hallucinations such as hearing voices are common in schizophrenia. Other types of hallucinations include seeing people or objects that are not there, smelling odors that no one else detects, and feeling things like invisible fingers touching the body.
  • Delusions are false beliefs that persist even after other people demonstrate that the beliefs are not true or logical. People with schizophrenia can have delusions that seem bizarre, such as believing that neighbors can control their behavior with magnetic waves. Sometimes they believe they are someone else, such as a famous historical figure. They may have paranoid delusions and believe that others are trying to harm them.
  • Thought disorders are unusual or dysfunctional ways of thinking. One form of a thought disorder is called "disorganized thinking." This is when a person has trouble organizing his or her thoughts or connecting them logically. They may talk in a confusing way that is hard to understand. Another form is called "thought blocking." This is when a person stops speaking abruptly in the middle of a thought. When asked why he or she stopped talking, the person may say that it felt as if the thought had been taken out of his or her head. A person with this symptom might make up meaningless words or neologisms.
  • Movement disorders may appear as agitated body movements. A person with a movement disorder may repeat certain motions over and over. In the other extreme, a person may become catatonic. Catatonia is a state in which a person does not move and does not respond to others. Catatonia is rare today, but it was more common when treatment for schizophrenia was not available.

Negative Symptoms

Negative symptoms are associated with disruptions to normal emotions and behaviors. These symptoms are harder to recognize as part of the disorder and can be mistaken for depression or other conditions. These symptoms include the following:

  • Flat affect (a person's face does not move or they talk in a dull or monotonous voice)
  • Lack of pleasure in everyday life
  • Lack of ability to begin and sustain planned activities
  • Speaking little, even when forced to interact

People with negative symptoms need help with everyday tasks. They often neglect basic personal hygiene. This may make them seem lazy or unwilling to help themselves, but the problems are symptoms caused by the disorder.

Cognitive Symptoms

Cognitive deficits are commonly present in people with schizophrenia, but they may be difficult to recognize as part of the disorder. Often, they are detected only when other tests are performed. Cognitive symptoms include the following:

  • Poor executive functioning (the ability to understand information and use it to make decisions)
  • Trouble focusing or paying attention
  • Problems with working memory (the ability to use information immediately after learning it)
  • Slower processing speed

Cognitive symptoms often make it hard to lead a normal life and earn a living. They can cause a great deal of emotional distress. Additionally, the people around an individual with schizophrenia may not realize cognitive deficits are present, so they become easily frustrated when the individual is increasingly confused or forgetful. 

In previous versions of the DSM, schizophrenia was categorized into the following sub-types: paranoid, disorganized, catatonic, undifferentiated, and residual types. In the DSM-5, schizophrenia is instead evaluated based on severity. 

Causes

Experts think schizophrenia is caused by several factors.

Genes and Environment: Scientists have long known that schizophrenia runs in families. The illness occurs in approximately 1 percent of the general population, but it occurs in 10 percent of people who have a first-degree relative with the disorder, such as a parent, brother, or sister. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop schizophrenia more often than the general population. The risk is highest for an identical twin of a person with schizophrenia. This individual has about a 50 percent chance of developing the disorder.

Schizophrenia is highly polygenic, meaning it is caused by many different genes, none of which alone is sufficient to produce the outcome. Behavioral geneticists believe that a polygenic risk score (PRS) for schizophrenia is on the horizon, especially for outlier cases, meaning those at the highest risk of developing the disorder. 

However, environmental factors are also in play, including exposure to viruses or malnutrition before birth, problems during birth, and other not yet known factors.

Drug Use: Research has suggested that using drugs during the teen years and young adulthood can increase the risk of schizophrenia. A growing body of evidence also indicates that smoking marijuana increases the risk of experiencing psychosis, though this may occur only in those already at high risk due to genetic factors. The younger and more frequent the use, the greater the risk of having a psychotic episode.

Treatments

Treatment for schizophrenia focuses on eliminating the symptoms of the disease. Treatments include anti-psychotic medications and psychotherapy.

It is important to note that people with schizophrenia are at high risk for suicide: 5-6 percent of people with schizophrenia die by suicide and 20 percent attempt suicide at least once. Seeking help for this treatable condition is particularly important to minimize the risk of suicide. 

Hospitalization

Hospitalization may be necessary during the acute phase of the illness if a person presents a danger to himself or others, or is unable to care for himself. Hospitalization is often recommended to ensure that the person take necessary medication. 

Medication

Antipsychotics have greatly improved the outlook for individual patients as they reduce psychotic symptoms and usually allow the patient to function more effectively and appropriately. Antipsychotic drugs are currently the best treatment available, but they do not cure schizophrenia or ensure that there will be no further psychotic episodes.

People with schizophrenia may be treated with first-generation or second-generation (atypical) antipsychotics. Second-generation medications are generally preferred by clinicians and patients because they have a lower risk of serious side effects.

Anti-psychotic drugs are often very effective in treating the positive symptoms of schizophrenia, particularly hallucinations and delusions. They are typically not as helpful, however, with negative symptoms, such as reduced motivation and emotional expressiveness. Older antipsychotics (neuroleptics) such as haloperidol or chlorpromazine may produce side effects that resemble symptoms that are more difficult to treat, such as dullness and movement disorders. Often, lowering the dose or switching to a different medicine may reduce these side effects. The newer medicines, including olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole and paliperidone appear less likely to have this problem. Sometimes when people with the illness become depressed, other symptoms can appear to worsen. The symptoms may improve with the addition of an antidepressant medication.

