Schizophrenia is a serious brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others. People with schizophrenia -- the most chronic and disabling of the major mental illnesses -- often have problems functioning in society, at work, at school, and in relationships. Schizophrenia can leave its sufferer frightened and withdrawn. It is a life-long disease that cannot be cured, but usually can be controlled with proper treatment
Contrary to popular belief, schizophrenia is not a split personality. Schizophrenia is a psychosis, a type of mental illness in which a person cannot tell what is real from what is imagined. At times, people with psychotic disorders lose touch with reality. The world may seem like a jumble of confusing thoughts, images, and sounds. The behavior of people with schizophrenia may be very strange and even shocking. A sudden change in personality and behavior, which occurs when people lose touch with reality, is called a psychotic episode.
Schizophrenia varies in severity from person to person. Some people have only one psychotic episode while others have many episodes during a lifetime but lead relatively normal lives between episodes. Schizophrenia symptoms seem to worsen and improve in cycles known as relapses and remissions.
Schizophrenia is a term given to a complex group of mental disorders. However, different types of schizophrenia may have some of the same symptoms. There are several subtypes of schizophrenia based on symptoms:
Paranoid schizophrenia: People with this type are preoccupied with false beliefs (delusions) about being persecuted or being punished by someone. Their thinking, speech and emotions, however, remain fairly normal.
Disorganized schizophrenia: People with this type often are confused and incoherent, and have jumbled speech. Their outward behavior may be emotionless or flat or inappropriate, even silly or childlike. Often they have disorganized behavior that may disrupt their ability to perform normal daily activities such as showering or preparing meals.
Catatonic schizophrenia: The most striking symptoms of this type are physical. People with catatonic schizophrenia are generally immobile and unresponsive to the world around them. They often become very rigid and stiff, and unwilling to move. Occasionally, these people have peculiar movements like grimacing or assume bizarre postures. Or, they might repeat a word or phrase just spoken by another person. People with catatonic schizophrenia are at increased risk of malnutrition, exhaustion, or self-inflicted injury.
Undifferentiated schizophrenia: This subtype is diagnosed when the person's symptoms do not clearly represent one of the other three subtypes.
Residual Schizophrenia: In this type of schizophrenia, the severity of schizophrenia symptoms has decreased. Hallucinations, delusions, or other symptoms may still be present but are considerably less than when the schizophrenia was originally diagnosed.
What Are the Symptoms of Schizophrenia?
People with schizophrenia may have a number of symptoms involving changes in ability and personality, and they may display different kinds of behavior at different times. When the illness first appears, symptoms usually are sudden and severe.
The most common symptoms of schizophrenia can be grouped into three categories: Positive symptoms, disorganized symptoms, and negative symptoms
Positive Symptoms of Schizophrenia
In this case, the word positive does not mean "good." Rather, it refers to obvious symptoms that are not present in people without schizophrenia. These symptoms, which are sometimes referred to as psychotic symptoms, include:
Delusions: Delusions are strange beliefs that are not based in reality and that the person refuses to give up, even when presented with factual information. For example, the person suffering from delusions may believe that people can hear his or her thoughts, that he or she is God or the devil, or that people are putting thoughts into his or her head.
Hallucinations: These involve perceiving sensations that aren't real, such as seeing things that aren't there, hearing voices, smelling strange odors, having a "funny" taste in your mouth, and feeling sensations on your skin even though nothing is touching your body. Hearing voices is the most common hallucination in people with schizophrenia. The voices may comment on the person's behavior, insult the person, or give commands.
Disorganized Symptoms of Schizophrenia
Disorganized symptoms of schizophrenia reflect the person's inability to think clearly and respond appropriately. Examples of disorganized symptoms include:
Talking in sentences that do not make sense or using nonsense words, making it difficult for the person to communicate or engage in conversation.
Shifting quickly from one thought to the next.
Being unable to make decisions.
Writing excessively but without meaning.
Forgetting or losing things.
Repeating movements or gestures, such as pacing or walking in circles.
Having problems making sense of everyday sights, sounds, and feelings.
Negative Symptoms of Schizophrenia
In this case, the word negative does not mean "bad," but reflects the absence of certain normal behaviors in people with schizophrenia. Negative symptoms of schizophrenia include:
Lack of emotion and expression or emotions, thoughts, and moods that do not fit with situations or events (for example, crying instead of laughing at a joke).
