What Is It?
Schizophrenia is a brain disorder, with many abnormalities of the brain structure, function and chemistry.
Schizophrenia is a chronic brain disorder that is usually progressively debilitating without medical treatment. According to the National Institute of Mental Health, about 1 percent of the population currently suffers from schizophrenia. While there is no known cure for this severe mental illness, new medications can help alleviate many of the disease's severe symptoms with fewer motor side effects than older medications.
The number of reported cases is split evenly between men and women, although schizophrenia tends to appear earlier for men—usually in the late teens or early 20s—compared to women, who generally begin to display symptoms in their 20s or early 30s. Onset of schizophrenia is rare before puberty and uncommon after age 45.
Schizophrenia presents differently in different people. Symptoms tend to appear gradually and can easily go unnoticed by friends and family in the beginning. However, in some cases, symptoms of schizophrenia occur suddenly and can be quite dramatic. As the illness advances, the symptoms can become more bizarre and severe.
People with schizophrenia tend to have psychotic symptoms, such as hearing voices when no one is speaking or insisting that other people are listening to their thoughts or attempting to control them. Many people with schizophrenia have active psychotic episodes, a state where hallucinations and/or delusions occur and they lose touch with reality. Most people with schizophrenia experience at least one relapse after their first such episode.
Other early signs of the disease include increasing social withdrawal and loss of interest in normal pursuits, unusual behavior or a decrease in overall functioning, often before the delusions and hallucinations begin. These are often the first warning signs that alert friends and family to a problem.
As the illness progresses, a person's speech and behavior tend to become progressively disorganized and confused, and their work performance usually deteriorates. Eventually, the symptoms become more extreme, appearing as if the person has undergone a dramatic personality change. If these and other symptoms persist for six months or longer and no external cause such as the effects of illicit drug use or a medical illness is detected, the person is usually diagnosed with schizophrenia.
People who have schizophrenia are more likely to commit suicide than people in the general population, with an estimated 10 percent of all people diagnosed with schizophrenia ending their life this way. Young adult males are most likely to commit suicide.
Role of Genetics
Genetics appear to play a role in schizophrenia. However, genetics alone do not explain the disease. An identical twin of someone with schizophrenia has a 40 percent to 65 percent chance of developing the illness, while children who have a first-degree relative with the disease have about 10 times the risk of developing it than that of someone who does not have a family member with the illness. People with a second-degree relative, such as an aunt, grandparent or cousin with schizophrenia, also have an increased risk.
Researchers believe multiple genes are involved in the risk for schizophrenia but that no single gene causes the disease by itself. Recent research shows certain gene mutations occur among families in which several members have the illness, but that these abnormalities are not found in other families. This suggests that mutations may occur in any of a number of genes that might result in schizophrenia. Affected genes have been linked to various aspects of brain functioning that could account for the symptoms of schizophrenia and could affect a patient's ability to function. Future research may be able to identify who is at risk for developing the disease based on genetic profiles.
Other factors, such as prenatal difficulties (including viral infections and complications around the time of birth), also appear to influence the development of the disease. In addition, some illicit drugs, such as marijuana and stimulants like cocaine and amphetamines, may make schizophrenia symptoms worse. Research has found increasing evidence of a link between marijuana use at a young age and a greater risk of developing schizophrenia.
Role of Brain Abnormalities
Schizophrenia is a brain disorder, with many abnormalities of the brain structure, function and chemistry. For example, several studies find people with schizophrenia have enlarged ventricles, cavities in the brain filled with cerebrospinal fluid. In addition, some studies find that people with schizophrenia tend to have specific areas of the brain that are smaller compared to people without schizophrenia, and that some of these areas have lower metabolic activity. However, scientists are careful to note that these and other abnormalities are subtle, are not found in all cases and could be present in people who never develop schizophrenia.
In addition, studies of brain tissue following death have revealed changes in the distribution or characteristics of brain cells in people with schizophrenia that may have taken place before birth as well as during other times of change in brain development. Considerable brain restructuring occurs during adolescence and may be further altered in schizophrenia, resulting in the characteristic onset of symptoms during this crucial developmental stage in life. Scientists are working to better determine exactly how schizophrenia develops.
A challenging part of diagnosing schizophrenia is that there is no way to confirm it with laboratory studies, so clinicians rely on a pattern of psychotic symptoms and functional deterioration. Many of the symptoms can be found in other mental disorders, which can present further challenges. For example, some individuals with schizophrenia have prolonged periods of elation or depression, which can be confused with bipolar disorder (also called manic depression) or major depressive disorder. People with bipolar disorder and major depression can also experience psychotic symptoms. These conditions need to be ruled out before diagnosing schizophrenia.
A mental health professional such as a psychologist or psychiatrist typically diagnoses schizophrenia. The clinician begins with a complete medical history and physical examination followed by blood and urine tests to rule out other medical causes for the symptoms. For instance, commonly abused drugs such as cocaine, methamphetamines or LSD can cause symptoms that mimic schizophrenia (including hallucinations or paranoia).
Interestingly, people who have schizophrenia tend to abuse drugs and alcohol at a higher rate than the general population. So just because someone is abusing drugs doesn't mean the person doesn't also have schizophrenia.
Psychiatrists often diagnose schizophrenia when someone has had at least two active symptoms of the disorder, such as a psychotic episode that includes delusions and hallucinations, for at least a month, with other symptoms, such as a decline in functioning and disturbed thoughts lasting six months or longer.
