What is the definition of schizophrenia?
Sometimes colloquially but inaccurately referred to as split personality disorder, schizophrenia is a chronic, severe, debilitating mental illness. It affects about 1% of the general population, corresponding to more than 2 million people in the United States alone. Other statistics about schizophrenia include that it affects men about one and a half times more commonly than women. While the first episode of schizophrenia tends to occur from 18-25 years of age for men, the age of onset for women peaks initially from 25-30 years of age and again at about 40 years of age. People who experience the first episode of this mental illness after the age of 40 years are considered to have late-onset schizophrenia.
Schizophrenia is one of the psychotic mental disorders and is characterized by symptoms of thought, behavior, and social problems. The thought problems associated with schizophrenia are described as psychosis, in that the person's thinking is completely out of touch with reality at times. For example, the sufferer may hear voices, smell odors, detect tastes, see people that are in no way present, or feel like bugs are crawling on their skin when there are none. The individual with this thought disorder may also have disorganized speech, disorganized behavior, physically rigid or lax behavior (catatonia), significantly decreased behaviors or feelings, as well as delusions, which are defined as ideas that have no basis in reality (for example, the individual might experience paranoia, in that he or she thinks others are plotting against them when they are not; a false belief of superiority, that thoughts are not one's own or that ordinary events have a special and personal meeting). While compulsive behaviors and obsessional thinking are not included as part of the diagnosis of schizophrenia, these symptoms occur in many people with this disorder.
Given that an individual can have various predominant symptoms of schizophrenia at different times as well as at the same time, the most recent Diagnostic Manual for Mental Disorders (DSM-5) has done away with what used to be described as five types of schizophrenia.
Schizophrenia is the most disabling mental illness.
What are schizophrenia causes? Is schizophrenia hereditary?
One frequently asked question about schizophrenia is if it is hereditary. As with most other mental disorders, schizophrenia is not directly passed from one generation to another genetically, and there is no single specific cause for this illness. Rather, it is the result of a complex group of genetic and other biological vulnerabilities, as well as psychological and environmental risk factors. Biologically, it is thought that people who have abnormalities in the brain neurochemical dopamine and lower brain matter in some areas of the brain are at higher risk for developing the condition. Other brain issues that are thought to predispose people to developing schizophrenia include abnormalities in the connections between different areas of the brain, called default mode network connectivity. Recent research is emerging that implicates potential abnormalities in the transmission of the brain neurochemical glutamate as a risk factor for having schizophrenia.
Schizophrenia is thought to have a significant but not solely genetic component. People who have immediate family members (first-degree relatives) with psychosis are more vulnerable to developing schizophrenia compared to people who do not have such a family history. Genetically, schizophrenia and bipolar disorder have much in common, in that the two disorders share a number of the same risk genes. However, the fact is that both illnesses also have some genetic factors that are unique. There are some genetic commonalities with schizophrenia and epilepsy, as well.
Environmentally, the risks of developing schizophrenia can even occur before birth. For example, the risk of schizophrenia is increased in individuals whose father is of advanced age or whose mother was malnourished or had one of certain infections during pregnancy. Difficult life circumstances during childhood, like the early loss of a parent, parental poverty, bullying, witnessing domestic violence; being the victim of emotional, sexual, or physical abuse or of physical or emotional neglect; and insecure attachment have been associated with increased risks of developing this illness. Using drugs, particularly marijuana (cannabis), amphetamines, and hallucinogens, has been found to increase the risk of developing schizophrenia. Factors like recent migration, being discriminated against, and how well represented an ethnic group is in a neighborhood can also be a risk or protective factor for developing schizophrenia in the long term. For example, some research indicates that ethnic minorities may be more at risk for developing this disorder if there are fewer members of the ethnic group to which the individual belongs in their neighborhood.
Schizophrenia: Symptoms, Types, Causes, Treatment
What are schizophrenia symptoms and signs?
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), symptoms of schizophrenia include the following:
Positive, more overtly psychotic symptoms
- Delusions are beliefs that have no basis in reality. Types of delusions include erotic, grandiose (for example, religious or false belief or superiority), jealous, persecutory, physical (somatic), mixed, and nonspecific.
