Disclaimer: The article below is for informational purposes only and should not be considered as direct advice, a personal diagnosis, or as an individual treatment plan. Always consult with a mental health professional or medical doctor if you have concerns.
Introduction and Overview
Schizophrenia is a chronic, severe, and disabling mental disorder in which the person's emotions, thinking, judgment, behavior, and perception of reality are so disturbed that the person cannot function normally. The Diagnostic and Statistical Manual of Mental Disorder (DSM-IV-TR) lists schizophrenia as a functional psychotic disorder. The term "functional" refers to the fact that based on the current information, schizophrenia is not caused by a nervous system lesion or a chemical or endocrine disturbance, while the term "psychotic" (according to DSM) refers to a group of symptoms which include delusions, prominent hallucinations, disorganized speech, disorganized or catatonic behavior.
Those that suffer from schizophrenia experience hallucinations, have delusions and a disturbed perception of reality, express blunted or flat emotions, and display distorted behaviors. They can hear voices that others don't hear, live with the impression that others can read their mind, control their thoughts, and/or plot against them.
They may appear bizarre to those around them either because they act odd (they can sit for hours without moving or saying anything), or in most cases, because they don't make sense when they talk. Due to the nature of this disorder, individuals with schizophrenia withdraw from people, society, and activities around them to retreat into a inner world.
Some of the first signs of the disorder occur typically around late adolescence or early adulthood, and "its symptoms differ from person to person and can fluctuate over time". When active, the disorder is "characterized by episodes in which the patient is unable to distinguish between real and unreal experiences", but when controlled by medication, the disorder subsides and the individual can lead a meaningful and rewarding life. Some individuals experience only one acute episode and either progress through a good recovery, or fall into a "continuous and progressive deterioration" while others experience multiple acute episodes which alternate with brief episodes of partial recovery or remission. Usually, the frequency of the acute episodes decrease with age.
Schizophrenia was a source of bewilderment and was problematic in terms of classification since the beginnings. According to Mesopotamian literature and written documents from the old Pharaonic Egypt, schizophrenia was present from the beginning of civilization, and those that suffered from this disorder were viewed as eccentric or possessed by demons in the Middle Ages. Only later, in the last century-and-a-half, schizophrenia was conceptualized as a medical disorder.
However, the first physician that provided a comprehensive description of the disorder was Emil Kraepelin in 1896, a German doctor that referred to this condition as dementia praecox (early dementia). According to this term, schizophrenia was considered a form of dementia. It wasn't until 1911, Eugen Bleuler, a Swiss psychiatrist changed the name of the condition in schizophrenia to prevent the misleading sense of the initial term.
The word "schizophrenia" comes from two Greek words "schizo" which means split and "phrenos" which means mind. Even today, when the research in understanding the cause, course, and treatment of schizophrenia is so advanced, the disorder continues to confound the health professionals and the public. In 2003, a debate held at the Institute of Psychiatry from London argued the existence of this disorder. The debate ended by half of the audience recognizing the existence of schizophrenia as a disease, and half as if did not exist.
Antipodal to the common perception sometimes reinforced by media and movies, schizophrenia does not mean split or multiple personalities. It is not caused by child abuse, bad parenting, or personal weakness, and people that suffer from this disorder are not mysterious, alien, and violent. Schizophrenics are usually not dangerous or violent, are not homeless, they don't live in hospitals, and most of them reside with their families, in group homes, or on their own.
According to the World Health Organization, schizophrenia was nominated as one of the ten most debilitating diseases affecting human beings and the incidence rate is about 1 to 4 cases per 10,000 population at risk per year. Approximately 2 million American adults suffer from this condition which represents 1 percent of the population over the age of 18. According to National Institute for Mental Health, approximately 51 million people suffer from schizophrenia worldwide.
Schizophrenia equally affects men and women, although it seems to be more severe in men than women. It occurs in similar rates in all ethnic groups around the world. The median age of onset for the American population is 21 for men and 27 for women. In rare cases, schizophrenia can occur during childhood and early adolescence years (although the symptoms are slightly different), but an early onset is associated with a severe manifestation of the disorder.
Life expectancy among individuals with schizophrenia is shorter than the normal population, and one of the factors that contributes to this is a high rate of suicide attempts. Approximately 10 percent of individuals with schizophrenia commit suicide, while 20 to 40 percent have at least one suicide attempt.
Today, many psychiatrists have agreed that schizophrenia is defined by at least three different sets of symptoms, classified as:
I. Positive symptoms (Psychotic)
II. Negative symptoms
III. Cognitive symptoms
I. Positive (or psychotic) symptoms, according to DSM-IV, "reflect an excess or distortion of normal functions" and include: delusions, hallucinations, disorganized speech, and disorganized or catatonic behavior. These symptoms can be effectively treated with antipsychotic medication.
1. Delusions are defined as "erroneous beliefs that usually involve a misinterpretation of perceptions or experience" and cannot be accounted for by the persons cultural or religious background or level of intelligence. (2) A person experiencing delusions strongly believe in their beliefs and will hold firmly to them regardless of the logical arguments and evidence presented. According to the delusion's content theme, schizophrenics can experience several different types of delusions, such as:
Persecutory Delusions: They are the most common form of delusions experienced in schizophrenia, and their content evolves around the theme of being spied on, followed, ridiculed, tricked, cheated, conspired against, etc. These persecutory delusions usually involve bizarre ideas and plots.
Referential Delusions: According to these delusions certain events, objects, remarks, gestures, comments, passages from a book, newspapers, songs lyrics, news, or environmental clues have a personal meaning or are directed to the individual.
