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Schizophrenia

Definition

Schizophrenia is a mental disorder that makes it difficult to tell the difference between real and unreal experiences, to think logically, to have normal emotional responses, and to behave normally in social situations.

Causes, incidence, and risk factors

Schizophrenia is a complex illness. Even experts in the field are not sure what causes it.

Genetic factors appear to play a role. People who have family members with schizophrenia may be more likely to get the illness themselves.

Some researchers believe that environmental events may trigger schizophrenia in people who are already genetically at risk for the disorder. For example, infection during development in the mother's womb or stressful psychological experiences may increase the risk for developing schizophrenia later in life. Social and family support appears to improve the illness.

Schizophrenia affects about 1% of people worldwide. It occurs equally among men and women, but in women it tends to begin later and be milder. For this reason, males tend to account for more than half of patients in services with high numbers of young adults. Although schizophrenia usually begins in young adulthood, there are cases in which the disorder begins later (over age 45).

Childhood-onset schizophrenia begins after age 5 and, in most cases, after normal development. Childhood schizophrenia is rare and can be difficult to tell apart from other developmental disorders of childhood, such as autism.

Symptoms

Schizophrenia may have a variety of symptoms. Usually the illness develops slowly over months or years. Like other chronic illnesses, schizophrenia cycles between periods of fewer symptoms and periods of more symptoms.

At first, you may feel tense, or have trouble sleeping or concentrating. You can become isolated and withdrawn, and have trouble making or keeping friends.

As the illness continues, psychotic symptoms develop:

• Appearance or mood that shows no emotion (flat affect)
• Bizarre movements that show less of a reaction to the environment (catatonic behavior)
• False beliefs or thoughts that are not based in reality (delusions)
• Hearing, seeing, or feeling things that are not there (hallucinations)

Problems with thinking often occur:

• Problems paying attention
• Thoughts "jump" between unrelated topics (disordered thinking)

Symptoms can be different depending on the type of schizophrenia:

• Paranoid types often feel anxious, are more often angry or argumentative, and falsely believe that others are trying to harm them or their loved ones.
• Disorganized types have problems thinking and expressing their ideas clearly, often exhibit childlike behavior, and frequently show little emotion.
• Catatonic types may be in a constant state of unrest, or they may not move or be underactive. Their muscles and posture may be rigid. They may grimace or have other odd facial expressions, and they may be less responsive to others.
• Undifferentiated types may have symptoms of more than one other type of schizophrenia.
• Residual types experience some symptoms, but not as many as those who are in a full-blown episode of schizophrenia.

People with any type of schizophrenia may have difficulty keeping friends and working. They may also have problems with anxiety, depression, and suicidal thoughts or behaviors.

Signs and tests

A psychiatrist should perform an evaluation to make the diagnosis. The diagnosis is made based on a thorough interview of the person and family members.

No medical tests for schizophrenia exist. The following factors may suggest a schizophrenia diagnosis, but do not confirm it:

• Course of illness and how long symptoms have lasted
• Changes from level of function before illness
• Developmental background
• Genetic and family history
• Response to medication

CT scans of the head and other imaging techniques may find some changes that occur with schizophrenia and may rule out other disorders.

Treatment

During an episode of schizophrenia, you may need to stay in the hospital for safety reasons, and to receive basic needs such as food, rest, and hygiene.

MEDICATIONS

Antipsychotic medications are the most effective treatment for schizophrenia. They change the balance of chemicals in the brain and can help control the symptoms of the illness.

These medications are helpful, but they can have side effects. However, many of these side effects can be addressed, and should not prevent people from seeking treatment for this serious condition.

Common side effects from antipsychotics may include:

• Sleepiness (sedation) or dizziness
• Weight gain and increased chance of diabetes and high cholesterol

Less common side effects include:

• Feelings of restlessness or "jitters"
• Problems of movement and gait
• Muscle contractions or spasms
• Tremor

Long-term risks of antipsychotic medications include a movement disorder called tardive dyskinesia. In this condition, people develop movements that they cannot control, especially around the mouth. Anyone who believes they are having this problem should check with their doctor right away.

For people who try and do not improve with several antipsychotics, the medication clozapine can be helpful. Clozapine is the most effective medication for reducing schizophrenia symptoms, but it also tends to cause more side effects than other antipsychotics.

Because schizophrenia is a chronic illness, most people with this condition need to stay on antipsychotic medication for life.

SUPPORT PROGRAMS AND THERAPIES

Supportive and problem-focused forms of therapy may be helpful for many people. Behavioral techniques, such as social skills training, can be used during therapy or at home to improve function socially and at work.

Family treatments that combine support and education about schizophrenia (psychoeducation) appear to help families cope and reduce the odds of symptoms returning. Programs that emphasize outreach and community support services can help people who lack family and social support.

Important skills for a person with schizophrenia include:

• Learning to take medications correctly and how to manage side effects
• Learning to watch for early signs of a relapse and knowing how to react when they occur
• Coping with symptoms that are present even while taking medications. A therapist can help persons with schizophrenia test the reality of thoughts and perceptions.
• Learning life skills, such as job training, money management, use of public transportation, relationship building, and practical communication

Family members and caregivers are often encouraged to help people with schizophrenia stick to their treatment.

Support Groups

Expectations (prognosis)

The outlook for a person with schizophrenia is difficult to predict. Most people with schizophrenia find that their symptoms improve with medication, and some can get good control of their symptoms over time. However, others have functional disability and are at risk for repeated episodes, especially during the early stages of the illness.

To live in the community, people with schizophrenia may need supported housing, work rehabilitation, and other community support programs. People with the most severe forms of this disorder may be too disabled to live alone, and may need group homes or other long-term, structured places to live. Some people with milder forms of schizophrenia are able to have satisfying relationships and work experiences.

Complications

• People with schizophrenia have a high risk of developing a substance abuse problem. Use of alcohol or other drugs increases the risk of relapse, and should be treated by a professional.
• Physical illness is common among people with schizophrenia due to an inactive lifestyle and side effects from medication. Physical illness may not be detected because of poor access to medical care and difficulties talking to health care providers.
• Not taking medication will often cause symptoms to return.

Calling your health care provider

Call your health care provider if:

• Voices are telling you to hurt yourself or others.
• You feel the urge to hurt yourself or others.
• You are feeling hopeless and overwhelmed.
• You are seeing things that aren't really there.
• You feel like you cannot leave the house.
• You are unable to care for yourself.

Prevention

There is no known way to prevent schizophrenia.

If you do have the condition, the best ways to prevent symptoms from coming back are to take the medication your doctor prescribed, and see your doctor or therapist regularly. Always talk to your doctor if you are thinking about changing or stopping your medications.

References

Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet. 2009;373:31-41. Epub 2008 Dec 6.

Freudenreich O, Weiss AP, Goff DC. Psychosis and schizophrenia. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 28.