- Hallucinations: hearing (for example, hearing voices), seeing, feeling (for example, feeling like bugs are crawling on the skin), smelling, or tasting things that have no basis in reality
- Disorganized speech: incoherent or often grossly off topic (derailed) speech
- Disorganized behaviors
Negative symptoms, potentially less overtly psychotic
- Inhibition of facial expressions and/or a lack of emotional responsiveness
- Catatonic behaviors: difficulty moving, resistance to moving, hyperactivity, repetitive or otherwise abnormal movements, and/or nonsense word repetition or of what others say or do
- Self-neglect, poor grooming, and lack of good hygiene
- Lack of speech
- Apathy/lack of motivation
Prior to the development of the full-blown disorder, people who go on to develop schizophrenia often exhibit more subtle and/or less specific symptoms, also called prodromal symptoms. Some characteristics of prodromal schizophrenia are thought to include slowness in activity and thought, lower cognitive functioning, including memory loss, disorientation and mental confusion; abnormal speech, including circumstantial, vague, or stereotyped speech. Individuals suffering from the prodromal symptoms of schizophrenia may exhibit odd ideas that have not reached the level of being delusions, like feeling detached from themselves, having beliefs that an ordinary event has special and personal meaning, or a belief that their thoughts aren't their own. People with prodromal schizophrenia also tend to have mood problems, like general discontent, inappropriate emotional responses, fear, mistrust, hostility, anger, aggression, excitability, agitation and inability to feel pleasure in activities they used to enjoy; social isolation, self-centeredness that borders on narcissism, and other problems socializing.
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What professionals diagnose and treat schizophrenia? Are there particular tests that assess schizophrenia?
As is true with virtually any mental health diagnosis, there is no one test that definitively indicates that someone has schizophrenia. Therefore, health care professionals like psychiatrists or other psychiatric medication prescribers, clinical psychologists or primary care providers diagnose this illness by gathering comprehensive medical, family, and mental health information. Patients tend to benefit when the practitioner performs a systematic review of their client's entire life and background. Examples of this include the person's gender, sexual orientation, cultural, religious and ethnic background, socioeconomic status, family, and other social relationships. The symptom sufferer might be asked to fill out a self-test that the professional will review if the person being evaluated is able to complete it.
The practitioner will also either perform a physical examination or request that the individual's primary care doctor perform one. The medical assessment will usually include lab tests to evaluate the person's general health and to explore whether or not the individual has a medical condition or has been exposed to certain medications (for example, amphetamines like methylphenidate [Ritalin or Concerta] or amphetamine and dextroamphetamine [Adderall] in the treatment of attention deficit hyperactivity disorder or corticosteroids for the treatment of severe asthma) that might produce psychological symptoms.
In asking questions about mental health symptoms, mental health professionals are often exploring if the individual suffers from hallucinations or delusions, depression and/or manic (for example, excessive anger or elevated mood, inappropriate emotional responses, rapid, pressured, and/or frenzied speaking, a lack of behavioral restraint, overexcitement, decreased need for sleep) symptoms as occurs in bipolar disorder or schizoaffective disorder, anxiety, substance abuse, as well as some personality disorders (like schizotypal personality disorder) and developmental disorders (for example, autism spectrum disorders including the condition that was formerly called Asperger disorder). How long symptoms occur is a factor in determining diagnosis. For example, psychosis sufferers whose symptoms resolve in no more than a month may qualify for the diagnosis of schizophreniform disorder rather than schizophrenia. Since some of the symptoms of schizophrenia can also occur in other psychiatric illnesses, the mental health screening is to assess if the individual suffers from schizoaffective disorder or other psychotic disorder, depressive disorder, bipolar disorder, an anxiety disorder, a personality disorder, or a substance-abuse/drug-induced psychosis (for example, marijuana, cocaine, amphetamines, or psychedelic drugs).
Any disorder that is associated with bizarre behavior, mood, or thinking, like another psychotic disorder, borderline personality disorder or dissociative identity disorder (DID), previously called multiple personality disorder (MPD), may be particularly challenging to distinguish from schizophrenia. However, people with DID often suffer from feeling detached from oneself, as well as what looks like amnesia for their dissociative episodes, which does not tend to be a characteristic of schizophrenia. In order to assess the person's current emotional state, health care professionals perform a mental-status examination, as well. In addition to providing treatment that is appropriate to the diagnosis, determining the presence of mental health conditions that may co-occur (be comorbid) with schizophrenia is important in improving the life of schizophrenia sufferers. For example, people with schizophrenia are at increased risk of having a substance-abuse, depressive, or anxiety disorder and committing suicide.
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What are treatments for schizophrenia and the side effects of those treatments?
Given the seriousness and chronic nature of schizophrenia, self-care without also getting treatment by a professional or home remedies are not deemed appropriate treatment for this illness. There is currently not thought to be a cure for schizophrenia, but there are a number of helpful treatments available, of which medication remains the cornerstone of treatment for people with this condition. These medications are often referred to as antipsychotics since they help decrease the intensity of psychotic symptoms. Many health care professionals prescribe one of these medications, sometimes in combination of one or more other psychiatric medications, in order to maximize the benefit for the person with schizophrenia.
