Schizophrenia

What Is It?

Schizophrenia is a chronic (long-lasting) mental illness that is difficult to define and is easily misunderstood. Although symptoms may vary widely, people with schizophrenia frequently have difficulty recognizing reality, thinking logically and behaving normally in social situations. It is surprisingly common, affecting 1 in every 100 people worldwide.

Experts believe schizophrenia results from a combination of genetic and environmental factors. The chance of having schizophrenia is 10% if an immediate family member (a parent or sibling) has the illness. The chance zooms to as much as 65% for those who have an identical twin with schizophrenia.

Scientists think several genes acting together make people vulnerable to this illness. In fact, with 20 or 30 or more problem genes being investigated, schizophrenia can be seen as several illnesses rather than one. These genes probably influence the way the brain develops and how nerve cells communicate with one another.

There is still no way to predict who will develop schizophrenia by looking at genetic material. We also still do not have a clear picture of which environmental factors or stresses make it more likely for someone to develop schizophrenia.

Schizophrenia may start as early as childhood and last throughout life. People with this illness periodically have difficulty with their thoughts and their perceptions. They may withdraw from social contacts, and if not treated, they will display more symptoms and become less functional as time passes. Schizophrenia is one of the "psychotic" disorders. Psychosis is defined in a variety of ways, but it is essentially an inability to recognize reality. It can include such symptoms as delusions (false beliefs), hallucinations (false perceptions), and disorganized speech or behavior. Because psychosis also can be a feature of other mental disorders, not all people who are psychotic have schizophrenia.

Symptoms in schizophrenia are described as either "positive" or "negative." Positive symptoms are psychotic symptoms such as delusions, hallucinations and disorganized behavior. Negative symptoms are the tendency toward restricted emotions, flat speech and the inability to start productive activity.

In addition to positive and negative symptoms, many people also have cognitive symptoms (problems with their intellectual functioning). People with schizophrenia may have trouble with "working memory." That is, they have trouble keeping recently learned information in mind and using it right away. They also have more trouble than average organizing themselves or making plans. These problems can be very subtle, but in many cases may account for why a person with schizophrenia has such a hard time managing day-to-day life.

Schizophrenia can be marked by a steady deterioration of logical thinking, social skills and behavior. These problems can contribute to a decline in functioning in personal relationships or at work. Self-care can also suffer. As people with schizophrenia realize what it means to have the disease, they may become depressed. People with schizophrenia are therefore at greater than average risk of committing suicide. Family members and health care professionals need to stay alert to this possibility.

People with schizophrenia are also at more risk of developing substance abuse problems. People who drink and use illicit drugs have more difficulty adhering to treatment. Schizophrenia is associated with higher rates of smoking than in the general population, leading patients with this illness to have more health problems. Schizophrenia has the following subtypes:

• Paranoid -- This is perhaps the best known subtype because people tend to wrongly believe that paranoia and schizophrenia always go together ("paranoid schizophrenic"). But only a limited number of people with schizophrenia have paranoid symptoms. What characterizes the paranoid type is the presence of delusions, whereas disorganization and emotional flatness are not prominent. In this subtype, the delusions may not even be paranoid in content; instead, they may have non-paranoid themes, such as religious delusions or "delusions of grandeur".
• Disorganized -- Speech or behavior may be disorganized, and emotional responses are blunted or unusual.
• Catatonic -- The person may become immobile or agitated, become peculiarly negative or mute, or display unusual behavior or speech.
• Undifferentiated -- The person has psychotic (positive) symptoms, but they do not clearly fit into any of the above categories.
• Residual -- The main symptoms are negative symptoms without any of the major psychotic symptoms seen in the other subtypes.

Symptoms

The symptoms of schizophrenia are defined as either "positive" or "negative."

Positive symptoms:

• Hallucinations (disordered perceptions) that may involve any of the five senses, including sight, hearing, touch, smell and taste
• Delusions (distorted thoughts)
• Disorganized speech
• Unusual or disorganized behavior

Negative symptoms:

• Restricted emotional range ("flat affect")
• Limited, unresponsive speech with little expression
• Disordered thinking, with problems making logical connections
• Trouble starting or pursuing goal-directed activity

Cognitive or intellectual symptoms are harder to detect and include problems retaining and using information for the purpose off organizing or planning.

Diagnosis

The diagnosis of schizophrenia may not be immediately apparent. Although it is frequently possible to tell in one meeting whether someone has psychotic symptoms, it is not possible to diagnose schizophrenia so quickly. The clinician may need to know the person for months or even years to determine whether the pattern of illness fits the description of schizophrenia. It is important to observe the course of the illness over time because psychosis alone is not enough to diagnose schizophrenia.

Just as there are many causes of fever, there are many causes of psychosis. The clinician doing the evaluation will consider a variety of alternative diagnoses, such as a mood disorder, a medical problem or a toxic substance. Experts know that brain function is impaired in schizophrenia, but tests that examine the brain directly cannot yet be used to make a diagnosis. A clinician may want to do tests such as computed tomography (CT), magnetic resonance imaging (MRI) or an electroencephalogram (EEG), which measures electrical activity. These tests will help to rule out causes of the symptoms other than schizophrenia, such as a tumor or a seizure disorder.

Expected Duration

Schizophrenia is a lifelong illness. However, many psychotic illnesses last a much shorter time, so the presence of psychosis does not necessarily mean a person will have a lifelong struggle. Also, the impact of the illness can be reduced by early and active treatment.

Prevention

There is no way to prevent schizophrenia, but the earlier the illness is detected, the better chance you have to prevent the worst effects of the illness.

Schizophrenia is never the parents' fault. But in families where the illness is prevalent, it may make sense to pursue genetic counseling before starting a family. Educated family members are often in a better position to understand the illness and provide assistance.