Somatic Delusions: These delusions focus on the diseased, changed, or abnormal characteristic of a bodily functioning, bodily sensation, or physical appearance. For example, the patient can believe that their body is infested by parasites or that their organs were removed and replaced with someone else's organs by a stranger that left no wounds or scars.
Religious Delusions: This type includes any delusion with a religious or spiritual content. Some of these delusions can have grandiose characteristics such as the belief that the person was chosen by God. However, religious delusions vary across cultures and in some cases, can lead to violent behaviors.
Grandiose Delusions: They express the individual's beliefs that they posses special powers, talents, abilities, are famous people, or have accomplished great achievements for which they never received sufficient recognition.
2. Hallucinations are false or distorted sensory experiences generated by the mind and not by external stimuli which appear to the person as real perceptions. The most common hallucinations experienced by individual with schizophrenia are:
Auditory Hallucinations: This type is by far the most common hallucination described by schizophrenics. They are mostly experienced as familiar or unfamiliar voices or sounds. A typical auditory hallucination in schizophrenia is one where there is, "two or more voices conversing with one another or voices maintaining a running commentary on the person's thoughts or behavior." (3) In many cases, these voices are critical, vulgar, or abusive. Auditory hallucination tend to get worse when the person is alone. When severe, these hallucinations intrude into the person's life and activities, and the patient can even respond to them as if in conversation.
Visual Hallucinations: This type of hallucinations are also divided in simple (elementary or non-formed) hallucinations such as dots, colors, flashing light, or geometric patterns, and complex (formed) hallucinations such as objects, animals, or people.
Olfactory Hallucinations (smell).
Tactile Hallucinations (touch):
3. Disorganized Speech: One of the characteristic features of schizophrenia is fragmented thinking. Fragmented thinking can be observed in the way the person talks (disorganized speech). This disorganization can vary in patients with schizophrenia. Some individuals can "slip out of track" from one subject to another, speek incoherently, or express illogical thinking. When answering questions, schizophrenics can "be obliquely related or completely unrelated." (4)
Some of the most common signs of disorganized speech include:
- Loose Associations:The person rapidly
shifts the conversation subject from one topic to another
without connecting them.
- Neologisms: Neologisms, in
schizophrenia, refer to those made-up words or phrases
that make sense only for the patient.
- Perseveration: The patients repeats the
same words or statements over and over.
- Clang: The patient uses different rhyming words in an order that doesn't make sense.
4. Grossly Disorganized or Catatonic Behavior: Disorganized behavior can manifest in various ways such as: childlike silliness, unpredictable agitation (shouting or swearing, muttering aloud in public), difficulties in performing activities of daily living (preparing meals or maintaining a proper hygiene), dressing in a bizarre manner (such as wearing multiples scarfs, multiple coats, or unsuitable cloth for the outside weather - gloves on a hot day), or display inappropriate sexual behaviors (masturbating in public).
On the other hand, individuals suffering from schizophrenia also display what is called a catatonic behavior. This behavior is characterized by muscular tightness (rigidity) and lack of response to the environment. In severe cases, the catatonic behavior can reach an extreme degree of complete unawareness (condition known in medical terms as catatonic stupor) when the body maintains a rigid posture and resists the efforts to be moved.
II. Negative symptoms are those symptoms that reflect the loss of normal functioning, and include: flat affection, avolition (withdrawal, loss of motivation, and ambivalence), anhedonia (loss of feeling or inability to express pleasure), and alogia (poverty of speech).
Approximately 25 percent of the patients with schizophrenia display what is called the deficit syndrome "defined by severe and persistent negative symptoms" (5). Unfortunately, negative symptoms are the main reason why individuals with schizophrenia cannot live an independent life, hold jobs, and establish personal relationships.
1. Affective flattening is a common symptom in schizophrenia, and is characterized by unchanging facial expressions where the face appears immobile and unresponsive, poor or no eye contact, reduced body language, and decreased spontaneous movements. A person with affective flattening "may stare vacantly into the space and speek in a flat, toneless voice." In certain occasions, an individual with affective flattening can smile or warm up, however their range of emotional expressiveness is diminished most of the time. (6)
2. Avolition is a symptom characterized by the absence of initiative or motivation to begin or maintain a goal-directed activity. This symptom involves a lack of energy, increased apathy, and/or lack of interest in daily activities. A person with avolition may sit for hours doing nothing and show little interest in engaging in social or work activities. They can lack the desire to maintain proper personal hygiene or to groom, and have difficulties taking decisions. When these symptoms occur in the clinical picture, it significantly interferes with the individual's ability to function normally in the work, social, or household settings.
3. Anhedonia represents the inability to feel joy. This symptom manifests when the individual lacks the interest in social or recreational activities and fails in developing close relationships.
4. Alogia or "poverty of speech" is characterized by "brief, laconic, empty replies." Individuals with alogia appear "to have a diminution of thoughts that is reflected in decreased fluency and productivity of speech", they tend to be vague and repetitious. (7) However, this symptom should not be confused with the lack of desire to speek.
III. Cognitive symptoms (or impairments) also called cognitive dysfunctions or disorganized symptoms are often present in people with schizophrenia. However, this type of symptom is subtle and is usually detected when the patient undergoes neuropsychological tests. Some of the common cognitive impairments associated with schizophrenia are:
- Difficulties prioritizing tasks and organizing their thoughts.
- Trouble with logical thinking.
- Confused and disordered speech.
- Inability to sustain attention.
- Difficulties making decisions.
