Schizophrenia Health Article

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 Generally, persons with schizophrenia seem emotionally disconnected and tend to be socially withdrawn.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)