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Schizophrenia

Schizophrenia

Concepts of schizophrenia

Clinical descriptions

Concepts of etiology

Therapy

Perspective

BIBLIOGRAPHY

Schizophrenia constitutes the core problem of insanity. The conditions subsumed under the heading are among the most devastating to which man is heir, blighting him in the process of development or in the prime years of life and commonly leading to his progressive enclosure in an autistic world beset by delusion, hallucination, and fear of involvement with life and people. Because of the diverse manifestations, courses, and outcomes, schizophrenic reactions elude precise definition and concise description. They may be defined as gross failures to achieve or maintain integrated personality functioning in which a person, unable to cope with problems of living and irreconcilable conflicts, withdraws and seeks solutions by breaking through the confines imposed by the culture’s ways of thinking and reasoning and by regressing to a period of childhood when reality gave way to fantasy and when the self and others were not yet clearly distinguished. The condition tends to be self-perpetuating because the patient abandons testing his ideas in terms of how they help master his environment and promote collaborative interaction with others. However, restitutive efforts are usually made because a person cannot achieve an equilibrium as an isolate and because fears of uncontrollable impulses interfere with autistic gratification.

Incidence and prevalence. Schizophrenia is among the most common conditions leading to profound incapacitation. Of the daily hospital census in the United States of about 1.4 million patients, approximately one-fourth are hospitalized because of schizophrenia. Although the large majority are discharged within the first year after admission, the average length of stay is 13 years because a sizable number remain in hospitals from adolescence or early adulthood until death from old age or some disease. Incidence and prevalence can be estimated only very roughly because of the number of schizophrenic patients who are never hospitalized or even diagnosed and because of the vague boundaries of the condition. It has been estimated that between 14 and 20 of every 1,000 children born in the United States will be hospitalized at some time in their lives with an illness diagnosed as schizophrenia. A minimum annual prevalence rate of 290 per 100,000 has been suggested for Western societies (Lemkau Crocetti 1958). Surveys in New Haven (Hollingshead Redlich 1958) and in England (Brooke 1959) have shown that both incidence and prevalence are much higher among the lower socioeconomic segments of the population than among the upper-middle and upper classes. [SeeMental Disorders, article onEpidemiology.]

Concepts of schizophrenia

The profound divergencies of opinion concerning the nature, etiology, and treatment of schizophrenic conditions reflect differing concepts of the nature of human adaptation and integration more than they reflect divergent findings. Traditionally, psychiatrists have considered that the profound incapacitations of schizophrenic patients and, particularly, the disordered thinking that forms a critical aspect of the condition must be due to some unknown biological impairment—a structural defect of the brain or some hereditary metabolic or toxic factor influencing cerebral functioning. A large majority continues to believe that the high familial incidence indicates a hereditary predisposition that is affected by environmental factors, perhaps through aggravating a metabolic dysfunction. However, others consider schizophrenic reactions as an extreme type of aberrant personality functioning resulting from faulty and distorting child rearing in deviant family environments.

The way in which schizophrenia is conceptualized is not simply a matter of academic interest but of vital moment, as it influences the direction of scientific investigations and therapeutic efforts and, as will become apparent, has even profoundly influenced the clinical picture and course of the condition. The conviction that schizophrenia is a disease due to a biological impairment leads to concentration of research in neuropathological, physiological, and biochemical fields and has created therapeutic pessimism. This attitude has often contributed to the neglect of patients and, at times, virtually condemned them to crowded and impersonal institutions that aggravated their autistic withdrawal. Such orientation left little room for the participation of social scientists, other than in studies of the economic and social implications of a devastating disease. In contrast, the conceptualization of schizophrenia as a type of aberrant personality development has made it possible to consider schizophrenic reactions in the study of how the developmental process can go awry and thus perhaps to clarify critical issues concerning human integration and emotional homeostasis. Investigations of such matters as the role of language in human adaptation, of the family as a critical social institution that mediates between biological and cultural directives and between the individual and society, of the influence of social class on the incidence of mental illness and how it relates to child-rearing practices, of cross-cultural influences on personality development, and of the social and political structure of mental hospitals and the society’s system of caring for the ill, and numerous other areas of study become a vital part of the effort to understand, control, and treat schizophrenic reactions. Further, as schizophrenia constitutes one of the dominant unsolved health problems, the training of all physicians as well as of psychiatrists in particular will be affected profoundly by the conceptualization of the problems and the projection of an approach to their solution.

Historical considerations. The concept of schizophrenia as a clinical entity derives from Emil Kraepelin’s recognition in 1896 of the relationship between three forms of insanity—catatonia, described by K. Kahlbaum in 1863; hebephrenia, described by E. Hecker in 1871; and the deteriorating paranoid psychoses—and his uniting them under the designation “dementia praecox,” which B. Morel had used for a type of deteriorating adolescent psychosis. Kraepelin brought a degree of order to psychiatric taxonomy by differentiating dementia praecox from the manic-depressive psychoses. He emphasized the progressive course of dementia starting in youth and envisioned a distinct disease entity for which a specific structural pathology or causative agent would be found. The term “schizophrenia” was introduced by Eugen Bleuler in 1911, because not all sufferers from dementia praecox were youthful and not all became demented; it also served to emphasize the splitting of the psychic functions—the intellectual, affective, and conative—in these patients. Bleuler considered the possibility of a psychological causation but favored a hereditary etiology. He considered that the unknown etiologic agent produced primary symptoms of disturbances in associations, abnormalities of affect, emotional and intellectual ambivalence, and turning from reality to fantasy, as well as autism, whereas such symptoms as delusions, hallucinations, motor disorders, etc., were secondary and amenable to psychological treatment. He also stressed the intact capacities for perception, memory, and intellectual functioning that differentiate schizophrenia from the organic and toxic psychoses. In essence, he outlined the critical paradox of schizophrenic conditions: thought disorders form a critical aspect and diagnostic requisite, but the anatomical and physiological capacities for perceiving, thinking, and remembering remain intact. Together with Carl Gustav Jung, Bleuler brought psychoanalytic insights into the study of the psychology of schizophrenia. [See the biographies ofBleuler; Jung; Kraepelin.]

Adolf Meyer’s view. For the vast majority of psychiatrists throughout the world, the schizophrenic syndrome has remained essentially unchanged since the publication of Bleuler’s monograph (1911), although many have adhered more closely to Kraepelin’s concepts of a clear-cut disease entity, as the collected papers of the 1957 World Congress devoted to schizophrenia demonstrate (World Congress . . . 1959). However, Adolf Meyer, the dominant American contemporary of Bleuler, did not consider schizophrenia as an illness but as a reaction type that could be brought on by faulty “habit patterns,” including habits of thinking and relating (Meyer 1896-1937). For many years Meyer was almost the only important influence advocating longitudinal dynamic studies of life histories of schizophrenic patients, and he countered the prevailing therapeutic pessimism with his melioristic approach which advocated a type of psychotherapeutic management in a socializing milieu. Meyer is largely responsible for the different perspectives concerning schizophrenia held by many American psychiatrists in contrast to those of their Continental colleagues. [See the biography ofMeyer.]

Psychoanalysis. Even though Freud had excluded the treatment of schizophrenia from the province of psychoanalysis because he tacitly accepted an organic or toxic etiology and considered that the regression to narcissism prevented formation of a transference relationship, psychoanalysis still made many major contributions to understanding schizophrenic patients and their symptoms. Such concepts as narcissistic fixation and regression, the psychosexual stages of development, infantile sexuality, the withdrawal of cathexes (libidinal investment) from objects, primary process thinking, the interpretation of dreams, the exposition of the defense mechanisms —particularly those of projection and introjection— and of the importance of homosexuality to paranoid states, etc., opened the way for a dynamic understanding of schizophrenic patients and for comprehension of productions that previously had seemed to be the incomprehensible utterances of a diseased mind. Harry Stack Sullivan was among the first analysts who focused attention on the treatment of schizophrenic patients and whose psychoanalytic orientation was greatly modified by work with them. In the process he found need and use for contributions from various behavioral sciences. Sullivan (1924-1933) and his colleague Fromm-Reichmann (1948) were major forces in demonstrating by determined efforts that psychoanalytic therapy could be adapted to the treatment of schizophrenic patients. [See the biography ofSullivan.]

Clinical descriptions

The nature of the disorder varies widely. Most often schizophrenic reactions become manifest in the adolescent or young adult when the impact of sexual drives and the attainment of independence, an identity, and a way of life present critical problems. The young person may gradually and insidiously become increasingly withdrawn, preoccupied, and resistant to direction from others. He may avoid facing problems and relating to others by sleeping through much of the day. Sudden outbursts of irritability or hostility toward family members ward off intrusions. Rumination over personal and philosophical problems increases, and intellectualizations displace commitment and show of emotions. Differentiation from adolescent “identity crises” or other types of adolescent turmoil is difficult, and the future of the youth may hang in the balance. Gradually withdrawal becomes more extreme, indecision paralyzing, and ambivalence of feelings pronounced. Appearance and bodily hygiene may be neglected. Communication becomes vague, missing the mark and leaving the listener puzzled. Feelings of unreality and de-personalization are common. Self-direction is rescinded or paralyzed, allowing drive, impulse, and fantasy to gain increased motivating force. Control of drives and hostilities becomes a major preoccupation, while motivation is sought through interpreting coincidental events and reading meanings into people’s expressions and gestures. Then delusional solutions and hallucinated directives are found. Unacceptable feelings and impulses are projected onto others, who become malevolent figures. Hypochondriacal complaints are common and may reflect fears of transformation into the opposite sex. Increasingly the patient lives in an autistic world, gaining a sense of worth or even greatness through fantasy; he is also a prey to delusions of persecution and to terror lest homicidal, suicidal, or incestuous impulses overwhelm him. In some patients the first serious indication of the psychosis comes in an outbreak of panic over loss of control or over projected dangers. Frequently, when the patient can remain isolated or when he is neglected in an institution, habits and bodily care deteriorate, communications become disorganized and bizarre, and the patient comes to live in a world of delusion and hallucination. He exists in a state of almost living death, a nonparticipant in society and its conventions, virtually beyond the reach of therapeutic intervention. However, such outcomes are not inherent to schizophrenic reactions and need not occur, and with improved treatment they are becoming less common even in large institutions. The course and outcome vary widely and are influenced markedly by the treatment provided. Under average current conditions, approximately two-thirds of hospitalized patients will be discharged within 12 months: about half of these will remain reasonably well, while the remainder will have further serious difficulties and tend to have a downhill course. The outlook is poor for those who cannot be discharged within the first year. However, as less flagrant forms of schizophrenia are now diagnosed more often than formerly and as better treatment opportunities are available to some, the diagnosis need not imply so poor a prognosis. Schizophrenic reactions are most likely to occur in persons who have socialized poorly and who tend to be shy, introspective, somewhat eccentric, and, perhaps, compliantly overcon-scientious. Still, a fair proportion have not been notably schizoid, and some have been outgoing but impetuous individuals. Lifelong difficulties in socializing and an early progressive withdrawal decrease chances of recovery.

Types of schizophrenia. Conventionally, four types of schizophrenia are described. Actually, most patients can be fitted into these types only arbitrarily, showing admixtures of two or more types, with shifts in the dominant symptomatology over time. However, brief outlines of these subgroupings will serve to describe some of the different clinical pictures.

Catatonic schizophrenia. In catatonic schizophrenia extremes of violent motor excitement or rigid immobility dominate the picture. Onset is often abrupt. The patient may maintain difficult postures for hours, days, or months and requires complete care. Alternations between extreme excitement and rigidity may occur. Frequently these patients are in the midst of some mystical experience, believing themselves in heaven or hell; they are often immobile and refuse to speak because they believe any movement or word can produce a universal catastrophe. Although they may appear out of contact, they are aware of and sensitive to their surroundings. The prognosis is more favorable than for other types but unpredictable in the individual case. Chronic catatonic states, once fairly common, are becoming infrequent in modern hospitals.

Simple schizophrenia. Simple schizophrenia usually refers to a gradual withdrawal of interest and a progressive decline of responsible behavior with absence of commitment to a definite way of life. The potentialities shown in youth dissipate, and the patient idles about the home or becomes a vagrant, etc. Theoretically, Bleuler’s primary symptoms are present with minimal secondary symptoms; however, many patients given this diagnosis are delusional but noncommunicative about their delusions and hallucinations.

Hebephrenic schizophrenia. Hebephrenic schizophrenia usually starts in adolescence and progresses rapidly: the patient soon displays silly, impulsive, and disorganized behavior. Delusions and hallucinations are poorly organized and shifting. Speech is often fragmented and almost incomprehensible, marked by frequent intrusions of primary process material.

Paranoid schizophrenia. In paranoid schizophrenia delusions of a persecutory type dominate thought and behavior; ideas of reference are common and blend with auditory hallucinations. Meg-alomanic delusions relate to ideas of being the focus of widespread plots. The later in life the onset, the more likely it is that the delusions will be systematized and the reaction type approach the condition described under paranoid states. [SeeParanoid Reactions.]

Other subcategories. The current official nomenclature includes a schizoaffective type to cover the numerous patients who display an admixture of schizophrenic and manic-depressive symptoms: if these are considered separate entities, such patients would be suffering from both conditions. However, if schizophrenic reactions are regarded as a type of aberrant development leading to failures of personality integration, other such combined diagnoses will be used. Sociopathic youths can also be more or less schizophrenic; hypochon-driacal neuroses may shift to psychoses with somatic or hypochondriacal delusions; obsessive patients can decompensate with obsessive thoughts becoming increasingly bizarre and delusional. Further, although the typical schizophrenic reactions are readily diagnosed, there are no clear boundaries that delimit the use of the diagnosis.

Those who are reluctant to relinquish the concept of schizophrenia as a progressive deteriorating disease seek to distinguish between process and nonprocess schizophrenia or between schizophrenia and schizophreniform conditions (Langfeldt 1933): the patients who recover or who are amenable to psychotherapy, etc., are not considered as true schizophrenics and supposedly can be distinguished by their premorbid behavior, heredity, and symptomatology—a view not widely shared in the United States.

The diagnosis of pseudoneurotic schizophrenia (Hoch Polatin 1949) is used by some psychiatrists to indicate patients with panneurotic symptomatology who are not amenable to psychotherapy because they are really schizophrenic, but others consider these as “borderline” patients whose neurotic symptoms form a defense against personality disorganization. Borderline schizophrenia refers to patients who maintain a tenuous integration with meager defenses against incursions of primitive impulses and strange primary process material into consciousness.

Childhood schizophrenia refers to cases occurring before adolescence. It is not clear if cases occurring early in childhood are related to the adult condition. Early infantile autism is a puzzling illness that occurs in the first few years of life; the child begins to display peculiar repetitive behavior and regresses, paying little attention to other persons. Some of these children clearly suffer from brain anomalies or brain damage; others have been raised by unempathic, intellectualizing parents. These conditions cannot be discussed adequately in this section. [SeeMental Disorders, article onchildhood mental disorders.]

The confusions concerning nomenclature have been presented because the various terms are in common usage but also because they reflect the difficulties and ambiguities in the field. Terms may be used in the literature with a certainty that can be misleading, leaving the inexperienced person— and even the experienced one—feeling ignorant rather than perplexed when he cannot make a clear-cut diagnosis.

Concepts of etiology

Impairment of brain functioning. The conviction that such profound personality disorganizations, marked by disordered thinking and often progressing to an almost vegetative state of existence, must reflect impairment of brain functioning has led to intensive investigations of post-mortem and biopsy sections of the brain and of every endocrine, toxic, and biochemical factor that might conceivably affect cerebral functioning. The erroneous assumption that insulin coma therapy cured schizophrenia led to an upsurge of such studies in the 1930s and 1940s, and currently the meliorating effects of the phenothiazine drugs have provided renewed impetus. Investigators have again and again reported some biochemical factor they consider specific to schizophrenia, and each of these findings has been invalidated sooner or later. A number of these factors have turned out to be related to such things as dietary inadequacies or are concerned with physiological disturbances secondary to chronic emotional disturbances or to prolonged inactivity or some other influence of chronic hospitalization.

Neuroanatomical investigations. None of the numerous reports of an abnormality of the brain has been validated. The similarities of the personalities and developmental histories of patients with psychomotor epilepsy and schizophrenia form an interesting lead that is under study.

Endocrine investigations. Although the thyroid, pituitary, gonadal, pineal, and adrenal cortical and medullary secretions have all been implicated, no evidence has held up. The intriguing hypothesis that epinephrine undergoes an anomalous breakdown into psychotoxic substances is being pursued (Hoffer 1964), but recent evidence does not bear out the initial enthusiasm.

Biochemical investigations. Recently emphasis has been directed to the study of brain amines and indole excretion, and to psychotogenic agents such as LSD-25 and the supposedly psychotogenic extracts of schizophrenic serum. Various theories relating several such factors have been proposed. Intensive work is advancing knowledge of brain chemistry and fosters hope for future discoveries pertinent to schizophrenia, but recent premature enthusiasms indicate a need for more carefully controlled and validated work before publication. [SeeMental disorders, article onbiological aspects.]

Genetic hypothesis. The high familial incidence of schizophrenia had led to virtual acceptance of the belief that some genetically transmitted factor plays an important role in the etiology of schizophrenia [see mental disorders, article on genetic aspects]. It has been primarily the evidence from twin studies that seemed to demand acceptance of a strong hereditary influence. Until very recently all twin studies reported a much higher concordance rate in identical twins than in same-sexed fraternal twins or siblings—as high as 86 per cent in identical as against 17 per cent in same-sexed fraternal twins. Lately, several investigators noted puzzling inconsistencies in the data. The only two studies of all twins born within a given span of time rather than of samples of hospitalized patients fail to validate the earlier findings. A survey of all male twins born in Finland between 1930 and 1935 found that none of the 16 schizophrenic patients among the identical twins had a schizophrenic co-twin (Tienari 1963). Studies in Norway of an even larger sample, although still incomplete, indicate that concordance rates for identical twins will not be much higher than for same-sexed siblings (Kringlen 1964). It appears as if the striking results of prior twin studies were due to sampling errors and that this basis for the genetic hypothesis of schizophrenia has been badly shaken.

Family environment. A high familial incidence of personality traits or illnesses has often led to erroneous overemphasis of genetic factors. Attention has been directed increasingly to the role of the family environment in producing schizophrenic offspring. Psychoanalytic theory, in considering schizophrenia related to fixations at the oral stage of development, drew attention to failures in the earliest mother-child transactions. As early as 1924, Sullivan emphasized the noxious influence of certain mothers on the development of their schizophrenic sons, both directly and because of their attitudes toward their husbands (1924-1933). Considerable etiologic significance has been given to the “schizophrenogenic mother” who is either aloof, unempathic, and unable to cathect in the child properly or, more typically, cannot establish boundaries between herself and the child, engulfing and controlling a child she needs to complete her life. Studies since 1949 (Lidz et al. 1965) have revealed deficiencies and abnormalities in the total intrafamilial environment. The fathers are frequently just as severely disturbed as the mothers. The family is split by enduring conflict between the parents in which each demolishes the worth of the other to the children, or the family transactions are distorted because one parent acquiesces to the spouse’s strange ways of rearing children and patterning the family life. The generation roles within the family are confused in a variety of ways such as parental rivalry with a child or parental dependency upon an immature child, including heterosexual or homosexual incestuous proclivities. Parents fail to adhere to their respective sex-linked roles, either because of homosexual tendencies or through reversing maternal and paternal roles, or because a mother cannot fill an affectional-expressive role or a father an instrumental role. The parent of the same sex as the child who becomes schizophrenic does not form an adequate model for identification, a situation that is often aggravated because this parent’s worth is undercut by the spouse.

Communication within the family is always disturbed and often clearly irrational or paralogical. The intrafamilial culture may deviate markedly from that of the society into which the child must eventually emerge. These families teach or indirectly inculcate irrationality, providing a poor foundation in reality testing and for understanding verbal and nonverbal communications outside of the family. The schizophrenic patient’s siblings are almost always seriously affected: more are psychotic than are reasonably well-integrated, and with rare exception their occasional “normality” is achieved at the price of serious constriction of the personality.

The finding that schizophrenic patients always grow up in seriously disturbed families forms the most consistent lead concerning the etiology of schizophrenia. Essentially similar phenomena have been reported by research groups in many different countries. In conceptualizing how such disturbed family transactions can lead to schizophrenia in an offspring, some investigators focus primarily upon how the disturbed patterns of communication foster the schizophrenic thought disorder. The “double bind” hypothesis (Bateson et al. 1956) notes how the patient is habitually caught in a bind because a parent covertly sends conflicting messages that perplex and paralyze, causing him to be rebuffed whichever way he responds; or he is caught between the opposing needs and demands of his two parents, and satisfying either parent provokes rejection by the other. Various other communication problems have been noted: the ways in which the child is taught to deny or ignore what should be obvious; the distortions of meanings to support a parent’s tenuous emotional equilibrium; the fostering of distrust in the utility of verbal communications; the teaching of eccentric or delusional beliefs; the blurring of the system of meanings and constructs by inconsistent reinforcement by parents, etc. (Lidz et al. 1965). The amorphous or fragmented nature of the thinking and communicating of one or both parents has been carefully documented (Wynne Singer 1963). Studies of the family communication patterns clarify why the patient suffers from a thought disorder and how such resultant impairments in thinking and communicating create profound disturbances in ego functioning.

The family disturbances, however, clearly affect the child’s development deleteriously in other significant ways. A broader approach to the problem takes cognizance of how failures of parental nur-turance, particularly the mother’s difficulties in relating to the child, interfere with the development of adequate autonomy; how the disturbances in the family structure distort the structuring of the child’s personality by improper channeling of drives, through confusing child and parent roles, by creating confusions in sexual identity, by impeding proper resolution of the oedipal situation, etc.; as well as of how parents’ failure to transmit adequately basic adaptive or instrumental techniques of the culture, including its system of meanings, impairs ego functioning and socializing capacities (Lidz et al. 1965).

The family studies have thus far been largely exploratory, paving the way for the formulation of hypotheses that are now being studied with more rigorous methodology. Although not definitive, they have served to move research concerning the etiology of schizophrenia out of the frustrating whirlpool in which it had been caught. Many puzzling aspects of schizophrenia now seem far more comprehensible. The findings interdigitate with those of other approaches, such as studies of the relationship between social class and incidence of schizophrenia, twin studies, and psychoanalytic concepts of developmental dynamics. The knowledge gained from these studies has also had a marked impact upon therapy, particularly through drawing attention to the need to consider the family as a unit rather than simply to focus upon the individual patient.

Therapy

Despite the absence of any specific method of treatment, marked changes have taken place in the therapy of schizophrenic patients since 1940. Perhaps the most important change has been the gradual but progressive abandonment of the defeatist attitude concerning schizophrenia that had pervaded most of psychiatry since the mid-nineteenth century. Although debates have waged concerning the value of insulin coma, electroshock, frontal lobotomy, milieu therapy, and various forms of individual and group psychotherapy, psychiatrists and other personnel finding something they could do or try to do became interested in the patients, and the patients responded. It became apparent to increasing numbers of psychiatrists that schizophrenic patients need not follow a downhill course, and that many of the extreme manifestations were products of neglect and virtual abandonment in impersonal institutions. The enormity of the problem of caring for and attempting to treat the masses of institutionalized patients has been overwhelming, and adequate treatment for any other than selected patients has had to await reorganizations of hospital systems and the training of the necessary personnel.

Therapeutic efforts must be suited to the patient, the facilities available, and the therapist’s abilities. Whereas the prognosis for schizophrenic reactions collectively is generally discouraging, the outlook for the individual patient, particularly if treatment begins soon after symptoms appear and intensive care can be provided, may be regarded hopefully.

“Organic” treatments. Although insulin coma therapy, introduced in 1933, did much to revive interest in the treatment of schizophrenic patients, it has now been virtually discarded, its apparent efficacy having resulted from the increased attention to patients it required. Electric convulsive treatments are of occasional value as a means of quieting extremely excited patients. Various tran-quilizing drugs, particularly the phenothiazines, have largely replaced other “organic” treatments. The phenothiazines serve to lessen anxiety and agitation and probably diminish distraction by extraneous stimuli and primary process intrusions. Trifluoperazine may be particularly useful in diminishing hallucinations. An array of psychotropic drugs is now available, and opinions differ as to the merits of each. Properly controlled experiments on the relative worth of these medications are extremely difficult to conduct. It seems reasonably certain that many patients can return to or remain in the community largely because of these agents. A major influence of tranquilizing drugs has been indirect; they have helped quiet the wards in mental institutions and provided a means of controlling seriously disturbed patients. This has helped produce great changes in mental hospitals through unlocking doors, permitting patients greater freedom, and allowing the staff time and opportunity to improve the therapeutic milieu. [SeeMental disorders, treatment of, article Onsomatic treatment.]

Milieu therapy. Establishing a suitable therapeutic hospital milieu has altered the prognosis for schizophrenic patients as much as the tranquilizing drugs, but in all except certain select institutions, reorganization had to await the quieting effects of the shock therapies and then the tranquilizers. Milieu therapy seeks to counter schizophrenic patients’ tendencies to withdraw; it also fosters socialization, promotes responsibility, and provides retraining in interpersonal relationships. The therapy includes a gamut of measures ranging from discarding restraints; minimizing isolation; giving attentive care and interest; fostering socializing, educational, and occupational activities; and providing group therapy to holding patient-staff meetings and setting up patient government to provide channels of communication and to encourage responsibility for the self and others. Opening the doors of hospitals has a salutary influence and can markedly change the attitudes of both patients and staff, but some patients who are afraid of their impulsivity, aggressions, or suicidal tendencies feel more secure and can socialize more readily when protected within a limited area until they are ready to assume responsibility for their actions.

As schizophrenic patients tend to regress, withdraw, and become passively dependent in institutions, there has been a movement to return such patients to the community as soon as feasible or to attempt to keep them out of hospitals altogether. On the other hand, efforts are often made to promote early hospitalization, for the chances of recovery are greater if treatment starts before symptoms become well established and if the patient can be removed from a pathogenic environment. The paradox revolves around the nature of the treatment a hospital can offer; optimally a hospital should be able to counter regressive tendencies. As yet, relatively few institutions can provide intensive care and treatment that seeks to promote essential- personality change rather than mere remission from a psychotic state.

Psychotherapy. Establishing a relationship to another person often—perhaps always—provides the impetus and forms the bridge for the schizophrenic patient’s return from psychotic withdrawal. The crux of the initial phases of psychotherapeutic work with these patients is the therapist’s use of himself to gain the patient’s trust and willingness to risk relating again despite the shattering dis-illusionments of the past. A persistent warm and honest interest by an untrained person may suffice and succeed where a highly trained but intel-lectualized and uncommitted therapist fails. Schizophrenic patients are usually highly sensitive to pretense, to being used by another person, and to another person’s withdrawal in the face of their intense needs or their hostilities. Usually, however, considerable skill and understanding of schizophrenic patients are required. Trust follows upon understanding, understanding requires communication, and the therapist faces the task of establishing communication across barriers imposed by the patient’s idiosyncratic language usage, his personalized metaphor, his efforts to conceal and yet convey, the delusions and hallucinatory interruptions, and the projections of the patient’s thoughts and feelings onto the therapist, etc. The therapist must be prepared and able to counter or weather the patient’s flights into withdrawal, particularly when the patient feels on the verge of trusting and becoming involved—setbacks that test the therapist’s commitment. Bringing a patient out of his psychotic regression and withdrawal can be a very real and rewarding achievement, but something that often occurs without specific psychotherapy; the process is more successful when the therapist is a focal point in a proper therapeutic milieu that counters the patient’s regression in many ways than when the emphasis is solely upon the individual psychotherapy.