- Problems with memory.
- Lack of insight into their condition.
Unfortunately, these symptoms interfere with the individual's ability to manage their own life by living a normal life or earning a living, usually causing significant emotional distress.
Schizophrenia is a disorder characterized by a "profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thoughts, perception, affect, and sense of self." (12) Its course is difficult to study because it does not follow a single pathway and varies considerably from person to person and for the same person, being influenced by different personal risk factors (biological and genetic vulnerabilities or neurocognitive impairments), family support (warmth, supportive versus critical, hostile attitude), and professional specialized support (skill-rebuilding assistance and rehabilitation). Some individuals experience periods of acute psychotic symptoms and remission, others have a relatively stable course, while some show a progressive worsening associated with moderate to severe disability.
Schizophrenia usually onsets in the early to mid 20s for men and late 20s for women. In rare cases, schizophrenia can start before adolescence or later in life, after the age of 45. The onset age seems to have a significant influence on the pathophysiological evolution of the disorder and its prognosis. Unfortunately, those that undergo an early onset are more often men, have a worse outcome, and the prominent manifestations are negative symptoms. Individuals with a later onset are more often women, display a better outcome, and have less cognitive impairments.
The disease onset can be abrupt or insidious. Usually, schizophrenia develops gradually with a prepsychotic stage, also known as the prodromal phase or prodrome. Approximately 80 to 90 percent of the patients diagnosed with schizophrenia go through this phase, while in 10 to 20 percent of the cases, the disease debuts straight with psychotic symptoms (delusions and hallucinations). The length of the prodromal phase varies from patient to patient and can last between a few weeks to few years. In general, it lasts for at least a year and is usually dominated by negative symptoms and behavioral changes.
The person slowly withdraws from family, friends, and society, exhibits different sleeping patterns than usual (either by sleeping too much, or too little), becomes agitated, irritable, oversensitive, or rebellious. Behavioral changes are accompanied by cognitive impairments. The person becomes easily confused, manifests difficulties concentrating and poor memory, becomes preoccupied with odd ideas, religion, or philosophy, and can be excessively suspicious. Some individuals can self-inflict injuries and attempt suicide.
One in ten individuals that suffer from schizophrenia commit suicide.
These cognitive impairments trigger social changes (social withdrawal) and changes in the general functioning (difficulties in the work setting, noticeable decline in academic performance, deterioration in personal hygiene and grooming, lack of interest or motivation, alcohol or drug abuse). Mood changes can also be evident during prodrome, and manifest as rapid mood changes, lack of emotional responses, or inappropriate moods (inappropriate smiling, laughing, or silly facial expressions). Altogether, these symptoms create significant disturbances in the daily life of these individuals, who find this period very frightening and in most of the cases, they prefer to not talk about what is happening in their live.
The prodrome's manifestations increase in intensity (in 75 percent of the cases the disorder worsens after its onset), and in time, they will become psychotic symptoms. The presence of psychotic symptoms marks the beginning of the active or acute phase of the disease. During the active/acute phase, symptoms usually fluctuate between episodes of severe positive symptoms (known as acute episodes of psychosis) and periods of stabilized symptoms (known as remission). An acute episode of psychosis is characterized by the presents of positive symptoms such as delusions and hallucinations, and negative symptoms such as avolition (lack of motivation) and anhedonia (inability to feel joy). Usually, in the first 5 to 10 years after the onset, each person develops a unique pattern of disorder manifestation.
In most cases, most individuals with schizophrenia in this phase are admitted for treatment. At admission, positive symptoms dominate the clinical picture, although in 10 percent of the cases extreme forms of disorganized symptoms can be present. In time, positive and disorganized symptoms tend to decrease while the negative symptoms become more prominent. Each acute episode of psychosis causes notable dysfunctions and is accompanied by distressing effects. It is highly unlikely that the person will return to normality or regain complete function after such episodes.
While positive symptoms can be effectively treated and decrease in frequency, negative symptoms increase over time for most patients and remain prominent during the residual phase of the disorder. The residual phase is characterized by the decrease of positive symptoms and worsening of the negative symptoms. However, the disease becomes easier to manage during the residual phase and individuals may regain some social and job-related skills, although a full recovery is not possible.
According to DSM-IV, there are 5 types of schizophrenia based on the specific symptoms exhibited by the person. It is not excluded that a person can be diagnosed with more than one type of schizophrenia during their life.
1. Paranoid Type
Paranoid schizophrenia is one of the most common forms of schizophrenia and is characterized by prominent persecutory or grandiose delusions and auditory hallucinations "related to the content of the delusional theme." In some patients, delusions organized around other themes such as jealousy, religiosity, or somatization (sexual or other body sensations) can also occur. This type of schizophrenia does not include disorganized speech and behavior, but patients affected by it exhibit anxiety, anger, aloofness, and argumentativeness. Individuals with paranoid schizophrenia may display a superior and patronizing attitude, and due to the persecutory and grandiose nature of their delusions and hallucination, they are predisposed to suicide and violent behavior. The onset age for this form of schizophrenia is later in life than other types and it tends to have a better prognosis "particularly with regard to occupational functioning and capacity for independent living."
