Schizophrenia

Definition

Schizophrenia is a disabling, chronic, and severe mental illness that affects more than 21 million people around the world. Symptoms include hearing internal voices, having false beliefs, disorganized thoughts and behavior, being emotionally flat, and having hallucinations. These symptoms may leave a person feeling fearful and withdrawn. Their disorganized behavior can be perceived as incomprehensible or frightening to others.

People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking, or may seem like they are talking to themselves. 

Families and society are affected by schizophrenia too. Many people with schizophrenia have difficulty holding a job or taking care of themselves, so they rely on others for help.

Schizophrenia affects both men and women similarly, although some research points to an earlier onset of symptoms in men. Schizophrenia is found in similar rates in all ethnic groups around the world. Symptoms such as hallucinations and delusions usually start between ages 16 and 30. It is not common for schizophrenia to be diagnosed in a person younger than 12 or older than 40. 

Schizophrenia rarely occurs in children, but awareness of childhood-onset schizophrenia is increasing. Additionally, it can be difficult to diagnose schizophrenia in teens. This is because the first signs of the illness can include a change of friends, a drop in grades, sleep problems, and irritability—common behaviors among teens. A combination of factors can predict schizophrenia in up to 80 percent of youth who are at high risk of developing the illness. These factors include isolating oneself and withdrawing from others, an increase in unusual thoughts and suspicions, and a family history of psychosis. In young people who develop the disease, this stage of the disorder when symptoms are vague and easy to miss is called the prodromal period.

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 anyone else. 

Schizophrenia is typically a chronic condition and people with this diagnosis cope with symptoms throughout life. However, many people with schizophrenia can lead rewarding and meaningful lives in their communities. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia. In the years to come, this work may help prevent and better treat the illness.

Symptoms

The first signs of schizophrenia often appear as confusing or even shocking changes in behavior. Coping with the symptoms can be challenging for family members who remember how vital and present a person was before their illness.

The symptoms of schizophrenia include positive, negative, and disorganized symptoms. 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. The symptoms must also cause major problems in functioning for an individual in various areas of their life, including work, relationships, or self-care. 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. These symptoms can come and go. Sometimes they are severe and at other times hardly noticeable, depending on whether the individual is receiving treatment. Positive symptoms include the following:

Hallucinations are things a person sees, hears, smells, or feels that no one else can see, hear, smell, or feel. Voices are the most common type of hallucination in schizophrenia. Many people with the disorder hear voices. The voices may talk to the person about his or her behavior, may order the person to do things, or warn the person of danger. Sometimes the voices talk to each other. People with schizophrenia may hear voices for a long time before family and friends notice the problem. 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 their body when no one is near.

Delusions are false beliefs that are not part of the person's culture and do not change. The person believes delusions even after other people prove 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. They may also believe that people on television are directing special messages to them, or that radio stations are broadcasting their thoughts aloud to others. 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, such as by cheating, harassing, poisoning, spying on, or plotting against them or the people they care about. These beliefs are called "delusions of persecution."

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. Finally, a person with a thought disorder 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 schizophrenia.

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. He or she has a 40 percent to 65 percent chance of developing the disorder.

We inherit our genes from both parents. Scientists believe several genes are associated with an increased risk of schizophrenia, but that no gene causes the disease by itself. In fact, recent research has found that people with schizophrenia tend to have higher rates of rare genetic mutations. These genetic differences involve hundreds of different genes and probably disrupt brain development.

Other recent studies suggest that schizophrenia may result in part when a certain gene that is essential to making important brain chemicals malfunction. This problem may affect the part of the brain involved in developing higher functioning skills. Research into this gene is ongoing, so it is not yet possible to use the genetic information to predict who will develop the disease.

In addition, it likely takes more than genes to cause the disorder. Scientists think interactions between genes and the environment may be necessary for schizophrenia to develop. Many environmental factors may be involved, such as exposure to viruses or malnutrition before birth, problems during birth, and other not yet known factors.

Different brain chemistry and structure: Scientists think that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate, and possibly others, play a role in schizophrenia. Neurotransmitters are substances that allow brain cells to communicate with each other. Scientists are learning more about brain chemistry and its link to schizophrenia.