Psychotherapy of schizophrenia usually implies more than bringing the patient out of the psychotic episode or into socially acceptable behavior. It often involves the effort to promote profound personality changes through psychoanalytically oriented interpersonal transactions. Such work with schizophrenic patients differs markedly from the analysis of psychoneurotic patients. It seeks to strengthen ego functioning through fostering a more cohesive identity, firmer boundaries between the self and others, and control of primitive impulses. Treatment almost always includes extensive re-evaluation of parental figures and efforts to modify the sway of sabotaging parental introjects. The intense nature of the transference relationship once it is established, together with the frangibility of the relationship, places great demands upon the therapist. It is a task for highly skilled therapists with specific experience and training in the field and will not be discussed here. The effectiveness of intensive psychotherapy with schizophrenic patients cannot be evaluated in statistical terms: the belief in its value derives from the excellent results obtained with a number of individuals and from the meaningfulness of the material gained in the process. Much depends on the specific therapist as well as on the specific patient. The aims of such work are directed in part toward the future—to increasing knowledge and improving techniques. [SeeClinical Psychology; Mental Disorders, Treatment of, especially the article onPsychological Treatment; Psychiatry.]

Family therapy. Recent advances in understanding of the pathology in the schizophrenic’s family of origin have brought the family into the therapeutic efforts in a variety of ways. Social workers or psychiatrists have worked with parents individually or in groups to allay their anxiety and guilt; to counter the common tendency of parents to interfere with or disrupt the patient’s therapy; to modify the parents’ attitudes toward each other as well as toward the patient; and to foster more direct and forthright communication. With some families a major effort is made to prevent exclusion of a hospitalized patient and withdrawal of interest in him and in others to help prevent disintegration of the family after the patient has been hospitalized. Conjoint family therapy in which parents and patient or the entire family are seen in group sessions has been found advantageous. The therapist has an opportunity to view directly the nature of the disturbed relationships and communications; the patient may gain a new perception of his parents and an appreciation of their limitations and idiosyncrasies; and other family members may recognize their own roles in provoking or continuing the patient’s illness, gain insights concerning the family transactions, and begin to relate differently. Although some psychiatrists consider conjoint family therapy to be the optimal treatment procedure, others use it as an important adjunct to alternative therapeutic measures.

Perspective

The disagreements between virtually all schools of psychiatry concerning the nature and etiology of schizophrenia have interfered with the presentation of a coherent and cohesive approach to the problem. Although schizophrenia is traditionally considered a disease of unknown etiology, a great deal is now known about the developmental problems and the dynamic psychopathology of these patients and about the family environments that tend to produce them. Man is unique in the degree that his adaptation rests on a lengthy period of dependency upon parental figures during which he must assimilate the instrumental techniques of his culture to implement his inborn adaptive capacities. There are countless chances for misdirection, confusion, and conflict to arise in the process. The very mechanism that permits his inordinate adaptability contains a major vulnerability. He depends upon language and a coherent way of thinking to guide him into the future and on an ability to communicate to enable collaborative interaction. Yet linguistic meanings and a system of logic are not inborn but acquired as a means of problem solving by communication with others and by sorting out life experiences. How correctly meanings are learned and how firmly they become ingrained depend largely on the parental tutors—the consistency of their communications as an aid to problem solving and the emotional relationships between parents and child. There are countless ways in which the enculturation process can go wrong. When a person is caught in insoluble conflicts, when a path into the future is barred, when even regression serves little because the persons upon whom one could depend are distrusted or feared, there is still a way. One can alter the perception of his own needs and motives and those of others. One can abandon causal logic, change his internal representation of events, retreat to a period of childhood when reality gave way to fantasy, and cut off movement toward a realistic future; that is, one can become schizophrenic. This path is so clearly open to man, particularly to those who have had confused or confusing guides to follow into adulthood and have received poor foundations in meaning systems and reality testing, or who have actually been trained to irrational ways in childhood, that conditions such as schizophrenia must be expected as anomalies of the human developmental process. The acceptance of such a theory that schizophrenic reactions result from anomalous socialization processes and that the family forms the primary enculturating agency provides numerous guides for research and therapy, and it directs the psychiatrist toward increased collaboration with behavioral scientists.

Theodore Lidz

[Directly related are the entriesMental disorders; Psychosis. Other relevant material may be found inMental disorders, treatment of; Psychiatry; Psychoanalysis; and in the biographies ofKraepelin; Meyer; Sullivan.]

BIBLIOGRAPHY

Alanen, Y. O. 1958 The Mothers of Schizophrenic Patients: A Study of the Personality and the Mother-Child Relationship of 100 Mothers and the Significance of These Factors in the Pathogenesis of Schizophrenia in Comparison With Heredity. Acta psychiatrica scandinavica 33 (Supplement 124).

Akieti, Silvano 1955 Interpretation of Schizophrenia. New York: Brunner. A readable and cogent presentation of a modern dynamic approach.

Bateson, Gregory et al. 1956 Toward a Theory of Schizophrenia. Behavioral Science 1:251-264.

Bellak, Leopold (editor) 1958 Schizophrenia: A Review of the Syndrome. New York: Logos. Reviews work in the field between 1946 and 1956; contains 4,000 references.

Bleuler, Eugen (1911) 1950 Dementia Praecox: Or, the Group of Schizophrenias. New York: International Universities Press. Still an outstanding work on the topic. Includes an extensive BIBLIOGRAPHY to 1950. First published as “Dementia Praecox oder die Gruppe der Schizophrenien” in Aschaffenburg’s Handbuch der Psychiatric.

Brody, Eugene B.; and Redlich, F. C. (editors) 1952 Psychotherapy With Schizophrenics. New York: International Universities Press.

Brooke, Eileen M. 1959 National Statistics in the Epidemiology of Mental Illness. Journal of Mental Science 105:893—908. Now called the British Journal of Psychiatry. CAMERON, NORMAN A. 1938 Reasoning, Regression and Communication in Schizophrenics. Psychological Monographs. Vol. 50, no. 1. Columbus, Ohio: Ohio State University. -* A classic study of schizophrenic thinking.

Delay, Jean; Denikeh, P.; and Green, A. 1957-1962 Le milieu familial des schizophrenes. 3 parts. En-cephale 46:189-232; 49:1-21; 51:5-73. Part 1: Position du probleme, 1957. Part 2: Methodes d’ap-proche, 1960. Part 3: Resultats et hypotheses, 1962.

Freeman, Thomas; Cameron, John L.; and McGhie, Andrew 1958 Chronic Schizophrenia. New York: International Universities Press.

Fromm-Reichmann, Frieda 1948 Notes on the Development of Treatment of Schizophrenics by Psychoanalytic Psychotherapy. Psychiatry 11:263-273.

Hoch, Paul; and Polatin, Phillip 1949 Pseudoneu-rotic Forms of Schizophrenia. Psychiatric Quarterly 23:248-276.

Hoffer, Abram 1964 The Adrenochrome Theory of Schizophrenia: A Review. Diseases of the Nervous System 25:173-178.

Hollingshead, August B.; and Reduce, F. C. 1958 Social Class and Mental Illness: A Community Study. New York: Wiley.

Jackson, Don D. (editor) 1960 The Etiology of Schizophrenia. New York: Basic Books. → An excellent collection of papers on various contemporary theories.

Kasanin, J. S. (editor) 1944 Language and Thought in Schizophrenia. Berkeley and Los Angeles: Univ. of California Press. Brief articles by various authorities that can serve as an introduction to the topic.

Kringlen, Einar 1964 Schizophrenia in Male Monozy-gotic Twins. Acta psychiatrica scandinavica 40 (Supplement 178):1-76.

Langfeldt, G. 1933 Some Points Regarding the Symptomatology and Diagnosis of Schizophrenia. Acta psychiatrica et neurologica scandinavica Supplement 80:7—26. → Now called Acta psychiatrica scandinavica.

Lemkau, Paul V.; and Crocetti, Guroo M. 1958 Vital Statistics of Schizophrenia. Pages 64-81 in Leopold Bellak (editor), Schizophrenia: A Review of the Syndrome. New York: Logos.

Lidz, Theodore; Fleck, Stephen; and Coknelison, Alice R. 1965 Schizophrenia and the Family. New York: International Universities Press. → Collected papers of an intensive study of the intrafamilial environment of schizophrenic patients.

Meyer, Adolf (1896-1937)1951 Collected Papers. Volume 2: Psychiatry. Baltimore: Johns Hopkins Press. For the origins of the genetic-dynamic approach, see the chapters “Dementia Praecox” and “Paranoia” on pages 413-560.

Rees, W. Linford 1957 Physical Characteristics of the Schizophrenic Patient. Pages 1-14 in Derek Richter (editor), Schizophrenia: Somatic Aspects. London: Pergamon.

Die Schizophrenie. 1932 Volume 9, special part 5 in Karl Wilmanns (editor), Handbuch der Geistes-krankheiten. Berlin: Springer. An authoritative source for the German approach in the Kraepelinian tradition. Contains an outstanding BIBLIOGRAPHY.

Singer, Margaret T.; and Wynne, Lyman C. 1965a Thought Disorder and Family Relations of Schizophrenics: III. Methodology Using Protective Techniques. Archives of General Psychiatry 12:187-200.

Singer, Margaret T.; and WYNNE, LYMAN C. 1965b Thought Disorder and Family Relations of Schizophrenics: IV. Results and Implications. Archives of General Psychiatry 12:201-212.

Sullivan, Harry Stack (1924-1933) 1962 Schizophrenia as a Human Process. New York: Norton.

Symposium international sur la psychotherapie de la schizophrenic. 1957 Acta psychotherapeutica, psychosomatica et orthopaedagogica 5:99-360.

Symposium ON Schizophrenia, San Francisco, 1958 1959 Schizophrenia: An Integrated Approach. Edited by Alfred Auerbach. New York: Ronald Press.

Tienari, P. 1963 Psychiatric Illnesses in Identical Twins. Acta psychiatrica scandinavica 39 (Supplement 171). The whole supplement is devoted to Tienari’s study.

World Congress OF Psychiatry, Second, Zurich, 3957 1959 Report. 4 vols. Zurich: Fiissli.

Wynne, Lyman C.; and Singer, Margaret T. 1963 Thought Disorder and Family Relations of Schizophrenics. 2 parts. Archives of General Psychiatry 9: 191-206. → Part 1: A Research Strategy. Part 2: A Classification of Forms of Thinking.

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Schizophrenia

Schizophrenia

Definition

Schizophrenia is the most chronic and disabling of the severe mental disorders, associated with abnormalities of brain structure and function, disorganized speech and behavior, delusions , and hallucinations . It is sometimes called a psychotic disorder or a psychosis .

Description

People diagnosed with schizophrenia do not always have the same set of symptoms; in addition, a given patient's symptoms may change over time. Since the nineteenth century, doctors have recognized different subtypes of the disorder, but no single classification system has gained universal acceptance. Some psychiatrists prefer to speak of schizophrenia as a group or family of disorders ("the schizophrenias") rather than as a single entity. A standard professional reference, The Diagnostic and Statistical Manual of Mental Disorders (also known as the DSM-IV-TR) acknowledges that its present classification of subtypes is not fully satisfactory for either clinical or research purposes, and states that "alternative subtyping schemes are being actively investigated."

The symptoms of schizophrenia can appear at any time after age six or seven, although onset during adolescence and early adult life is the most common pattern. There are a few case studies in the medical literature of schizophrenia in children younger than five, but they are extremely rare. Schizophrenia that appears after age 45 is considered late-onset schizophrenia. About 1%2% of cases are diagnosed in patients over 80.

The onset of symptoms in schizophrenia may be either abrupt (sudden) or insidious (gradual). Often, however, it goes undetected for about two to three years after the onset of diagnosable symptoms, because the symptoms occur in the context of a previous history of cognitive and behavioral problems. The patient may have had panic attacks, social phobia , or substance abuse problems, any of which can complicate the process of diagnosis . In most cases, however, the patient's first psychotic episode is preceded by a prodromal (warning) phase, with a variety of behaviors that may include angry outbursts, withdrawal from social activities, loss of attention to personal hygiene and grooming, anhedonia (loss of one's capacity for enjoyment), and other unusual behaviors. The psychotic episode itself is typically characterized by delusions, which are false but strongly held beliefs that result from the patient's inability to separate real from unreal events; and hallucinations, which are disturbances of sense perception. Hallucinations can affect any of the senses, although the most common form of hallucination in schizophrenia is auditory ("hearing voices"). Autobiographical accounts by people who have recovered from schizophrenia indicate that these hallucinations are experienced as frightening and confusing. Patients often find it difficult to concentrate on work, studies, or formerly pleasurable activities because of the constant "static" or "buzz" of hallucinated voices.

There is no "typical" pattern or course of the disorder following the first acute episode. The patient may never have a second psychotic episode; others have occasional episodes over the course of their lives but can lead fairly normal lives otherwise. About 70% of patients diagnosed with schizophrenia have a second psychotic breakdown within five to seven years after the first one.

Some patients remain chronically ill; of these, some remain at a fairly stable level while others grow steadily worse and become severely disabled.

About 20% of patients with schizophrenia recover the full level of functioning that they had before the onset of the disorder, according to NIMH statistics; but the remaining 80% have problems reintegrating into mainstream society. These patients are often underachievers in school and in the workplace, and they usually have difficulty forming healthy relationships with others. The majority (60%70%) of patients with schizophrenia do not marry or have children, and most have very few friends or social contacts. The impact of these social difficulties as well as the stress caused by the symptoms themselves is reflected in the high suicide rate among patients with schizophrenia. About 10% commit suicide within the first 10 years after their diagnosis a rate 20 times higher than that of the general population.

Subtypes of schizophrenia

DSM-IV-TR specifies five subtypes of schizophrenia:

  • Paranoid type. The central feature of this subtype is the presence of auditory hallucinations or delusions alongside relatively unaffected mood and cognitive functions. The patient's delusions usually involve persecution, grandiosity, or both. About a third of patients diagnosed with schizophrenia in the United States belong to this subtype.
  • Disorganized type. The core features of this subtype include disorganized speech, disorganized behavior, and flat or inappropriate affect. The person may lose the ability to perform most activities of daily living, and may also make faces or display other oddities of behavior. This type of schizophrenia was formerly called hebephrenic (derived from the Greek word for puberty), because some of the patients' behaviors resemble adolescent silliness.
  • Catatonic type. Catatonia refers to disturbances of movement, whether remaining motionless for long periods of time or excessive and purposeless movement. The absence of movement may take the form of catalepsy, which is a condition in which the patient's body has a kind of waxy flexibility and can be repositioned by others; or negativism, a form of postural rigidity in which the patient resists being moved by others. A catatonic patient may assume bizarre postures or imitate the movements of other people.
  • Undifferentiated type. Patients in this subtype have some of the characteristic symptoms of schizophrenia but do not meet the full criteria for the paranoid, disorganized, or catatonic subtypes.
  • Residual type. Patients in this category have had at least one psychotic episode, continue to have some negative symptoms of schizophrenia, but do not have current psychotic symptoms.

Cultural variables

There appear to be some differences across cultures in the symptoms associated with schizophrenia. The catatonic subtype appears to be more common in non-Western countries than in Europe or North America. Other studies indicate that persons diagnosed with schizophrenia in developing countries have a more acute onset of the disorder but better outcomes than patients in the developed countries.

Causes and symptoms

Causes

As of 2002, schizophrenia is considered the end result of a combination of genetic, biochemical, developmental, and environmental factors, some of which are still not completely understood. There is no known single cause of the disorder.

GENETIC. Researchers have known for many years that first-degree biological relatives of patients with schizophrenia have a 10% risk of developing the disorder, as compared with 1% in the general population. The monozygotic (identical) twin of a person with schizophrenia has a 40%50% risk. The fact that this risk is not higher, however, indicates that environmental as well as genetic factors are implicated in the development of schizophrenia.

Some specific regions on certain human chromosomes have been linked to schizophrenia. In late 2001, a multidisciplinary team of researchers reported positive associations for schizophrenia on chromosomes 15 and 13. Chromosome 15 is linked to schizophrenia in European-American families as well as some Taiwanese and Portuguese families. A recent study of the biological pedigrees found among the inhabitants of Palau (an isolated territory in Micronesia) points to chromosomes 2 and 13. Still another team of researchers has suggested that a disorder known as 22q deletion syndrome may actually represent a subtype of schizophrenia, insofar as people with this syndrome have a 25% risk of developing schizophrenia. At present scientists are inclined to think that the genetic factors underlying schizophrenia vary across different ethnic groups, so that it is highly unlikely that susceptibility to the disorder is determined by only one gene. As of 2002, schizophrenia is considered a polygenic disorder.

There appears to be a connection between aging and genetic mutations that increases susceptibility to schizophrenia. A recent Israeli study found that the age of a person's father is a risk factor for schizophrenia; the older the father, the higher the rate of mutations in sperm cells. The child of a father older than 50 is three times more likely to develop schizophrenia than children born to younger men. The researchers suggest that mutations in the sperm cells of older men help to explain why schizophrenia has persisted in the human population even though few schizophrenics marry and have children.

DEVELOPMENTAL. As of 2002, there is some evidence that schizophrenia may be a type of developmental disorder related to the formation of faulty connections between nerve cells during fetal development. The changes in the brain that normally occur during puberty then interact with these connections to trigger the symptoms of the disorder. Other researchers have suggested that a difficult childbirth may result in developmental vulnerabilities that eventually lead to schizophrenia.

NEUROBIOLOGICAL. In early 2002, researchers at the NIMH demonstrated the existence of a connection between two abnormalities of brain functioning in patients with schizophrenia. The researchers used radioactive tracers and positron emission tomography (PET) to show that reduced activity in a part of the brain called the prefrontal cortex was associated in the patients, but not in the control subjects, with abnormally elevated levels of dopamine in the striatum. High levels of dopamine are related to the delusions and hallucinations of psychotic episodes in schizophrenia. The findings suggest that treatment directed at the prefrontal cortex might be more effective than present antipsychotic medications, which essentially target dopamine levels without regard to specific areas of the brain.

Another area of investigation concerns abnormalities in brain structure that are found in some patients with schizophrenia. One of these abnormalities is the increased size of the ventricles, which are cavities in the interior of the brain filled with cerebrospinal fluid. Another is a decrease in size of some areas of the brain. A California study of MRI scans of teenagers with early-onset schizophrenia found that they lost over 10% of the gray matter of the brain over the course of five years. The frontal eye fields showed the most rapid rate of tissue lossabout 5% per year. A major difficulty in interpreting these findings is that these abnormalities are not found in the brains of all patients with schizophrenia. In addition, they sometimes occur in the brains of people who do not have the disorder.

ENVIRONMENTAL. Certain environmental factors during pregnancy are associated with an increased risk of schizophrenia in the offspring. These include the mother's exposure to starvation or famine; influenza during the second trimester of pregnancy; and Rh incompatibility in a second or third pregnancy.

Some researchers are investigating a possible connection between schizophrenia and viral infections of the hippocampus, a structure in the brain that is associated with memory formation and the human stress response. It is thought that damage to the hippocampus might account for the sensory disturbances found in schizophrenia. Another line of research related to viral causes of schizophrenia concerns a protein deficiency in the brain. Researchers at the University of Kiel in Germany think that the deficiency is the result of viral infections.

Environmental stressors related to home and family life (parental death or divorce, family dysfunction) or to separation from the family of origin in late adolescence (going away to college or military training; marriage) may trigger the onset of schizophrenia in individuals with genetic or psychological vulnerabilities.

Symptoms

The symptoms of schizophrenia are divided into two major categories: positive symptoms , which are defined by DSM-IV-TR as excesses or distortions of normal mental functions; and negative symptoms , which represent a loss or reduction of normal functioning. Of the two types, the negative symptoms are more difficult to evaluate because they may be influenced by a concurrent depression or a dull and unstimulating environment, but they account for much of the morbidity (unhealthiness) associated with schizophrenia.

POSITIVE SYMPTOMS. The positive symptoms of schizophrenia include four so-called "first-rank" or Schneiderian symptoms, named for a German psychiatrist who identified them in 1959:

  • Delusions. A delusion is a false belief that is resistant to reason or to confrontation with actual facts. The most common form of delusion in patients with schizophrenia is persecutory; the person believes that others family members, clinical staff, terrorists, etc.are "out to get" them. Another common delusion is referential, which means that the person interprets objects or occurrences in the environment (a picture on the wall, a song played on the radio, laughter in the corridor, etc.) as being directed at or referring to them.
  • Somatic hallucinations. Somatic hallucinations refer to sensations or perceptions about one's body organs that have no known medical cause, such as feeling that snakes are crawling around in one's intestines or that one's eyes are emitting radioactive rays.
  • Hearing voices commenting on one's behavior or talking to each other. Auditory hallucinations are the most common form of hallucination in schizophrenia, although visual, tactile, olfactory, and gustatory hallucinations may also occur. Personal accounts of recovery from schizophrenia often mention "the voices" as one of the most frightening aspects of the disorder.
  • Thought insertion or withdrawal. These terms refer to the notion that other beings or forces (God, aliens from outer space, the CIA, etc.) can put thoughts or ideas into one's mind or remove them.

Other positive symptoms of schizophrenia include:

  • Disorganized speech and thinking. A person with schizophrenia may ramble from one topic to another (derailment or loose associations); may give unrelated answers to questions (tangentiality); or may say things that cannot be understood because there is no grammatical structure to the language ("word salad" or incoherence).
  • Disorganized behavior. This symptom includes such behaviors as agitation; age-inappropriate silliness; inability to maintain personal hygiene; dressing inappropriately for the weather; sexual self-stimulation in public; shouting at people, etc. In one case study, the patient played his flute for hours on end while standing on top of the family car.
  • Catatonic behavior. Catatonic behaviors have been described with regard to the catatonic subtype of schizophrenia. This particular symptom is sometimes found in other mental disorders.

NEGATIVE SYMPTOMS. The negative symptoms of schizophrenia include:

  • Blunted or flattened affect. This term refers to loss of emotional expressiveness. The person's face may be unresponsive or expressionless, and speech may lack vitality or warmth.
  • Alogia. Alogia is sometimes called poverty of speech. The person has little to say and is not able to expand on their statements. A doctor examining the patient must be able to distinguish between alogia and unwillingness to speak.
  • Avolition. The person is unable to begin or stay with goal-directed activities. They may sit in one location for long periods of time or show little interest in joining group activities.
  • Anhedonia. Anhedonia refers to the loss of one's capacity for enjoyment or pleasure.

OTHER SYMPTOMS AND CHARACTERISTICS. Although the following symptoms and features are not diagnostic criteria of schizophrenia, most patients with the disorder have one or more:

  • Dissociative symptoms, particularly depersonalization and derealization.
  • Anosognosia. This term originally referred to the inability of stroke patients to recognize their physical disabilities, but is sometimes used to refer to lack of insight in patients with schizophrenia. Anosognosia is associated with higher rates of noncompliance with treatment, a higher risk of repeated psychotic episodes, and a poorer prognosis for recovery.
  • High rates of substance abuse disorders. About 50% of patients diagnosed with schizophrenia meet criteria for substance abuse or dependence. While substance abuse does not cause schizophrenia, it can worsen the symptoms of the disorder. Patients may have particularly bad reactions to amphetamines , cocaine, PCP ("angel dust") or marijuana. It is thought that patients with schizophrenia are attracted to drugs of abuse as self-medication for some of their symptoms. The most common substance abused by patients with schizophrenia is tobacco; 90% of patients are heavy cigarette smokers, compared to 25%30% in the general adult population. Smoking is a serious problem for people with schizophrenia because it interferes with the effectiveness of their antipsychotic medications as well as increasing their risk of lung cancer and other respiratory diseases.
  • High risk of suicide . About 40% of patients with schizophrenia attempt suicide at least once, and 10% eventually complete the act.
  • High rates of obsessive-compulsive disorder and panic disorder.
  • Downward drift. Downward drift is a sociological term that refers to having lower levels of educational achievement and/or employment than one's parents.

VIOLENT BEHAVIOR. The connection between schizophrenia and personal assault or violence deserves mention because it is a major factor in the reactions of family members and the general public to the diagnosis. Researchers in both the United Kingdom and the United States have found that schizophrenia carries a heavier stigma than most other mental disorders, largely because of the mass media's fascination with bizarre murders, dismemberment of animals, or other gruesome acts committed by people with schizophrenia. Many patients report that the popular image of a schizophrenic as "a time bomb waiting to explode" is a source of considerable emotional stress.

Risk factors for violence in a patient diagnosed with schizophrenia include male sex, age below 30, prediagnosis history of violence, paranoid subtype, nonadherence to medication regimen, and heavy substance abuse. On the other hand, it should be noted that most crimes of violence are committed by people without a diagnosis of schizophrenia. In addition, a study of patients with schizophrenia living in the community found that "... individuals in this sample were at least 14 times more likely to be victims of a violent crime than to be arrested for one."

Demographics

In the United States, Canada, and Western Europe, the sex ratio in schizophrenia is 1.2:1, with males being affected slightly more often than females. There is a significant gender difference in average age at onset, however; the average for males is between ages 18 and 25, whereas for women there are two peaks, one between ages 25 and 35, and a second rise in incidence after age 45. About 15% of all women who develop schizophrenia are diagnosed after age 35. In some women, the first symptoms of the disorder appear postpartum (after giving birth). Many women with schizophrenia are initially misdiagnosed as having depression or bipolar disorder , because women with schizophrenia are likely to have more difficulties with emotional regulation than men with the disorder. In general, however, females have higher levels of functioning prior to symptom onset than males.

The incidence of schizophrenia in the United States appears to be uniform across racial and ethnic groups, with the exception of minority groups in urban neighborhoods in which they are a small proportion of the total population. A recent study done in the United Kingdom replicated American findings: there are significantly higher rates of schizophrenia among racial minorities living in large cities. The rates of schizophrenia are highest in areas in which these minority groups form the smallest proportion of the local population. The British study included Africans, Caribbeans of African descent, and Asians.

The incidence of schizophrenia in most developed countries appears to be higher among people born in cities than among those born in rural areas. In addition, there appears to be a small historical/generational factor, with the incidence of schizophrenia gradually declining in later-born groups.

Schizophrenia is a leading cause of disability, not only in the United States, but in other developed countries around the world. In 1997, the World Health Organization (WHO) listed schizophrenia as the world's ninth leading cause of disability. According to the National Institute of Mental Health (NIMH), 2.2 million American adults, or 1.1% of the population over age 18, suffer from schizophrenia. Other estimates run as high as 1.5% of the population.

Schizophrenia is disproportionately costly to society for reasons that go beyond the sheer number of people affected by the disorder. Although patients with schizophrenia are little more than 1% of the population, they account for 2.5% of all health care costs$40 billion per year in the United States, $2.35 billion in Canada (in Canadian dollars), and 2.6 billion pounds sterling (about $7.28 billion in US dollars) in Great Britain. In the United States, patients with schizophrenia fill 25% of all hospital beds and account for about 20% of all Social Security disability days.

In addition, the onset of the disorder typically occurs during a young person's last years of high school or their first years in college or the workforce; thus it often destroys their long-term plans for their future. According to the federal Agency for Healthcare Research and Quality, 70%80% of people diagnosed with schizophrenia are either unemployed or underemployed (working in jobs well below their actual capabilities). Ten percent of Americans with permanent disabilities have schizophrenia, as well as 20%30% of the homeless population.