2. Disorganized Type
Disorganised schizophrenia (also known as hebephrenic schizophrenia) is characterized by disorganized thinking (inability to form logical and coherent thoughts, inability to initiate plans), disorganized speech (to wander through a topic, jump from an idea to another, on unintelligible speech), and disorganized behavior (childlike silliness, swearing or shouting out of the blue, neglecting personal hygiene, inappropriate sexual behavior in public, wearing many layers of clothes on a warm day, urinating in public, grimacing, mannerisms), and flat or inappropriate affect. In some cases, delusions and hallucinations can be present but they are not organized into a coherent theme. This type of schizophrenia severely disrupts the person's ability to function normally. The person cannot perform daily activities (showering, grooming, dressing, or preparing meals) and interact with others. Disorganized schizophrenia is associated with an early and insidious onset, and "a continuous course without significant remissions."
3. Catatonic Type
Catatonic schizophrenia is a rare form of schizophrenia among the North American and Europian population, and is characterized by marked psychomotor disturbances such as
(1) motoric immobility (catalepsy - persisting in unusual postures or facial expressions regardless of the exterior stimuli, or stupor - lack of cognitive function and level of consciousness when the person is almost entirely unresponsive and responds only to base stimuli such as pain),
(2) excessive motor activity (the motor activity appears bizarre, purposeless, and unconnected with the surroundings),
(3) extreme negativism (maintaining a rigid posture by resisting all the instructions or attempts to be moved),
(4) mutism (inability or unwillingness to speak),
(5) peculiarities of voluntary movement (voluntary assumption of inappropriate or bizarre posture or prominent grimacing),
(6) echolalia (pathological, apparently senseless repetition of a word or phrase spoken by somebody else), or
(7) echopraxia (involuntary repetition or imitation of someone else movements).
During episodes of catatonic stupor or excitement, the patient requires careful supervision in order to avoid harming themselves or those around them. The main health risks associated with catatonic schizophrenia include malnutrition, exhaustion, self-inflicted injuries, or hyperpyrexia (excessive or unusual high body temperature).
4. Undifferentiated Type
This is a type of schizophrenia diagnosed when the patient exhibits symptoms of schizophrenia which are not sufficiently formed or specific enough to meet the criteria of other types.
5. Residual Type
This type of schizophrenia is usually diagnosed when the patient suffered at least one episode of schizophrenia, but "the current clinical picture is without prominent positive symptoms" (delusions, hallucinations, disorganized speech or behavior). Residual schizophrenia is characterized by the presence of negative symptoms (flat affect, poverty of speech, or avolition) that can be briefly interrupted by a few positive symptoms such as odd beliefs, delusions and hallucinations, mildly disorganized speech, or eccentric behavior, but they are not prominent and do not cause severe dysfunctions. Residual schizophrenia can be indefinitely with or without acute exacerbations, and represents the transition period between full-blown psychotic episodes and complete remission.
Decades of research on schizophrenia did not produce any major breakthroughs, but it slowly helped scientists to understand and identify some of its risk factors. Experts have reached the conclusion that schizophrenia develops "as the result of the interplay" between biological predispositions and environmental factors. Brain development disruptions are the result of genetic predispositions, environmental stressors during early development (such as pregnancy and early childhood), and environmental factors later in life which can either worsen or lessen the expression of genetics by increasing or decreasing the risk to develop schizophrenia. A risk factor is any characteristic (age, sex, race) or variable that can increase a person's chance to develop the disease. However, a single risk factor cannot alone determine the development of the disorder, and nobody can establish which of the factors contribute to the onset of schizophrenia.
Furthermore, scientists believed for a long time that personality, intelligence, health, or other traits are influenced in certain percentages by nature (genes) and environment (for example through a nature/environment relationship of 60/40 or 50/50). Based on recent studies, the relationship between nature and environment in determining the presence of certain traits is different. Some genes become active only when the person is exposed to a certain kind of environment. Also, according to a new field of research called epigenetics, our DNA is coated with a "second code" that can change during our life as a result of a certain diets, chemicals that we are exposed to, and the way we behave. This means that humans are influenced by DNA, while the DNA is influenced by humans. (9)
Schizophrenia has a strong hereditary component and is supported by family, twins, and adoption studies. First-degree biological relatives of individuals with schizophrenia have a 10x greater risk to develop the disorder themselves than the normal population. The risk of developing the disorder is higher in monozygotic (identical) twins than in siblings or dizygotic (fraternal) twins. This vulnerability towards schizophrenia can be partially explained by the presence and involvement of certain genes and mutations associated with this disorder.
Although the study of schizophrenia genes is ongoing and researchers believe that 50 to 100 genes can be involved in the development of the disorder, several studies have identified a few of them: DTNBP1, NRG1, G72, COMT, DISCI, PPP3CC, EGR, WKL1, and GRM3. However, no gene alone can cause the disorder and furthermore, schizophrenia inheritance patterns "involves multiple genes acting together or many single genes acting separately into heterogeneous patterns." (10)
DTNBP1 is cited "as one of the most promising candidates for a schizophrenia susceptibility gene". DTNBP1 (dystrobrevin binding protein 1) gene was first associated with schizophrenia in an Irish pedigree study in 2002 and since than it has been intensively studied in many case-control and family-based studies in diverse populations (Germans, Chinese, Swedish, and Irish). This gene is located on the chromosome 6 and encodes the protein product called dysbindin-1. Although, the exact role of dysbindin-1 is not known, the presence of this protein was discovered to be "widely expressed in the brain". However, postmortem studies conduceted on the brain of schizophrenics revealed reduced levels of DTNBP1 in the prefrontal cortex, midbrain, and hippocampus. (11)
NRG1 or Neuregulin-1 is another gene strongly associated with schizophrenia. NRG1 is located on the chromosome 8 and some of the proteins produced by this gene are "growth factors involved in the growth of the brain, especially its supportive cells," in "synaptic plasticity which is important for memory" and growth of motor neurons, while others are signaling proteins which influence the receptivity of the brain cells to several type of neurotransmitter. It is also thought that NRG1 gene may govern the process in which new synapses are made while old ones are unmade in response to the brain's experiences. (12)
G72 is another gene significantly associated with susceptibility for schizophrenia. This gene is located on chromosome 13 and studies suggest that it may indirectly effect NMDA neurotransmitters (which play a critical role in synaptic plasticity, the cellular mechanism for learning, and memory). Postmortem studies of schizophrenics has revealed an overproduced G72 and a lower NMDA glutamate receptor activity.