Withdrawal from family, friends, and social activities.
Lack of motivation.
Loss of pleasure or interest in life.
Poor hygiene and grooming habits.
Problems functioning at school, work, or other activities.
Moodiness (being very sad or very happy, or having swings in mood).
Catatonia (a condition in which the person becomes fixed in a single position for a very long time).
What Causes Schizophrenia?
The exact cause of schizophrenia is not yet known. It is known, however, that schizophrenia -- like cancer and diabetes -- is a real illness with a biological basis. It is not the result of bad parenting or personal weakness. Researchers have uncovered a number of factors that appear to play a role in the development of schizophrenia, including:
Genetics (heredity): Schizophrenia tends to run in families, which means the likelihood to develop schizophrenia may be passed on from parents to their children.
Brain chemistry: People with schizophrenia may have an imbalance of certain chemicals in the brain. They may be either very sensitive to or produce too much of a brain chemical called dopamine. Dopamine is a neurotransmitter, a substance that helps nerve cells in the brain send messages to each other. An imbalance of dopamine affects the way the brain reacts to certain stimuli, such as sounds, smells, and sights and can lead to hallucinations and delusions.
Brain abnormality: Newer research has found abnormal brain structure and function in people with schizophrenia. However, this type of abnormality doesn't happen in all schizophrenics and can occur in people without the disease.
Environmental factors: Evidence suggests that certain environmental factors, such as a viral infection, poor social interactions, or highly stressful situations, may trigger schizophrenia in people who have inherited a tendency to develop the disorder. Schizophrenia more often surfaces when the body is undergoing hormonal and physical changes, such as those that occur during the teen and young adult years.
Who Gets Schizophrenia?
Anyone can get schizophrenia. It is diagnosed all over the world and in all races and cultures. While it can occur at any age, schizophrenia typically first appears in the teenage years or 20s. The disorder affects men and women equally, although symptoms generally appear earlier in men (in their teens or 20s) than in women (in their 20s or early 30s). Children over the age of 5 can develop schizophrenia, but it is very rare before adolescence.
How Common Is Schizophrenia?
Schizophrenia is a relatively common disorder. About 1% of the population, or 2.2 million Americans ages 18 and older, will develop schizophrenia.
How Is Schizophrenia Diagnosed?
If symptoms of schizophrenia are present, the doctor will perform a complete medical history and physical exam. While there are no laboratory tests to specifically diagnose schizophrenia, the doctor may use various tests, such as X-rays and blood tests, to rule out a physical illness as the cause of the symptoms.
If the doctor finds no physical reason for the schizophrenia symptoms, he or she may refer the person to a psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists use specially designed interview and assessment tools to evaluate a person for a psychotic disorder. The therapist bases his or her diagnosis on the person's report of symptoms and his or her observation of the person's attitude and behavior. A person is considered to have schizophrenia if he or she has characteristic symptoms that last for at least six months
How Is Schizophrenia Treated?
The goal of schizophrenia treatment is to reduce the symptoms and to decrease the chances of a relapse, or return of symptoms. Treatment for schizophrenia may include:
Medications: The primary medications used to treat schizophrenia are called antipsychotics. These medicines do not cure schizophrenia but help relieve the most troubling symptoms, including delusions, hallucinations, and thinking problems. Older medications used include: Thorazine, Prolixin, Haldol, Navane, Stelazine, Trilafon and Mellaril. Newer medications used to treat schizophrenia include: Abilify, Clozaril, Geodon, Invega, Risperdal, Saphris, Seroquel, and Zyprexa .
Psychosocial therapy: While medication may help relieve symptoms of schizophrenia, various psychosocial treatments can help with the behavioral, psychological, social, and occupational problems associated with the illness. Through therapy, patients also can learn to control their symptoms, identify early warning signs of relapse, and develop a relapse prevention plan. Psychosocial therapies include:
Rehabilitation, which focuses on social skills and job training to help people with schizophrenia function in the community and live as independently as possible.
Individual psychotherapy, which can help the person better understand his or her illness, and learn coping and problem-solving skills.