Medications that have been found to be particularly effective in treating the positive symptoms of schizophrenia and therefore are considered top choices or first-line treatments, include orally taken medications like risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris), lurasidone (Latuda), brexpiprazole (Rexulti), and iloperidone (Fanapt). Medications that may be taken by injection or by mouth include chlorpromazine, haloperidol (Haldol), fluphenazine, risperidone (Risperdal Consta), olanzapine (Zyprexa Relprevv), aripiprazole (Abilify, Abilify Maintena, Aristrada), and paliperidone (Invega Sustenna). Injectable medications tend to be more long-acting compared to oral preparations, lasting as much as four weeks at a time, thereby improving consistency of treatment.
Although older antipsychotic medications in this class like haloperidol (Haldol), thioridazine (Mellaril), perphenazine (Trilafon), and molindone (Moban) are more likely to cause muscle stiffness, impaired motor coordination, shakiness, and very rarely uncoordinated muscle twitches (tardive dyskinesia) that can be permanent, health care professionals appropriately monitor the people they treat for these potential side effects, as well. Some of the abnormal muscle movements, like tremors (for example, akathisia) or stiffness (dystonia) can be managed using anti-tremor medications like benztropine (Cogentin) or amantadine (Symmetrel). Also, more recent research regarding all antipsychotic medications seems to demonstrate that the older (first-generation) antipsychotics are just as effective as the newer ones, both in the management of current symptoms and prevention of future symptoms, and have no higher rate of people stopping treatment because of any side effect the medications cause. Not all medications that treat schizophrenia in adults have been approved for use in treating childhood schizophrenia.
Clozapine (Clozaril), while thought to be highly effective for treating schizophrenia, has potentially serious, even fatal side effects that prevent it from being used prescribed more often. Those side effects can include dangerously low white blood cell count, inflammation of the heart muscle (myocarditis), as well as what are classified as metabolic side effects, like elevated blood sugar and cholesterol levels, weight gain, and elevated prolactin levels. While reserpine, a medication that also reduces blood pressure, has also been found to decrease psychotic symptoms, the fact that safer, more effective medications now exist has resulted in its being far less frequently used these days. Prochlorperazine (Compazine) has strong antipsychotic effects but is used to treat nausea, vomiting, and vertigo.
Mood-stabilizer medications like lithium (Lithobid), divalproex (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal) can be useful in treating mood swings that sometimes occur in individuals who have a diagnosable mood disorder in addition to psychotic symptoms (for example, schizoaffective disorder, depression, in addition to schizophrenia). These medications may take a bit longer to work compared to the antipsychotic medications. Some (for example, lithium, divalproex, and carbamazepine) require monitoring of medication blood levels, and some can be associated with birth defects when taken by pregnant women. Divalproex and lamotrigine carry the rare potential of causing a potentially rare autoimmune reaction (Stevens-Johnson syndrome).
Antidepressant medications are the primary medical treatment for the depression that can often accompany schizophrenia and meta-analyses (systematic reviews of published studies) of how people with this illness fare when taking antidepressants support treatment with these medications. Examples of antidepressants that are commonly prescribed for that purpose include serotonergic (SSRI) medications that affect levels of the neurotransmitter serotonin (like fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil], citalopram [Celexa], escitalopram [Lexapro], vortioxetine [Trintellix], and vilazodone [Viibryd]) and combination serotonergic/adrenergic medications (SNRIs) (like venlafaxine [Effexor] and duloxetine [Cymbalta] and levomilnacipran [Fetzima], as well as bupropion [Wellbutrin], which is a dopaminergic [affecting dopamine levels] antidepressant medication).
Despite its stigmatized history, electroconvulsive therapy (ECT) can be a viable treatment for people whose schizophrenia has inadequately responded to a number of medication trials and psychosocial interventions.
When treating pregnant women with schizophrenia, health care practitioners take great care to balance the need to maintain the person's more stable thoughts and behavior while minimizing the problems that medications used to treat this disorder may present. While some medications that treat schizophrenia may carry risks to the fetus in pregnancy and during breastfeeding, careful monitoring of how much medication is administered and the health of the fetus and of the mother can go a long way toward protecting the fetus from any such risks, while maximizing the chance that the fetus will grow in the healthier environment provided by an emotionally healthy mother.
Psychosocial interventions for schizophrenia
Family psycho-education and support: In addition to educating family members about the symptoms, course, and treatment of schizophrenia, this form of treatment consists of providing family with supportive therapy, problem-solving skills, and access to ongoing community supports, including care providers during times of crises. When this intervention is consistently provided for at least several months, it has been found to decrease the relapse rate for the person with schizophrenia and improve social and emotional outcomes. Also, the burden that family members experience as a result of having a loved one with schizophrenia is less, family members tend to be more knowledgeable about the disorder and feel more supported by the professionals involved, and family relationships are improved.