COMT is another one of the top candidate genes for schizophrenia. COMT (catechol-O-methyltransferate) gene is located on chromosome 22 and is involved in degradation of dopamine. One of the hypothesis highly debated is that schizophrenics' brains produce more dopamine than a normal brain, which can by responsible for some of the schizophrenia positive symptoms. However, the exact mechanism by which altered levels of dopamine in certain areas of the brain (prefrontal cortex, striatum, and limbic system) produce schizophrenia is not known.
DISC1 gene is located on the chromosome 1 and was initially identified as a potential focus for schizophrenia risk and recent studies focus on the impact of the gene mutation. The DISC1's protein is involved in the development and function of the hippocampus, and acts similar to a conductor agent for the newly formed nerve cells "guiding them to their proper location at the appropriate tempo so they can seamlessly integrate into our complex and intertwined nervous system." When DISC1's protein does not operate properly, the new nerve cells can integrate faster into the brain circuit and cause impairments. Mutation of the gene encoding can effectively reproduce some schizophrenia symptoms (anxiety, hyperactivity, apathy and an altered sense). According to several studies, the distribution of DISC1 is altered in the orbitofrontal cortex cells in individuals experiencing psychosis. (13)
PPP3CC (protein phosphatase 3, catalytic subunit, gamma isoform) gene is located on chromosome 8 and encodes calcineurin, a protein phosphatase which regulates synaptic plasticity (the ability of the synapse formed between two neurons to change in strength) and neuronal adaptation (a change over time in the responsiveness of the sensory system to a constant stimulus). PPP3CC gene is involved in the diagnosis of schizophrenia in Caucasians, African-Americans, and Japanese.
EGR (early growth response) family gene plays an important role in the development of the nervous system and the function of the adult nervous system. EGR protein is involved in cellular growth and differentiation. EGR family gene includes EGR1, EGR2, EGR3, and EGR4. Postmortem studies revealed that expression of EGR1, EGR2, and EGR3 is reduced in patients with schizophrenia.
WKL1 gene is located on chromosome 22 and produces a protein "similar to those which play a crucial role in transmitting electric currents along the nerves." Mutations of the WKL1 gene seems to play an important role in the development of catatonic schizophrenia. (14)
GRM3 (glutamate receptor) gene is responsible with glutamate regulation in synapses and has been associated with some schizophrenia traits. This gene increases the risk for schizophrenia by altering glutamate transmission and brain physiology.
Genetic Markers - In addition to genes' research, scientists also focus on the study of genetic markers. In 2007, the Feinstein Institute for Medical Research announced that they identified nine genetic markers that can increase the risk for schizophrenia. Genetic markers are phenotypes (observable physical characteristics of an organism) and "represent biological or neuropsychological traits that indicate a genetic tendency towards" developing a certain disorder. (15)
Schizophrenia genetic markers include several major neurocognitive deficits (impairments in attention, memory, and problem solving domains), perceptual deficits (olfactory identification deficit, sensory gating, smooth pursuit eye-tracking abnormalities), and social interaction deficits (impairments in verbal fluency, perception of emotion, and social understanding). (16)
Based on the discovery of the genetic markers, scientists have conducted studies where they simultaneously examined the genetic information of the patient's parents by trying to identify pieces of chromosomes that are identical. These studies discovered nine regions along the chromosomes that might play a significant role in the development of schizophrenia. Four of the regions also contain some genes previously associated with schizophrenia, while the genes located in the remaining five regions "are involved with structure and survival of neurons." (17) Based on this information, scientists believe that schizophrenia can be inherited in a recessive manner. The risk to develop the disorder is significantly increased when the individual inherits identical copies of the markers from each parent.
When studing schizophrenia risk factors, scientists use the term environment to include everything else that is not genetic, but influence the development of the disease traits such as: nutritional, hormonal, and chemical factors present during pregnancy, and social factors during childhood and adolescence (social dynamic, stress, the use of different drugs, education, viruses exposure).
Prenatal Risk Factors
Scientists believe that events occuring during early brain development stages (such as prenatal and perinatal periods) may increase the risk for schizophrenia. This belief is supported by brain imaging studies which revealed premorbid brain abnormalities and minor physical anomalies (minor malformations of the head, eyes, ears, hands, mouth, of feet) in patients with schizophrenia. The presence of infectious agents during pregnancy has detrimental effects on the development of the fetal brain.
Recent research suggests that children born to mothers who were affected by viruses (cytomegalovirus - CMV, herpes simplex virus/ HSV, or poliovirus) or infectious conditions (influenza and rubella) during pregnancy have up to 700 percent higher risk to develop schizophrenia than children not exposed to such conditions.