Family therapy, which can help families deal more effectively with a loved one who has schizophrenia, enabling them to better help their loved one.
Group therapy/support groups, which can provide continuing mutual support.
Hospitalization: Most people with schizophrenia may be treated as outpatients. However, people with particularly severe symptoms, or those in danger of hurting themselves or others may require hospitalization to stabilize their condition.
Electroconvulsive therapy (ECT): This is a procedure in which electrodes are attached to the person's head and a series of electric shocks are delivered to the brain. The shocks induce seizures, causing the release of neurotransmitters in the brain. This form of treatment is rarely used today in the treatment of schizophrenia. ECT may be useful when all medications fail or if severe depression or catatonia makes treating the illness difficult.
Psychosurgery: Lobotomy, an operation used to sever certain nerve pathways in the brain, was formerly used in some patients with severe, chronic schizophrenia. It is now performed only under extremely rare circumstances. This is because of the serious, irreversible personality changes that the surgery may produce and the fact that far better results are generally attained from less drastic and hazardous procedures
Are People With Schizophrenia Dangerous?
Popular books and movies often depict people with schizophrenia and other mental illnesses as dangerous and violent. This is not always true. Most people with schizophrenia are not violent. More typically, they prefer to withdraw and be left alone. In some cases, however, people with mental illness who also abuse alcohol or drugs may engage in dangerous or violent behavior.
On the other hand, people with schizophrenia can be a danger to themselves. Suicide is the number one cause of premature death among people with schizophrenia.
What Is the Outlook for People With Schizophrenia?
With proper treatment, most people with schizophrenia can lead productive and fulfilling lives. They are able to live with their families or in community settings rather than in long-term psychiatric institutions.
Ongoing research on the brain and how brain disorders develop will likely lead to more effective medicines with fewer side effects.
Can Schizophrenia Be Prevented?
There is no known way to prevent schizophrenia. However, early diagnosis and treatment can help avoid or reduce frequent relapses and hospitalizations, and help decrease the disruption to the person's life, family, and friendships.
Schizophrenia Types and Symptoms
Usually with schizophrenia, the person's inner world and behavior change notably. Behavior changes might include the following:
Depersonalization (intense anxiety and a feeling of being unreal)
Loss of appetite
Loss of hygiene
Hallucinations (hearing or seeing things that aren't there)
The sense of being controlled by outside forces
A person with schizophrenia may not have any outward appearance of being ill. In other cases, the illness may be more apparent, causing bizarre behaviors. For example, a person with schizophrenia may wear aluminum foil in the belief that it will stop one's thoughts from being broadcast and protect against malicious waves entering the brain.
People with schizophrenia vary widely in their behavior as they struggle with an illness beyond their control. In active stages, those affected may ramble in illogical sentences or react with uncontrolled anger or violence to a perceived threat. People with schizophrenia may also experience relatively passive phases of the illness in which they seem to lack personality, movement, and emotion (also called a flat affect). People with schizophrenia may alternate in these extremes. Their behavior may or may not be predictable.
In order to better understand schizophrenia, the concept of clusters of symptoms is often used. Thus, people with schizophrenia can experience symptoms that may be grouped under the following categories:
Positive symptoms -- Hearing voices, suspiciousness, feeling under constant surveillance, delusions, or making up words without a meaning (neologisms).
Negative (or deficit) symptoms -- Social withdrawal, difficulty in expressing emotions (in extreme cases called blunted affect), difficulty in taking care of themselves, inability to feel pleasure (These symptoms cause severe impairment and are often mistaken for laziness.)
Cognitive symptoms -- Difficulties attending to and processing of information, in understanding the environment, and in remembering simple tasks
Affective (or mood) symptoms -- Most notably depression, accounting for a very high rate of attempted suicide in people suffering from schizophrenia
Helpful definitions in understanding schizophrenia include the following:
Psychosis: Psychosis is defined as being out of touch with reality. During this phase, one can experience delusions or prominent hallucinations. People with psychoses are not aware that what they are experiencing or some of the things that they believe are not real. Psychosis is a prominent feature of schizophrenia but is not unique to this illness.
Schizoid: This term is often used to describe a personality disorder characterized by almost complete lack of interest in social relationships and a restricted range of expression of emotions in interpersonal settings, making a person with this disorder appear cold and aloof.