Response to Medication

Anti-psychotics are usually in pill or liquid form. Some anti-psychotics are in an injectable form that is given once or twice a month.

Symptoms of schizophrenia, such as feeling agitated and having hallucinations, usually go away within days. Symptoms like delusions usually go away within a few weeks. After about six weeks, many people will see a lot of improvement.

Some people may have a relapse, meaning their symptoms may come back or get worse. Usually, relapses happen when people stop taking their medication, or when they take it inconsistently. Some people stop taking the medication because they feel better or they may feel they don't need it anymore. No one should stop taking an anti-psychotic medication without talking to his or her doctor.

Side Effects of Medication

Antipsychotic drugs have many unwanted side effects. Side effects include drowsiness, restlessness, muscle spasms, dry mouth, tremor, blurred vision, rapid heartbeat, sun sensitivity, skin rashes or menstrual problems for women. Atypical antipsychotic medications can cause major weight gain and changes in a person's metabolism. This may increase a person's risk of getting diabetes and high cholesterol. A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking an atypical anti-psychotic medication. Typical anti-psychotic medications can cause side effects related to physical movement, such as rigidity, persistent muscle spasms, tremors, or restlessness. Most side effects go away after a few days and often can be managed successfully by adjusting the dosage or by using other medications. 

One long-term side effect may pose a more serious problem. Tardive dyskinesia (TD) is a disorder characterized by involuntary movements most often affecting the mouth, lips, and tongue, and sometimes other parts of the body. TD is less common among those who use atypical anti-psychotics, but some people may still get TD. People who think that they might have TD should check with their doctor before stopping their medication.

Psychotherapeutic Treatment

Therapeutic treatments can help people with schizophrenia who are already stabilized on antipsychotic medication. These treatments help people deal with the everyday challenges of their illness, such as difficulty with communication, self-care, work, and forming and keeping relationships. Learning and using coping mechanisms to address these problems allows people with schizophrenia to socialize and attend school and work.

Patients who receive regular treatment also are more likely to keep taking their medication, and they are less likely to have relapses or be hospitalized. A therapist can help patients better understand and adjust to living with schizophrenia. The therapist can provide education about the disorder, common symptoms or problems patients may experience, and the importance of staying on medications.

Illness Management Skills

People with schizophrenia can take an active role in managing their own illness. Once patients learn basic facts about schizophrenia and its treatment, they can make informed decisions about their care. If they know how to watch for the early warning signs of relapse and make a plan to respond, patients can learn to prevent relapses. Patients can also use coping skills to deal with persistent symptoms.

Integrated Treatment for Co-Occurring Substance Use Disorder

Substance use disorder is the most common co-occurring disorder in people with schizophrenia. Many treatment programs, however, do not address the specific needs of people with schizophrenia.  

Rehabilitation

Rehabilitation includes a wide array of non-medical interventions emphasizing social and vocational training to help patients and former patients overcome difficulties. Because schizophrenia usually develops in people during the critical career-forming years of life (ages 18 to 35), and because the disease makes normal thinking and functioning difficult, most patients do not receive training in the skills needed for a job. Rehabilitation programs work well when they include both job training and specific therapy designed to improve cognitive or thinking skills. Programs may include vocational counseling, job training, problem-solving, money management skills, use of public transportation, and social skills training. Programs like this help patients hold jobs, remember important details, and improve their functioning.

Individual Psychotherapy

Individual psychotherapy involves regularly scheduled talks between the patient and a mental health professional. The sessions may focus on current or past problems, experiences, thoughts, feelings, or relationships. A positive relationship with a therapist gives the patient a reliable source of information, sympathy, encouragement, and hope, all of which are essential for managing the disease. The therapist can help patients better understand and adjust to living with schizophrenia by educating them about the causes, symptoms or problems they may be having. However, psychotherapy is not a substitute for anti-psychotic medication.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) for schizophrenia helps people test the reality of their thoughts and perceptions, including how to "not listen" to their voices, and how to manage their symptoms overall. CBT can help reduce the severity of symptoms and reduce the risk of relapse.

Family Education

People with schizophrenia are often discharged from the hospital into the care of their family, so it is important that family members understand the difficulties associated with the illness. With the help of a therapist, they can learn ways to minimize the person's chance of relapse by having an arsenal of coping strategies and problem-solving skills to support their ill relative. In this way, the family can help make sure their loved one sticks with treatment and stays on his or her medication. Additionally, families should learn where to find outpatient and family services.

Self-Help Groups

Self-help groups for people with schizophrenia and their families are becoming increasingly common. Although not led by a professional therapist, these groups may be therapeutic because members provide continuing mutual support as well as comfort in knowing that they are not alone. Self-help groups may also serve other important functions. Families working together can more effectively serve as advocates for research and more hospital and community treatment programs. Also, groups may be able to draw public attention to the discrimination many people with mental illnesses face.

References

  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • National Alliance on Mental Illness
  • National Institute of Mental Health
  • US Department of Health and Human Services
  • Archives of General Psychiatry
  • World Health Organization
  • Journal of Translational Neuroscience 

Last reviewed 02/14/2019