Other medical conditions highly associated with schizophrenia are reeclampsia (a pregnancy condition characterized by maternal hypertension, edema - excessive swelling, and excess protein in the urine) and obesity. Also, a high risk to develop schizophrenia is met among children with mothers that were exposed to toxic agents (such as lead in gasoline or paint, alcohol, painkillers, or smoking) during pregnancy. (18)
Another significant factor that can increase the risk to develop schizophrenia is prenatal nutritional deprivation, especially micronutrient deficiencies. Micronutrients are those nutrients needed by the body in small quantities, such as iron, cobalt, iodine, magnesium, selenium, zinc, etc.
A much more prominent cause of schizophrenia than infections and nutritional deprivation is prenatal trauma (obstetric complications). The most common obstetric complications highly associated with schizophrenia include: hypoxia (lack of oxygen for the fetus), prolong labor (associated with two frequent schizophrenia brain abnormalities - cerebral atrophy and small hippocampi), and placental complications.
Many studies also show that babies born between December and March have a slightly higher risk than average rate to develop schizophrenia. Some scientist suggest that a schizophrenia seasonality risk can be explained by the lack of sunlight which leads to a vitamin D deficiency. Vitamin D deficiency is believed to alter the development of baby's brain before and after birth.
Stress plays a large role in a wide range of diseases and conditions. Stress was discovered to be particularly harmful in those individuals affected by schizophrenia, although stress does not cause schizophrenia. People that suffer from schizophrenia are more likely to report a stressful event preceding an acute episode of psychosis and stressful events tend to precipitate episodes of illness.
Studies conducted on young individuals revealed that children and teenagers brains are very sensitive to stress, 5 to 10 times more sensitive than the adult brain. Chronic stress or periods of moderate stress can have damaging effects on the brain of children and adolescents. Some of the regions affected by stress include hypothalamus, pituitary and adrenal gland. Some scientists believe that when the brain is exposed to high levels of stress it suffers a neurotoxic reaction that can cause cells' damage. Researchers suggest that children genetically or biological predisposed to schizophrenia if raised in high stress dysfunctional families have a higher risk to develop the disorder than children raised in low stress household.
In adults, the social stress associated with immigration seems to increase the risk of developing schizophrenia. A study conducted in Sweden suggested that first-generation immigrants were three times more likely to develop psychotic disorders. The risk is higher in immigrants with dark skin.
Schizophrenia has been associated with several social conditions, such as (1) social isolation and poor or disrupted interpersonal relationships during childhood, adolescence, and early adulthood, (2) social adversity (low socioeconomic status, single-parent households, unemployment), and (3) urban living. In the past 10 years, studies conducted on developed countries have revealed that the incidence of schizophrenia is two times higher in the urban population. It is unclear why there is a higher rate of psychotic disorders in the urban setting than rural areas, but some researchers suggest it might be explained by an increased exposure to toxins and viruses, and the social context people live in. However, living in a very isolated rural area can also increase the risk of schizophrenia due to social isolation.
Schizophrenia is a chronic, lifetime mental disorder that cannot be cured, but can be effectively treated and managed. Research conducted in developed countries revealed that about 20 to 35 percent of patients undergo a rapid improvement when treated. Approximately, 70 percent of the patients suffer a relapse of acute symptoms within the next 2 to 5 years after being discharged from hospital. The risk of relapse usually decreases 10 years after the initial onset.
A positive long-term outcome is associated with an acute onset featured by positive symptoms which occurs after adolescence. Unfortunately, a poor prognosis is associated with several conditions:
(1) slow, gradual onset that occurs at a young age,
(2) male gender,
(3) no precipitating signs,
(4) predominance of negative symptoms,
(5) delay in receiving treatment,
(6) family history of the disorder, and
(7) presence of other conditions (substance abuse).
Although for the most part the medical field shares the belief that individuals suffering from schizophrenia can overcome their disease symptoms only if they are maintained on medication, there are significant amounts of evidence that does not support this theory. The recovery rate widely varies between 29 and 83 percent, however 20 to 30 percent of the people with schizophrenia deteriorate rather than recover. However, these data should be carefully considered as the prognostic might be more encouraging as the numbers show.
Most of the current statistical facts are based on patients that are in the evidence of mental health providers, while those that chose to take their faith in their own hands and are not under the evidence of psychiatrist or hospital records were lost out of sight and not considered. In general lines, recovery is possible through a variety of different services that include pharmacologic management (medication), and rehabilitation programs in an inpatient or outpatient setting. (23)
Most individuals diagnosed with schizophrenia require hospitalization at some point or another during the course of the disorder. In most cases, hospitalization is needed during acute or severe psychotic episodes that require intensive observation and care, and when the signs and symptoms exhibited constitute a possible risk of danger to the safety and health of the patient and those around them.
For some individuals with schizophrenia, day care programs are available which can be an alternative to hospitalization. The advantage of this type of programs is that patients are allowed "to remain in their familiar surroundings and thus avoid the stigma that results from patients no longer being visible among their peers and friends" (19), while continuing the treatment. Outpatient treatment is recommended to all individuals that have experienced an acute episode of psychotic symptoms. It offers the advantage of a more exclusive relationship, patient - psychiatrist, and fulfills the patient's need for autonomy which is important in long-term treatments.
The psychiatric treatment for different mental illnesses, especially schizophrenia, have benefitted from the marked progress in the pharmaceutical industry. Before medication, schizophrenics were carrying the stigma of a mental disorder and were institutionalized for long periods of time away from family and society, and condemned to a life in isolation. Medication helped individuals with schizophrenia to live relatively normal and fulfilled lives within the boundaries of the community.