Schizotypal: This term defines a more severe personality disorder characterized by acute discomfort with close relationships as well as disturbances of perception and bizarre behaviors, making people with schizophrenia seem odd and eccentric because of unusual mannerisms.
Hallucinations: A person with schizophrenia may have strong sensations of objects or events that are real only to him or her. These may be in the form of things that they believe strongly that they see, hear, smell, taste, or touch. Hallucinations have no outside source, and are sometimes described as "the person's mind playing tricks" on him or her.
Illusion: An illusion is a mistaken perception for which there is an actual external stimulus. For example, a visual illusion might be seeing a shadow and misinterpreting it as a person. The words "illusion" and "hallucination" are sometimes confused with each other.
Delusion: A person with a delusion has a strong belief about something despite evidence that the belief is false. For instance, a person may listen to a radio and believe the radio is giving a coded message about an impending alien invasion. All of the other people who listen to the same radio program would hear, for example, a feature story about road repair work taking place in the area.
Types of schizophrenia are as follows:
Paranoid-type schizophrenia is characterized by delusions and auditory hallucinations but relatively normal intellectual functioning and expression of affect. The delusions can often be about being persecuted unfairly or being some other person who is famous. People with paranoid-type schizophrenia can exhibit anger, aloofness, anxiety, and argumentativeness.
Disorganized-type schizophrenia is characterized by speech and behavior that are disorganized or difficult to understand, and flattening or inappropriate emotions. People with disorganized-type schizophrenia may laugh at the changing color of a traffic light or at something not closely related to what they are saying or doing. Their disorganized behavior may disrupt normal activities, such as showering, dressing, and preparing meals.
Catatonic-type schizophrenia is characterized by disturbances of movement. People with catatonic-type schizophrenia may keep themselves completely immobile or move all over the place. They may not say anything for hours, or they may repeat anything you say or do senselessly. Either way, the behavior is putting these people at high risk because it impairs their ability to take care of themselves.
Undifferentiated-type schizophrenia is characterized by some symptoms seen in all of the above types but not enough of any one of them to define it as another particular type of schizophrenia.
Residual-type schizophrenia is characterized by a past history of at least one episode of schizophrenia, but the person currently has no positive symptoms (delusions, hallucinations, disorganized speech or behavior). It may represent a transition between a full-blown episode and complete remission, or it may continue for years without any further psychotic episodes.
Schizophrenia Exams and Tests
To diagnose schizophrenia, one has first to rule out any medical illness that may be the actual cause of the behavioral changes. Once medical causes have been looked for and not found, a psychotic illness such as schizophrenia could be considered. The diagnosis will best be made by a licensed mental health professional (preferably a psychiatrist) who can evaluate the patient and carefully sort through a variety of mental illnesses that might look alike at the initial exam.
The doctor will examine someone in whom schizophrenia is suspected either in an office or in the emergency department. The doctor's role is to ensure that the patient doesn't have any medical problems. The doctor takes the patient's history and performs a physical exam. Laboratory and other tests, sometimes including a computerized tomography (CT) scan of the brain, are performed. Physical findings can relate to the symptoms associated with schizophrenia or to the medications the person may be taking.
People with schizophrenia can exhibit mild confusion or clumsiness.
Subtle minor physical features, such as highly arched palate or wide or narrow set eyes, have been described, but none of these findings alone allow a doctor to make the diagnosis.
Most symptoms found are related to movement (motor symptoms). Some of these can be side effects of prescribed medications. Drugs may, for example, cause dry mouth, constipation, drowsiness, stiffness on one side of the neck or jaw, restlessness, tremors of the hands and feet, and slurred speech.
Tardive dyskinesia is one of the most serious side effects of medications used to treat schizophrenia. It is usually seen in older people and involves facial twitching, jerking and twisting of the limbs or trunk of the body, or both. It is a less common side effect with the newer generation of drugs used to treat schizophrenia. It does not always go away, even when the medicine that caused it is discontinued.
A rare, but life-threatening complication resulting from the use of neuroleptic (antipsychotic, tranquilizing) drugs is neuroleptic malignant syndrome (NMS). It involves extreme muscle rigidity, sweatiness, salivation, and fever. If this is suspected, it should be treated as an emergency.