Assertive community treatment (ACT): This intervention consists of members of the person's treatment team meeting with that individual on a daily basis, in community settings (for example, home, work, or other places the person with schizophrenia frequents) rather than in an office or hospital setting. The treatment team is made up of a variety of professionals. For example, a psychiatrist, nurse, case manager, employment counselor, and substance-abuse counselor often make up an ACT team. Over the long term, ACT tends to be successful in reducing how often people with schizophrenia are psychiatrically hospitalized or become homeless.
Substance abuse treatment: Providing medical and psychosocial interventions that address substance abuse should be an integral part of treatment as about 50% of individuals with schizophrenia suffer from some kind of substance abuse or dependence.
Social skills training: Also called illness management and recovery programming, social-skills training involves teaching clients ways to handle social situations appropriately. It may be conducted as part of individual or group psychotherapy and often involves the person scripting (thinking through or role-playing) situations that occur in social settings in order to prepare for those situations when they actually occur. This treatment type has been found to help people with schizophrenia resist using drugs of abuse, as well as improve their relationships with health care professionals and with people at work.
Supported employment: This intervention provides supports like a job coach (someone who periodically or consistently counsels the client in the workplace), as well as instruction on constructing a résumé, interviewing for jobs, and education and support for employers to hire individuals with chronic mental illness. Supported employment has been found to help schizophrenia sufferers secure and maintain employment, earn more money, and increase the number of hours they are able to work.
Cognitive behavioral therapy (CBT): CBT is a reality-based intervention that focuses on helping a client understand and change patterns that tend to interfere with his or her ability to interact with others and otherwise function. Except for people who are actively psychotic, CBT has been found to help individuals with schizophrenia decrease symptoms and improve their ability to function socially. This intervention can be done either individually or in group therapy.
Group therapy: Group therapy is usually supportive and expressive, in that participants are encouraged in their efforts to care for themselves and otherwise engage in healthy, appropriate behaviors in the community.
Weight management: Educating people with schizophrenia about weight gain and related health problems that can be a side effect of some antipsychotic and other psychiatric medications has been found to be helpful in resulting in a modest weight loss. That is also true when schizophrenia sufferers are provided with behavioral interventions to help with weight loss.
What research is being done on schizophrenia?
Repetitive transient magnetic stimulation (rTMS), a procedure that involves multiple sessions of applying magnetic pulses to the brain, has been shown in some studies to decrease hearing voices (verbal auditory hallucinations) in schizophrenia sufferers as a result of stimulating certain areas of the brain. However, more studies are needed to determine the effectiveness of this intervention before it is widely used.
Cognitive remediation continues to be an experimental treatment that addresses the cognitive problems that are associated with schizophrenia (for example, memory problems, speech impairment, learning problems). Clinical trials using this intervention in combination with vocational rehabilitation to improve work functioning have shown some promise, but more research is needed, particularly that which focuses on improving how well the person with schizophrenia functions in real-world situations as a result of this treatment.
Peer-to-peer treatment is a promising possible intervention since it promotes active constructive involvement from people who have schizophrenia, provides role models for individuals whose functioning is less stable, and may be accessible in individual and group settings, in person as well as by telephone or through the Internet. However, further research is necessary to demonstrate its effectiveness in decreasing symptoms or otherwise clearly improving functioning for people with schizophrenia.
In terms of weight management, more research is needed to explore how to best help people with schizophrenia retain the weight loss they achieve and even to prevent weight gain.
Is it possible to prevent schizophrenia?
Prevention of schizophrenia for individuals who have yet to develop even the early symptoms of the disorder focuses on decreasing many of the environmental insults that increase the likelihood of developing the disorder. Therefore, improving prenatal care, ameliorating poverty, bullying, child abuse and neglect, as well as protecting people from family and community violence are important aspects of preventing schizophrenia. For people who show early signs of schizophrenia, some clinical trial research is exploring the potential use of medications to prevent full-blown schizophrenia.
Where can people get more information about schizophrenia? How can people
find a support/self-help group, specialists who treat the illness, or other assistance for schizophrenia?
1600 South Avenue, Suite 230
Rochester, NY 14620-3924
Phone: 1-800-836-0475 (toll free)
National Institute of Mental Health
9000 Rockville Pike
Bethesda, Maryland 20892
NAMI (National Alliance on Mental Illness)
Medically Reviewed on 3/16/2018
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