The first choice of treatment for individuals diagnosed with schizophrenia is antipsychotic medication. Antipsychotic medication does not cure, but is the best treatment available. It reduces the positive and negative symptoms by correcting the chemical imbalance that contributes to them. Usually, more than one antipsychotic medication is prescribed and it is recommended for patients to keep on taking the medication once they started. Antipsychotic medication requires approximately 4 to 6 weeks to reduce symptoms and stabilize behavior. However, finding the right drug or drug combination, and the right dosage takes time.
There are two type of antipsychotic medication:
1. Conventional neuroleptic agents are the first antipsychotic medication developed to treat schizophrenia symptoms. They are effective in reducing positive symptoms (hallucinations and delusions) by influencing different neurotransmitters, particularly dopamine (by blocking the receptors in the brain's dopamine pathways). Some researchers believe that positive symptoms in schizophrenia are caused by too much dopamine in the brain or sensitive dopamine receptors.
Some of the most common conventional antipsychotic medication includes:
- haloperidole (Haldol),
- zuclopenthioxol (Cisordinol),
- perphenazin (Trilafon),
- fluphenazine (Prolixin),
- alimemazin (Theralen),
- thiothixene (Navane),
- trifluoperazine (Stelazine),
- thioridazine (Mellaril), and
- chlorpromazine (Hibernal).
Some of the conventional neuroleptics agents side effects include: dry mouth, blurred vision, drowsiness, movement disorders (tremor, muscle stiffness, a sense of restless motion, inability to be still), tardive dyskinesia (a variety of uncontrolled facial movements and involuntary, repetitive body movements such as jerking or twisting), and hyperprolactinaemia (the presence of abnormally high levels of prolactin).
2. Atypical antipsychotic medication is a newer approach in treating psychotic symptoms and it offers better results in relieving negative symptoms (withdrawal, lack of energy, and thinking problems), improve cognitive functioning, and produce less side effects. Some of the atypical antipsychotic drugs include:
- clozapine (Clozaril) usually prescribed when other antipsychotic drugs do not work,
- risperidone (Risperdal),
- quetiapine (Seroquel),
- olanzapine (Zyprexal), and
- abilify (Aripiprazole).
The atypical antipsychotic medication side effects include: weight gain, the risk of diabetes, obesity, high cholesterol, and agranulocytosis (low white blood cell count). Agranulocytosis is one of the clozapine's side effects.
In the past, in addition to medication doctors had also used different physical treatments to reduce some of the schizophrenia symptoms and manifestations. Most of them have been discarded in time such as hot or cold baths, wet or dry packs (a patient was wrapped into a dry or wet sheet to keep him immobile), or insulin therapy.
Such physical treatment used in rare cases is the electroconvulsive treatment (ECT) or electroshock therapy. Despite the bad press attached to this procedure, electroconvulsive treatment is a safe and humane treatment that seems to help schizophrenics that "respond poorly to drugs and who, as a the result of their disordered thinking and feelings, are severely disorganized, cannot eat, or are suicidal." One of the electrochock therapy side effects is memory loss, however the modern electroconvulsive treatment device uses less current which causes mild and transitory memory disturbances. (20)
Unfortunately, there are few sources that accurately talk about the reality of the side effects of the neuroleptic and antipsychotic medication. Although for the most part their benefits are reinforced, the cruel and sad reality of individuals medicated is concealed from the general public. All drugs have a risk-benefit profile, and the usual thought within medicine is that a drug should provide a benefit that outweighs the risks.
However, a better understanding of how these drugs actually work reveals a different reality. While antipsychotic medication is able to reduce symptoms such as unrealistic thinking, anxiety, suspiciousness, auditory hallucinations, and prove to be effective over the short term, it actually increases the relapse rate, turns the patients in emotional zombies, decreases their motivation and impairs them cognitively and socially.(23)
According to Guy Chouinard and Barry Jones (two physicians at McGill University), neuroleptics result in a dopamine supersensitivity that will casue dyskinetic and psychotic symptoms. They explained that neuroleptics put a break on dopamine transmission, and in response the brain puts down the dopamine accelerator. If the drug is abruptly withdrawn, the brake on dopamine is suddenly released while the accelerator is still pressed to the floor which causes the system to be widely out of balance.
Regarding the outcome of those individuals medicated vs. unmedicated, Martin Harrow published in the Journal of Nervous and Mental Disease in 2007 a report on a long-term study started in 1975 on 64 young schizophrenics. According to the report, at the end of the two years the group not on antipsychotics were doing slightly better on a global assessment scale than the group on drugs.
But the dramatic changes between groups started showing in the following next 13 months. The off-med group began to improve significantly, and by the end of 4.5 years, 39 percent were in recovery and more than 60 percent were working.
Unfortunately, the med groups general state worsened, their global functioning declined slightly, and at the 4.5 year mark, only 6 percent were in recovery and few were working. Fifteen-years later, within the off-med group 40 percent were in recovery, more than half were working, and only 28 percent suffered from psychotic symptoms.
Within the med group, 5 percent were in recovery, and 64 percent were actively psychotic.
In conclusion, the available data suggests that there is no good evidence that antipsychotics improve long-term schizophrenia outcomes, while for the previous 50 years there is a tremendous amount of studies that show these drugs are worsening the long-term outcomes. This data is also supported by historical proof as in the era before the introduction of neuroleptics (1974). Sixty-five percent of first-episode schizophrenics were discharged within 12 months and would not be rehospitalized in follow-up periods of four and five years. While the current data shows that only 5 percent of patients treated long-term with psychotic medication reach the recovery stage.(23)
While medication helps to control schizophrenia psychotic symptoms, rehabilitation programs help the person to be more adaptable in society (to keep a job and manage money, to communicate, work and establish functional relationships with those around them, and to cope with the condition). Rehabilitation programs include a wide range of non-medical intervention such as psychotherapy, vocational rehabilitation, and cognitive rehabilitation.