Generally, results are normal in schizophrenia for the lab tests and imaging studies available to most doctors. If the person has a particular behavior as part of their mental disorder, such as drinking too much water, then this might show as a metabolic abnormality in the person's laboratory results. Some medications can trigger a decreased immune response, reflected by a low number of white blood cells in the blood. Likewise, in people with NMS, metabolism may be abnormal.
Family members or friends of the person with schizophrenia can help by giving the doctor a detailed history and information about the patient, including behavioral changes, previous level of social functioning, history of mental illness in the family, past medical and psychiatric problems, medications, and allergies (to foods and medications), as well as the person's previous physicians and psychiatrists. A history of hospitalizations is also helpful so that old records at these facilities might be obtained and reviewed.
In schizophrenia, antipsychotic medications are proven effective in treating acute psychosis and reducing the risk of future psychotic episodes. The treatment of schizophrenia thus has two main phases: an acute phase, when higher doses might be necessary in order to treat psychotic symptoms, followed by a maintenance phase, which is usually life-long. During the maintenance phase, dosage is gradually reduced to the minimum required to prevent further episodes. If symptoms reappear on a lower dosage, a temporary increase in dosage may help prevent a relapse.
Even with continued treatment, some patients experience relapses. By far, the most common cause of a relapse is stopping medications.
The large majority of schizophrenia patients experience substantial improvement when treated with antipsychotic drugs. Some patients, however, do not respond to medications, and a few may seem not to need them.
Since it is difficult to predict which patients will fall into what groups, it is essential to have long-term follow-up, so that the treatment can be adjusted and any problems addressed promptly.
Antipsychotic drugs are the cornerstone in the management of schizophrenia. They have been available since the mid-1950s, and although antipsychotics do not cure the illness, they greatly reduce the symptoms and allow the patient to function better, have better quality of life, and enjoy an improved outlook. The choice and dosage of medication is individualized and is best done by a physician who is well trained and experienced in treating severe mental illness.
The first antipsychotic drug was discovered by accident and then used for schizophrenia. This was Thorazine, which was soon followed by medications such as Haldol, Prolixin, Navane, Stelazine, Trilafon, and Mellaril. These drugs have become known as "neuroleptics" because, although effective in treating positive symptoms (acute symptoms such as hallucinations, delusions, thought disorder, loose associations, ambivalence, or emotional lability), they cause side effects, many of which affect the nervous system. These older medications are not as effective against symptoms such as decreased motivation and lack of emotional expressiveness.
In 1989, a new class of antipsychotics -- called atypical antipsychotics -- has been introduced. At the correct doses, few of these neurological side effects -- which often include such symptoms as muscular rigidity, painful spasms, restlessness, or tremors -- are seen.
The first of the new class, Clozaril is the only drug that has been shown to be effective where other antipsychotics have failed. It is not linked with the side effects mentioned above, but it does produce other side effects, including possible decrease in the number of white cells, so the blood needs to be monitored every week during the first six months of treatment and then every two weeks to catch this side effect early if it occurs.
Other atypical antipsychotics include Abilify, Geodon, Invega, Risperdal, Saphris, Seroquel, and Zyprexa. The use of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizophrenia.
Although more effective and better tolerated, the use of these drugs is also associated with side effects, and current medical practice is developing better ways of understanding these effects, identifying people at risk, and monitoring for the emergence of complications.
Most of these medications take two to four weeks to take effect. Patience is required if the dose needs to be adjusted, the specific medication changed, and another medication added. In order to be able to determine whether an antipsychotic is effective or not, it should be tried for at least six to eight weeks (or even longer with Clozaril).
Because the risk of relapse of illness is higher when antipsychotic drugs are taken irregularly or discontinued, it is important that people with schizophrenia follow a treatment plan developed in collaboration with their doctors and with their families. The treatment plan will involve taking the prescribed medication in the correct amount and at the times recommended, attending follow-up appointments, and following other treatment recommendations.
People with schizophrenia often do not believe that they are ill or that they need treatment. Other possible things that may interfere with the treatment plan include side effects from medications, substance abuse, negative attitudes towards treatment from families and friends, or even unrealistic expectations. When present, these issues need to be acknowledged and addressed for the treatment to be successful.