Diagnosis

There are no symptoms that are unique to schizophrenia and no single symptom that is a diagnostic hallmark of the disorder. In addition, as of 2002 there are no laboratory tests or imaging studies that can establish or confirm a diagnosis of schizophrenia. The diagnosis is based on a constellation or group of related symptoms that are, according to DSM-IV-TR, "associated with impaired occupational or social functioning."

As part of the process of diagnosis, the doctor will take a careful medical history and order laboratory tests of the patient's blood or urine in order to rule out general medical conditions or substance abuse disorders that may be accompanied by disturbed behavior. X rays or other imaging studies of the head may also be ordered. Medical conditions to be ruled out include epilepsy, head trauma, brain tumor, Cushing's syndrome, Wilson's disease, Huntington's disease, and encephalitis. Drugs of abuse that may cause symptoms resembling schizophrenia include amphetamines ("speed"), cocaine, and phencyclidine (PCP). In older patients, dementia and delirium must be ruled out. If the patient has held jobs involving exposure to mercury, polychlorinated biphenyls (PCBs), or other toxic substances, environmental poisoning must also be considered in the differential diagnosis.

The doctor must then rule out other mental disorders that may be accompanied by psychotic symptoms, such as mood disorders; brief psychotic disorders; dissociative disorder not otherwise specified or dissociative identity disorder ; delusional disorder ; schizotypal, schizoid, or paranoid personality disorders ; and pervasive developmental disorders . In children, childhood-onset schizophrenia must be distinguished from communication disorders with disorganized speech and from attention-deficit/hyperactivity disorder .

After the doctor has ruled out other organic and mental disorders, he or she must then determine whether the patient meets the following criteria, as specified by DSM-IV-TR :

  • Presence of positive and negative symptoms. The patient must have two (or more) of the following symptoms during a one-month period: delusions; hallucinations; disorganized speech; disorganized or catatonic behavior; negative symptoms.
  • Decline in social, interpersonal, or occupational functioning, including personal hygiene or self-care.
  • Duration. The symptomatic behavior must last for at least six months.

Treatments

Current treatment of schizophrenia focuses on symptom reduction and relapse prevention, since the causes of the disorder have not yet been clearly identified. Unfortunately, not all patients with schizophrenia receive adequate treatment. In 2000, the NIMH released the results of a large-scale community study, which indicated that fewer than half of patients with schizophrenia receive correct dosages of their medications or adequate psychosocial treatment.

Medications

Medications are the mainstay of treatment for schizophrenia. Drug therapy for the disorder, however, is complicated by several factors: the unpredictability of a given patient's response to specific medications, the number of potentially troublesome side effects, the high rate of substance abuse among patients with schizophrenia, and the possibility of drug interactions between antipsychotic medications and antidepressants or other medications that may be prescribed for the patient.

NEUROLEPTICS. The first antipsychotic medications for schizophrenia were introduced in the 1950s, and known as dopamine antagonists, or DAs. They are sometimes called neuroleptics, and include haloperidol (Haldol), chlorpromazine (Thorazine), perphenazine (Trilafon), and fluphenazine (Prolixin). About 40% of patients, however, fail to respond to treatment with these medications. Neuroleptics can control most of the positive symptoms of schizophrenia as well as reduce the frequency and severity of relapses but they have little effect on negative symptoms. In addition, these medications have problematic side effects, ranging from dry mouth, blurry vision, and restlessness (akathisia) to such long-term side effects as tardive dyskinesia (TD). TD is a disorder characterized by involuntary movements of the mouth, lips, arms, or legs; it affects about 15%20% of patients who have been receiving neuroleptic medications over a period of years. Discomfort related to these side effects is one reason why 40% of patients treated with the older antipsychotics do not adhere to their medication regimens.

ATYPICAL ANTIPSYCHOTICS. The atypical antipsychotics are newer medications introduced in the 1990s. They are sometimes called serotonin dopamine antagonists, or SDAs. These medications include clozapine (Clozaril), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), and olanzapine (Zyprexa). These newer drugs are more effective in treating the negative symptoms of schizophrenia and have fewer side effects than the older antipsychotics. Clozapine has been reported to be effective in patients who do not respond to neuroleptics, and to reduce the risk of suicide attempts. The atypical antipsychotics, however, do have weight gain as a side effect; and patients taking clozapine must have their blood monitored periodically for signs of agranulocytosis, or a drop in the number of white blood cells. These drugs are now considered first-line treatments for patients having their first psychotic episode.

OTHER PRESCRIPTION MEDICATIONS. Patients with schizophrenia have a lifetime prevalence of 80% for major depression; others suffer from phobias or other anxiety disorders. The doctor may prescribe antidepressants or a short course of benzodiazepines along with antipsychotic medications.

Inpatient treatment

Patients with schizophrenia are usually hospitalized during acute psychotic episodes, to prevent harm to themselves or to others, and to begin treatment with antipsychotic medications. A patient having a first psychotic episode is usually given a computed tomography (CT) or magnetic resonance imaging (MRI) scan to rule out structural brain disease.

Outpatient treatment

In recent years, patients with schizophrenia who have been stabilized on antipsychotic medications have been given psychosocial therapies of various types to assist them with motivation, self-care, and forming relationships with others. In addition, because many patients have had their education or vocational training interrupted by the onset of the disorder, they may be helped by therapies directed toward improving their social functioning and work skills.

Specific outpatient treatments that have been used with patients with schizophrenia include:

  • Rehabilitation programs. These programs may offer vocational counseling, job training, problem-solving and money management skills, use of public transportation, and social skills training .
  • Cognitive-behavioral therapy and supportive psychotherapy .
  • Family psychoeducation . This approach is intended to help family members understand the patient's illness, cope with the problems it creates for other family members, and minimize stresses that may increase the patient's risk of relapse.
  • Self-help groups . These groups provide mutual support for family members as well as patients. They can also serve as advocacy groups for better research and treatment, and to protest social stigma and employment discrimination.

Alternative and complementary therapies

Alternative and complementary therapies that are being investigated for the treatment of schizophrenia include gingko biloba , an Asian shrub, and vitamin therapy. One Chinese study reported that a group of patients who had not responded to conventional antipsychotic medications benefited from a thirteen-week trial of gingko extract, with significantly fewer side effects. Vitamin therapy is recommended by naturopathic practitioners on the grounds that many hospitalized patients with schizophrenia suffer from nutritional deficiencies. The supplements recommended include folic acid, niacin, vitamin B6, and vitamin C.

Prognosis

The prognosis for patients diagnosed with schizophrenia varies. About 20% recover their previous level of functioning, while another 10% achieve significant and lasting improvement. About 30%35% show some improvement with intermittent relapses and some disabilities, while the remainder are severely and permanently incapacitated. Factors associated with a good prognosis include relatively good functioning prior to the first psychotic episode; a late or sudden onset of illness; female sex; treatment with antipsychotic medications shortly after onset; good compliance with treatment; a family history of mood disorders rather than schizophrenia; minimal cognitive impairment; and a diagnosis of paranoid or nondeficit subtype. Factors associated with a poor prognosis include early age of onset; a low level of prior functioning; delayed treatment; heavy substance abuse; noncompliance with treatment; a family history of schizophrenia; and a diagnosis of disorganized or deficit subtype with many negative symptoms.

Prevention

The multifactorial and polygenic etiology (origins or causes) of schizophrenia complicates the search for preventive measures against the disorder. It is possible that the complete mapping of the human genome will identify a finite number of genes that contribute to susceptibility to schizophrenia. The NIMH has presently compiled the world's largest registry of families affected by schizophrenia in order to pinpoint specific genes for further study. The NIMH also sponsors a Prevention Research Initiative to identify points in the development of schizophrenia at which patients could benefit from the application of preventive efforts.

See also Medication-induced movement disorders

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.

Friedrich, Otto. Going Crazy: An Inquiry Into Madness in Our Time. New York: Avon Books, 1977.

Martin, John H., PhD. Neuroanatomy: Text and Atlas. Second edition. Norwalk, CT: Appleton and Lange, 1996.

North, Carol S., MD. Welcome Silence: My Triumph Over Schizophrenia. New York: Simon and Schuster, Inc.,1989.

Pelletier, Kenneth R., MD. "CAM Therapies for Specific Conditions: Schizophrenia." In The Best Alternative Medicine, Part II. New York: Simon and Schuster, 2002.

"Schizophrenia and Related Disorders." Section 15, Chapter 193 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

Wahl, Otto F. Telling Is Risky Business: Mental Health Consumers Confront Stigma. New Brunswick, NJ: Rutgers University Press, 1999.

PERIODICALS

AACAP Council. "Practice Parameter for the Assessment and Treatment of Children and Adolescents with Schizophrenia." Journal of the American Academy of Child and Adolescent Psychiatry 40 (July 2001 Supplement): 4S23S.

Barrowclough, Christine, Gillian Haddock, Nicholas Tarrier, and others. "Randomized Controlled Trial of Motivational Interviewing, Cognitive Behavior Therapy, and Family Intervention for Patients with Comorbid Schizophrenia and Substance Use Disorders." American Journal of Psychiatry 158 (October 2001): 17061713.

Bassett, A. S., S. O'Neill, J. Murphy, and others. "Expression of Schizophrenic Symptoms in 22q Deletion Syndrome." American Journal of Human Genetics 69 (October2001): 287.

Bower, Bruce. "Back from the Brink (Therapies for Schizophrenia)." Science News 159 (April 28, 2001): 268.

Boydell, J., J. van Os, K. McKenzie, and others. "Incidence of Schizophrenia in Ethnic Minorities in London: Ecological Study Into Interactions With the Environment." British Medical Journal 323 (December 8, 2001): 13361338.

Brekke, John S. "Risks for Individuals with Schizophrenia Who Are Living in the Community." Journal of the American Medical Association 286 (December 19, 2001): 2922.

Camp, Nicola J., Susan L. Neuhausen, Josepha Tiobech, and others. "Genomewide Multipoint Linkage Analysis of Seven Extended Palauan Pedigrees with Schizophrenia, by a Markov-Chain Monte Carlo Method." American Journal of Human Genetics 69 (December 2001): 12781289.

"Consider Clozapine for Reducing Suicide Risk in Schizophrenia." Clinical Psychiatry News 29 (November2001): 22.

Cormac, I., C. Jones, C. Campbell. "Cognitive Behaviour Therapy for Schizophrenia (Cochrane Review)." Cochrane Database Systems Review (2002): CD000524.

Fisher, Daniel B. "Recovering from Schizophrenia." (Guest Editorial). Clinical Psychiatry News 29 (November 2001): 30.

Frangou, Sophia. "How to Manage the First Episode of Schizophrenia: Early Diagnosis and Treatment May Prevent Social Disability Later." British Medical Journal 321 (September 2, 2000): 522.

Jancin, Bruce. "Women Often Defy Schizophrenia's Classic Course." Clinical Psychiatry News 29 (October 2001): 30.

Lehman, A. F., R. Goldberg, L. B. Dixon, and others. "Improving Employment Outcomes for Persons with Severe Mental Illness." Archives of General Psychiatry 59 (February 2002): 165172.

McGrath, John. "Treatment of Schizophrenia." British Medical Journal 319 (October 16, 1999): 10451083.

"MRI Reveals Brain Changes Associated with Schizophrenia." Mental Health Weekly 11 (October 1,2001): 8.

Myin-Germeys I., L. Krabbendam, J. Jolles, and others. "Are Cognitive Impairments Associated with Sensitivity to Stress in Schizophrenia? An Experience Sampling Study." American Journal of Psychiatry 159 (March 2002): 443449.

Nakaya, M., K. Kusumoto, K. Ohmori. "Subjective Experiences of Japanese Inpatients with Chronic Schizophrenia." Journal of Nervous and Mental Disorders 190 (February 2002): 8085.

"Old Fathers and Schizophrenia." Harvard Mental Health Letter 18 (October 2001).

Ross, Brendan. "Novel Antipsychotic Drugs in the Management of Schizophrenia." Drug Topics (May 7,2001): 7284.

"Schizophrenia May Be Linked to Brain Protein Deficiency." Mental Health Weekly 11 (November 19, 2001): 7.

Swofford, Cheryl D. "Double Jeopardy: Schizophrenia and Substance Abuse." American Journal of Drug and Alcohol Abuse 26 (August 2000): 343.

Weiser, Mark, Avraham Reichenberg, Jonathan Rabinowitz, and others. "Association Between Nonpsychotic Psychiatric Diagnoses in Adolescent Males and Subsequent Onset of Schizophrenia." Archives of General Psychiatry 58 (October 2001): 959964.

Werbach, Melvyn R. "Vitamins for Treating Schizophrenia." Townsend Letter for Doctors and Patients (April 2001): 5560.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007.(202) 966-7300. Fax: (202) 966-2891. <www.aacap.org>.

The National Alliance for the Mentally Ill (NAMI). 200 North Glebe Road, Suite 1015, Arlington, VA 22203-3754.(800) 950-NAMI or (703) 524-7600. <www.nami.org>.

National Alliance for Research on Schizophrenia and Depression (NARSAD). 60 Cutter Mill Road, Suite 404, Great Neck, NY 11021. (516) 829-0091. <www.mhsource.com>.

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <www.nimh.nih.gov>.

National Mental Health Association (NMHA). 1021 Prince Street, Alexandria, VA 22314-2971. (800) 969-6942 or(703) 684-7722. <www.nmha.org>.

OTHER

National Institute of Mental Health (NIMH). The Numbers Count. NIH Publication No. 01-4584 (2000). <www.nimh.nih.gov/publicat/numbers.cfm>.

National Institutes of Health (NIH). News Release, January 28, 2002. "Scans Link 2 Key Pieces of Schizophrenia Puzzle." <www.nih.gov/news/pr/jan2002/nimh-28.htm>.

Rebecca J. Frey, Ph.D.

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Schizophrenia

Schizophrenia

Definition

Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming.

The prevalence of schizophrenia is thought to be about 1% of the population around the world; it is thus more common than diabetes, Alzheimer's disease, or multiple sclerosis. In the United States and Canada, patients with schizophrenia fill about 25% of all hospital beds. The disorder is considered to be one of the top ten causes of long-term disability worldwide.

Description

The course of schizophrenia in adults can be divided into three phases or stages. In the acute phase, the patient has an overt loss of contact with reality (psychotic episode) that requires intervention and treatment. In the second or stabilization phase, the initial psychotic symptoms have been brought under control but the patient is at risk for relapse if treatment is interrupted. In the third or maintenance phase, the patient is relatively stable and can be kept indefinitely on antipsychotic medications. Even in the maintenance phase, however, relapses are not unusual and patients do not always return to full functioning.

The English term schizophrenia comes from two Greek words that mean "split mind." It was observed around 1908, by a Swiss doctor named Eugen Bleuler, to describe the splitting apart of mental functions that he regarded as the central characteristic of schizophrenia.

Recently, some psychotherapists have begun to use a classification of schizophrenia based on two main types. People with Type I, or positive schizophrenia, have a rapid (acute) onset of symptoms and tend to respond well to drugs. They also tend to suffer more from the "positive" symptoms, such as delusions and hallucinations. People with Type II, or negative schizophrenia, are usually described as poorly adjusted before their schizophrenia slowly overtakes them. They have predominantly "negative" symptoms, such as withdrawal from others and a slowing of mental and physical reactions (psychomotor retardation).

There are five subtypes of schizophrenia:

Paranoid

The key feature of this subtype of schizophrenia is the combination of false beliefs (delusions) and hearing voices (auditory hallucinations), with more nearly normal emotions and cognitive functioning (cognitive functions include reasoning, judgment, and memory). The delusions of paranoid schizophrenics usually involve thoughts of being persecuted or harmed by others or exaggerated opinions of their own importance, but may also reflect feelings of jealousy or excessive religiosity. The delusions are typically organized into a coherent framework. Paranoid schizophrenics function at a higher level than other subtypes, but are at risk for suicidal or violent behavior under the influence of their delusions.

Disorganized

Disorganized schizophrenia (formerly called hebephrenic schizophrenia) is marked by disorganized speech, thinking, and behavior on the patient's part, coupled with flat or inappropriate emotional responses to a situation (affect). The patient may act silly or withdraw socially to an extreme extent. Most patients in this category have weak personality structures prior to their initial acute psychotic episode.

Catatonic

Catatonic schizophrenia is characterized by disturbances of movement that may include rigidity, stupor, agitation, bizarre posturing, and repetitive imitations of the movements or speech of other people. These patients are at risk for malnutrition, exhaustion, or self-injury. This subtype is presently uncommon in Europe and the United States. Catatonia as a symptom is most commonly associated with mood disorders.

Undifferentiated

Patients in this category have the characteristic positive and negative symptoms of schizophrenia but do not meet the specific criteria for the paranoid, disorganized, or catatonic subtypes.

Residual

This category is used for patients who have had at least one acute schizophrenic episode but do not presently have strong positive psychotic symptoms, such as delusions and hallucinations. They may have negative symptoms, such as withdrawal from others, or mild forms of positive symptoms, which indicate that the disorder has not completely resolved.

The risk of schizophrenia among first-degree biological relatives is ten times greater than that observed in the general population. Furthermore the presence of the same disorder is higher in monozygotic twins (identical twins) than in dizygotic twins (nonidentical twins). The research concerning adoption studies and identical twins also supports the notion that environmental factors are important, because not all relatives who have the disorder express it. There are several chromosomes and loci (specific areas on chromosomes which contain mutated genes), which have been identified. Research is actively ongoing to elucidate the causes, types and variations of these mutations.

Most patients are diagnosed in their late teens or early twenties, but the symptoms of schizophrenia can emerge at any age in the life cycle. The male/female ratio in adults is about 1.2:1. Male patients typically have their first acute episode in their early twenties, while female patients are usually closer to age 30 when they are recognized with active symptoms.

Schizophrenia is rarely diagnosed in preadolescent children, although patients as young as five or six have been reported. Childhood schizophrenia is at the upper end of the spectrum of severity and shows a greater gender disparity. It affects one or two children in every 10,000; the male/female ratio is 2:1.

Causes and symptoms

Theories of causality

One of the reasons for the ongoing difficulty in classifying schizophrenic disorders is incomplete understanding of their causes. It is thought that these disorders are the end result of a combination of genetic, neurobiological, and environmental causes. A leading neurobiological hypothesis looks at the connection between the disease and excessive levels of dopamine, a chemical that transmits signals in the brain (neurotransmitter). The genetic factor in schizophrenia has been underscored by recent findings that first-degree biological relatives of schizophrenics are ten times as likely to develop the disorder as are members of the general population.

Prior to recent findings of abnormalities in the brain structure of schizophrenic patients, several generations of psychotherapists advanced a number of psychoanalytic and sociological theories about the origins of schizophrenia. These theories ranged from hypotheses about the patient's problems with anxiety or aggression to theories about stress reactions or interactions with disturbed parents. Psychosocial factors are now thought to influence the expression or severity of schizophrenia rather than cause it directly.

As of 2004, migration is a social factor that is known to influence people's susceptibility to psychosis. Psychiatrists in Europe have noted the increasing rate of schizophrenia and other psychotic disorders among immigrants to almost all Western European countries. Black immigrants from Africa or the Caribbean appear to be especially vulnerable. The stresses involved in migration include family breakup, the need to adjust to living in large urban areas, and social inequalities in the new country.

Another hypothesis suggests that schizophrenia may be caused by a virus that attacks the hippocampus, a part of the brain that processes sense perceptions. Damage to the hippocampus would account for schizophrenic patients' vulnerability to sensory overload. As of 2004, researchers are focusing on the possible role of the herpes simplex virus (HSV) in schizophrenia, as well as human endogenous retroviruses (HERVs). The possibility that HERVs may be associated with schizophrenia has to do with the fact that antibodies to these retroviruses are found more frequently in the blood serum of patients with schizophrenia than in serum from control subjects.

Symptoms of schizophrenia

Patients with a possible diagnosis of schizophrenia are evaluated on the basis of a set or constellation of symptoms; there is no single symptom that is unique to schizophrenia. In 1959, the German psychiatrist Kurt Schneider proposed a list of so-called first-rank symptoms, which he regarded as diagnostic of the disorder.

These symptoms include:

  • delusions
  • somatic
  • hallucinations
  • hearing voices commenting on the patient's behavior
  • thought insertion or thought withdrawal

Somatic hallucinations refer to sensations or perceptions concerning body organs that have no known medical cause or reason, such as the notion that one's brain is radioactive. Thought insertion and/or withdrawal refer to delusions that an outside force (for example, the FBI, the CIA, Martians, etc.) has the power to put thoughts into one's mind or remove them.

POSITIVE SYMPTOMS. The positive symptoms of schizophrenia are those that represent an excessive or distorted version of normal functions. Positive symptoms include Schneider's first-rank symptoms as well as disorganized thought processes (reflected mainly in speech) and disorganized or catatonic behavior. Disorganized thought processes are marked by such characteristics as looseness of associations, in which the patient rambles from topic to topic in a disconnected way; tangentially, which means that the patient gives unrelated answers to questions; and "word salad," in which the patient's speech is so incoherent that it makes no grammatical or linguistic sense. Disorganized behavior means that the patient has difficulty with any type of purposeful or goal-oriented behavior, including personal self-care or preparing meals. Other forms of disorganized behavior may include dressing in odd or inappropriate ways, sexual self-stimulation in public, or agitated shouting or cursing.

NEGATIVE SYMPTOMS. Schizophrenia includes three so-called negative symptoms. They are called negative because they represent the lack or absence of behaviors. The negative symptoms that are considered diagnostic of schizophrenia are a lack of emotional response (affective flattening), poverty of speech, and absence of volition or will. In general, the negative symptoms are more difficult for doctors to evaluate than the positive symptoms.

Diagnosis

A doctor must make a diagnosis of schizophrenia on the basis of a standardized list of outwardly observable symptoms, not on the basis of internal psychological processes. There are no specific laboratory tests that can be used to diagnose schizophrenia. Researchers have, however, discovered that patients with schizophrenia have certain abnormalities in the structure and functioning of the brain compared to normal test subjects. These discoveries have been made with the help of imaging techniques such as computed tomography scans (CT scans).

When a psychiatrist assesses a patient for schizophrenia, he or she will begin by excluding physical conditions that can cause abnormal thinking and some other behaviors associated with schizophrenia. These conditions include organic brain disorders (including traumatic injuries of the brain), temporal lobe epilepsy, Wilson's disease, prion diseases, Huntington's chorea, and encephalitis. The doctor will also need to rule out heavy metal poisoning and substance abuse disorders, especially amphetamine use.

After ruling out organic disorders, the clinician will consider other psychiatric conditions that may include psychotic symptoms or symptoms resembling psychosis. These disorders include mood disorders with psychotic features; delusional disorder; dissociative disorder not otherwise specified (DDNOS) or multiple personality disorder ; schizotypal, schizoid, or paranoid personality disorders ; and atypical reactive disorders. In the past, many individuals were incorrectly diagnosed as schizophrenic. Some patients who were diagnosed prior to the changes in categorization should have their diagnoses, and treatment, reevaluated. In children, the doctor must distinguish between psychotic symptoms and a vivid fantasy life, and also identify learning problems or disorders. After other conditions have been ruled out, the patient must meet a set of criteria specified:

  • the patient must have two (or more) of the following symptoms during a one-month period: delusions; hallucinations; disorganized speech; disorganized or catatonic behavior; negative symptoms
  • decline in social, interpersonal, or occupational functioning, including self-care
  • the disturbed behavior must last for at least six months
  • mood disorders, substance abuse disorders, medical conditions, and developmental disorders have been ruled out

Treatment

The treatment of schizophrenia depends in part on the patient's stage or phase. Psychotic symptoms and behaviors are considered psychiatric emergencies, and persons showing signs of psychosis are frequently taken by family, friends, or the police to a hospital emergency room. A person diagnosed as psychotic can be legally hospitalized against his or her will, particularly if he or she is violent, threatening to commit suicide, or threatening to harm another person. A psychotic person may also be hospitalized if he or she has become malnourished or ill as a result of failure to feed, dress appropriately for the climate, or otherwise take care of him- or herself.

A patient having a first psychotic episode should be given a CT or MRI (magnetic resonance imaging ) scan to rule out structural brain disease.

Antipsychotic medications

The primary form of treatment of schizophrenia is antipsychotic medication. Antipsychotic drugs help to control almost all the positive symptoms of the disorder. They have minimal effects on disorganized behavior and negative symptoms. Between 60-70% of schizophrenics will respond to antipsychotics. In the acute phase of the illness, patients are usually given medications by mouth or by intramuscular injection. After the patient has been stabilized, the antipsychotic drug may be given in a long-acting form called a depot dose. Depot medications last for two to four weeks; they have the advantage of protecting the patient against the consequences of forgetting or skipping daily doses. In addition, some patients who do not respond to oral neuroleptics have better results with depot form. Patients whose long-term treatment includes depot medications are introduced to the depot form gradually during their stabilization period. Most people with schizophrenia are kept indefinitely on antipsychotic medications during the maintenance phase of their disorder to minimize the possibility of relapse.

As of the early 2000s, the most frequently used antipsychotics fall into two classes: the older dopamine receptor antagonists, or DAs, and the newer serotonin dopamine antagonists, or SDAs. (Antagonists block the action of some other substance; for example, dopamine antagonists counteract the action of dopamine.) The exact mechanisms of action of these medications are not known, but it is thought that they lower the patient's sensitivity to sensory stimuli and so indirectly improve the patient's ability to interact with others.

DOPAMINE RECEPTOR ANTAGONIST. The dopamine antagonists include the older antipsychotic (also called neuroleptic) drugs, such as haloperidol (Haldol), chlorpromazine (Thorazine), and fluphenazine (Prolixin). These drugs have two major drawbacks: it is often difficult to find the best dosage level for the individual patient, and a dosage level high enough to control psychotic symptoms frequently produces extrapyramidal side effects, or EPS. EPSs include parkinsonism, in which the patient cannot walk normally and usually develops a tremor; dystonia, or painful muscle spasms of the head, tongue, or neck; and akathisia, or restlessness. A type of long-term EPS is called tardive dyskinesia, which features slow, rhythmic, automatic movements. Schizophrenics with AIDS are especially vulnerable to developing EPS.

SEROTONIN DOPANINE ANTAGONISTS. The serotonin dopamine antagonists, also called atypical antipsychotics, are newer medications that include clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa). The SDAs have a better effect on the negative symptoms of schizophrenia than do the older drugs and are less likely to produce EPS than the older compounds. The newer drugs are significantly more expensive in the short term, although the SDAs may reduce long-term costs by reducing the need for hospitalization. They are also presently unavailable in injectable forms. The SDAs are commonly used to treat patients who respond poorly to the DAs. However, many psychotherapists now regard the use of these atypical antipsychotics as the treatment of first choice; in particular, clozapine appears to be more effective than other antipsychotics in controlling persistent aggression in some patients.

NEWER DRUGS. Some newer antipsychotic drugs have been approved by the Food and Drug administration (FDA) in the early 2000s. These drugs are sometimes called second-generation antipsychotics or SGAs. Aripiprazole (Abilify), which is classified as a partial dopaminergic agonist, received FDA approval in August 2003. Two drugs that are still under investigation, a neurokinin antagonist and a serotonin 2A/2C antagonist respectively, show promise in the treatment of schizophrenia and schizoaffective disorder.

