Schizophrenia

Definition

Schizophrenia is a disabling, chronic, and severe mental illness that affects more than 2 million Americans age 18 and over. Symptoms include hearing internal voices, thinking that other people are reading one's mind, controlling one's thoughts, or plotting harm, which may leave a person feeling fearful and withdrawn. Their disorganized behavior can be perceived as incomprehensible or frightening.

People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking.

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 men and women equally. It occurs at similar rates in all ethnic groups around the world. Symptoms such as hallucinations and delusions usually start between ages 16 and 30. Men tend to experience symptoms a little earlier than women. Most of the time, people do not get schizophrenia after age 45. 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 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 is called the "prodromal" period.

Regardless of available treatments that can relieve many problems associated with the illness, most people with schizophrenia 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 especially challenging for family members who remember how vital and present a person was before illness. The symptoms of schizophrenia are categorized into three groups: positive, negative, and disorganized. Symptoms may include the presence of two or more of the following for at least one week.

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. They 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 bodies 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 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 garbled 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.

"Voices" are the most common type of hallucination in schizophrenia.

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 he or she talks 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 symptoms are subtle. Like negative symptoms, cognitive symptoms 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).

Cognitive symptoms often make it hard to lead a normal life and earn a living. They can cause great emotional distress.

Symptoms can be different depending on the type of schizophrenia:

• Paranoid types often feel anxious, are more often angry or argumentative, and falsely believe that others are trying to harm them or their loved ones. • Disorganized types have problems thinking and expressing their ideas clearly, often exhibit childlike behavior, and frequently show little emotion. • Catatonic types may be in a constant state of unrest, or they may not move or be underactive. Their muscles and posture may be rigid. They may grimace or have other odd facial expressions, and they may be less responsive to others. • Undifferentiated types may have symptoms of more than one other type of schizophrenia. • Residual types experience some symptoms, but not as many as those who are in a full-blown episode of schizophrenia.

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 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 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 malfunctions. 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 probably takes more than genes to cause the disorder. Scientists think interactions between genes and the environment are 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 psychosocial 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, plays 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, in small ways the brains of people with schizophrenia look 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 also have 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. Scientists have learned a lot about schizophrenia, but more research is needed to help explain how it develops.

Treatments

Since schizophrenia may not be a single condition and its causes are not yet known, treatments focus on eliminating the symptoms of the disease. Treatments include antipsychotic medications and various psychosocial treatments.

Hospitalization

Hospitalization is necessary during the acute phase of the illness. It is necessary when the patient is at risk because of serious suicidal thoughts or his unable to care for himself. Hospitalization is also necessary to treat delusions, hallucinations, or problems with drugs and alcohol.

Medication

Anti-psychotics have greatly improved the outlook for individual patients as they reduce the 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. Only a qualified physician can make the choice and dosage of medication in the medical treatment of mental disorders. The dosage of medication is individualized for each patient; the amount of drug needed to reduce symptoms may vary.

The large majority of people with schizophrenia show substantial improvement when treated with antipsychotic drugs. Some patients, however, are not helped by the medications and a few do not seem to need them. It is difficult to predict which patients will fall into either group and to distinguish them from the large majority of patients who do benefit from treatment with antipsychotic drugs.

New antipsychotic drugs (atypical anti-psychotics) have been introduced since 1990. The first of these, clozapine, has proven more effective than other antipsychotics. There is the possibility of severe side effects-in particular a condition called agranulocytosis or loss of white blood cells that fight infection. People who take clozapine must get their white blood cell counts checked every week or two. This problem and the cost of blood tests make treatment with clozapine difficult for many people. But clozapine is potentially helpful for people who do not respond to other antipsychotic medications. Other new antipsychotic drugs including risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole and paliperidone are safer than the older drugs because they do not cause agranulocytosis. Several additional antipsychotics are currently under development.

Antipsychotic drugs are often very effective in treating symptoms of schizophrenia, particularly hallucinations and delusions. However they may not be as helpful with other 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. 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.

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

Another misconception about antipsychotic drugs is that they act as a kind of mind control, or a chemical straitjacket. Antipsychotic drugs used at the appropriate dosage do not knock out people or take away their free will. While these medications can produce a sedative effect that can be useful 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, antipsychotic medications should eventually help an individual to deal with the world more rationally.

Response to Medication

Antipsychotics are usually in pill or liquid form. Some anti-psychotics are shots that are 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 antipsychotic 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-their symptoms come back or get worse. Usually, relapses happen when people stop taking their medication, or when they only take it sometimes. Some people stop taking the medication because they feel better or they may feel they don't need it anymore. But no one should stop taking an antipsychotic medication without talking to his or her doctor. When a doctor says it is okay to stop taking a medication, it should be gradually tapered off, never stopped suddenly.

Side Effects of Medication

Antipsychotic 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. Most side effects go away after a few days and often can be managed successfully by adjusting the dosage or by using other medications. People who are taking antipsychotics should not drive until they adjust to their new medication. Different patients have different treatment responses, so one drug may be more helpful than another. 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 antipsychotic medication. Typical antipsychotic medications can cause side effects related to physical movement, such as rigidity, persistent muscle spasms, tremors or restlessness.

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 antipsychotics, but some people may still get TD. People who think that they might have TD should check with their doctor before stopping their medication.

Antipsychotic medications developed in recent years all appear to have a much lower risk of producing TD. The risk is not zero, however, and they can produce side effects such as weight gain. In addition, if given at too high of a dose, the newer medications may lead to problems such as social withdrawal and symptoms resembling Parkinson's. Antipsychotics 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 antipsychotics are a significant advance, and their optimal use in people with schizophrenia is a subject of current research.

Psychosocial Treatment

Psychosocial treatments can help people with schizophrenia who are already stabilized on antipsychotic medication. Psychosocial treatments help these patients deal with the everyday challenges of the 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 psychosocial 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. But ordinary substance abuse treatment programs usually do not address this population's special needs. When schizophrenia treatment programs and drug treatment programs are used together, patients get better results.

Find an Integrated Treatment Program here.

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 antipsychotic medication.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a type of psychotherapy that focuses on thinking 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

Oftentimes patients with schizophrenia are 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 patient's chance of relapse by having an arsenal of coping strategies and problem-solving skills to manage 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

  • 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
  • CNS Drugs
  • American Journal of Medical Genetics
  • Molecular Psychiatry
  • Science
  • Journal of Neuroscience
  • New England Journal of Medicine
  • Expert Opinion on Pharmacotherapy
  • Schizophrenia Research
  • Journal of Rehabilitation Research and Development
Last reviewed 02/17/2015