What Is It?
Schizophrenia is a chronic (long-lasting) brain disorder 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 causes. The chance of having schizophrenia is 10% if an immediate family member (a parent or sibling) has the illness. The risk is as high 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, so many problem genes have been investigated that 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.
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. Without treatment, symptoms get worse.
Schizophrenia is one of several “psychotic” disorders. Psychosis can be defined as the inability to recognize reality. It may include such symptoms as delusions (false beliefs), hallucinations (false perceptions), and disorganized speech or behavior. Psychosis is a symptom of many mental disorders. In other words, having a psychotic symptom does not necessarily mean a person has 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 affect (diminished emotional expressiveness), and the inability to start or continue 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 information in mind in order to use it, for example, remembering a phone number that they have just heard. 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 substances have a harder time adhering to treatment. People with schizophrenia smoke more than people in the general population. The smoking leads to more health problems.
Schizophrenia has historically been divided into several subtypes, but researchers in the last several years have determined that these divisions are probably not clinically useful. It is expected that the next version of the diagnostic manual in psychiatry will eliminate schizophrenia subtypes.
The symptoms of schizophrenia are often defined as either “positive” or “negative.”
- Hallucinations (disordered perceptions) that may involve any of the five senses, including sight, hearing, touch, smell and taste
- Delusions (distorted thoughts)
- Disorganized speech
- Unusual motor activity or disorganized behavior
- Restricted emotional range (“flat affect”)
- Limited, unresponsive speech with little expression
- Trouble starting or continuing goal-directed activity
Negative symptoms may be result from a reduced ability to express emotions. Another possibility is that individuals can’t experience pleasure, which may lead to apathy.
Cognitive or intellectual symptoms are harder to detect and include problems retaining and using information for the purpose of organizing or planning.
The diagnosis of schizophrenia is often not easy to make. It is not possible to make the diagnosis in one meeting. Even if the person has psychotic symptoms, that does not mean he or she has schizophrenia. It may take months or even years to see if the pattern of illness fits the description of schizophrenia.
Just as there are many causes of fever, there are many causes of psychosis. The clinician doing the evaluation will look for some of these other causes, for example, 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 do tests such as computed tomography (CT), magnetic resonance imaging (MRI) or an electroencephalogram (EEG). These tests will help to rule out causes of the symptoms other than schizophrenia, such as a tumor or a seizure disorder.
Schizophrenia is a lifelong illness. Psychotic symptoms tend to wax and wane, while the negative symptoms and cognitive problems are more persistent. In general, the impact of the illness can be reduced by early and active treatment.
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.
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 generally effective for treating the positive symptoms of schizophrenia. 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 (“first generation”) and newer (“second generation”) groups. In recent years, it has been shown that — in general — one group is not more effective than the other, but side effects differ from one group to the other. 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 depends upon a thoughtful trial and error process.
Patients who are having a first episode of psychosis are both more responsive to these medicines and are more sensitive to adverse effects. Thus, experts recommend starting with any of the available antipsychotics, in low to moderate doses. They also suggest avoiding a couple of the newer drugs, clozapine (Clozaril) and olanzapine (Zyprexa), in the first round, because they are more likely to cause weight gain. Also, about 1 in 100 people who take clozapine lose the capacity to produce the white blood cells needed to fight infection (see below).
People who suffer a relapse can try any other medication in the first or second generation of antipsychotics. Once a person has found a drug or combination of drugs that helps, it is a good idea to continue maintenance treatment in order to reduce the risk of relapse.
- Older “first generation” antipsychotics. As the first antipsychotics, these medications are also sometimes called “typical.” The group includes chlorpromazine (Thorazine), haloperidol (Haldol) or perphenazine (Trilafon). First generation agents have been shown to be as effective as most newer ones. 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 potentially irreversible involuntary muscle movements (called tardive dyskinesia).
- Newer “atypical” antipsychotics. In addition to olanzapine and clozapine, newer medications include risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris) and iloperidone (Fanapt). The major risk with some of these agents is weight gain and changes in metabolism. They tend to increase the risk for diabetes and high cholesterol.
- Other side effects. 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. Clozapine (Clozaril) is a unique antipsychotic that works differently enough from other antipsychotics that it is useful to try if no other medication has been effective. However, since it can impair the body’s ability to make white blood cells, anyone taking this drug must have regular blood tests to check those cell counts. Other side effects include changes in heart rate and blood pressure, weight gain, sedation, excessive salivation, and constipation. On the positive side, people tend not to 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.
There is growing evidence that psychosocial treatments are essential to the treatment of schizophrenia. These treatments are not given instead of medications; they are given in addition to medications.
In other words, the combination of medication and psychosocial treatment is most helpful.
Several approaches are useful:
- Psychotherapy. Cognitive behavior therapy (CBT) can reduce symptoms in schizophrenia. CBT in schizophrenia is conducted differently from CBT for depression. When treating schizophrenia, the therapist puts a heavy emphasis on understanding the person’s experience, developing a relationship, and explaining psychotic symptoms in realistic terms to defuse their distressing effect.
- Assertive Community Treatment. A community-based team with a variety of caregivers (for example, a psychiatrist, psychologist, nurse, social worker, and/or case manager) makes frequent contact with patients, monitors treatment adherence, and assesses psychosocial and health needs. The team may also provide emotional support to families. Some patients do well living in housing where staff can monitor progress and provide practical assistance.
- Supported Employment. Such programs rely upon rapid job placement rather than an extensive training period before employment. Programs work hard to honor the person’s preferences regarding work. They integrate on-the-job support and mental health services into the program. Most careful studies have found such an approach to be more effective than traditional vocational services.
- Family Education. Schizophrenia profoundly affects families. Education about the illness and practical advice can reduce relapse rates of patients as well as reduce family distress and help family members support the person suffering with the illness.
- Substance Abuse Treatment. Substance abuse, which is a common problem in schizophrenia, can make the illness worse. Such treatment is essential when substance problems emerge.
- General Health. Patients with schizophrenia have a higher incidence of smoking and overweight. Thus, a comprehensive program may include a way to help patients with these problems. Examples are smoke-ending advice, weight-loss programs or nutritional counseling.
The overall goal of psychosocial treatment is to provide ongoing emotional and practical support, education about the illness, perspective on the symptoms of the illness, advice about managing relationships and health, skills for improved functioning and orientation to reality. There may be an emphasis on sustaining motivation and solving problems. All of these efforts can help a patient stick with treatment. The longer and more trusting the relationships (with a therapist or case manager), the more useful it will be for the person affected by this illness.
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.
The outlook for schizophrenia varies. By definition, schizophrenia is a long-lasting condition that includes some periods of psychosis. Functioning may fall short of expectations, when measured against the person’s abilities prior to becoming ill. Poor functioning is, however, not inevitable with early treatment and proper supports.
Life expectancy may be shortened if a person with schizophrenia 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.
The prognosis is better if the first symptoms began after age 30 and if the onset was rapid. Better functioning before the onset of illness is linked to better responses to treatment. The absence of a family history of schizophrenia is also a good sign.
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