Psychotherapy

Most schizophrenics can benefit from psychotherapy once their acute symptoms have been brought under control by antipsychotic medication. Psychoanalytic approaches are not recommended. Behavior therapy, however, is often helpful in assisting patients to acquire skills for daily living and social interaction. It can be combined with occupational therapy to prepare the patient for eventual employment.

Family therapy

Family therapy is often recommended for the families of schizophrenic patients, to relieve the feelings of guilt that they often have as well as to help them understand the patient's disorder. The family's attitude and behaviors toward the patient are key factors in minimizing relapses (for example, by reducing stress in the patient's life), and family therapy can often strengthen the family's ability to cope with the stresses caused by the schizophrenic's illness. Family therapy focused on communication skills and problem-solving strategies is particularly helpful. In addition to formal treatment, many families benefit from support groups and similar mutual help organizations for relatives of schizophrenics.

Prognosis

One important prognostic sign is the patient's age at onset of psychotic symptoms. Patients with early onset of schizophrenia are more often male, have a lower level of functioning prior to onset, a higher rate of brain abnormalities, more noticeable negative symptoms, and worse outcomes. Patients with later onset are more likely to be female, with fewer brain abnormalities and thought impairment, and more hopeful prognoses.

The average course and outcome for schizophrenics are less favorable than those for most other mental disorders, although as many as 30% of patients diagnosed with schizophrenia recover completely and the majority experience some improvement. Two factors that influence outcomes are stressful life events and a hostile or emotionally intense family environment. Schizophrenics with a high number of stressful changes in their lives, or who have frequent contacts with critical or emotionally over-involved family members, are more likely to relapse. Overall, the most important component of long-term care of schizophrenic patients is complying with their regimen of antipsychotic medications.

KEY TERMS

Affective flattening A loss or lack of emotional expressiveness. It is sometimes called blunted or restricted affect.

Akathisia Agitated or restless movement, usually affecting the legs and accompanied by a sense of discomfort. It is a common side effect of neuroleptic medications.

Catatonic behavior Behavior characterized by muscular tightness or rigidity and lack of response to the environment. In some patients rigidity alternates with excited or hyperactive behavior.

Delusion A fixed, false belief that is resistant to reason or factual disproof.

Depot dosage A form of medication that can be stored in the patient's body tissues for several days or weeks, thus minimizing the risk of the patient forgetting daily doses. Haloperidol and fluphenazine can be given in depot form.

Dopamine receptor antagonists (DAs) The older class of antipsychotic medications, also called neuroleptics. These primarily block the site on nerve cells that normally receive the brain chemical dopamine.

Dystonia Painful involuntary muscle cramps or spasms.

Extrapyramidal symptoms (EPS) A group of side effects associated with antipsychotic medications. EPS include parkinsonism, akathisia, dystonia, and tardive dyskinesia.

First-rank symptoms A set of symptoms designated by Kurt Schneider in 1959 as the most important diagnostic indicators of schizophrenia. These symptoms include delusions, hallucinations, thought insertion or removal, and thought broadcasting. First-rank symptoms are sometimes referred to as Schneiderian symptoms.

Hallucination A sensory experience of something that does not exist outside the mind. A person can experience a hallucination in any of the five senses. Auditory hallucinations are a common symptom of schizophrenia.

Huntington's chorea A hereditary disease that typically appears in midlife, marked by gradual loss of brain function and voluntary movement. Some of its symptoms resemble those of schizophrenia.

Negative symptoms Symptoms of schizophrenia characterized by the absence or elimination of certain behaviors. DSM-IV specifies three negative symptoms: affective flattening, poverty of speech, and loss of will or initiative.

Neuroleptic Another name for the older type of antipsychotic medications given to schizophrenic patients.

Parkinsonism A set of symptoms originally associated with Parkinson disease that can occur as side effects of neuroleptic medications. The symptoms include trembling of the fingers or hands, a shuffling gait, and tight or rigid muscles.

Positive symptoms Symptoms of schizophrenia that are characterized by the production or presence of behaviors that are grossly abnormal or excessive, including hallucinations and thought-process disorder. DSM-IV subdivides positive symptoms into psychotic and disorganized.

Poverty of speech A negative symptom of schizophrenia, characterized by brief and empty replies to questions. It should not be confused with shyness or reluctance to talk.

Psychotic disorder A mental disorder characterized by delusions, hallucinations, or other symptoms of lack of contact with reality. The schizophrenias are psychotic disorders.

Serotonin dopamine antagonist (SDA) The newer second-generation antipsychotic drugs, also called atypical antipsychotics. SDAs include clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa).

Wilson disease A rare hereditary disease marked by high levels of copper deposits in the brain and liver. It can cause psychiatric symptoms resembling schizophrenia.

Word salad Speech that is so disorganized that it makes no linguistic or grammatical sense.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, D.C.: American Psychiatric Association, 2000.

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Psychiatric Emergencies." Section 15, Chapter 194 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Schizophrenia and Related Disorders." Section 15, Chapter 193 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Wilson, Billie Ann, Margaret T. Shannon, and Carolyn L. Stang. Nurse's Drug Guide 2003. Upper Saddle River, NJ: Prentice Hall, 2003.

PERIODICALS

DeLeon, A., N. C. Patel, and M. L. Crismon. "Aripiprazole: A Comprehensive Review of Its Pharmacology, Clinical Efficacy, and Tolerability." Clinical Therapeutics 26 (May 2004): 649-666.

Frankenburg, Frances R., MD. "Schizophrenia." eMedicine June 17, 2004. http://www.emedicine.com/med/topic2072.htm.

Hutchinson, G., and C. Haasen. "Migration and Schizophrenia: The Challenges for European Psychiatry and Implications for the Future." Social Psychiatry and Psychiatric Epidemiology 39 (May 2004): 350-357.

Meltzer, H. Y., L. Arvanitis, D. Bauer, et al. "Placebo-Controlled Evaluation of Four Novel Compounds for the Treatment of Schizophrenia and Schizoaffective Disorder." American Journal of Psychiatry 161 (June 2004): 975-984.

Mueser, K. T., and S. R. McGurk. "Schizophrenia." Lancet 363 (June 19, 2004): 2063-2072.

Volavka, J., P. Czobor, K. Nolan, et al. "Overt Aggression and Psychotic Symptoms in Patients with Schizophrenia Treated with Clozapine, Olanzapine, Risperidone, or Haloperidol." Journal of Clinical Psychopharmacology 24 (April 2004): 225-228.

Yolken, R. "Viruses and Schizophrenia: A Focus on Herpes Simplex Virus." Herpes 11, Supplement 2 (June 2004): 83A-88A.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. http://www.psych.org.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Suite 300 Arlington, VA 22201. (703) 524-7600 HelpLine: (800) 950-NAMI. http://www.nami.org/.

National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. http://www.nimh.nih.gov.

Schizophrenics Anonymous. 15920 W. Twelve Mile, Southfield, MI 48076. (248) 477-1983.

United States Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857-0001. (888) INFOFDA. http://www.fda.gov.

OTHER

"Schizophrenia." Internet Mental Health. http://www.mentalhealth.com/dis/p20-ps01.html.

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Schizophrenia

Schizophrenia

Definition

Schizophrenia is a psychotic disorder (or group of disorders) marked by severely impaired thinking, emotions, and behaviors. The term schizophrenia comes from two Greek words that mean "split mind." It was coined around 1908 by a Swiss doctor named Eugen Bleuler to describe the splitting apart of mental functions that he regarded as the central characteristic of schizophrenia. (Note that the splitting apart of mental functions in schizophrenia differs from the split personality of people with multiple personality disorder.) Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming.

Although schizophrenia was described by doctors as far back as Hippocrates (500 b.c.), it is difficult to classify. Many writers prefer the plural terms schizophrenias or schizophrenic disorders to the singular schizophrenia because of the lack of agreement in classification, as well as the possibility that different subtypes may eventually be shown to have different causes.

Description

The schizophrenic disorders are a major social tragedy because of the large number of persons affected and the severity of their impairment. It is estimated that people who suffer from schizophrenia fill 50% of the hospital beds in psychiatric units and 25% of all hospital beds. A number of studies indicate that about 1% of the world's population is affected by schizophrenia, without regard to race, social class, level of education, or cultural influences. (However, outcome may vary from culture to culture, depending on the familial support of the patient.) Most patients are diagnosed in their late teens or early 20s, but the symptoms of schizophrenia can emerge at any point in the life cycle. The male/female ratio in adults is about 1.2:1. Males typically have their first acute episode in their late teens or early 20s, while females are usually well into their 20s when diagnosed.

Schizophrenia is rarely diagnosed in preadolescent children, although patients as young as five or six have been reported. Childhood schizophrenia is at the upper end of the spectrum of severity and shows a greater gender disparity. It affects one or two children in every 10,000; the male/female ratio is 2:1.

The course of schizophrenia in adults can be divided into three phases or stages. In the acute phase, the patient has an overt loss of contact with reality (psychotic episode) that requires intervention and treatment. In the second or stabilization phase, the initial psychotic symptoms have been brought under control but the patient is at risk for relapse if treatment is interrupted. In the third or maintenance phase, the patient is relatively stable and can be kept indefinitely on antipsychotic medications. Even in the maintenance phase, however, relapses are not unusual and patients do not always return to full functioning.

Recently, some psychiatrists have begun to use a classification of schizophrenia based on two main types. People with Type I, or positive schizophrenia, have a rapid (acute) onset of symptoms and tend to respond well to drugs. They also tend to suffer more from the positive symptoms, such as delusions and hallucinations. People with Type II, or negative schizophrenia, are usually described as poorly adjusted before their schizophrenia slowly overtakes them. They have predominantly negative symptoms, such as withdrawal from others and a slowing of mental and physical reactions (psychomotor retardation).

The fourth revised (2000) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ) specifies five subtypes of schizophrenia:

Paranoid

The key feature of this subtype of schizophrenia is the combination of false beliefs (delusions) and hearing voices (auditory hallucinations), with more nearly normal emotions and cognitive functioning. (Cognitive functions include reasoning, judgment, and memory.) The delusions of paranoid schizophrenics usually involve thoughts of being persecuted or harmed by others or exaggerated opinions of their own importance, but may also reflect feelings of jealousy or excessive religiosity. The delusions are typically organized into a coherent framework. Paranoid schizophrenics function at a higher level than other subtypes, but are at risk for suicidal or violent behavior under the influence of their delusions.

Disorganized

Disorganized schizophrenia (formerly called hebephrenic schizophrenia) is marked by disorganized speech, thinking, and behavior on the patient's part, coupled with flat or inappropriate emotional responses to a situation (affect). The patient may act silly or withdraw socially to an extreme extent. Most patients in this category have weak personality structures prior to their initial acute psychotic episode.

Catatonic

Catatonic schizophrenia is characterized by disturbances of movement that may include rigidity, stupor, agitation, bizarre posturing, and repetitive imitations of the movements or speech of other people. These patients are at risk for malnutrition, exhaustion, or self-injury. This subtype is presently uncommon in Europe and the United States. Catatonia as a symptom is most commonly associated with mood disorders.

Undifferentiated

Patients in this category have the characteristic positive and negative symptoms of schizophrenia but do not meet the specific criteria for the paranoid, disorganized, or catatonic subtypes.

Residual

This category is used for patients who have had at least one acute schizophrenic episode but do not presently have such strong positive psychotic symptoms as delusions and hallucinations. They may have negative symptoms, such as withdrawal from others, or mild forms of positive symptoms, which indicate that the disorder has not completely resolved.

Causes & symptoms

One of the reasons for the ongoing difficulty in classifying schizophrenic disorders is incomplete understanding of their causes. It is thought that these disorders are the end result of a combination of genetic, neurobiological, and environmental causes. A leading neurobiological hypothesis looks at the connection between the disease and excessive levels of dopamine, a chemical that transmits signals in the brain (neurotransmitter). The genetic factor in schizophrenia has been underscored by recent findings that first-degree biological relatives of schizophrenics are 10 times as likely to develop the disorder as are members of the general population.

Prior to recent findings of abnormalities in the brain structure of schizophrenic patients, several generations of psychiatrists advanced a number of psychoanalytic and sociological theories about the origins of schizophrenia. These theories ranged from hypotheses about the patient's problems with anxiety or aggression to theories about stress reactions or interactions with disturbed parents. Psychosocial factors are now thought to influence the expression or severity of schizophrenia, rather than cause it directly.

Another hypothesis suggests that schizophrenia may be caused by a virus that attacks the hippocampus, a part of the brain that processes sense perceptions. Damage to the hippocampus would account for schizophrenic patients' vulnerability to sensory overload. As of mid-1998, researchers were preparing to test antiviral medications on schizophrenics.

In 2002, scientists at the University of Southern California (UCLA) used a special technique to determine that people with schizophrenia have significantly less gray matter in certain regions of the brain than others, even than their identical twins. This discovery shows that gray matter reductions are partly due to genetics and partly due to environmental factors. It also helps show the difficulty schizophrenic patients face in focusing and organizing information in their brains. The scientists hope that their work will eventually lead to targeting of exactly how and where gray matter loss occurs so that maybe researchers can develop methods to stop the process and prevent or reduce loss of brain function in those areas.

Patients with a possible diagnosis of schizophrenia are evaluated on the basis of a set or constellation of symptoms; there is no single symptom that is unique to schizophrenia. In 1959, the German psychiatrist Kurt Schneider proposed a list of so-called first-rank symptoms, which he regarded as diagnostic of the disorder:

  • delusions
  • somatic hallucinations
  • hearing voices commenting on behavior
  • thought insertion or withdrawal

Somatic hallucinations refer to sensations or perceptions concerning body organs that have no known medical cause or reason, such as the notion that one's brain is radioactive. Thought insertion and/or withdrawal refer to delusions that an outside force (for example, the FBI, the CIA, Martians, etc.) has the power to put thoughts into one's mind or remove them.

POSITIVE SYMPTOMS. The positive symptoms of schizophrenia are those that represent an excessive or distorted version of normal functions. Positive symptoms include Schneider's first-rank symptoms as well as disorganized thought processes (reflected mainly in speech) and disorganized or catatonic behavior. Disorganized thought processes are marked by such characteristics as looseness of associations, in which the patient rambles from topic to topic in a disconnected way; tangentiality, which means that the patient gives unrelated answers to questions; and word salad, in which the patient's speech is so incoherent that it makes no grammatical or linguistic sense. Disorganized behavior means that the patient has difficulty with any type of purposeful or goal-oriented behavior, including personal self-care or preparing meals. Other forms of disorganized behavior may include dressing in odd or inappropriate ways, sexual self-stimulation in public, or agitated shouting or cursing.

NEGATIVE SYMPTOMS. The DSM-IV definition of schizophrenia includes three so-called negative symptoms. They are called negative because they represent the lack or absence of behaviors. The negative symptoms that are considered diagnostic of schizophrenia are a lack of emotional response (affective flattening), poverty of speech, and absence of volition or will. In general, the negative symptoms are more difficult for doctors to evaluate than the positive symptoms.

Diagnosis

A doctor must make a diagnosis of schizophrenia on the basis of a standardized list of outwardly observable symptoms, not on the basis of internal psychological processes. There are no specific laboratory tests that can be used to diagnose schizophrenia. Researchers have, however, discovered that patients with schizophrenia have certain abnormalities in the structure and functioning of the brain compared to normal test subjects. These discoveries have been made with the help of such imaging techniques as computed tomography (CT) scans, magnetic resonance imaging (MRI), and positron emission tomography (PET) scans.

When a psychiatrist assesses a patient for schizophrenia, he or she will begin by excluding physical conditions that can cause abnormal thinking and some other behaviors associated with schizophrenia. These conditions include organic brain disorders (including traumatic injuries of the brain), temporal lobe epilepsy , Wilson's disease, Huntington's chorea, and encephalitis. The doctor will also need to rule out substance abuse disorders, especially amphetamine use.

After ruling out organic disorders, the doctor will consider other psychiatric conditions that may include psychotic symptoms or symptoms resembling psychosis. These disorders include mood disorders with psychotic features; delusional disorder; dissociative disorder not otherwise specified (DDNOS) or multiple personality disorder; schizotypal, schizoid, or paranoid personality disorders; and atypical reactive disorders. In the past, many individuals were incorrectly diagnosed as schizophrenic. Some patients who were diagnosed prior to the changes in categorization introduced by DSM-IV should have their diagnoses and treatment reevaluated. In children, the doctor must distinguish between psychotic symptoms and a vivid fantasy life, and also identify learning problems or disorders. After other conditions have been ruled out, the patient must meet a set of criteria specified by DSM-IV :

  • Characteristic symptoms. The patient must have two (or more) of the following symptoms during a one-month period: delusions; hallucinations; disorganized speech; disorganized or catatonic behavior; negative symptoms.
  • Decline in social, interpersonal, or occupational functioning, including self-care.
  • Duration. The disturbed behavior must last for at least six months.
  • Diagnostic exclusions. Mood disorders, substance abuse disorders, medical conditions, and developmental disorders have been ruled out.

Treatment

The treatment of schizophrenia depends in part on the patient's stage or phase. Patients in the acute phase are hospitalized in most cases, to prevent harm to the patient or others and to begin treatment with antipsychotic medications. A patient having a first psychotic episode should be given a CT or MRI scan to rule out structural brain disease.

Psychotic patients require conventional antipsychotic medications. Once a patient is stabilized and non-psychotic, other alternative treatments may be used. A 2002 study reported that patients who received ginkgo biloba extract showed enhanced effectiveness and reduced toxicity of haloperidol. This raised the possibility that ginkgo might be useful as an adjunct to antipsychotic drugs. Essential fatty acids (fish oil , flax oil, etc.), multivitamins with a high vitamin B potency, and ginseng may help to balance the mind and decrease or improve the side effects of antipsychotic medication, but should not be taken without consultation with a doctor. Grounding and stress-reducing therapies such as breathwork and movement therapy (yoga, t'ai chi , and qigong ) are also beneficial. However, long-term compliance with a medication regime is critical to controlling the disorder.

Allopathic treatment

The primary form of treatment for schizophrenia is antipsychotic medication. Antipsychotic drugs help to control almost all the positive symptoms of the disorder. They have minimal effects on disorganized behavior and negative symptoms. Between 6070% of schizophrenics will respond to antipsychotics. In the acute phase of the illness, patients are usually given medications by mouth or by intramuscular injection.

One of the most difficult challenges in treating schizophrenia patients with medications is helping them stay on medication. After the patient has been stabilized, an antipsychotic drug may be given in a long-acting form called a depot dose. Depot medications last for two to four weeks; they have the advantage of protecting the patient against the consequences of forgetting or skipping daily doses. In addition, some patients who do not respond to oral neuroleptics have better results with depot form. In 2002, scientists at the University of Pennsylvania Medical School designed an implantable device that can deliver medication to patients over a five-month period. While still in clinical trials, the device showed promise in allowing for measured, consistent doses of antipsychotic drugs to schizophrenic patients. The device can be implanted in a simple 15-minute procedure under local anesthesia. Most people with schizophrenia are kept indefinitely on antipsychotic medications during the maintenance phase of their disorder to minimize the possibility of relapse.

The most frequently used antipsychotics fall into two classes: the older dopamine receptor antagonists, or DAs, and the newer serotonin dopamine antagonists, or SDAs. (Antagonists block the action of some other substance; for example, dopamine antagonists counteract the action of dopamine.) The exact mechanisms of action of these medications are not known, but it is thought that they lower the patient's sensitivity to sensory stimuli and so indirectly improve the patient's ability to interact with others.

The dopamine antagonists include the older antipsychotic (also called neuroleptic) drugs, such as haloperidol (Haldol), chlorpromazine (Thorazine), and fluphenazine (Prolixin). These drugs have two major drawbacks: it is often difficult to find the best dosage level for the individual patient, and a dosage level high enough to control psychotic symptoms frequently produces extrapyramidal side effects, or EPSs. EPSs include parkinsonism, in which the patient cannot walk normally and usually develops a tremor; dystonia, or painful muscle spasms of the head, tongue, or neck; and akathisia, or restlessness. A type of long-term EPS is called tardive dyskinesia, which features slow rhythmic automatic movements. Schizophrenics with AIDS are especially vulnerable to developing EPS.

The serotonin dopamine antagonists, also called atypical antipsychotics, are newer medications that include clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa). The SDAs have a better effect on the negative symptoms of schizophrenia than do the older drugs and are less likely to produce EPS than the older compounds. These drugs are significantly more expensive in the short term, although the SDAs may reduce long-term costs by reducing the need for hospitalization.

Most schizophrenics can benefit from psychotherapy once their acute symptoms have been brought under control by antipsychotic medication. Psychoanalytic approaches are not recommended. Behavior therapy, however, is often helpful in assisting patients to acquire skills for daily living and social interaction. It can be combined with occupational therapy to prepare the patient for eventual employment.

Family therapy is often recommended for the families of schizophrenic patients, to relieve the feelings of guilt that they often have as well as to help them understand the patient's disorder. The family's attitude and behaviors toward the patient are key factors in minimizing relapses (for example, by reducing stress in the patient's life), and family therapy can often strengthen the family's ability to cope with the stresses caused by the schizophrenic's illness. Family therapy focused on communication skills and problem-solving strategies is particularly helpful. In addition to formal treatment, many families benefit from support groups and similar mutual help organizations for relatives of schizophrenics.

Expected results

Patients with early onset of schizophrenia are more often male, have a lower level of functioning prior to onset, a higher rate of brain abnormalities, more noticeable negative symptoms, and worse outcomes. Patients with later onset are more likely to be female, with fewer brain abnormalities and thought impairment, and more hopeful prognoses.

The average course and outcome for schizophrenics are less favorable than those for most other mental disorders, although as many as 30% of patients diagnosed with schizophrenia recover completely and the majority experience some improvement. Schizophrenics with a high number of stressful changes in their lives, or who have frequent contacts with critical or emotionally involved family members, are more likely to relapse. Overall, the most important component of long-term care of schizophrenic patients is complying with their regimen of antipsychotic medications.

Resources

BOOKS

Clark, R. Barkley. "Psychosocial Aspects of Pediatrics & Psychiatric Disorders." Current Pediatric Diagnosis & Treatment. Edited by William W. Hay Jr., et al. Stamford, CT: Appleton & Lange, 1997.

Day, Max, and Elvin V. Semrad. "Schizophrenia: Comprehensive Psychotherapy." The Encyclopedia of Psychiatry, Psychology, and Psychoanalysis. Edited by Benjamin B. Wolman. New York: Henry Holt and Company, 1996.

Eisendrath, Stuart J. "Psychiatric Disorders." Current Medical Diagnosis & Treatment 1998. Edited by Lawrence M. Tierney Jr., et al. Stamford, CT: Appleton & Lange, 1997.

Marder, Stephen R. "Schizophrenia." Conn's Current Therapy. Edited by Robert E. Rakel. Philadelphia: W. B. Saunders Company, 1998.

"Schizophrenia and Other Psychotic Disorders." Diagnostic and Statistical Manual of Mental Disorders. 4th ed. rev Washington, DC: The American Psychiatric Association, 2000.

Schultz, Clarence G. "Schizophrenia: Psychoanalytic Views." The Encyclopedia of Psychiatry, Psychology, and Psychoanalysis. Edited by Benjamin B. Wolman. New York: Henry Holt and Company, 1996.

PERIODICALS

"Brain Defects Identified by UCLA Scientists." Pain & Central Nervous System Week (April 1, 2002):3.

Gaby, Alan R. "Ginkgo for Schizophrenia (Literature Review & Commentary)." Townsend Letter for Doctors and Patients. (June 2002):31.

"Implant May Stabilize Treatment." Pain & Central Nervous System Week, (June 17, 2002):2.

Winerip, Michael. "Schizophrenia's Most Zealous Foe." The New York Times Magazine. (February 22, 1998): 26-29.

Paula Ford-Martin

Teresa G. Odle

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Schizophrenia

Schizophrenia

Definition

Schizophrenia is a mental illness characterized by disordered thinking, delusions, hallucinations, emotional disturbance, and withdrawal from reality.

Description

Some experts view schizophrenia as a group of related illnesses with similar characteristics. Although the term, coined in 1911 by Swiss psychologist Eugene Bleuler (18571939), is associated with the idea of a "split" mind, the disorder is different from a "split personality" (dissociative identity disorder), with which it is frequently confused. In the United States, schizophrenics occupy more hospital beds than patients suffering from cancer , heart disease, or diabetes. At any given time, they account for up to half the beds in long-term care facilities and 40 percent of the treatment days.

Demographics

The incidence of childhood schizophrenia is thought to be one in 10,000 births. In comparison, the incidence among adolescents and adults is approximately one in 100. The condition occurs with equal frequency in males and females (although the onset of symptoms is usually earlier in males). At least 2.5 million Americans are thought to be afflicted with schizophrenia, with an estimated 100,000 to 200,000 new cases every year. Schizophrenia is commonly thought to disproportionately affect people in the lowest socioeconomic groups, although some people claim that socially disadvantaged persons with schizophrenia are only more visible than their more privileged counterparts, not more numerous.

Causes and symptoms

While the exact cause of schizophrenia is not known, it is believed to be caused by a combination of physiological and environmental factors. Studies have shown that there is clearly a hereditary component to the disorder. Family members of schizophrenics are ten times more prone to schizophrenia than the general population, and identical twins of schizophrenics have a 46 percent likelihood of having the illness themselves. Relatives of schizophrenics also have a higher incidence of other milder psychological disorders with some of the same symptoms as schizophrenia, such as suspicion, communication problems, and eccentric behavior.

In the years following World War II (193945), many doctors blamed schizophrenia on bad parenting. In the latter twentieth century, however, advanced neurological research strengthened the case for a physiological basis for the disease. It has been discovered that the brains of schizophrenics have certain features in common, including smaller volume, reduced blood flow to certain areas, and enlargement of the ventricles (cavities filled with fluid that are found at the brain's center). Much attention has focused on the connection between schizophrenia and neurotransmitters, the chemicals that transmit nerve impulses within the brain. One such chemical, dopamine, has been found to play an especially important role in the disease. Additional research has concentrated on how and when the brain abnormalities that characterize the disorder develop. Some are believed to originate prenatally for a variety of reasons, such as trauma, viral infections, malnutrition during pregnancy, or Rh sensitivity (a reaction caused when the mother lacks a certain blood protein called Rh that the baby has). Environmental factors associated with schizophrenia include birth complications, viral infections during infancy, and head injuries in childhood. While the notion of child-rearing practices causing schizophrenia has been largely discredited, there is evidence that certain family dynamics do contribute to the likelihood of relapse in persons who already have shown symptoms of the disease.

Researchers have found correlations between childhood behavior and the onset of schizophrenia in adulthood. A 30-year longitudinal research project studied over 4,000 people born within a single week in 1946 in order to document any unusual developmental patterns observed in those children who later became schizophrenic. It was found that a disproportionate number of them learned to sit, stand, and walk late. They were also twice as likely as their peers to have speech disorders at the age of six and to have played alone when they were young. Home movies have enabled other researchers to collect information about the childhood characteristics of adult schizophrenics. One study found that the routine physical movements of these children tended to be slightly abnormal in ways that most parents would not suspect were associated with a major mental illness and that the children also tended to show fear and anger to an unusual degree.