Treatment

Schizophrenia requires a combination of treatments, including medication, psychological counseling and social support.

The major medications used to treat schizophrenia are called antipsychotics. They are quite effective at treating the positive symptoms of schizophrenia, but relatively less successful for negative symptoms, with one notable exception (see clozapine, below). Every person reacts a little differently to antipsychotic drugs, so a patient may need to try several before finding the one that works best. It is also important to continue the treatment even after symptoms get better, because there is a high likelihood that psychosis will return without medication, and each returning episode may be worse.

Newer medications called "atypical" antipsychotics usually are tried first. They are as effective as older medications at treating the psychotic symptoms of schizophrenia, and they also may be a little better at treating cognitive symptoms. These medications include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon) and aripiprazole (Abilify). The most serious side effect of these newer drugs is weight gain, which increases the risk of developing diabetes or high cholesterol.

Older antipsychotic medications, such as chlorpromazine (Thorazine) and haloperidol (Haldol), are still quite effective and worth trying if atypical antipsychotics do not provide enough relief. However, the older medications can cause sedation, muscle spasms or rigidity, restlessness, dry mouth, constipation, weight gain, or changes in blood pressure. With long-term use, there is a risk of developing involuntary muscle movements (called tardive dyskinesia).

Clozapine (Clozaril) is a unique antipsychotic that is effective not just for positive symptoms, but also the negative symptoms of schizophrenia. However, it has a potentially dangerous side effect. About 1 in 100 people who take this drug lose the capacity to produce the white blood cells needed to fight infection. Anyone taking this drug must have regular tests to check blood counts. Other side effects include changes in heart rate and blood pressure, weight gain, sedation, excessive salivation, and constipation. On the positive side, people do not develop the muscle rigidity or the involuntary muscle movements seen with older antipsychotics. Because clozapine may be the best overall treatment for schizophrenia symptoms, some people may decide that the potential benefit of taking it is worth the risks.

Because other disorders can either mimic the symptoms of schizophrenia or accompany schizophrenia, other medications may be tried, such as antidepressants and mood stabilizers. Sometimes anti-anxiety medications help to control anxiety or agitation.

There is growing evidence that cognitive behavior therapy (CBT) can reduce symptoms in schizophrenia. CBT in schizophrenia is not conducted in the same way as CBT for depression. When treating schizophrenia, the therapist puts a heavy emphasis on understanding the person's experience, developing an alliance, and finding alternative explanations for psychotic symptoms in order to defuse their distressing effect.

In addition to specific CBT techniques, a therapist or case manager must be involved to provide ongoing emotional and practical support, education about the illness, advice about managing relationships and orientation to reality. All of these efforts will help the patient stick with treatment. The longer and more trusting the relationship, the more useful it will be for the person affected by this illness.

Family members also need education about the disease so they can better provide assistance. Often a person with schizophrenia needs additional social support. A residential treatment facility can provide a safe place to live. Vocational rehabilitation gives some hope that the person can do something productive. A social program may give the person structure, activity and an opportunity to improve relationships with others.

When To Call a Professional

Anyone showing psychotic symptoms or who has difficulty functioning because of problems in their thinking should be in treatment. Although the vast majority of people with this disorder never harm themselves or others, there is some increased risk of suicide or violence in schizophrenia, another reason to seek treatment. There is increasing evidence that earlier and continuous treatment leads to a better outcome and, because new treatments are always in development, a relationship with a psychiatrist will increase the person's access to these treatments as they become available.

Prognosis

The outlook for schizophrenia varies. By definition, schizophrenia is a chronic condition that includes persistent or recurring psychosis and poor functioning. Life expectancy may even be shortened if the person drifts away from supportive relationships, if personal hygiene or self-care decline, or if poor judgment leads to accidents. However, with active treatment, the effects of the illness can be significantly reduced. A better prognosis is likely if the first symptoms began after age 30 and if the onset was rapid. The better a person functioned before the onset of illness, the better he or she is likely to do. The absence of a family history of schizophrenia is also a good sign.

Additional Info

American Foundation for Suicide Prevention

120 Wall St.

22nd Floor

New York, NY 10005

Phone: 212-363-3500

Toll-Free: 1-888-333-2377

Fax: 212-363-6237

Email: inquiry@afsp.org

http://www.afsp.org/index-1.htm

American Psychiatric Association

1000 Wilson Blvd.

Suite 1825

Arlington, VA 22209-3901

Phone: 703-907-7300

Toll-Free: 1-888-357-7924

Email: apa@psych.org

Web site: http://www.psych.org/Public information site: http://www.healthyminds.org/

American Psychological Association

750 First St., NE

Washington, DC 20002-4242

Phone: 202-336-5510

Toll-Free: 1-800-374-2721

TTY: 202-336-6123

http://www.apa.org/

National Alliance for the Mentally Ill

Colonial Place Three

2107 Wilson Blvd.

Suite 300

Arlington, VA 22201-3042

Phone: 703-524-7600

Toll-Free: 1-800-950-6264

TTY: 703-516-7227

Fax: 703-524-9094

http://www.nami.org/

National Mental Health Association

2001 N. Beauregard St., 12th Floor

Alexandria, VA 22311

Phone: 703-684-7722

Toll-Free: 1-800-969-6642

TTY: 1-800-433-5959

Fax: 703-684-5968

http://www.nmha.org/

National Institute of Mental Health

Office of Communications

6001 Executive Blvd.

Room 8184, MSC 9663

Bethesda, MD 20892-9663

Phone: 301-443-4513

Toll-Free: 1-866-615-6464

TTY: 301-443-8431

Fax: 301-443-4279

Email: nimhinfo@nih.gov

http://www.nimh.nih.gov/