Individual Psychotherapy: Psychotherapy is an important part of the treatment for a person that suffers from schizophrenia, and is used as an adjunct to medication. Psychotherapy helps the patient to stay on medications, to establish and achieve weekly goals, it allows them to explore feelings, thoughts, and experiences connected to the disorder, to learn how to cope and to come to terms with what it means to suffer from a psychotic illness, and it helps the patient reintegrate into society. Individual psychotherapy offers the understanding, acceptance, and reassurance that individual with schizophrenia need in order to become constructive and build a fulfilled life for them in the terms of the disorder.
Group Therapy: Group therapy is also used as an adjunct to medication and it proved to be more efficient than medication alone. Patients with schizophrenia tend to benefit from this type of treatment when everyday problems caused by the disorder are discussed. Group therapy offers mutual support and comfort for its members by reducing the social isolation often experienced by patients with schizophrenia.
Family Therapy: This form of therapy was particularly popular a few years ago when family problems were thought to cause schizophrenia. These days, family therapy continues to be important in the treatment of schizophrenia because it focuses on the family education on the nature of the disorder, problem-solving training, crisis intervention training, and support. Studies have showed that when family is involved in the treatment - the rate of relapses, noncompliance to treatment, and rehospitalization significantly decreased among patients with schizophrenia.
Cognitive Rehabilitation: Cognitive rehabilitation is becoming an important intervention in the treatment of schizophrenia, although there is lot of debate among researchers whether this type of treatment is really effective (the available data supporting its efficiency are not impressive). Cognitive rehabilitation focuses on improving the cognitive functioning by retraining the ability to think, use judgment, and make decisions, and correcting deficits in memory, perception, learning, planning, sequencing, attention, and concentration. (21)
Vocational Rehabilitation: Vocational rehabilitation includes a set of services offered to individuals with schizophrenia with the purpose of helping them to achieve an independent lifestyle and to integrate in society (family, local community, and workplace). This type of intervention is designed to "enable participants to attain skills, resources, attitudes, and expectations needed to compete in the interview process, get a job, and keep a job". (22)
Schizophrenia is very rare in children, affecting only 1 in 40,000 children. Although, in most cases, some of the first signs of schizophrenia become noticeable after adolescence, children as young as five can be affected by this disorder. Due to the fact that such a disorder is so rare among children, it is very difficult to recognize and diagnose in its early stages. When a disabling mental illness like schizophrenia is considered as a possible diagnosis, specialists pay great attention to the child developmental stage (some behaviors can be normal among a certain age group and be abnormal for another), and look for a persistent pattern of abnormal behaviors such as a lack of interest in friends, hearing voices that either talk condescending about the child, or converse with one another, staring at objects or a creature that does not exist.
The behavior of a child or teen that suffers from schizophrenia can differ from the one displayed by an adult suffering from the same disorder. However, some of the symptoms displayed by children are similar to the adult symptom, such as hallucinations, delusions, social withdrawal, flattened emotions, loss of social and personal care skills, and even an increased risk of suicide. Certain symptoms such as delays in language, motor, and social development, or behaviors such as rocking, posturing, and arm flapping, are similar with some of the symptoms displayed by children with autism or pervasive developmental disorder.
Some of the symptoms displayed by children with schizophrenia include:
- Seeing and hearing things or sounds that are not real.
- Displaying an eccentric,odd, or improper behavior for their age.
- Having unusual, odd, bizarre, or strange ideas and thoughts.
- Extreme moodiness.
- Confused thinking.
- Severe anxiety and fearfulness.
- Difficulties relating to peers and having friends.
- Confusing television and dreams from reality.
- Decline in personal hygiene.
- Withdrawn and increased isolation.
- Impaired memory and reasoning.
- Problems paying attention.
- Ideas that people are "out to get them" or "talk bad about them."
In most cases, these symptoms infiltrate slowly into the behavior of a child and the disorder lacks the sudden psychotic episode usually experienced in most types of schizophrenia cases that develops in adolescence and young adult years. For example, a child that enjoys having a friend and spending time in the company of their peers, becomes more withdrawn and shy and are drawn into their own world. Some children start talking about strange ideas and fears inadequate for their age and that in most cases don't make sense. If the child attends school, usually the teachers tend to notice the behavioral changes and cognitive impairments.
Although schizophrenia in children tends to be harder to treat and has a worse prognosis than adult-onset schizophrenia, clinicians try to help the young patients with antipsychotic medication, individual therapy, family therapy, and specialised programs. An early diagnosis and medication can cause significant improvements in children with schizophrenia, however an earlier onset is associated with poor outcomes.
The data revealing the efficiency of medication in treating children with schizophrenia is not sufficient due to the lack of controlled trials, and the existing information comes form case reports and small and uncontrolled trials lacking scientific validity. Based on the existing data, schizophrenia in children seems to be resistant to typical antipsychotics. Approximately, 15 to 45 percent of the children medicated with typical antipsychotic agents show little or no improvement. However, some of the atypical psychotic medication such as clozapine and risperidone showed marginal success in children with schizophrenia. Unfortunately, children are more vulnerable than adults to the medication side effects (weight gain and associated metabolic abnormalities).
Disclaimer: The report above is for informational purposes only and should not be considered as direct advice, a personal diagnosis, or as an individual treatment plan. Always consult with a mental health professional or medical doctor if you have concerns.
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