The initial symptoms of schizophrenia usually occur between the ages of 16 and 30, with some variation depending on the type. Disorganized schizophrenia tends to begin early, usually in adolescence or young adulthood, while paranoid schizophrenia tends to start later, usually after the age of 25 or 30. The onset of schizophrenia before the age of 13 is rare and is associated with more serious symptoms. The onset of acute symptoms is referred to as the first psychotic break or break from reality. In general, the earlier the onset of symptoms, the more severe the illness is. Before the disease becomes full-blown, schizophrenics may go through a period called the prodromal stage, lasting about a year, when they experience behavioral changes that precede and are less dramatic than those of the acute stage. These may include social withdrawal, trouble concentrating or sleeping, neglect of personal grooming and hygiene, and eccentric behavior.

The prodromal stage is followed by the acute phase of the disease, which usually requires medical intervention. During this stage, three-fourths of schizophrenics experience delusions, illogical and bizarre beliefs that are held despite objections. An example of a delusion is the belief that the afflicted person is under the control of a sinister force located in the sewer system that dictates his every move and thought. Hallucinations are another common symptom of acute schizophrenia. These may be auditory (hearing voices) or tactile (feeling as though worms are crawling over one's skin). The acute phase of schizophrenia is also characterized by incoherent thinking, rambling or discontinuous speech, use of nonsense words, and odd physical behavior, including grimacing, pacing, and unusual postures. Persons in the grip of acute schizophrenia may also become violent, although often this violence is directed at themselves: it is estimated that 15 to 20 percent of schizophrenics commit suicide out of despair over their condition or because the voices they hear "tell" them to do so, and up to 35 percent attempt to take their own lives or seriously consider doing so. In addition, about 25 to 50 percent of people with schizophrenia abuse drugs or alcohol. As the positive symptoms of the acute phase subside, they may give way to what is called residual schizophrenia. Symptoms include flat or inappropriate emotions, an inability to experience pleasure (anhedonia), lack of motivation, reduced attention span, lack of interest in one's surroundings, and social withdrawal.

When to call the doctor

Parents should contact a healthcare professional if their child begins to have auditory or visual hallucinations, has a sudden change in behavior, shows signs of suicide ideation, or exhibits other symptoms of schizophrenia.

Diagnosis

Schizophrenia is generally divided into four types. The most prevalent, found in some 40 percent of affected persons, is paranoid schizophrenia, characterized by delusions and hallucinations centering on persecution, and by feelings of jealousy and grandiosity. Other possible symptoms include argumentativeness, anger, and violence. Catatonic schizophrenia is known primarily for its catatonic state, in which persons retain fixed and sometimes bizarre positions for extended periods of time without moving or speaking. Catatonic schizophrenics may also experience periods of restless movement. In disorganized (hebephrenic) schizophrenia, the patient is incoherent, with flat or inappropriate emotions, disorganized behavior, and bizarre, stereotyped movements and grimaces. Catatonic and disorganized schizophrenia affect far fewer people than paranoid schizophrenia. Most schizophrenics not diagnosed as paranoid schizophrenics fall into the large category of undifferentiated schizophrenia (the fourth type), which consists of variations of the disorder that do not correspond to the criteria of the other three types. Generally, symptoms of any type of schizophrenia must be present for six months before a diagnosis can be made.

Childhood schizophrenia has been known to appear as early as five years of age. Occurring primarily in males, it is characterized by the same symptoms as adult schizophrenia. Diagnosis of schizophrenia in children can be difficult because delusions and hallucinations may be mistaken for childhood fantasies. Other signs of schizophrenia in children include moodiness, problems relating to others, attention difficulties, and difficulty dealing with change. In many cases, children are improperly diagnosed with the disease; one study found as many as 95 percent of children initially diagnosed with childhood-onset schizophrenia did not meet the diagnostic criteria.

It is important for schizophrenia to be diagnosed as early as possible. The longer the symptoms last, the less well afflicted individuals respond to treatment.

Treatment

Even when treated, schizophrenia interferes with normal development in children and adolescents and makes new learning difficult.

Schizophrenia has historically been very difficult to treat, usually requiring hospitalization during its acute stage. In the late 1900s, antipsychotic drugs became the most important component of treatment. These can control delusions and hallucinations, improve thought coherence, and, if taken on a long-term maintenance basis, prevent relapses. However, antipsychotic drugs do not work for all schizophrenics, and their use has been complicated by side effects, such as akathisia (motor restlessness), dystonia (rigidity of the neck muscles), and tardive dyskinesia (uncontrollable repeated movements of the tongue and the muscles of the face and neck). In addition, many schizophrenics resist taking medication, some because of the side effects, others because they may feel better and mistakenly decide they do not need the drugs anymore, or because being dependent on medication in order to function makes them feel bad about themselves. The tendency of schizophrenics to discontinue medication is very harmful. Each time a schizophrenic goes off medication, the symptoms of the disease return with greater severity, and the effectiveness of the drugs is reduced.

Low doses of antipsychotic medication have been used successfully with children and adolescents, especially when administered shortly after the onset of symptoms. Their rate of effectiveness in children between the ages of five and 12 has been found to be as high as 80 percent. Until about 1990, the drugs most often prescribed for schizophrenia were neuroleptics such as Haldol, Prolixin, Thorazine, and Mellaril. A major breakthrough in the treatment of schizophrenia occurred in 1990 with the introduction of the drug clozapine to the U.S. market. Clozapine, which affects the neurotransmitters in the brain (specifically serotonin and dopamine), has been dramatically successful in relieving symptoms of schizophrenia, especially in patients in whom other medications have not been effective. However, even clozapine does not work for all patients. In addition, about 1 percent of those who take it develop agranulocytosis, a potentially fatal blood disease, within the first year of use, and all patients on clozapine must be monitored regularly for this side effect. (Clozapine was first developed in the mid twentieth century but could not be introduced until it became possible to screen for this disorder.) The screening itself is expensive, creating another problem for those using the drug. Risperidone, a subsequent and safer medication that offers benefits similar to those of clozapine, was introduced in 1994 and is as of the early 2000s the most frequently prescribed antipsychotic medication in the United States. Olanzapine, another in the subsequent generation of schizophrenia drugs, received FDA approval in the fall of 1996, and more medications are under development. Electroconvulsive therapy (ECT, also called electric shock treatments) has been utilized to relieve symptoms of catatonia and depression in schizophrenics, especially in cases where medication is not effective.

Although medication is an important part of treatment, psychotherapy can also play an important role in helping schizophrenics manage anxiety and deal with interpersonal relationships, and treatment for the disorder usually consists of a combination of medication, therapy, and various types of rehabilitation. Family therapy has worked well for many patients, educating both patients and their families about the nature of schizophrenia and helping them in their cooperative effort to cope with the disorder.

Alternative treatment

Some of the alternative treatments that have been used with varying success to treat children with schizophrenia include biofeedback, acupressure, chiropractic work, massage, and herbal drops.

Nutritional concerns

Some families have reported a benefit to making adjustments to or supplementing the diet of a child with schizophrenia, including reducing the amount of processed sugar consumed and supplementing with vitamins and minerals such as copper, zinc, folic acid , etc.

Prognosis

With the aid of antipsychotic medication to control delusions and hallucinations, about 70 percent of schizophrenics are able to function in society. Over the long term, about one-third of patients experience recovery or remission. Children afflicted with schizophrenia have a poorer prognosis than that of adults.

Prevention

There is no proven way to prevent onset of schizophrenia. Researchers have investigated the possibility of treating schizophrenia during the prodromal stage or even before symptoms start (such as when the likelihood of hereditary transmission is high). Other areas of research include the links between schizophrenia and family stress, drug use, and exposure to certain infectious agents.

Parental concerns

Parents play a key role in the everyday treatment and management of schizophrenia. The affected child should be closely monitored to ensure he or she is taking all prescribed medications. Working with the child's school teachers to formulate a day-to-day schedule can help maintain consistency for the child and address specific developmental delays. Parents should be educated on the signs of relapse and of adverse reactions to the medication, and encourage children in remission to self-report any possible signs of relapse.

Resources

BOOKS

Dalton, Richard, Marc A. Forman, and Neil W. Boris. "Childhood Schizophrenia." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E Behrman, Robert M. Kliegman, and Hal B. Jenson. Philadelphia: Saunders, 2004.

Moore, David P., and James W. Jefferson, eds. "Schizophrenia." In Handbook of Medical Psychiatry, 2nd ed. New York: Mosby, 2004.

PERIODICALS

Jarbin, Hakan, et al. "Adult Outcome of Social Function in Adolescent-Onset Schizophrenia and Affective Psychosis." Journal of the American Academy of Child and Adolescent Psychiatry 42, no.2 (February 2003): 17683.

McClellan, Jon, et al. "Symptom Factors in early-Onset Psychotic Disorders." Journal of the American Academy of Child and Adolescent Psychiatry 41, no. 7 (July 2002): 7918.

Schaeffer, John L., and Randal G. Ross. "Childhood-Onset Schizophrenia: Premorbid and Prodromal Diagnostic and Treatment Histories." Journal of the American Academy of Child and Adolescent Psychiatry 41, no. 5 (May 2002): 53845.

ORGANIZATIONS

National Alliance for Research on Schizophrenia and Depression. 60 Cutter Mill Rd., Suite 404, Great Neck, NY 11021. Web site: <www.narsad.org>.

National Schizophrenia Foundation. 403 Seymour Ave., Suite 202, Lansing, MI 48933. Web site: <www.nsfoundation.org>.

WEB SITES

Dunn, David W. "Schizophrenia and Other Psychoses." eMedicine, June 17, 2004. Available online at <http://www.emedicine.com/ped/topic2057.htm> (accessed January 17, 2005).

Stephanie Dionne Sherk

KEY TERMS

Neurotransmitters Chemicals in the brain that transmit nerve impulses.

Ventricles Four cavities within the brain that produce and maintain the cerebrospinal fluid that cushions and protects the brain and spinal cord.

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Schizophrenia

Schizophrenia


Schizophrenia is a debilitating, often chronic, mental disorder characterized by disturbances in thinking, perception, emotion, and social relationships. The term schizophrenia, which literally means "split mind," was first applied by Swiss psychiatrist Eugen Bleuler in 1911 to describe individuals whose thoughts were split from their emotions, leading to a disintegration of normal personality. Unfortunately, Bleuler's intended meaning is often lost on the lay public, which tends to equate schizophrenia with multiple personality disorder (also called dissociative identity disorder), an unrelated condition that typically shares few features with schizophrenia.


Nature of Schizophrenia

To be diagnosed with schizophrenia, an individual must demonstrate a six-month period of marginal functioning accompanied by a mixture of psychotic symptoms (delusions and hallucinations), disordered speech, disorganized behavior, emotional disturbance, and motivational impairment. Hallmark delusions (false beliefs) involve the conviction that individuals are conspiring to harm the patient and bizarre beliefs such as that one's thoughts are being broadcast or controlled by an external force. Auditory hallucinations (false sensory experiences) such as hearing voices are typical, but unusual bodily sensations (e.g., the perception that one is being touched) and visions (e.g., the image of the Virgin Mary) are also possible. Speech may be vague and difficult to follow, at times becoming incomprehensible. Normal variation in facial expressions may be restricted with the patient seldom smiling or displaying appropriate anger. Reduced ability to experience pleasure, a lack of drive and initiative, an absence of close friends, neglect of personal hygiene, and inappropriate behavior—such as public masturbation or childlike silliness—also comprise the symptom picture (American Psychiatric Association 1994). No one individual is likely to have all or even most of these symptoms, thus complicating diagnosis and leading to great heterogeneity in the clinical picture.

People with schizophrenia often have other problems as well. Despite the debilitation accompanying schizophrenia, many patients lack insight that they have a problem or are so mistrustful that they will not seek treatment. Depression often accompanies schizophrenia, with approximately 10 percent of patients committing suicide. Substance abuse, including nicotine addiction and alcoholism, is common. Medical conditions can result from poor self-care and chronic substance use. Unfortunately, the most effective drugs used to treat schizophrenia sometimes have deleterious health consequences, including excessive weight gain, diabetes, and an irreversible, involuntary movement disorder called tardive dyskinesia.

Schizophrenia afflicts slightly less than one out of every 100 people. Studies conducted with the sponsorship of the World Health Organization (WHO) suggest that when uniform diagnostic criteria are used to identify cases, the prevalence of schizophrenia varies little across cultures as diverse as the United States, Japan, and India ( Jablensky et al. 1992). However, the content of delusions may vary across countries, emphasizing regionally popular themes. There may be some cultures where the prevalence varies slightly from the averaged estimate. For instance, African Caribbeans in the United Kingdom appear to have higher rates of schizophrenia than other inhabitants of this European country.

Schizophrenia typically begins during adolescence or early adulthood, with females lagging behind the average age of onset in males by about five years. Although the disorder can begin abruptly, most individuals experience an extended period of impairment characterized by mild symptom expression and a decline in social, educational, or occupational functioning. The course is variable, with a minority of individuals recovering whereas most experience recurrent episodes interspersed with periods of partial remission or a chronic course characterized by incoherence, unwavering delusions, and recurring hallucinations. Although the prevalence of schizophrenia in men and women is believed to be the same, men appear to experience a more chronic course and are thus more likely to be hospitalized and included in research investigations. The course and outcome of schizophrenia may be more favorable in developing than developed nations, perhaps because the cultures of developing countries are characterized by more intact families and community networks, fewer job related demands, and greater acceptance of the unconventional beliefs and behavior characteristic of affected individuals.

Risk for Disorder

Numerous twin, family, and adoption studies from around the world indicate a familial basis for schizophrenia and point to a genetic influence. The first-degree biological relatives (parents, siblings, and children) of a person with schizophrenia have about a 10 percent chance of having the diagnosis whereas the risk for second-degree relatives (uncles, aunts, cousins, and grandparents) drops by more than half. The risk to the co-twin of an identical twin with schizophrenia is about 50 percent (Gottesman 1991). Findings such as these hold even when individuals are not raised by their biological relatives and clearly indicate that the risk of having schizophrenia is a function of the degree of genetic overlap with an affected person. If schizophrenia were due only to heredity, then because identical twins share all of their genes in common, both members of a pair would be affected if one develops the disorder. When both are affected, the pair is said to be concordant. The fact that identical twins are often discordant for schizophrenia confirms the important role environmental factors play in its genesis. These findings have given rise to a diathesis-stress model positing that it is the risk for schizophrenia (the diathesis) that is inherited, not schizophrenia per se. Whether schizophrenia arises in an individual with the diathesis depends on other factors, including the nature of environmental stress encountered over the lifespan.

Various research strategies have taken advantage of the familial nature of schizophrenia risk in an effort to elucidate causal mechanisms. One approach has been to study prospectively the young children of those with schizophrenia. As adults, study participants can be divided into those who did and those who did not develop schizophrenia and can be compared on measures collected before the onset of illness. Several of these investigations, called longitudinal high-risk studies, have been launched in different countries including Denmark, Israel, Sweden, and the United States (see Erlenmeyer-Kimling 2000). Compared to children of healthy participants, children of schizophrenic parents tend to have neurological, motor, social, memory, planning, and attentional dysfunctions that precede illness and are similar to those seen in adult schizophrenia (Erlenmeyer-Kimling 2000).

No genes for schizophrenia have been found, and the genetic mechanism by which the diathesis for schizophrenia is transmitted is unknown. There is growing concern that this state of affairs will persist as long as the identification of gene carriers depends on diagnosing schizophrenia based on the self-report of symptoms. The symptoms of schizophrenia are not present in all gene carriers (as the findings of discordant identical twins illustrate). Moreover, these symptoms may not be directly reflective of the biological underpinnings of the disorder. Because biological relatives of schizophrenia patients share genes with the patient, it is possible that many of them, even though they are not symptomatic, will exhibit neurobehavioral characteristics that are manifestations of the genetic diathesis. Many such characteristics have been documented in schizophrenia families, including difficulty producing certain kinds of simple eye movements and poor performance on tasks of attention and memory (Kremen et al. 1994). These investigations, like the high-risk studies mentioned above, are producing promising results, but much remains to be done before the biological mechanisms underlying the diathesis are clearly understood.

Environmental risk factors investigated in schizophrenia can be broadly grouped into social and neurobiological factors. Early theories of schizophrenia positing social influences, such as rearing by a cold and domineering (schizophrenogenic) mother (Fromm-Reichmann 1948), have not been supported by the results of controlled scientific investigation. The evidence that stressful life events contribute to the development of schizophrenia, as opposed to being a consequence of its early manifestation, is also limited. A correlation has been observed between social class membership and schizophrenia, with schizophrenia predominating in the underclass. This observation has been used to advance the hypothesis that the stresses associated with underclass rearing contribute to the development of schizophrenia. Investigations of this hypothesis have shown that this correlation is due in part to the debilitating consequences of schizophrenia leading to social migration from the upper classes into the underclass (Gottesman 1991). Nevertheless, schizophrenia patients are disproportionately born into the underclass, an observation that may reflect the likelihood that the accomplishment of the parents of schizophrenia patients is compromised because they too carry the genetic diasthesis for schizophrenia.

Birth complications constitute a neurobiological factor associated with the risk for schizophrenia. Schizophrenia has been associated with an excess of winter births. This finding is consistent with results from other investigations suggesting that events that are more likely to occur during winter pregnancies, such as viral infections, may affect the prenatal development of schizophrenia-prone persons (Torrey et al. 1994).

Investigations of risk factors have supported neurodevelopmental theories of schizophrenia. These theories hypothesize that schizophrenia develops from deleterious events early in life that disrupt pre- and post-natal brain development. This disruption may lead to poor communication among different brain regions, dysregulation of particular neurotransmitters such as the chemical messenger dopamine, and many of the neurobehavioral deviations associated with schizophrenia (Weinberger and Lipska 1995). Investigations with identical twins who are discordant for schizophrenia have indicated that a twin with schizophrenia can have abnormalities in brain structures that are not observed to the same degree in the healthy cotwin. Because identical twins have the same genetic diathesis for schizophrenia, this finding is consistent with the hypothesis that birth complications or in-utero viruses could, in a genetically vulnerable individual, constitute environmental stressors leading to disruptions in brain development.


Treatment

The aims of schizophrenia treatment are to reduce the severity and frequency of active episodes and to maximize healthy functioning between episodes (American Psychiatric Association 1997). Medications that reduce psychotic symptoms have been available since the 1950s and have contributed substantially to the deinstitutionalization of schizophrenia patients over the last half-century. Unfortunately, the medications do not provide a cure and have unpleasant side effects that, along with denial of illness, homelessness, cultural beliefs, and the stigma associated with the diagnosis, can reduce treatment compliance. Enhancement of medication treatment compliance is often a goal of psychosocial treatment. Psychosocial treatment is also intended to enhance occupational and social functioning by providing ongoing outpatient care following hospitalization that emphasizes vocational and social skills training.

When family members participate in programs combining education about the illness with training in problem solving skills, family support, and crisis intervention, relapse rates for schizophrenia patients are significantly reduced (Lauriello, Bustillo, and Keith 1999). Several studies support the role of specific relational influences on the risk for recurrence of active schizophrenia symptoms. Expressed emotion refers to the level of criticism, emotional overinvolvement, and hostility held about a psychiatric patient by another individual, typically a family member. Schizophrenia patients who have been hospitalized and return to households characterized by a high level of expressed emotion have increased likelihood of relapse. Cultural factors or ethnicity may mediate the impact or nature of expressed emotion (Butzlaff and Hooley 1998). Communication deviance, or the degree to which a relative's communication is unclear, fragmented, or disruptive, also increases relapse risk. When minimized, these factors, which may be related to the stress and burden of coping with a patient's illness, have been found to protect against relapse.

Because family members may be directly involved in the care of an affected relative, they can experience difficulties such as disruptions to family relationships, constraints on social leisure and work, financial problems, and feelings of loss, depression, anxiety, or embarrassment. As a result, various family and relative self-help group treatments have been developed to improve family members' knowledge of schizophrenia and available coping strategies and to enhance involvement in patient treatment. Despite the availability and efficacy of individual and family interventions, services to patients and family members appear to be underimplemented, with families of older patients and African-American families being among those least likely to take advantage of such services (Lehman, Steinwachs, and Co-Investigators 1998).


See also:Chronic Illness; Developmental Psychopathology; Health and Families

Bibliography

american psychiatric association. (1994). diagnostic and statistical manual of mental disorders: dsm-iv. washington, dc: author.

american psychiatric association. (1997). practice guideline for the treatment of schizophrenia. washington, dc: author.

butzlaff, r. l., and hooley, j.m.. (1998). "expressed emotion and psychiatric relapse: a meta-analysis." archives of general psychiatry 55(6):547–552.

erlenmeyer-kimling, l. (2000). "neurobehavioral deficits in offspring of schizophrenic parents: liability indicators and predictors of illness." american journal of medical genetics 97(1):65–71.

fromm-reichmann, f. (1948). "notes on the development of treatment of schizophrenics by psychoanalysis and psychotherapy." psychiatry 11:263–273.

gottesman, i. i. (1991). schizophrenia genesis: the origins of madness. new york: freeman.

jablensky, a.; sartorius, n.; ernberg, g.; anker, m.; korten, a.; cooper, j. e.; day, r.; and bertelsen, a. (1992). "schizophrenia: manifestations, incidence and course in different cultures. a world health organization ten-country study." psychological medicine 20(monograph supplement):1–97.

kremen, w. s.; seidman, l. j.; pepple, j. r.; lyons, m. j.; tsuang, m. t.; and faraone, s. v. (1994). "neuropsychological risk indicators for schizophrenia: a review of family studies." schizophrenia bulletin 20:103–119.

lauriello, j.; bustillo, j.; and keith, s. j. (1999). "a critical review of research on psychosocial treatment of schizophrenia." biological psychiatry 46(10):1409–1417.

lehman, a. f.; steinwachs, d. m.; and survey co-investigators of the port project. (1998). "patterns of usual care for schizophrenia: initial results from the schizophrenia patient outcomes research team (port) client survey." schizophrenia bulletin 24(1):11–20.

torrey, e. f., bowler, a. e.; taylor, e. h.; and gottesman, i. i. (1994). schizophrenia and manic-depressive disorder: the biological roots of mental illness as revealed by the landmark study of identical twins. new york: basic books.

weinberger, d. r., and lipska, b. k. (1995). "cortical maldevelopment, anti-psychotic drugs, and schizophrenia: a search for common ground." schizophrenia research 16(2):87–110.

monica e. calkins

william g. iacono

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"Schizophrenia." International Encyclopedia of Marriage and Family. 2003. Encyclopedia.com. 1 Jul. 2016 <http://www.encyclopedia.com>.

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Schizophrenia

Schizophrenia

Definition

Schizophrenia is a collection of related psychiatric disorders of unknown etiology that follow a specific pattern of behavior. Typical behavior seen in schizophrenia includes psychotic episodes in which there is a severe mental disturbance and perceptions of reality are distorted. Psychotic episodes may also involve hallucinations. Schizophrenics often have delusions about personal identity, immediate surroundings or society, and paranoia. Schizophrenia has a component of heredity, but many factors other than genetics are involved. Schizophrenia is treated with antipsychotic medication.

Description

Schizophrenia involves a specific type of disordered thinking and behavior. It could be described as the splitting of the mind's cognitive functions pertaining to thought, perception, and reasoning from the appropriate emotional responses. Family history of schizophrenia increases an individual's chance of having the disorder, but the exact mode of inheritance is unknown. Only some schizophrenic patients have detectable anatomical brain abnormalities. The cause of schizophrenia has not been determined, yet drugs effective in its treatment have been identified. Schizophrenia is treated with antipsychotic drugs that primarily act on receptors in the brain for the neurotransmitters dopamine and serotonin. These neurotransmitters are chemicals that the brain uses to communicate normal functioning behavior. Receptors for neurotransmitters are sites on the surface of neurons that bind to the neurotransmitters and allow the communication. In schizophrenia, some of the communication mediated by the neurotransmitters dopamine and serotonin and their receptors is abnormal. By inhibiting the activity of these receptors, antipsychotics are effective at decreasing some of the bizarre behavior patterns associated with schizophrenia. Unfortunately, the medication necessary for schizophrenic patients also has severe and pronounced adverse side effects, mostly affecting the control of movement. Schizotypal personality disorder is a milder form of the disease.

Demographics

Schizophrenia is estimated to afflict 1% of the world's population, whereas schizotypal personality disorder afflicts 23%. Approximately 2.7 million people have schizophrenia in the United States. The incidence of schizophrenia among parents, children, and siblings of patients with the disease is 15%. The rate of adopted children with schizophrenic parents is also 15%. However, the disease is not caused entirely by genetic factors, as identical twins have only a 3050% tendency to have the same schizophrenic illness. Schizophrenia occurs equally in males and females. The disease may be seen at any age, but the average age for the initiation of treatment is from 2834 years. Schizophrenia is associated with low economic status, probably due to a lack of proper health care during fetal development.

Causes and symptoms

The cause of schizophrenia is unknown. Some patients display specific physical abnormalities in the brain that are associated with the disease. These include atrophy or degeneration in some brain areas and enlargement of fluid-filled cavities called ventricles. Schizophrenics also have abnormalities in chemical neurotransmitters the brain normally uses to communicate information, specifically the neurotransmitters dopamine and serotonin and their receptors. The imbalance in the activity of these communication components is complex, with overactivity in some parts of the brain and decreased activity in others responsible for different symptoms. The symptoms of schizophrenia are divided into three types: the positive, negative, and disorganized symptoms.

Positive symptoms

Positive symptoms reflect the presence of distinctive behaviors. There are many different positive symptoms of schizophrenia. Schizophrenic patients may experience

strange or paranoid delusions that are out of touch with reality such as the belief that others are persecuting them, or that others are controlling their minds. Schizophrenic patients may have disturbing or frightening hallucinations. The most common hallucinations are auditory, but may also be visual. Other positive symptoms include sensitivity and fearful reaction to ordinary sights, sounds, or smells, along with agitation, tension, and the inability to sleep (insomnia).

Negative symptoms

Negative symptoms reflect the absence of normal social and interpersonal behaviors. Negative symptoms of schizophrenia are varied. Schizophrenic patients often have a reduction in their ability to experience appropriate emotions, or express their emotions. This reduced expressiveness often leads to periods of withdrawal from others. Patients may also experience a lack of motivation, energy, and ability to experience pleasure. Schizophrenic patients often have poverty of speech, and will not speak readily with others.

Disorganized symptoms

Schizophrenic patients may have confused thinking and speech, which makes it difficult for them to communicate effectively with others. Disorganized behaviors such as unnecessary, repetitive movements are also common.

Diagnosis

Schizophrenics often initially display prodromal signs, which are signs preceding a psychotic episode. Schizophrenic prodromal signs may include social isolation, odd behavior, lack of personal hygiene, and blunted emotions. The prodromal phase is followed by one or more separate psychotic episodes, which are characterized by severe mental disturbances and distorted perceptions of reality. Physicians examining this set of behaviors first attempt to exclude disorders of mood that respond to antidepressants, such as manic depression . Sometimes schizophrenia is diagnosed through the patient's response to different therapeutic regimens. Schizophrenic symptoms are not affected by antidepressants, but rather are alleviated by antipsychotics.

Once other disorders have been excluded, the criteria for a diagnosis of schizophrenia is that a patient be continuously ill for at least six months, and that there be one psychotic phase followed by one residual phase of odd behavior. During the psychotic phase, one or more of three groups of psychotic symptoms must be present. The three groups are bizarre delusions, hallucinations, and a disordered or incoherent thought pattern.

Treatment team

Schizophrenic patients are diagnosed and treated by psychiatrists. A licensed therapist performs rehabilitation therapy. Treatment teams from supportive agencies may help with everyday living.

