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 neurotransmittersdopamine 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 2–3%. 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 30–50% 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 28–34 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 25–30 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.
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>.
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>.
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