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 a hard time recognizing reality, thinking logically and behaving naturally in social situations. Schizophrenia is surprisingly common, affecting 1 in every 100 people worldwide.
Experts believe schizophrenia results from a combination of genetic and environmental influences. The chance of having schizophrenia is 10% if an immediate family member (a parent or sibling) has the illness. The risk swells to as much as 65% for those who have an identical twin with schizophrenia.
Scientists have identified several genes that increase the risk of getting 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 affect the way the brain develops and how nerve cells communicate with one another. In a vulnerable person, a stress (such as a toxin, an infection or a nutritional deficiency) may trigger the illness during critical periods of brain development.
Although the biology has yet to be worked out in detail, mental health professionals should eventually acquire tools to identify the people most at risk for developing schizophrenia. This kind of knowledge should help individuals minimize the negative impact of the illness.
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 function less well as time passes.
Schizophrenia is one of the "psychotic" disorders. Psychosis can be defined as the inability to recognize reality. It can include such symptoms as delusions (false beliefs), hallucinations (false perceptions), and disorganized speech or behavior. Psychosis is a feature of many mental disorders. In other words, 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 with schizophrenia also have cognitive symptoms (problems with their intellectual functioning). They may have trouble with "working memory." That is, they have trouble keeping recently learned information in mind in order to use it, for example, for making plans or for organizing themselves. 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 interfere with personal relationships or functioning 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 for 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:
Symptoms
The symptoms of schizophrenia are defined as either "positive" or "negative."
Positive symptoms:
Negative symptoms:
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 there is 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.
Medication
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.
If a medication does help, it is important to continue it even after symptoms get better. Without medication, there is a high likelihood that psychosis will return, and each returning episode may be worse.
Antipsychotic medications are divided into older ("typical") and newer ("atypical") groups. In recent years, it has been shown that -- in general -- one group is not more effective than another. Also there are differences among the medications within each group. For any individual person with schizophrenia it is impossible to predict which medicine will be best. Therefore, finding the most favorable balance of benefits and side effects will depend upon a thoughtful trial and error process.
Newer medications include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon) and aripiprazole (Abilify). Some of these drugs can cause significant weight gain, which increases the risk of developing diabetes or high cholesterol.
Older antipsychotic medications, such as chlorpromazine (Thorazine) and haloperidol (Haldol) have been shown to be as effective as the newer agents. Side effects can be minimized if modest doses are used. These older drugs, since they are available in generic form, also tend to be more cost effective. The disadvantage of these drugs is the risk of muscle spasms or rigidity, restlessness and -- with long-term use -- the risk of developing involuntary muscle movements (called tardive dyskinesia).
Other side effects for all antipsychotic medications include feeling sedated, slowed or unmotivated, trouble concentrating, changes in sleep, dry mouth, constipation, or changes in blood pressure.
Clozapine (Clozaril) is a unique antipsychotic that is effective not just for positive symptoms, but also for 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. For some people, clozapine may be the best overall treatment for schizophrenia symptoms, so they may decide that the potential benefit of taking it is worth the risks.
Because other disorders can either mimic the symptoms of schizophrenia or may accompany schizophrenia, other medications may be tried, such as antidepressants and mood stabilizers. Sometimes anti-anxiety medications help to control anxiety or agitation.
Psychotherapy
There is 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 to defuse their distressing effect.
In addition to specific CBT techniques, a therapist or case manager provides ongoing emotional and practical support, education about the illness, advice about managing relationships and orientation to reality. There may be an emphasis on sustaining motivation and solving problems. 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.
There is a growing interest in developing community programs that provide comprehensive, active support by reaching out to patients with schizophrenia and their families. The aim is to monitor adherence to treatment, shore up functioning and improve overall quality of life. 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 help. There is increasing evidence that earlier and continuous treatment leads to a better outcome. Plus, a relationship with a team of care providers increases access to new 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 after treatment. 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
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: 202-336-5500
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
Fax: 703-524-9094
http://www.nami.org/
Mental Health America
2001 N. Beauregard St., 6th 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
TTY Toll-Free: 1-866-415-8051
Fax: 301-443-4279
Email: nimhinfo@nih.gov
http://www.nimh.nih.gov/