Treatment

Schizophrenia is treated with antipsychotic drugs used in the lowest effective doses. The antipsychotic drugs work mainly to antagonize (inhibit) dopamine and serotonin receptors in specific areas of the brain that are in dysfunction. Classical antipsychotics function primarily on dopamine receptors and have more side effects than modern, atypical antipsychotics that also work on serotonin receptors. The newer, atypical antipsychotics are the treatment of choice because of their comparative lack of side effects, but classical antipsychotics may still be used if a patient is already doing well on the drug. The positive, psychotic symptoms of schizophrenia respond better to antipsychotic treatment than the negative symptoms.

Recovery and rehabilitation

Although antipsychotic drug treatment is necessary for schizophrenic patients, it is not enough for rehabilitation alone. Rehabilitation also requires supportive psychotherapy. Various psychosocial treatments are available for varying stages in the disease, and each patient requires a unique treatment regimen. Doctor and therapist appointments for medication management and psychological healing are necessary in all stages of recovery, even when symptoms are under control. Peer support groups are also very important for rehabilitation. Assertive community treatment (ACT) programs are available for patients who have a severe and unstable course of illness. These programs provide intensive services within a patient's home on a day-to-day basis. ACT teams can follow a patient through all courses of illness and assist them in normal living activities. Patients who are in the later stages of recovery and have few lingering symptoms may get involved with programs designed to help them achieve personal goals pertaining to work, education, and social interactions.

Clinical trials

Most clinical trials performed by the National Institute of Mental Health (NIMH) as of January 2004 are centered around three new atypical antipsychotics: olanzapine, risperidone, and aripiprazole. Many clinical trials are being conducted in the United States in different phases. Some studies of schizophrenic patients examine the causes of and potential treatments for negative symptoms as a group, specific symptoms such as cognitive dysfunction, schizophrenia in different age groups such as childhood-onset psychosis, and schizophrenia in different phases of disease course such as first-episode psychosis. Conventional antipsychotics that have excellent initial effects on first episodes also have severe side effects, and hence are associated with eventual patient noncompliance and relapses. The newer antipsychotics may alleviate this problem. Because of this, an NIMH clinical study scheduled to end in June 2004 is examining the role of new atypical antipsychotics in treatment of first psychotic schizophrenic episodes. Clinical trials also examine the ability of specific areas of the brain to function after cognitive stimulation in schizophrenic patients, or analyze DNA samples from families of patients with schizophrenia.

Prognosis

The prognosis for schizophrenia is varied. A diagnosis of schizophrenia does not necessarily mean that the patient will experience a life-long illness. Over a time period of 2530 years, approximately one-third of schizophrenic patients experience remission or even recovery. Recovery may be in the form of a lack of symptoms or learning to

live acceptably with some minor symptoms. For this reason, an early negative prognosis should be avoided. However, schizophrenia can be a severe and even dangerous disorder. A wide range of outcomes has been reported, including opposite extremes of full recovery to severe incapacity. A significant proportion of schizophrenic patients have resultant negative outcomes, including an increased mortality rate mostly associated with suicide. Suicide, accidents, and disease are common among patients with schizophrenia, along with an approximate 10-year decrease in lifespan.

Special concerns

A special concern for patients with schizophrenia is the importance of patient compliance even when symptoms have lessened or ceased. It is extremely important for patients to remain in close contact with their treatment team, take all medications consistently, and keep all appointments associated with therapy in order to prevent relapse.

Resources

BOOKS

Neve, Kim A., and Rachael L. Neve, eds. The Dopamine Receptors. Totowa, NJ: Humana Press Inc., 1997.

Thomas, Clayton L., ed. Taber's Cyclopedic Medical Dictionary. Philadelphia: F. A. Davis Company, 1993.

Zigmond, Michael J., Floyd E. Bloom, Story C. Landis, James L. Roberts, and Larry R. Squire, eds. Fundamental Neuroscience. New York: Academic Press, 1999.

OTHER

Weiden, Peter J., Patricia L. Scheifler, Joseph P. McEvoy, Allen Frances, and Ruth Ross, eds. A Guide For Patients and Families. Expert Consensus Treatment Guidelines for Schizophrenia, 1999.

WEBSITES

Internet Mental Health. American Description of Diagnostic Criteria for Schizophrenia. (April 4, 2004). <http://www.mentalhealth.com>.

National Institute of Mental Health. Clinical Trials. (April 4, 2004). <http://clinicaltrials.gov>.

Mental Health: A Report of the Surgeon General Chapter 4. (April 4, 2004). <http://www.schizophrenia.com/research/surg.general.2002.htm>.

ORGANIZATIONS

National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201. (703) 524-7600 or (800) 950-6264; Fax: (703) 524-9094. info@nami.org. <http://www.nami.org>.

National Hopeline Network Crisis Center. 201 N. 23rd Street, Suite 100, Purcellville, VA 20132. (540) 338-5756 or (800) 784-2433. Reese@hopeline.com. <http://www.hopeline.com>.

National Institutes of Mental Health. 6001 Executive Blvd., Room 8184, MSC 9663, Bethesda, MD 20892. (301) 443-4513 or (866) 615-6464; (301) 443-4279. nimhinfo@od.nih.gov. <http://www.nimh.nih.gov>.

National Mental Health Association. 2001 N. Beauregard Street, 12th Floor, Alexandria, VA 22311. (703) 684-7722 or (800) 969-6642; (703) 684-5968. <http://nmha.org>.

National Mental Health Consumer Self Help Clearinghouse. 1211 Chestnut Street, Suite 1207, Philadelphia, PA 19107. (215) 751-1810 or (800) 553-4539; Fax: (215) 636-6312. info@mhselfhelp.org. <http://www.mhselfhelp.org>.

Maria Basile, PhD

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Schizophrenia

Schizophrenia

A mental illness characterized by disordered thinking, delusions, hallucinations, emotional disturbance, and withdrawal from reality.

Some experts view schizophrenia as a group of related illnesses with similar characteristics. The condition affects between one-half and one percent of the world's population, occurring with equal frequency in males and females (although the onset of symptoms is usually earlier in males). Between 1 and 2% of Americans are thought to be afflicted with schizophreniaat least 2.5 million at any given time, with an estimated 100,000 to 200,000 new cases every year. Although the name "schizophrenia," coined in 1911 by Swiss psychologist Eugene Bleuler (1857-1939), is associated with the idea of a "split" mind, the disorder is different from a "split personality" (dissociative identity disorder ), with which it is frequently confused. Schizophrenia is commonly thought to disproportionately affect people in the lowest socioeconomic groups, although some claim that socially disadvantaged persons with schizophrenia are only more visible than their more privileged counterparts, not more numerous. In the United States, schizophrenics occupy more hospital beds than patients suffering from cancer, heart disease, or diabetes. At any given time, they account for up to half the beds in long-term care facilities. With the aid of antipsychotic medication to control delusions and hallucinations , about 70% of schizophrenics are able to function adequately in society.

Causes of schizophrenia

While the exact cause of schizophrenia is not known, it is believed to be caused by a combination of physiological and environmental factors. Studies have shown that there is clearly a hereditary component to the disorder. Family members of schizophrenics are ten times more prone to schizophrenia than the general population, and identical twins of schizophrenics have a 46% likelihood of having the illness themselves. Relatives of schizophrenics also tend to have milder psychological disorders with some of the same symptoms as schizophrenia, such as suspicion, communication problems, and eccentric behavior.

In the years following World War II, many doctors blamed schizophrenia on bad parenting. In recent years, however, advanced neurological research has strengthened the case for a physiological basis for the disease. It has been discovered that the brains of schizophrenics have certain features in common, including smaller volume, reduced blood flow to certain areas, and enlargement of the ventricles (cavities filled with fluid that are found at the brain's center). Over the past decade much attention has focused on the connection between schizophrenia and neurotransmitters, the chemicals that transmit nerve impulses within the brain . One such chemicaldopaminehas been found to play an especially important role in the disease. Additional research has concentrated on how and when the brain abnormalities that characterize the disorder develop. Some are believed to originate prenatally for a variety of reasons, including trauma, viral infections, malnutrition during pregnancy, or a difference in Rh blood factor between the fetus and the mother. Environmental factors associated with schizophrenia include birth complications, viral infections during infancy , and head injuries in childhood . While the notion of child rearing practices causing schizophrenia has been largely discredited, there is evidence that certain family dynamics do contribute to the likelihood of relapse in persons who already have shown symptoms of the disease.

Types of schizophrenia

Schizophrenia is generally divided into four types. The most prevalent, found in some 40% of affected persons, is paranoid schizophrenia, characterized by delusions and hallucinations centering on persecution, and by feelings of jealousy and grandiosity. Other possible symptoms include argumentativeness, anger , and violence . Catatonic schizophrenia is known primarily for its catatonic state, in which persons retain fixed and sometimes bizarre positions for extended periods of time without moving or speaking. However, catatonic schizophrenics may also experience periods of restless movement. In disorganized, or hebephrenic, schizophrenia, the patient is incoherent, with flat or inappropriate emotions, disorganized behavior, and bizarre, stereotyped movements and grimaces. Catatonic and disorganized schizophrenia affect far fewer people than paranoid schizophrenia. Most schizophrenics not diagnosed as paranoid schizophrenics fall into the large category of undifferentiated schizophrenia (the fourth type), which consists of variations of the disorder that do not correspond to the criteria of the other three types. Generally, symptoms of any type of schizophrenia must be present for at least six months before a diagnosis can be made. Over the long term, about one-third of patients experience recovery or remission.

The initial symptoms of schizophrenia usually occur between the ages of 16 and 30, with some variation depending on the type. (The average age of hospital admission for the disease is between 28 and 34.) Disorganized schizophrenia tends to begin early, usually in adolescence or young adulthood, while paranoid schizophrenia tends to start later, usually after the age of 25 or 30. The onset of acute symptoms is referred to as the first psychotic break, or break from reality. In general, the earlier the onset of symptoms, the more severe the illness will be. Before the disease becomes full-blown, schizophrenics may go through a period called the prodromal stage, lasting about a year, when they experience behavioral changes that precede and are less dramatic than those of the acute stage. These may include social withdrawal, trouble concentrating or sleeping, neglect of personal grooming and hygiene, and eccentric behavior.

The prodromal stage is followed by the acute phase of the disease, which is characterized by "positive" symptoms and requires medical intervention. During this stage, three-fourths of schizophrenics experience delusionsillogical and bizarre beliefs that are held despite objections. A typical delusion might be a belief that the afflicted person is under the control of a sinister force located in the sewer system that dictates his every move and thought. Hallucinations are another common symptom of acute schizophrenia. These may be auditory (hearing voices) or tactile (feeling as though worms are crawling over one's skin). The acute phase of schizophrenia is also characterized by incoherent thinking, rambling or discontinuous speech, use of nonsense words, and odd physical behavior, including grimacing, pacing, and unusual postures. Persons in the grip of acute schizophrenia may also become violent, although often this violence is directed at themselvesit is estimated that 15-20% of schizophrenics commit suicide out of despair over their condition or because the voices they hear "tell" them to do so, and up to 35% attempt to take their own lives or seriously consider doing so. In addition, between 25 and 50% of people with schizophrenia abuse drugs or alcohol. As the positive symptoms of the acute phase subside, they may give way to the negative symptoms of what is called residual schizophrenia. These include flat or inappropriate emotions, an inability to experience pleasure (anhedonia), lack of motivation ; reduced attention span, lack of interest in one's surroundings, and social withdrawal.

Researchers have found correlations between childhood behavior and the onset of schizophrenia in adulthood. A 30-year longitudinal research project studied over 4,000 people born within a single week in 1946 in order to document any unusual developmental patterns observed in those children who later became schizophrenic. It was found that a disproportionate number of them learned to sit, stand, and walk late. They were also twice as likely as their peers to have speech disorders at the age of six and to have played alone when they were young. Home movies have enabled other researchers to collect information about the childhood characteristics of adult schizophrenics. One study found that the routine physical movements of these children tended to be slightly abnormal in ways that most parents wouldn't suspect were associated with a major mental illness and that the children also tended to show fear and anger to an unusual degree.

Treatment

Schizophrenia has historically been very difficult to treat, usually requiring hospitalization during its acute stage. In recent decades, antipsychotic drugs have become the most important component of treatment. They can control delusions and hallucinations, improve thought coherence, and, if taken on a long-term maintenance basis, prevent relapses. However, antipsychotic drugs do not work for all schizophrenics, and their use has been complicated by side effects, such as akathisia (motor restlessness), dystonia (rigidity of the neck muscles), and tardive dyskinesia (uncontrollable repeated movements of the tongue and the muscles of the face and neck). In addition, many schizophrenics resist taking medication, some because of the side effects, others because they may feel better and mistakenly decide they don't need the drugs anymore, or because being dependent on medication to function makes them feel bad about themselves. The tendency of schizophrenics to discontinue medication is very harmful. Each time a schizophrenic goes off medication, the symptoms of the disease return with greater severity, and the effectiveness of the drugs is reduced.

Until recently, the drugs most often prescribed for schizophrenia have been neuroleptics such as Haldol, Prolixin, Thorazine, and Mellaril. A major breakthrough in the treatment of schizophrenia occurred in 1990 with the introduction of the drug clozapine to the U.S. market. Clozapine, which affects the neurotransmitters in the brain (specifically serotonin and dopamine), has been dramatically successful in relieving both positive and negative symptoms of schizophrenia, especially in patients in whom other medications have not been effective. However, even clozapine doesn't work for all patients. In addition, about 1% of those who take it develop agranulocytosis, a potentially fatal blood disease, within the first year of use, and all patients on clozapine must be monitored regularly for this side effect. (Clozapine was first developed decades ago but could not be introduced until it became possible to screen for this disorder.) The screening itself is expensive, creating another problem for those using the drug. Risperidone, a new, safer medication that offers benefits similar to those of clozapine, was introduced in 1994 and is now the most frequently prescribed antipsychotic medication in the United States. Olanzapine, another in the new generation of schizophrenia drugs, received FDA approval in the fall of 1996, and more medications are under development. Electroconvulsive therapy (ECT, also called electric shock treatments) has been utilized to relieve symptoms of catatonia and depression in schizophrenics, especially in cases where medication is not effective.

Although medication is the most important part of treatment, psychotherapy can also play an important role in helping schizophrenics manage anxiety and deal with interpersonal relationships, and treatment for the disorder usually consists of a combination of medication, therapy, and various types of rehabilitation . Family therapy has worked well for many patients, educating both patients and their families about the nature of schizophrenia and helping them in their cooperative effort to cope with the disorder.

Further Reading

Atkinson, Jacqueline M. Schizophrenia: A Guide to What It Is and What Can Be Done to Help. San Bernardino, CA: R. Reginald Borgo Press, 1989.

Hoffer, Abram, and Humphry Osmond. How to Live with Schizophrenia. New York: Carol Publishing Group, 1992.

Lidz, Theodore. The Origin and Treatment of Schizophrenic Disorders. International Universities Press, 1990.

Walsh, Maryellen. Schizophrenia: Straight Talk for Families and Friends. New York: William Morrow, 1985.

Further Information

American Schizophrenia Association. 900 North Federal Highway, Suite 330, Boca Raton, FL 33432, (407) 3936167.

National Alliance for Research on Schizophrenia and Depression. 60 Cutter Mill Rd., Suite 200, Great Neck, NY 11202, (516) 8290091.

Schizophrenics Anonymous. 1209 California Rd., Eastchester, NY 10709, (914) 3372252.

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Schizophrenia

Schizophrenia

Schizophrenia (pronounced skiht-zo-FREH-nee-uh) is a severe mental condition that interferes with normal thought processes, causing delusions, hallucinations, and mental disorganization. As the most common of the extremely serious mental disorders known as psychosis (pronounced sy-KO-sis), it affects men and women equally, is found all over the world, and is usually a long-term illness with no definite cure.

Its victims

Schizophrenia is described by the National Institute of Mental Health (NIMH) as a "chronic, severe, and disabling brain disease." NIMH estimates that approximately 1 percent of the American population at some point suffers from schizophrenia, meaning that more than two million Americans are considered to be schizophrenic in any given year. Others estimate that as many as half the patients in U.S. mental hospitals are schizophrenics. Although it occurs in women as often as in men, it seems to appear earlier in men, usually in their late teens or early twenties. Very young people, however, can sometimes be affected.

To be schizophrenic is to suffer from a profound disruption of cognition, meaning that the schizophrenic individual has a major problem with knowing and thinking. Some describe this condition as a thought disorder, and once we understand the sometimes terrifying symptoms that schizophrenics experience in their minds, we can better see why their perception of reality is often a distorted one. The mental disturbances they experience also affect their emotions, their actions, and even their language. People with schizophrenia often do not see or experience things the way most people do, and their world is often one of delusions and hallucinations. It is not unusual for them to hear "voices" or see things that are not really there. A common delusion or false personal belief of schizophrenics is that someone or something is controlling their thoughts or plotting against them. Hallucinations are false sensory experiences; a person experiencing hallucinations thinks he or she is seeing, hearing, or even touching something that in reality is not there or does not exist.

Delusions and hallucinations

Once we understand what schizophrenics are experiencing mentally, we should not be surprised when their behavior becomes strange or even bizarre. Often they are fearful and withdrawn, but other times their actions and speech can be frightening or at least very confusing to others. Other recognizable symptoms of schizophrenia are socially inappropriate behavior, dulled emotional responses, isolation and withdrawal that suggest a loss of any social interests, an inability to concentrate or "think straight," and a loss of a sense of self as a unique and separate individual. Since schizophrenics experience hallucinations and delusions of all sorts, they are often very frightened, anxious, and confused people. At times they may act totally detached and remote, sitting rigid for hours. Other times they may be highly agitated, moving constantly. They are understandably difficult to be with and are just as difficult to treat.

Words to Know

Delusions: Incorrect beliefs about reality that are clearly false.

Hallucinations: Images, sounds, or odors that are seen, heard, or smelled by a person, but do not exist in reality.

Neurosis: Any emotional or mental disorder that affects only part of the personality, such as anxiety or mild depression, as a result of stress.

Neurotransmitter: A chemical that transmits electrical impulses (information) between nerve cells or nerve and muscle cells.

Psychosis: A major psychiatric disorder characterized by the inability to tell what is real from what is not real.

Historical evidence

Although some argue that schizophrenia is a modern disease, most agree that there is sufficient historical evidence to suggest that it is as old as humans. Stories of "mad" people whose behavior was beyond the limits or control of others and whose behavior was bizzare and unexplainable are found throughout the ancient history of all cultures. Ancient Babylonian documents are said to contain such evidence, and nearly 2,500 years ago, Greek historian Herodotus (480425 b.c.) described the mad king of Sparta. In the second century a.d., Roman writer Celsus described three types of insanity, one of which sounds very much like schizophrenia. Many believe that schizophrenia was clearly described during the Middle Ages (period in European history from about a.d. 500 to 1500), and by the sixteenth century there are published accounts of clearly schizophrenic cases called "mania" or "melancolia." Some writers claim that the first printed description of schizophrenia was given by British physician Thomas Willis (16211675) when he described a certain type of "dementia."

Most agree, however, that the first modern description of symptoms now recognized as schizophrenia was given by German psychiatrist Emil Kraepelin (18561926) in 1896. Kraepelin's main contribution was his classification of mental illnesses, and it was Kraepelin who pointed out the difference between what is recognized today as manic-depressive psychosis and schizophrenia, which he called "dementia praecox" (pronounced deh-MEHN-shia PREE-cocks).

It was another German psychiatrist, however, who actually first suggested the term schizophrenia for the disease. In 1908, Eugen Bleuler (18571939) used the word schizophrenia in a paper he had written that was based on a study of 647 patients. Bleuler, who was a colleague of Austrian psychoanalyst Sigmund Freud (18561939), came up with the name to describe what he said was some sort of split in the proper functioning of the brain. He used the word split because he said that a schizophrenic's

ideas are often isolated or separate from his feelings. Bleuler's new name for this condition was therefore derived from the Greek words for "split" and "mind" and soon replaced the older term dementia praecox. It should be noted, however, that schizophrenia is neither a condition exhibiting a "split personality" nor one of "multiple personalities." Rather, these rare conditions are considered to be a type of neurosis (pronounced nur-OH-sis) that is a less severe emotional disorder.

Types of schizophrenia

The main difference between schizophrenia and any other type of neurosis is that a neurosis is an emotional disorder, whereas schizophrenia is considered a form of organic brain disease, meaning that there is a physical (and not an emotional) reason why something is wrong. Until recently, science could only describe or categorize the different types of schizophrenia, and the categories offered by Kraepelin are still used. Paranoid schizophrenics typically suffer from delusions of persecution; the hebephrenic (pronounced hee-beh-FREN-ik) type has very disorganized thinking, difficulty in communicating, and shows inappropriate emotional responses (like laughing at a funeral); the catatonic schizophrenic suffers from uncontrollable bodily movements. In reality, many schizophrenics often display symptoms from each type.

Causes

Although there are a number of competing theories as to the causes of schizophrenia, no one explanation has yet been proven. Unfortunately, this means that there is no known single cause of schizophrenia. That does not mean, however, that science is completely baffled and helpless in trying to understand this brain disease. Some of the early, more psychoanalytical explanations suggested that people who lacked affection during infancy and early childhood became schizophrenic, but these psychological theories could not be proven.

Science then naturally moved to seek more physical explanations, and with twenty-first century advances in biomedical research and advanced imaging technologies, most theories now have a basis in biology. That is, they seek to find the primary cause or causes of schizophrenia in the body itself, specifically in the brain. For example, it has long been known that schizophrenia runs in families, and that individuals with a close relative who suffered from the disease have a greater chance of developing it than people who have no relatives with the illness. This suggests that there are some genetic factors involved, and that perhaps a genetic predisposition (a tendency toward something) makes some more susceptible than others. In fact, research on the human genome, which is the complete collection of genes found in a single set of human chromosomes, suggests that the defect may be found somewhere on chromosomes 13 and 6, although this has not yet been proven conclusively.

Despite this possible genetic link, scientists know for many reasons that genes cannot be the sole cause of schizophrenia. A good proof of this is a set of identical twins, only one of whom suffers from schizophrenia. More likely, schizophrenia does not have a single cause, but instead is determined by a combination of biological factors. Another major avenue of investigation is in the chemistry of the brain. This new research focuses on the brain's neurotransmitters (pronounced ner-o-trans-MIH-terz), which are substances that allow the neurons or nerve cells to communicate with one another. Investigators are therefore concentrating on the neurotransmitters called dopamine (pronounced DOPE-uh-meen) and glutamate (pronounced GLUE-tuh-mait) to find if too much or too little is important to schizophrenia.

Other scientists are using new brain-imaging techniques to examine the brains of living schizophrenics to try to find abnormalities in structure or function. They now know, for example, that schizophrenics have enlarged ventricles, which are fluid-filled cavities inside the brain. Another brain-related theory is that schizophrenia is caused by some sort of developmental disorder that happened when the fetus was still growing inside the mother's womb. Some suggest that this damage may stay hidden or dormant until puberty, when the brain's normal changes somehow activate them. Finally, another theory is that the disease is caused by a slow-acting virus.

Treatment

Since schizophrenia has no one known cause, the best medicine can do is to treat the symptoms. Before the 1950s, electroconvulsive treatment or shock therapy was the only known method of treatment. Since that time, various drugs have been used to try to minimize the symptoms of schizophrenia. Reserpine was the first drug to work, and it was based on a plant used in folk medicine to treat insomnia and insanity. Later, the new drug named Thorazine was developed. Both it and Reserpine were found to work by blocking the neurotransmitter dopamine. In the 1990s, a new group of antipsychotic drugs were produced that were very effective in keeping delusions and hallucinations under control, but they also left their patients emotionally empty and even reduced their normal motivation.

Today, doctors are able to give new antipsychotic drugs in more calibrated or finely-tuned dosages so that they work to minimize the terrors, but do not put the person in a complete "emotional straitjacket." With their "demons" under better control, schizophrenics are able to deal with the everyday world in a more rational way. The key to every schizophrenic's health is to keep strictly to his or her treatment plan. However, although these new drugs are far better than the old ones, they still pose a long-term risk that the patient may develop serious side-effects involving the muscles.

Despite all the treatment, research, and gains in understanding, the fact remains that today's treatment for schizophrenia has limits. Very often, no matter how symptom-free the patient is, he or she may still have problems being "normal" in ways that matterlike caring for themselves, communicating with others, being motivated, and most important of all, establishing and keeping relationships with other people. It has been shown, however, that for patients whose symptoms are under control, the help and understanding they receive from their family, friends, and even self-help and support groups goes a long way toward making them better able to manage their condition. Continued understanding is needed as much as continued research.

[See also Psychiatry; Psychosis; Tranquilizer ]

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Schizophrenia

Schizophrenia

BIBLIOGRAPHY

Approximately one percent of the population suffers from schizophrenia, a severe and persistent mental disorder that is characterized by a wide range of cognitive, social, behavioral, and emotional symptoms and that has been identified by the World Health Organization as one of the ten most debilitating diseases. As specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM -IV-TR) (APA 2000), positive symptoms of schizophrenia include hallucinations, delusions, disorganized speech, and grossly disorganized or catatonic behavior. Negative symptoms include affective flattening (a lack of emotional response), alogia (poverty of speech), and avolition (an absence of motivation). In addition, impairment is present in one or more major areas of functioning, such as work, interpersonal relations, or self-care. Subtypes of schizophrenia include paranoid, catatonic, disorganized, undifferentiated, and residual schizophrenia.

The vulnerability-stress model offers a useful way of integrating current thinking about schizophrenia. The model assumes that schizophrenia involves a biogenetic vulnerability or predisposition to develop the disorder. A range of biological and psychosocial factors can interact with this vulnerability to affect the manifestation and course of the illness. Certain risk factors, such as substance abuse, are associated with symptom exacerbation and an increased likelihood of relapse. Protective factors, such as social support and coping strategies, can ameliorate the symptoms of the disorder and make relapse less likely.

Both diagnostic and functional assessment are important in designing individualized treatment and rehabilitation plans. The use of standardized instruments, such as the Structured Clinical Interview for DSM -IV-TR (SCID), can increase the likelihood of an accurate diagnosis. Functional assessment focuses on potential deficits in skills and resources that can result in impairment in the ability to function at home, work, and school.

Effective and efficacious psychopharmacological and psychosocial treatments have become available during the past three decades. Since the late 1970s there has been increasing development of new antipsychotic medications. Evidence-based psychosocial interventions have replaced older psychodynamic approaches and accelerated community reintegration of patients who were formerly institutionalized. The benefits of antipsychotic medications include decreased symptoms, reduced risk of relapse, and increased response to psychosocial interventions. Generally combined with medications, psychosocial interventions have demonstrated benefits in the areas of relapse and rehospitalization, housing stability, competitive employment, social functioning, psychotic symptoms, and substance use disorders (Mueser et al. 2003).