Also, the brains of people with schizophrenia look slightly different than those of healthy people. For example, fluid-filled cavities at the center of the brain called ventricles are larger in some people with schizophrenia. The brains of people with the illness also tend to have less gray matter, and some areas of the brain may have less or more activity. Studies of brain tissue after death have also revealed differences in the brains of people with schizophrenia. Scientists found small changes in the distribution or characteristics of brain cells that likely occurred before birth. Some experts think problems during brain development before birth may lead to faulty connections. The problem may not show up in a person until puberty. The brain undergoes major changes during puberty, and these changes could trigger psychotic symptoms. 

Drug Use: Research has suggested that taking drugs during the teen years and young adulthood can increase the risk of schizophrenia. A growing body of evidence indicates that smoking marijuana increases the risk of experiencing psychosis. 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, psychotherapy, and various treatments.

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. An inpatient stay becomes necessary when a person may be a danger to themselves or others, or is unable to care for themselves. Hospitalization may be necessary to stabilize the person on their medication, which will help improve their psychotic symptoms. 

Medication

Anti-psychotics have greatly improved the outlook for individual patients as they reduce psychotic symptoms and usually allow the patient to function more effectively and appropriately. Anti-psychotic drugs are currently the best treatment available, but they do not cure schizophrenia or ensure that there will be no further psychotic episodes. The dosage of medication is individualized for each patient; the amount of drug needed to reduce symptoms may vary.

A large majority of people with schizophrenia show substantial improvement when treated with anti-psychotic drugs. Some patients, however, are not helped by medication. Doctors and patients often collaborate to figure out which medication is best for each patient, as some drugs may have unwanted side effects. The large majority of patients do benefit from treatment with anti-psychotic drugs.

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

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 anti-psychotics (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 anti-depressant medication.

Patients and families sometimes become worried about the anti-psychotic medications used in treating this disease both in terms of side effects and possible addiction. However, anti-psychotic medications do not produce euphoria or addictive behavior in people who take them.

Another misconception about anti-psychotic drugs is that they act as a kind of mind control, or a chemical straitjacket. Anti-psychotic drugs used at the appropriate dosage do not knock people out or take away their free will. While these medications can produce a sedative effect that can be beneficial when treatment is initiated, the utility of the drugs is not due to sedation but to their ability to diminish the hallucinations, agitation, confusion, and delusions of a psychotic episode. Thus, anti-psychotic medications should eventually help an individual to deal with the world more rationally.

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.

However, people respond in different ways to anti-psychotic medications, and no one can tell beforehand how a person will respond. Sometimes a person needs to try several medications before finding the right one. Doctors and patients can work together to find the best medication or medication combination, as well as the right dose.

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, at the risk of experiencing a relapse of symptoms. 

Side Effects of Medication

Anti-psychotic drugs, like virtually all medications, have 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 anti-psychotic 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. For many people, however, the benefit they receive from the medication they take outweighs the side effects they experience. 

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 happens to fewer people who take the 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.

Anti-psychotics can produce unpleasant or dangerous side effects when taken with certain medications. For this reason, all doctors treating a patient need to be aware of all the medications that person is taking. Doctors need to know about prescription and over-the-counter medicine, vitamins, minerals, and herbal supplements. People also need to discuss any alcohol or other drug use with their doctor. Nevertheless, the newer anti-psychotics are a significant advance, and their optimal use in people with schizophrenia is a subject of current research.

Psychotherapeutic Treatment

Therapeutic treatments can help people with schizophrenia who are already stabilized on anti-psychotic 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 allow 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 abuse

Substance abuse is the most common co-occurring disorder in people with schizophrenia. Many substance abuse treatment programs, however, do not usually address the specific needs of people with schizophrenia. When schizophrenia treatment programs and drug treatment programs are used together, patients get better results.

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) is a type of psychotherapy that focuses on thoughts and behavior. CBT helps patients with symptoms that do not go away even when they take medication. The therapist teaches people with schizophrenia how to test the reality of their thoughts and perceptions, 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.

Sources

  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • National Alliance of Mental Illness
  • National Institute of Mental Health
  • US Department of Health and Human Services
  • Archives of General Psychiatry
  • Lancet
  • Brain Research Review
  • American Journal of Medical Genetics
  • Molecular Psychiatry
  • Journal of Neuroscience
  • New England Journal of Medicine
  • Journal of Rehabilitation Research and Development
  • World Health Organization
Last reviewed 02/09/2017