Evidence-based psychosocial interventions include assertive community treatment (ACT), family psychoeducation, supported employment, training in illness-management and recovery skills, and integrated dual disorders treatment. The ACT model was developed to meet the needs of individuals with a history of high service utilization or severe functional impairment. Services are provided on a twenty-four-hour basis in natural living environments by multidisciplinary treatment and rehabilitation teams. Family psychoeducation generally includes services both for people with schizophrenia and for their family members. Components include education about mental illness and its management, skills training, and social support. Supported employment services include rapid job search rather than extensive prevocational assessment; competitive wages for jobs in integrated settings; ongoing support once a job has been obtained; and combined vocational and mental health services. Interventions that target illness management and recovery are designed to help people with schizophrenia acquire the information and skills needed to collaborate in their treatment, to minimize the effects of the disorder on their lives, and to be able to pursue personally meaningful goals. Integrated dual disorders treatment focuses on substance use disorder, which is the most common and clinically significant comorbidity associated with schizophrenia. Integrated mental health and substance abuse programs provide simultaneous treatment of both disorders in a single setting. Social and cultural variables are relevant to the etiology, epidemiology, phenomenology, course, and prognosis of schizophrenia.

Because schizophrenia seemed more prevalent in lower socioeconomic groups, earlier sociologists postulated social stress as a casual factor; others attributed clustering in poor areas to downward social drift. Although psychogenic or sociogenic theories have largely been nullified by biogenetic findings, other correlates of the social environment have apparent etiological significance. For example, maternal exposure to wartime famine or the type A influenza virus during fetal development predicts significantly higher risk for later development of schizophrenia.

World Health Organization studies have consistently shown that despite standardized diagnostic criteria, the prognosis for schizophrenia is significantly better in developing countries than in the industrialized West. Some analysts attribute this to the presence of less virulent variants of the syndrome. Others point to cultural variables that mitigate the impact of schizophrenia in traditional societies, including magical causal theories that view mental disorders as temporary. In developed countries, in contrast, the person and illness are often fused, generating damaged identity. In addition, traditional agrarian societies offer more normalization through flexible work roles and arranged marriages. In these societies, people with schizophrenia are five times more likely to marry than in the industrialized West (Hopper 2004). In developing countries, extended kinship networks relieve the burden often experienced by smaller households in developed countries. The nuclear family structure, with its limited capacity for caregiving, is related to high expressed emotion, which entails hostile criticism or emotional overinvolvement in some family members. High expressed emotion is correlated with patient relapse, but is less frequent in non-Western cultures and is largely remediable with family psychoeducation (Leff and Vaughn 1985).

In contrast to now discredited theories that implicated families in causation, a literature has emerged on the impact of schizophrenia on families. Research indicates that the families of people with schizophrenia face both objective burden, which include the time, energy, and finances devoted to illness management, and subjective burden, which refers to the emotional costs of coping with difficult behaviors and the pain and losses of a loved one. Families have dealt with their distress by organizing into movements throughout the world to improve research and services and to combat stigma. People with schizophrenia suffer the terrors of psychosis, diminished life aspirations, and social devaluation. Social and cultural conceptions range from retribution for personal or ancestral misconduct to the split personality definition that has made the word schizophrenic an erroneous synonym for self-contradiction. Media accounts of violence reinforce societal stigma, although people with schizophrenia are more often victims than perpetrators.

In spite of these challenges, many deinstitutionalized patients are functioning well in their communities. Longitudinal studies in Europe and the United States show that more than half of formerly hospitalized, presumably chronic patients with schizophrenia can, with proper treatment, lead satisfying, relatively symptom-free lives. Studies of mostly first-episode patients show from 48 percent to 91 percent experiencing symptomatic remission posthospitalization (Liberman and Kopelowicz 2005). A burgeoning consumer movement of former patients, many with schizophrenia, offers peer services, recovered role models, and hope. With continuing research on improved medications, psychosocial interventions, peer services, and genetic predictors of more exact individualized treatments, the prognosis looks more favorable than ever before.

SEE ALSO Kinship; Manias; Mental Health; Mental Illness; Psychotherapy; Psychotropic Drugs; Stress;World Health Organization

BIBLIOGRAPHY

American Psychiatric Association (APA). 2000. Diagnostic and Statistical Manual of Mental Disorders (DSM -IV-TR). 4th ed., text rev. Washington, DC: Author.

Hopper, Kim. 2004. Interrogating the Meaning of Culture in the WHO International Studies of Schizophrenia. In Schizophrenia, Culture, and Subjectivity: The Edge of Experience, eds. Janis H. Jenkins and Robert J. Barrett, 6286. Cambridge, U.K.: Cambridge University Press.

Leff, Julian, and Christine Vaughn, eds. 1985. Expressed Emotion in Families: Its Significance for Mental Illness. New York: Guilford.

Liberman, Robert P., and Alex Kopelowicz. 2005. Recovery from Schizophrenia: A Concept in Search of Research. Psychiatric Services 56 (6): 735742.

Mueser, Kim T., et al. 2003. Implementing Evidence-based Practices for People with Severe Mental Illness. Behavior Modification 27 (3): 387411.

Diane T. Marsh

Harriet P. Lefley

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Schizophrenia

SCHIZOPHRENIA

For psychoanalysis, as for medical research and the entire field of mental health, schizophrenia is a complex, baffling, and frustrating disorder. It is not particularly rare, affecting about 1 percent of the population; its distribution is worldwide. A century after Emil Kraepelin created the diagnosis of dementia praecox and its extensive symptomologyrenamed schizophrenia by Eugen Bleulerit remains poorly understood. In spite of revolutionary advances in biology and neuroscience, no treatment or combination of therapies offers a reliable cure.

Like all the psychotic disorders, schizophrenia was thought from the start to have an organic basis, but Kraepelin was forced describe it as a "functional disorder." Early age of onset and absence of brain lesions such as might be found in epilepsy or tertiary syphilis, for example, encouraged early analysts to attempt treatment, especially in light of the limitations of other therapeutic modalities. It became plausible to suggest, at least tentatively, that schizophrenia was a psychological disorder that originated, like neurotic conflicts, in infancy and early childhood. The fact that some small but significant percentage of patients experienced full or partial recovery made it a target for therapies of all kinds, including psychoanalysis.

Although Freud himself was skeptical about prospects for successfully treating schizophrenia, the disorder was central to the activity of many early analysts, who often were associated with hospitals for the insane. Karl Abraham's first letters to Freud concerned psychosis; like Carl Jung, he worked at the Burgholzi Central Asylum and University Clinic in Zurich, which Bleuler directed. In the United States, where psychiatry only gradually became a primarily office practice beginning about 1920, psychiatrists influenced by Freud also worked in asylums. Adolf Meyer and William Alanson White were both hospital-based psychiatrists, as was Harry Stack Sullivan, who reported impressive results with his analytically oriented treatment beginning in the 1920s. Particularly influential, Sullivan's work led to the creation of a psychoanalytic enclave at Chestnut Lodge in Rockville, Maryland, devoted to the treatment of patients with schizophrenia and related disorders.

The rapid growth of psychoanalysis as a medical specialty in the United States after World War II affected the way that schizophrenia was perceived, understood, and treated. The broad theoretical reach of psychoanalysis, with its ambitious aims to provide a general psychology, extended to schizophrenia both as an explanatory tool and treatment modality. In retrospect it is clear that as a treatment it was not successful and that the early-childhood environmental deficit model that analysts proposed could not be sustained. At the time, however, without benefit of drugs or a significant knowledge base in neurochemistry, and in the wake of a period during which biological explanations of mental disease had favored eugenics, psychoanalysts appeared to be modern and forward-looking professionals who were making an earnest and humane effort to understand severe psychopathology in terms of developmental deficits.

Psychoanalysis was not seriously affected by the introduction of phenothiazine in the mid-1950s. But the narcoleptics and their successor drugs set the stage for the de-institutionalization of the mentally ill that began a decade later and also opened the way for the dopamine hypothesis, the first of various neurochemical pathways to be implicated in schizophrenia. By the late 1960s the authority of psychoanalysis was eroding, both as therapy and theory, and it had to compete with a diversified marketplace of competing treatments. As psychoanalysis in the United States entered a period of steep decline in the 1980s, its efforts on both a theoretical and clinical level were often held to be of no account. However, one positive outcome of analytic interest in the severe mental disorders, in fact, was a sophisticated and durable typology of what became known as the borderline and narcissistic disorders (Kernberg 1975), which developed along separate lines and found a respected place in clinical psychiatry and mental health practice more generally.

The list of analysts who studied and wrote about schizophrenia is long and includes interpersonalists, ego psychologists, Kleinians and their successors, together with any number who might be described as individualistic or idiosyncratic. Key texts included papers by Paul Federn, Melanie Klein, Harold Searles, and many others. Some analysts published books on schizophrenia that remained in print for decades, such as Frieda Fromm-Reichman's Principles of Intensive Psychotherapy (1950) and Silvano Arieti's The Interpretation of Schizophrenia (1955). Arieti served for years as editor of the voluminous American Handbook of Psychiatry.

Today, psychoanalysts view schizophrenia through a diversity of lenses. Many if not most would acknowledge the medical consensus that it is essentially a biological disorder and would not recommend the kind of intensive therapeutic efforts employed in the past. Analysts seeking an in media res would hold that analytic therapy can be beneficial while giving up earlier etiological views. A minority of analysts, post-Kleinians and others, continue to view schizophrenia as amenable in a global sense to therapeutic intervention and theoretical elaboration. Although the classic psychoanalytic model of the etiology of schizophrenia is definitively obsolete, all these currents can coexist and develop alongside the diathesis-stress model of the disorder, currently dominant in psychiatry and medicine.

John Galbraith Simmons

See also: Ambivalence; Anti-Oedipus: Capitalism and Schizophrenia ; As if personality; Basic Problems of Ethnopsychiatry; Blank/nondelusional psychoses; Character Analysis ; "Claims of Psycho-Analysis to Scientific Interest"; Collected Papers on Schizophrenia and Related Subjects ; Dementia; Disintegration, feelings of, (anxieties); Ego Psychology and Psychosis ; Foreclosure; Infantile schizophrenia; Internal/external reality; Language and disturbances of language; "Metapsychological Supplement to the Theory of Dreams"; Narcissism, secondary; Numinous (analytical psychology); "On the Origin of the 'Influencing Machine' in Schizophrenia"; Organic psychoses; Paranoia; Paranoid psychosis; Paranoid-schizoid position; Paraphrenia; Persecution; Psychological types (analytical psychology); Psychology of Dementia præcox ; Psychology of the Unconscious, The ;Psychoses, chronic and delusional; Psychotic/neurotic; Psychotic transference; Splitting of the ego; Symbolic equation; Symbolic realization; Thought-thinking apparatus; "Unconscious, The"; Violence of Interpretation, The: From Pictogram to Statement ; Word-presentation.

Bibliography

Arieti, Silvano. (1955). The interpretation of schizophrenia. New York: Brunner.

Fromm-Reichmann, Freida. (1950). Principles of intensive psychotherapy. Chicago: University of Chicago Press.

Kernberg, Otto. (1975). Borderline personality disorders and pathological narcissism. New York: Jason Aronson.

Shapiro, Sue. (1981). Contemporary theories of schizophrenia: Review and synthesis. New York: McGraw-Hill.

Willick, Martin. (2001). Psychoanalysis and schizophrenia: A cautionary tale. Journal of the American Psychoanalytic Association, 49, 27-56.

Further Reading

Munich, R.L. (1997). Contemporary treatment of schizophrenia. Bulletin of the Menninger Clinic, 61, 189-221.

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Schizophrenia

SCHIZOPHRENIA

Schizophrenia, often misunderstood as split personality, is a chronic mental illness characterized by psychosis, or loss of reality testing. It is a heterogeneous disease in its presentation, course, effect on functioning, response to treatment, and possibly even etiology. In 1990, the total cost of schizophrenia in the United States, including mental health and societal costs, was estimated at $32.5 billion. The risk of suicide in schizophrenia is at least 10 percent, which is twenty times the risk in the general population. Over 70 percent of persons with schizophrenia are unemployed. An estimated 30 to 50 percent of the homeless population has schizophrenia. As one of the most chronically disabling mental illnesses, it can be devastating for those afflicted and their families, and it has a significant impact on public mental health systems.

Schizophrenia presents as a syndrome. The symptoms are organized into three major categories: positive symptoms, negative symptoms, and cognitive impairment. Positive symptoms include hallucinations, delusions, thought disorders, and bizarre behaviors. Hallucinations are most commonly auditory, usually experienced as voices talking to or about the person. Delusions are false beliefs and tend to be paranoid, grandiose, or bizarre in nature. Disorganized speech is presumed to be a manifestation of an underlying thought disorder. The flow of ideas is illogical and may range from being mildly confusing to incomprehensible. Words may be strung together based on sound rather than meaning, or entirely new words may be created. Bizarre behavior may be observed as repetitive movements, unusual mannerisms, odd ways of dressing, and disregard for social norms.

Negative symptoms include flat affect (facial expression), avolition, and apathy. A flat affect is one revealing little emotion or expression. Generally, persons with schizophrenia seem emotionally disconnected and tend to be socially withdrawn. Avolition and apathy are characterized by a lack of motivation and poor grooming and hygiene. In addition to the positive and negative symptoms of schizophrenia, cognitive impairment with deficits in attention span, memory, and information processing is often present. Persons with schizophrenia experience varying constellations and severities of symptoms resulting in a range of impaired functioning.

The prevalence of schizophrenia is approximately 0.85 percent of the population worldwide and is fairly consistent across race and geographical regions. Men and women are equally affected. Average age of onset in men is 15 to 25 years of age, while in women it is 25 to 35 years of age. No clear risk factors for developing schizophrenia have been identified except a family history of the disease. The disease course is marked by relapses and remissions. Although some persons with schizophrenia regain their premorbid functioning, most experience chronic debilitating symptoms. Acute onset, female gender, being married, and good premorbid adjustment are factors associated with a better prognosis.

The etiology of schizophrenia is poorly understood. Prevailing theories propose a biological vulnerability to developing schizophrenia with both environmental and psychological factors contributing. The biological vulnerability is likely genetic and is suggested by twin studies, adoption studies, and an increased rate of schizophrenia in relatives of persons with the disorder. Immunological abnormalities, viral infections, and hypoxia have all been hypothesized as mechanisms of environmental assaults on the developing brain. Pathological theories focus on abnormalities in the neural circuitry and in neurotransmitters, particularly dopamine. The role of dopamine in schizophrenia is supported by studies showing that increased dopamine activity can induce psychotic symptoms, while blocking dopamine receptors can decrease psychosis.

Schizophrenia is a chronic illness that is managed, not cured. Treatment is most effective when elements of pharmacotherapy, supportive therapy, and psychosocial rehabilitation are integrated. Pharmacotherapy with antipsychotic medications, also called neuroleptics, is the mainstay of treatment and is crucial for diminishing the acute symptoms of schizophrenia as well as maintaining remission. The presumed mechanism of action of these medications is blockade of dopamine receptors in neural tissue. Due to the severity of symptoms and the functional impairments they produce, psychosocial supports and rehabilitation are important for individuals with schizophrenia and their families. Individual supportive therapy and group therapy can promote the development of strategies to manage psychotic symptoms and to manage stress, which can contribute to relapses. Rehabilitation targets the improvement of vocational and social skills. Case management facilitates access to social services, entitlements, housing, and medical care. Up to 25 percent of those with schizophrenia are too impaired to care for themselves in the community and require residential treatment programs or long-term hospitalization. Even when a person is able to live in the community, brief hospitalizations are often necessary to treat exacerbations of psychosis.

Stuart J. Eisendrath

Kara Powers

(see also: Community Metal Health Centers )

Bibliography

Eisendrath, S. J., and Lichtmacher, J. E. (1999). "Psychiatric Disorders." In Current Medical Diagnosis and Treatment 1999, eds. L. M. Tierney, S. J. Mcphee, and M. A. Papadakis. Stamford, CT: Appleton and Lange.

Kaplan, H. I., and Sadock, B. J. (1998). Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 6th edition. Baltimore, MD: Williams & Wilkins.

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schizophrenia

schizophrenia (skĬt´səfrē´nēə), group of severe mental disorders characterized by reality distortions resulting in unusual thought patterns and behaviors. Because there is often little or no logical relationship between the thoughts and feelings of a person with schizophrenia, the disorder has often been called "split personality." However, the condition should not be confused with multiple personality, a disorder in which the individual has two or more distinct personalities that dominate at different times.

In 1896, the German psychiatrist Emil Kraepelin grouped what were previously considered unrelated mental diseases under the term dementia praecox. It was not until 1908, however, that an influential essay by Swiss psychiatrist Eugen Bleuler corrected Kraepelin's theory that the disease was an organic brain deterioration and thus incurable. Bleuler introduced the term schizophrenia to replace dementia praecox, emphasizing the dissociative phenomena in the mind and avoiding the implications of early onset and progressive brain deterioration.

Schizophrenic disorders generally begin in the late teenage years or early adulthood and tend to occur in withdrawn, seclusive individuals. The lifetime prevalence worldwide has been estimated to be just under 1%, and the disorder affects 1.5 to 2 million people in the United States alone. Symptoms include disturbances of thought, both in form and content (see delusion), and disturbances of perception, most commonly appearing as visual or aural hallucinations.

There are five major types of schizophrenia listed by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders. The most severe are disorganized (hebephrenic) schizophrenia, characterized by hallucinations, delusions, inappropriate laughing and crying, incoherent speech, and infantile behavior; and catatonic schizophrenia, characterized by physical rigidity or hyperactivity. Paranoid schizophrenics can often function relatively normally, although they may be disturbed by persecutory delusions and hallucinations, and they tend to exhibit argumentative behavior. The presence of a combination of symptoms from other types is classified as undifferentiated schizophrenia. Residual schizophrenia is constituted by minor symptoms, which occur as an active episode diminishes.

The cause of schizophrenia is unknown. Genetic factors appear to be involved in producing susceptibility to the condition, with studies among identical twins showing a 30%–50% concordance rate, a figure that has been confirmed by the results of adoption studies. Biochemical research suggests that high levels of the neurotransmitter dopamine, or excessive numbers of receptors for dopamine, may be at the root of schizophrenia. Medical imaging studies have revealed various physical and physiological anomalies in some patients. Other research has focused on mistiming of neural responses to stimuli in the brain. Many researchers maintain that a combination of influences, including such environmental factors as viral illness or malnutrition in the patient's mother during pregnancy, may lead to schizophrenia,

Antipsychotic drugs (see psychopharmacology), sometimes in conjunction with psychotherapy, have greatly improved the treatment of schizophrenia. Hospitalization is sometimes needed initially to provide basic personal needs (safety, food, and hygiene) while acute symptoms are treated. Most patients return to the community with varying degrees of independence and with good prospects for long-term remission of symptoms.

See R. Miller and S. Mason, Diagnosis: Schizophrenia (2002); studies by I. I. Gottesman (1991) and H. Häfner and W. F. Gattaz, ed. (1991).

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Schizophrenia

SCHIZOPHRENIA

Schizophrenia is a psychiatric illness that can be profoundly disabling and is usually chronic in nature. The cause is not known, but there appears to be a genetic predisposition. The etiology has been conceptualized in a stress/diathesis (vulnerability) model: Biological and environmental factors (e.g., drug abuse, psychosocial stresses) interact with a genetic vulnerability to precipitate the illness. Several theories have been proposed to explain the observed biological abnormalities of the disorder, including over-activity of the dopamine neurotransmitter systems in the central nervous system, changes in brain structure (e.g., enlargement of the lateral cerebral ventricles) and brain function (e.g., decreased frontal lobe function [hypofrontality], as evidenced by diminished blood flow, and deficits in attention and sensory filtering). Psychological and social factors are considered important in the expression and course of the disorder. It is likely that schizophrenia constitutes a group of disorders rather than a single entity; these disorders present with similar clinical signs and symptoms, but the etiologies, treatment responsiveness, and course of illness in each vary.

Detailed descriptions of the illness date back to the nineteenth century. Emil Kraepelin (1856-1926) used the term dementia praecox to describe psychiatric states with an early onset and deteriorating course. Eugen Bleuler (1857-1939) coined the term schizophrenia for a "splitting of the mind," in his belief that the illness was a result of the disharmony of psychological functions. The diagnosis of schizophrenia requires observation and clinical interviewing. No sign or symptom is specific for the illness, nor do any laboratory tests exist to establish the diagnosis. The Diagnostic and Statistical Manual for Mental Disorders-3rd edition contains the diagnostic guidelines of the American Psychiatric Association for schizophrenia. These include: the presence of characteristic psychotic symptoms (delusions, Hallucinations, a thought disorder, inappropriate emotion); impaired work, social functioning, and selfcare; and continuous signs of the illness for at least six months. The symptoms of an affected individual can change with time, therefore longitudinal follow-up is important. It should be noted that certain of these symptoms can be indicative of other conditions (including drug abuse [cocaine, crack, PCB, amphetamines], head injury, brain tumors, as well as other psychiatric disorders). Furthermore, it is important to take into account the educational level, intellectual ability, and cultural affiliation of the individual when making a diagnosis. The onset of illness is usually in late adolescence or early adulthood and is generally insidious. The typical course of schizophrenia is characterized by exacerbations and remissions. A gradual deterioration in functioning generally occurs that eventually reaches a plateau. However, a small proportion of persons may recover. It is estimated that 20 percent to 30 percent of affected individuals can lead somewhat normal lives whereas another 20 to 30 percent continue to experience moderate symptoms.

The prevalence rates of schizophrenia vary to a limited degree worldwide, but in the United States the lifetime prevalence is estimated to be 1 percent (about one in one-hundred people). In industrialized countries, there is a disproportionate number of schizophrenic patients in the lower socioeconomic classes. Some experts feel this is due to the schizophrenic's loss of education and social opportunity, while others feel this is more a direct result of the stresses of poverty.

The management of affected individuals involves hospitalization when there is an exacerbation of the illness, plus the use of medication. The mainstay of pharmacologic treatment is the class of drugs known as Antipsychotics. Many antipsychotics are available and they act to control the psychotic symptoms; most of them do so by blocking the actions of the neurotransmitter, dopamine. About 75 percent of patients respond to these drugs; however, there are side effects, including muscle stiffness, tremors, and weight gain. The drugs may also cause tardive dyskinesia (TD), a disorder that causes involuntary, repetitive movements of the body, mouth, and tongue.

Some of the more commonly prescribed antipsychotics include: chlorpromazine, fluphenazine, haloperidol, olanzapine, and risperidone. The atypical antipsychotic, clozapine, has been identified as the best choice for managing resistant schizophrenia; however, up to 73 percent of patients treated with clozapine report clinically relevant side effects. These can be quite severe, and include potentially fatal neuroleptic malignant syndrome (NMS), myocarditis, cardiomyopathy, and dangerous lowering of white blood cell count (for the latter, regular and frequent blood testing is required during the treatment period). In a study following 8,000 patients in Australia who started clozapine treatment between January 1993 and March 1999, fifteen developed myocarditis, and eight developed cardiomyopathy; a total of six patients died within the six years.

After a person has recovered from an acute episode of schizophrenia, the emphasis is on practical aspects of management: living arrangements, self-care, employment, and social relationships. Education of and support made available to family members are important and can have an impact on relapse rates in the patient. Many schizophrenic patients have to remain on antipsychotic medication for prolonged periods, since the rate of relapse is high after drug discontinuation. Side effects, primarily of a neurologic nature (e.g., TD), are a source of concern, but in most cases the benefits of symptom control outweigh the risks of pharmacotherapy. Making sure that the patient complies with medication use is often a problem.

(See also: Amphetamine ; Cannabis sativa ; Complications: Mental Disorders )

BIBLIOGRAPHY

Andreasen, N. C. (1986). Schizophrenia. In A. J. Frances & R. E. Hales (Eds.), Psychiatry updateThe American Psychiatric Association annual review (Vol. 5). Washington, DC: American Psychiatric Press.

Apgar, B. (1999). Antipsychotic drugs for treatment of schizophrenia. American Family Physician, 60, 1220.

Berkow, R. (Ed.) (1997). The merck manual of medical informationhome edition. Whitehouse Station, NJ: Merck Research Laboratories.

Karno, M., et al. (1989). Schizophrenia. In H. I. Kaplan & B. J. Sadock (Eds.), Comprehensive textbook of psychiatry (5th ed., Vol. 1). Baltimore, MD: Williams & Wilkins.

Kilian, J. G., et al. (1999). Myocarditis and cardiomyopathy associated with clozapine. The Lancet, 354, 1841.

Oldham, J. M. (1995). Schizophrenia and psychosis. In G. J. Subak-Sharpe, M. S. (Ed.), The Columbia university college of physicians & surgeons complete home medical guide (3rd ed.). New York: Crown Publishers, Inc.

Myroslava Romach

Karen Parker

Revised by Kimberly A. McGrath

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ROMACH, MYROSLAVA; PARKER, KAREN; MCGRATH, KIMBERLY A.. "Schizophrenia." Encyclopedia of Drugs, Alcohol, and Addictive Behavior. 2001. Encyclopedia.com. 1 Jul. 2016 <http://www.encyclopedia.com>.

ROMACH, MYROSLAVA; PARKER, KAREN; MCGRATH, KIMBERLY A.. "Schizophrenia." Encyclopedia of Drugs, Alcohol, and Addictive Behavior. 2001. Encyclopedia.com. (July 1, 2016). http://www.encyclopedia.com/doc/1G2-3403100409.html

ROMACH, MYROSLAVA; PARKER, KAREN; MCGRATH, KIMBERLY A.. "Schizophrenia." Encyclopedia of Drugs, Alcohol, and Addictive Behavior. 2001. Retrieved July 01, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3403100409.html

Schizophrenia

SCHIZOPHRENIA

DEFINITION


Schizophrenia (pronounced skit-suh-FREH-nee-uh) is a psychotic disorder or group of psychotic disorders that cause a patient to lose touch with reality. It is marked by severely impaired reasoning and emotional instability and can cause violent behavior.

Schizophrenic patients are often unable to make sense of the signals they receive from the world around them. They imagine objects and events to be very different from what they really are. If untreated, most people with schizophrenia gradually withdraw from the outside world.

Exactly what schizophrenia is has been the source of considerable disagreement among psychiatrists (doctors who deal with mental disorders). There is some thought that the disease psychiatrists call schizophrenia is actually a number of different conditions classified under a single heading.

DESCRIPTION


Schizophrenia is a serious mental disorder that affects millions of people worldwide. By some estimates, 1 percent of the world's population may be schizophrenic. People diagnosed with schizophrenia make up about half of all patients in psychiatric hospitals and may occupy as many as one quarter of the world's hospital beds.

Schizophrenia can affect people of any age, race, sex, social class, level of education, or ethnic background. Slightly more men than women develop the condition. Most patients are diagnosed in their late teens or early twenties, but the disorder can appear at any time in a person's life. Schizophrenia is rarely diagnosed in children, though it has been reported in children as young as five years of age.

Psychiatrists today recognize five subtypes of schizophrenia.

Paranoid Schizophrenia

Patients diagnosed with paranoid schizophrenia tend to suffer from delusions and hallucinations. A delusion is a belief about the world that is not consistent with the facts. For instance, a patient may believe he or she is someone other than who he or she really is. A patient suffering from a paranoid delusion may believe, unrealistically, that someone intends to do the patient harm.

Hallucinations often take the form of hearing imaginary voices and a patient may believe that he or she is receiving messages from a supernatural or unknown source.

Although people with paranoid schizophrenia have relatively normal emotions and cognitive (thinking) functions, compared to those who suffer other forms of schizophrenia, their delusions and hallucinations, put them at high risk for violent or suicidal behavior.

Disorganized Schizophrenia

Patients with disorganized schizophrenia have confused, disorganized patterns of speech, thought, and behavior. They may act silly or withdraw from the world around them. At one time, disorganized schizophrenia was called hebephrenia (pronounced HEE-buh-FREN-ee-uh).

Schizophrenia: Words to Know

Catatonic behavior:
Behavior characterized by muscular tightness or rigidity and lack of response to the environment.
Computed tomography (CT) scan:
A technique in which X-ray photographs of a particular part of the body are taken from different angles. The pictures are then fed into a computer that creates a single composite image of the internal (inside) part of the body. CT scans provide an important tool in the diagnosis of brain and spinal disorders, cancer and other conditions.
Computerized axial tomography (CAT) scan:
Another name for a computed tomography (CT) scan.
Delusion:
A fixed, false belief that is resistant to reason or factual disproof.
Depot dosage:
A form of medication that can be stored in the patient's body for several days or weeks.
Hallucination:
A perception of objects (or sounds) that have no reality. Seeing or hearing something that does not actually exist.
Neurotransmitters:
Chemicals that carry electrical messages between nerve cells.
Paranoia:
Excessive or irrational suspicion or distrust of others.
Psychotic disorder:
A mental disorder characterized by delusions, hallucinations, and other symptoms indicating a loss of contact with the real world.

Catatonic Schizophrenia

Catatonic schizophrenia is characterized by abnormal types of posture and movement. A patient may stand or walk in peculiar patterns, may repeat certain motions over and over again, or become rigid and unmoving for long periods of time.

Undifferentiated Schizophrenia

This category is reserved for patients who show some symptoms of schizophrenia but do not fit into any of the three categories described above.

Residual Schizophrenia

Patients in this category have had at least one schizophrenic episode but no longer display the most severe symptoms of the first three types of schizophrenia.

CAUSES


People have argued for centuries about the causes of mental illnesses such as schizophrenia. Historically, people with these afflictions have been defined as "mad" or "insane" or were believed to be possessed by evil spirits. Those suffering from mental illness were often beaten, tortured, or locked up in special facilities.

For much of the twentieth century, scientists thought that stressful or traumatic conditions in a person's life could cause mental disorders. Psychiatrists believed that a neglected or abused child, for example, ran a higher risk of developing some mental disorders.

This theory is now less popular with scientists, who generally agree that the disease is biological and not caused by life experiences. There are, however, several competing theories as to what does cause the illness.

Heredity

Research shows that the condition tends to run in families. A person with schizophrenic relatives is ten times as likely to develop schizophrenia as someone who has no history of the disease in the family.

Viral Infection

Some researchers have argued that schizophrenia is caused by a virus that attacks the brain. The virus is thought to attack the part of the brain that interprets messages from the senses. Damage to this part of the brain may account for a person's delusions and hallucinations.

Chemical Imbalance

A popular theory is that schizophrenia is caused by an imbalance of neurotransmitters in the brain. Neurotransmitters (pronounced NOOR-oh-TRANZ-mit-urz) are chemicals that carry electrical messages between nerve cells. Too much of a neurotransmitter, or too little, may account for various mental disorders, including schizophrenia.

There is still no consensus (agreement) as to which, if any, of these theories is correct, or whether the disease is caused by a combination of factors.

SYMPTOMS


Because schizophrenia's cause is unknown, the disease is defined by a set of symptoms. Most patients have some, but not all, of these symptoms. The most common symptoms are delusions and hallucinations, which may include hearing imaginary voices.

Another common symptom is called insertion or withdrawal of thought. This term refers to the patient's belief that someone or something can put thoughts in the patient's head or take them out. For example, some patients believe that God, the FBI, or alien beings talk to them and tell them how to behave.

Disorganized thinking and behavior are also characteristic of schizophrenia. A patient may have trouble completing a sentence, thinking through an idea, or answering a question clearly. He or she may also have trouble carrying out routine tasks such as tying shoe laces, washing, or getting dressed.

Those suffering from schizophrenia may exhibit other abnormal behavior. For example a patient may show no emotions, or be unable to speak, or may avoid taking any action at all.

DIAGNOSIS


There are currently no laboratory tests by which schizophrenia can be diagnosed. Some imaging techniques, such as computed tomography (CT) scans, which use X rays to create a picture of internal organs, can be helpful in showing abnormal structures in the brain. CT scans are also sometimes called computerized axial tomography (CAT) scans. For the most part, however, doctors must observe a patient's behavior to decide if he or she is schizophrenic.

The first step in this process is to rule out other physical and mental disorders. Some diseases and disorders of the brain cause symptoms similar to those of schizophrenia. Encephalitis (see encephalitis entry), or brain fever, is one such disease. Encephalitis is caused by a virus and must be treated very differently from schizophrenia.

Psychiatrists also try to distinguish various types of mental disorders from each other. While many disorders have symptoms similar to those of schizophrenia, they may require quite different treatments.

Psychiatrists usually rely on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) in diagnosing a mental disorder. DSMIV is a standard reference book that lists all recognized mental disorders. It also lists the basis on which each disorder is diagnosed. The standards used for diagnosing schizophrenia are as follows:

  • A patient must have two or more of the following symptoms during a one-month period: delusions, hallucinations, disorganized speech, disorganized behavior, or lack of normal behaviors (such as the ability to speak).
  • The patient shows a decline in social, personal, or occupational functions, including the ability to care for him or herself.
  • The disturbed behavior must last for at least six months.
  • Other physical and mental problems must be ruled out as causes of the abnormal behavior.

TREATMENT


The treatment for schizophrenia depends in part on the stage of the patient's condition.

Hospitalization

In the early stages, hospitalization may be necessary. Hospitalization prevents patients from doing harm to themselves or others. Hospitalization often lasts until treatment with medications begins.

Medication

The primary form of treatment for schizophrenia is medication. Drugs are now available to control many of the symptoms of the disorder. Between 60 to 70 percent of patients with schizophrenia respond to drug treatment.

In the early stages of the disorder, patients may be given regular doses of medicine. The drugs may be swallowed or given by injections. As the patient improves, drugs may be given in depot doses, a form of medication that works in the system for two to four weeks. Depot doses are used because patients often forget to take their medication. Most people with schizophrenia will need to stay on medication throughout their lives.

The most successful medications used in the treatment of schizophrenia are neurotransmitter antagonists. An antagonist is a chemical that acts against some substance in the body.

Researchers now believe that schizophrenia may be caused when the brain produces too much neurotransmitter. Neurotransmitters are chemicals that carry electrical messages between nerve cells. Too much neurotransmitter can cause brain cells to remain active far longer than they would normally. Neurotransmitter antagonists fight off the excess neurotransmitters, helping the brain cells relax and behave more normally.

Psychotherapy

At one time doctors thought that counseling could help cure schizophrenia, by helping patients understand the events in their history that led to the disorder. That view is no longer as popular because most researchers think schizophrenia is a biological problem rather than a problem caused by early upbringing or life events.

Still, some forms of psychotherapy can help schizophrenic patients. Behavior therapy, example, can teach patients to cope with daily activities and may improve the way they interact with other people.

Family therapy

Family members can also benefit from some forms of therapy. For instance, parents may feel that they are somehow responsible for a child's schizophrenia. Professional therapists can help all family members better understand the mental disorder. They can also outline ways in which family members can provide support for the patient. Family therapy may also focus on improving the family's ability to communicate with each other and solve mutual problems brought about by the disease.

PROGNOSIS


The prognosis for schizophrenia is related to the age at which a patient first develops symptoms. The earlier the condition appears, the more permanent the damage is likely to be. Patients who develop the condition later in life have a better chance for leading relatively symptom-free lives.

PREVENTION


There is currently no way to prevent the development of schizophrenia.

FOR MORE INFORMATION


Books

Mueser, Kim Tornval. Coping With Schizophrenia: A Guide for Families. Oakland, CA: New Harbinger Publications, 1994.

Torrey, E. Fuller. Surviving Schizophrenia: A Manual for Families Consumers and Providers, 3rd edition. New York: Harperperennial Library, 1995.

Tsuang, Ming T., et al. Schizophrenia: The Facts, 2nd edition. New York: Oxford University Press, 1997.

Periodicals

Winerip, Michael. "Schizophrenia's Most Zealous Foe." New York Times Magazine (February 22, 1998): 2629.

Web sites

"Ask NOAH About: Mental Health." NOAH: New York Online Access to Health. [Online] http://www.noah.cuny.edu/mentalhealth/mental.html#Schizophrenia (accessed on October 31, 1999).

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Schizophrenia

Schizophrenia

What Happens to People with Schizophrenia?

How Is Schizophrenia Diagnosed and Treated?

Living with Schizophrenia

Resources

Schizophrenia (SKIT-zo-FREE-ni-a) is a complex, serious, and chronic brain disorder. It results from disruptions in the structure and function of the brain and neurotransmitter pathways of the central nervous system. These disruptions may cause psychotic symptoms, which are frightening distortions in thoughts, feelings, moods, perceptions, and behavior that interfere with daily life. With the correct combination of medication and therapy, the symptoms of schizophrenia often can be managed effectively.

KEYWORDS

for searching the Internet and other reference sources

Catatonia

Delusions

Hallucinations

Neuroleptics

Neurotransmitters

Psychosis

Information in the form of electrical signals flows down nerve cells in the brain, triggering the release of neurotransmitters. These chemical messengers transmit information from one nerve cell to another. In healthy people, neurotransmitter traffic usually flows smoothly, with occasional hills, valleys, bumps, and potholes that represent the stresses and challenges of growing up and interacting with other people. In people with schizophrenia, however, neurotransmitter traffic runs into major roadblocks, unscheduled stops, and unmapped detours to frightening and unreal places. These traffic disruptions result in periods of psychosis, during which people with schizophrenia lose touch with healthy reality and seem to get trapped in alternate realities. With anti-psychotic medication, people with schizophrenia often find their way back to the healthy realities of everyday life.

What Happens to People with Schizophrenia?

Neurotransmitter disruptions

Researchers know that in our chromosomes* are genes that direct the development of all the structures and functions of the brain and central nervous system, including the production and release of neurotransmitters. In schizophrenia, faulty genes may create coding errors affecting several different neurotransmitters. When those miscodings interact with environmental factors during childhood and adolescence, and even before birth, they may affect brain neurotransmitter levels and function, resulting in symptoms that doctors usually classify as positive and negative. Most often, the serious symptoms of schizophrenia do not appear until a persons late teens or early twenties.

* chromosomes
(KRO-mo-somz) are threadlike chemical structures inside cells on which the genes are located. There are 46 (23 pairs) chromosomes in normal human cells. Genes on the X and Y chromosomes (known as the sex chromosomes) help determine whether a person is male or female. Females have two X chromosomes; males have one X and one Y chromosome.

Positive symptoms

The positive symptoms of schizophrenia are those that seem to distort and exaggerate sights, sounds, thoughts, perceptions, beliefs, and behaviors. People with schizophrenia usually do not experience positive symptoms until their late teens or early twenties, and doctors usually cannot diagnose schizophrenia before positive symptoms occur. The positive symptoms of schizophrenia may include delusions, hallucinations, and disorganized speech, thoughts, beliefs, movements, and behaviors.

Positron emission tomography (PET) scans are computer-generated images of brain activity. When compared with PET scans of healthy people, the scans of people with schizophrenia show disruptions in brain activity, changes in brain structures like the ventricles, and decreased function in the frontal cortex. Photo Researchers, Inc.

  • Delusions: Delusions are false beliefs that a person holds onto even when they are bizarre or could not possibly be true. Delusions may involve fears (paranoid delusions), guilt, jealousy, religion, spirits, ones role in life (delusions of grandeur), ones body, and mind control. People with schizophrenia might believe, for example, that their inner thoughts are being broadcast out loud or that outside people, spirits, or aliens are inserting thoughts into their heads or are touching their bodies.
  • Hallucinations: Hallucinations involve seeing, hearing, or feeling things that are not real. People with schizophrenia often hear voices in their heads (auditory hallucinations) that other people cannot hear and that are not just their inner thoughts. The voices may tell them what to do, may carry on conversations about them, or may have arguments with each other.
  • Disorganized speech, thoughts, and beliefs: People with schizophrenia may lose track of their ideas, meanings, and words (word salad;). Ideas and images may become jumbled or linked together for illogical reasons, or words and meanings that should be linked instead may become disconnected.
  • Disorganized movements and behaviors: People with schizophrenia may use exaggerated or repeated gestures, or they may seem to be fidgeting or hyperactive or preoccupied with meaningless physical movements.

The Genetics of Schizophrenia

Scientists know that schizophrenia tends to run in families and that it affects both males and females, but they have not yet located the genetic coding errors that lead to the neurotransmitter disruptions that are seen in schizophrenia.

Studies of inheritance patterns show the following estimates of a persons risk of developing schizophrenia:

  • 1%: general population
  • 8%: when a sibling has schizophrenia
  • 12%: when a parent has schizophrenia
  • 14%: when a fraternal twin has schizophrenia
  • 25%-35%: when both parents have schizophrenia
  • 45%-50%: when an identical twin has schizophrenia.

Identical twins are siblings who develop from the same embryo. They always are the same sex and they share the same genetic material. If schizophrenia were entirely the result of a single genetic coding error, then the risk that identical twins both would inherit schizophrenia would be close to 100%.

Scientists believe that several different genes interacting with environmental factors is the likeliest underlying mechanism for schizophrenia. The U.S. National Institute of Mental Health has launched a Schizophrenia Genetics Initiative to gather data from people and families with schizophrenia. To find out more about it, check their website at www.nimh.nih.gov.

Negative symptoms

The negative symptoms of schizophrenia usually involve a reduction in a persons normal level of functioning. People with schizophrenia may seem to think, speak, feel, and move less than healthy people do:

  • Alogia (a-LO-jee-a) and poverty of speech: People with schizophrenia may speak very little, or their speech may have little meaningful content, or they may have long delays between words and sentences, as if the connections between thoughts and speech were interrupted or blocked.
  • Flattening or blunting of affect: People with schizophrenia may have reduced emotional expression. They may not smile or frown in response to happy or sad events, their voices may not change tone or pitch, and they may not maintain eye contact or other kinds of emotional links with other people.
  • Avolition and anhedonia: People with schizophrenia may seem to lose interest in and energy for pleasurable activities and achievements.
  • Catatonia and posturing: People with schizophrenia may seem to freeze into unusual body positions, or they may seem to stop moving entirely.

Remissions and relapses

The negative symptoms of schizophrenia sometimes are seen during early childhood, when they may resemble autism and similar developmental disorders. By the late teens or early twenties, the positive symptoms of schizophrenia begin to appear. Mental health activist Ken Steele, for example, reported in The Day the Voices Stopped: A Memoir of Madness and Hope that his voices began when he was 14 years old.

Symptoms often occur in cycles, alternating periods of improvement (remissions) with periods of psychosis (relapses). Because schizophrenia is a permanent (chronic) disorder, it often gets worse as a person gets older, as periods of active psychosis interfere with perceptions of reality and activities of daily living. With the correct combination of medication and therapy, however, the positive and negative symptoms of schizophrenia often can be managed and controlled effectively.

How Is Schizophrenia Diagnosed and Treated?

Diagnosis

The first step toward diagnosis is a complete medical examination and medical history. This helps the doctor to rule out other possible causes of psychotic symptoms, including substance abuse, bipolar disorder, brain tumors, brain infections, and metabolic disorders that affect the brain and central nervous system. The doctor also may order lab tests or imaging studies. People with schizophrenia often do not have all possible signs and symptoms, but doctors generally will screen patients for delusions, hallucinations, voices, and disruptions of normal speech, thought, and feeling patterns. Brief psychotic disorder and schizophreniform (SKIT-zo-FREN-ni-form) disorder have symptoms similar to schizophrenia, but these conditions usually last for six months or less. A diagnosis of schizophrenia means that long-term treatment will be necessary.

Auditory Hallucinations and Son of Sam

During the 1970s, a man who called himself Son of Sam killed several people in New York City. When the killer was caught, he was identified as a man named David Berkowitz, who was having auditory hallucinations. In those hallucinations, Berkowitz heard the voice of a neighbors dog (named Sam;) giving him orders to kill people in parked cars. Berkowitz still is in prison in New York.

People with schizophrenia experience disruptions in ordinary reality. Through art therapy, they are able to express their energy and subconscious feelings in a creative and uninhibited way. A therapist may be able to interpret the persons experience through this visual, symbolic form of communication. Paul Almasy/Corbis

Medications

Schizophrenia is considered a chronic disorder. There is not yet a cure for it, but there are medications that can offer relief from psychotic symptoms. These medications, called antipsychotics, can help quiet the voices that interfere with daily activities and can result in dramatic improvements in the quality of life for people with schizophrenia.

Doctors must work very carefully with patients and their families to choose the right medication at the right dosage. When an effective medication is found, it often improves both the positive and negative symptoms of schizophrenia, reducing delusions and hallucinations and increasing social functioning.

Originally introduced during the 1950s, chlorpromazine (Thorazine) was the first medication used to treat schizophrenia. It was considered a major tranquilizer and it often produced unpleasant side effects. In the decades since then, researchers have discovered many newer medications that target malfunctioning neurotransmitters more accurately, improve symptoms more effectively, and cause fewer side effects. Newer medications introduced during the 1990s include clozapine (Clozaril), resperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon).

Emil Kraepelin was a German psychiatrist who identified dementia praecox as a disorder in which people lost touch with reality. Kraepelins colleague Eugen Bleuler later renamed the disorder schizophrenia. National Library of Medicine

Medication dosages often require adjustments over time to maintain effectiveness or to reduce side effects. Sometimes people with schizophrenia stop taking their medication or stop checking in with their doctors, possibly because they feel better or because of unpleasant side effects from the medication. Without medication, however, psychotic symptoms are likely to return or worsen.

Side effects

Antipsychotic medications sometimes result in side effects that can make it difficult or distressing for patients to follow their doctors recommended treatment plan. The older medications like chlorpromazine (Thorazine) often produced symptoms like sluggishness, emotional numbing, drowsiness, restlessness, muscle spasms or tremors, dry mouth, weight gain, and blurring of vision. A more serious side effect of long-term use of the older medications was a condition called tardive dyskinesia (TAR-div dis-ki-NEE-zee-a). People with tardive dyskinesia experienced involuntary movements of the face or arms or legs, movements that sometimes did not disappear when the medication was stopped. Often, people who developed tardive dyskinesia chose to continue taking their medication because the beneficial effects outweighed this serious side effect. It is important to note that each new generation of medications works more effectively than the older ones in relieving psychotic symptoms, reducing the severity of side effects, and reducing the risk of tardive dyskinesia.

Psychotherapy and support networks

As with other chronic diseases, people with schizophrenia need support from doctors, counselors, social workers, family, friends, and other people with the same disorder. Therapy can help people with schizophrenia learn how to accept their diagnosis, manage their symptoms and relapses, and adjust their daily lives to incorporate their medication and treatment plans.

Living with Schizophrenia

Once it was the norm for people with schizophrenia and other psychotic disorders to be hospitalized when they were diagnosed and to remain hospitalized for the rest of their lives. Today it is more common for patients to be hospitalized for only a short period of time, while their psychotic symptoms are being brought under control. As long as they remain on medication under a doctors supervision, many people with schizophrenia are now able to remain at home with their families or in supervised group homes.

Dementia Praecox And Schizophrenia: Emil Kraepelin And Eugen Bleuler

Psychosis has been written about since before the time of the ancient Greeks, but the scientific study of mental disorders is still rather new in human history. Previous generations often believed that psychosis was a form of possession by supernatural spirits because people with schizophrenia seemed to see things and hear voices that were not real. Often people with schizophrenia and other psychotic disorders were put in prisons or in lunatic asylums.

It was not until 1896 that the German psychiatrist Emil Kraepelin (18561926) developed a classification system for mental illnesses in which he identified a group of psychotic symptoms that he called dementia praecox (de-MEN-sha PRAY-cox), from the Latin term meaning precocious or premature dementia. Kraepelin took note of many of the distorted thoughts and perceptions that signaled the start of the disorder, the age at which it seemed to occur most often, the periods of remission and relapse, and the fact that the disorder was chronic and usually got worse with the passage of time.

The Swiss psychiatrist Eugen Bleuler (18571939) later renamed the disorder schizophrenia from the Latin phrase for splitting of the mind. Bleuler did not mean that people with schizophrenia had dissociative identity disorder (multiple personality disorder) or Jekyll and Hyde personalities. Rather he meant that people with schizophrenia had minds that seemed to become fragmented and disrupted when they needed to coordinate thoughts, emotions, and behavior with the real world. Processes of mind that ran smoothly in healthy people instead seemed to split into fragments in people with schizophrenia.

Current research suggests that Bleuler was on the right track. As researchers identify the specific functions of the neurotransmitters that become disrupted in schizophrenia, the medications designed to target those neurotransmitters become more effective and cause fewer side effects.

Therapy for people with schizophrenia

Psychotherapy often helps people with schizophrenia learn to manage the behaviors that accompany psychotic symptoms and adjust to the rhythms and requirements of chronic illness. Therapy may involve a token economy technique that uses rewards for behavioral change. It also may involve rehabilitation and social skills training so that people with schizophrenia can catch up with the everyday skills and opportunities that had to be put on hold during periods of psychosis. Taking care of oneself, talking and listening during ordinary conversations, and interacting with friends, family, coworkers, and community in the real world all are skills that can be learned or relearned.

Family education

Family members also must learn how to overcome the confusion, shame, guilt, regret, grief, and stigma often attached to mental illness. Help in understanding the biology of schizophrenia is important, as is acceptance by family members that the signs and symptoms of schizophrenia are real and not just a way to avoid accepting reality and responsibility.

Family members must learn how to cope with specific symptoms like delusions and with alternating cycles of remission and relapse. People with schizophrenia are at a higher risk for depression and suicide, making it essential that family members know when to intervene and summon professional help. During periods of active psychosis, it usually is not helpful for friends and families to challenge delusions. But it is possible for them to communicate openly and honestly that they do not share the psychotic delusions even though they know that they are real for the person with schizophrenia.

Family members also play an important role in helping patients stick to their prescribed treatment plan. Patients with disorganized thinking may forget to take their medications, or their voices may tell them they do not need medication at all. At such times, family members who recognize the signs and symptoms of schizophrenia can take action to get immediate treatment, to prevent a relapse, and to keep the person with schizophrenia in touch with the reality of managing his or her disorder.

See also

Bipolar Disorder

Birth Defects and Brain Development

Brain Chemistry (Neurochemistry)

Delusions

Dementia

Depression

Dissociative Identity Disorder

Genetics and Behavior

Hallucination

Paranoia

Psychosis

Substance Abuse

Suicide

Therapy

Resources

Books

Greenberg, Joanne. I Never Promised You a Rose Garden. New York: New American Library, 1984. Originally written under the pseudonym Hannah Green to protect the author from the stigma of mental illness, Joanne Greenbergs classic novel about a girl with schizophrenia was published in 1964 and has been in print continuously ever since.

Steele, Ken, and Claire Berman. The Day the Voices Stopped: A Memoir of Madness and Hope. New York: Basic Books, 2000. This moving autobiography tells the story of mental health activist Ken Steele, whose voices began when he was 14 years old and continued for decades until his doctors found the right medication to control his symptoms.

Organizations

U.S. National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. This division of the National Institutes of Health oversees research on schizophrenia and other mental illnesses. It publishes the Schizophrenia Bulletin for researchers and many helpful fact sheets for the public. Telephone 301-443-4513 http://www.nimh.nih.gov

American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Ave. NW, Washington, DC, 20016-3007. The American Academy of Child and Adolescent Psychiatry website posts Facts for Families about schizophrenia and other psychiatric disorders. Telephone 202-966-7300 http://www.aacap.org

National Alliance for Research on Schizophrenia and Depression, 60 Cutter Mill Road, Suite 404, Great Neck, NY 11021. This nonprofit organization supports scientific research on brain and behavior disorders. Telephone 516-829-0091 or 800-829-8289 http://www.narsad.org

National Alliance for the Mentally Ill (NAMI), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201-3042. This information, advocacy, and support group for people with mental illness and their families and friends sponsors a self-help education program called Living with Schizophrenia and Other Mental Illnesses (LWS). LWS programs currently are active in more than 30 states. Telephone 800-950-NAMI or 703-524-7600 http://www.nami.org

American Psychiatric Association, 1400 K Street NW, Washington, DC, 20005. An organization of physicians that provides information about schizophrenia. Telephone 888-357-7924 http://www.psych.org

National Mental Health Association, 1021 Prince Street, Alexandria, VA 22314-2971. A nonprofit organization that addresses all aspects of mental illness and health and supports education and research to improve mental health. Telephone 800-969-6642 or 703-684-7722 http://www.nmha.org

National Mental Health Consumers Self-Help Clearinghouse, 1211 Chestnut Street, Suite 1207, Philadelphia, PA 19107. This organization makes information available to consumers about various mental health issues, including mental health services and resources. Telephone 800-553-4539 or 215-751-1810 http://www.mhselfhelp.org

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schizophrenia

schizophrenia (skits-ŏ-freen-iă) n. a severe mental illness characterized by a disintegration of the process of thinking, of contact with reality, and of emotional responsiveness. Delusions and auditory hallucinations (especially in the form of a running commentary or of voices talking about the patient among themselves) are common, and the patient feels that his or her thoughts, sensations, and actions are controlled by, or shared with, others (see thought alienation). Treatment is with antipsychotic drugs and with vigorous psychological and social management and rehabilitation.
schizophrenic (skits-ŏ-fren-ik) adj.

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schizophrenia

schiz·o·phre·ni·a / ˌskitsəˈfrēnēə; -ˈfrenēə/ • n. a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation. ∎  (in general use) a mentality or approach characterized by inconsistent or contradictory elements. DERIVATIVES: schiz·o·phren·ic / -ˈfrenik/ adj. & n.

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schizophrenia

schizophrenia A psychosis, more broadly defined in the United States than Britain, typically characterized by delusions or hallucinations, usually developing in late adolescence, and regarded as paradigmatic of madness. The term was introduced in the early twentieth century and applied to a condition identified in the mid-nineteenth century as dementia praecox. Evidence indicates genetic predisposition but also the aetiological importance of environment.

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schizophrenia

schizophrenia Severe mental disorder marked by disturbances of cognitive functioning, particularly thinking. As well as the characteristic loss of contact with reality, symptoms can include hallucinations and delusions, and muffled or inappropriate emotions. Research suggests that schizophrenia may be caused by high levels of dopamine, a neurotransmitter.

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schizophrenia

schizophreniaCampania, Catania, pannier •apnoea •Oceania, Tanya, Titania •biennia, denier, quadrennia, quinquennia, septennia, triennia •Albania, balletomania, bibliomania, crania, dipsomania, egomania, erotomania, kleptomania, Lithuania, Lusitania, mania, Mauritania, megalomania, miscellanea, monomania, nymphomania, Pennsylvania, Pomerania, pyromania, Rainier, Romania, Ruritania, Tasmania, Transylvania, Urania •Armenia, bergenia, gardenia, neurasthenia, proscenia, schizophrenia, senior, SloveniaAbyssinia, Bithynia, curvilinear, Gdynia, gloxinia, interlinear, Lavinia, linear, rectilinear, Sardinia, triclinia, Virginia, zinnia •insignia • Sonia • insomnia • Bosnia •California, cornea •Amazonia, ammonia, Antonia, Babylonia, begonia, bonier, Catalonia, catatonia, Cephalonia, Estonia, Ionia, Laconia, Livonia, Macedonia, mahonia, Patagonia, pneumonia, Rondônia, sinfonia, Snowdonia, valonia, zirconia •junior, petunia •hernia, journeyer

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