Schizophrenia appears to improve and worsen over the course of the illness. When it improves, the person suffering from the disease may appear perfectly normal. Unfortunately, this is when many people decide to stop taking their medication and relapse. During an acute psychotic episode, patients often lose their ability to think logically or may lose their perception of who they are or of others around them.
Most people with schizophrenia also have social and occupational problems, including problems in the workplace, with interpersonal relationships and in the way they care for themselves.
Symptoms of schizophrenia are usually split into positive, negative and neurocognitive categories.
Positive symptoms are unusual thoughts, perceptions or distortion of normal functions. They include:
- Delusions. These are firmly held erroneous beliefs that result from distortions or exaggerations of reasoning or misinterpretations of a person's perceptions or experiences. Common delusions include unrealistic beliefs that the person is being watched or followed (e.g. paranoia).
- Hallucinations. These are abnormalities of perception that can occur in any of the senses, although auditory hallucinations (hearing voices even though no one is speaking) are most common. These voices often insult the person, comment on his or her behavior or give commands. Visual hallucinations are the second most common type.
- Thought disorders. These are dysfunctional or unusual ways of thinking. "Disorganized thinking" is when a person can't organize or connect his or her thoughts. Speech may be garbled and hard to understand. "Thought blocking" is when a person stops talking in the middle of a thought. Another form of thought disorders may cause a person to make up meaningless words.
Negative symptoms relate to disruptions of normal emotions, motivation and drive. Symptoms to look for include:
- "Flat affect," when a person's emotional expressions go "flat," and there is little change in their facial expressions, voice or body language. The person may avoid eye contact.
- Lack of pleasure in everyday life and/or needing help with everyday activities. May include a neglect of basic personal hygiene.
- Speaking little, even when spoken to, or giving only disinterested replies.
- Disinterest in social interaction and retreat into an "inner world."
Neurocognitive symptoms of schizophrenia are symptoms that have to do with the person's ability to think and reason. They include:
- Problems with attention
- Trouble with certain types of memory
- Problems with functions that allow one to plan and organize
Some patients with schizophrenia also experience abnormal movements, such as twitching, repetitive gestures or catatonia (for example, maintaining unusual positions or not moving or responding at all). For reasons that are not understood, more severe forms of catatonia were more common before the availability of antipsychotic medications. On the other hand, certain motor movements, such as tremor, rigidity and restlessness, commonly occur as side effects to antipsychotic medications.
Several subtypes of schizophrenia have been suggested, based on a person's range and intensity of symptoms. There several recognized types of schizophrenia, including the following:
- Paranoid schizophrenia. A person experiences predominantly positive symptoms (delusions and hallucinations), without a lot of disorganization or negative symptoms. The person may feel suspicious, persecuted and/or grandiose.
- Disorganized schizophrenia (also called hebephrenic schizophrenia). People with disorganized schizophrenia have difficulty with logical, coherent thinking and speech. They also sometimes lack motivation, emotion and the ability to feel pleasure.
- Catatonic schizophrenia. People with catatonic schizophrenia exhibit extreme inactivity or activity that's disconnected from his or her environment or encounters with other people. These episodes can last for minutes to hours.
- Undifferentiated schizophrenia. People with undifferentiated schizophrenia meet diagnostic criteria for schizophrenia, but not the paranoid, disorganized or catatonic subtypes.
- Residual schizophrenia. People with residual schizophrenia have a history of schizophrenic episodes characterized by negative symptoms or mild positive symptoms. People with this form of schizophrenia differ from those with other forms in that they lack prominent psychotic symptoms.
Although schizophrenia is usually a lifelong illness, some people develop all the symptoms of schizophrenia that resolve spontaneously. When the symptoms last less than one month, a diagnosis of brief psychotic disorder is given. When symptoms last less than six months, the diagnosis schizophreniform disorder is used. Unfortunately, schizophreniform disorder is rare, and most people progress to chronic schizophrenia.
The best treatment for any individual suffering from schizophrenia blends a combination of antipsychotic medications with psychosocial interventions. Psychosocial interventions include supportive psychotherapy, illness management skills, integrated treatment for any coexisting substance abuse, family participation in therapy and psychosocial and vocational rehabilitation.
People with schizophrenia who need a high degree of social services should receive assistance from an interdisciplinary treatment team.
Antipsychotic medications for schizophrenia can eliminate or reduce the hallucinations and delusions of the disorder. These drugs, which help restore biochemical imbalances, may also help people regain their coherent thinking abilities. The older "conventional" or "typical" antipsychotic drugs were introduced in the 1950s. Over the years, studies have found that these drugs are very effective in treating acute episodes of delusions or hallucinations and can provide long-term maintenance and prevention of future schizophrenic relapses. However, these drugs can cause unpleasant side effects such as dry mouth, constipation, blurred vision and difficulty urinating. These types of side effects are called "anticholinergic."
These medications can also cause extrapyramidal side effects (EPS), which affect how the body moves. For example, restlessness, tremors and slowing of normal gestures and movements can occur after days to weeks of treatment. Some patients report muscle spasms and cramps in the head and neck area, as well as stiff muscles throughout their body.
Tardive dyskinesia (TD) is a type of EPS that can occur after months or years of treatment with antipsychotic medications. The risk of TD increases the longer antipsychotic medications are taken. This condition is more common among older patients. It involves small involuntary movements of the fingers, tongue, lips, face or jaw. The symptoms tend to get worse and turn into thrusting and rolling motions of the tongue, lip smacking, grimacing or uncontrollable sucking motions. Involuntary movements of the hands, feet, neck and shoulders can also occur. Tardive dyskinesia can be a permanent, irreversible side effect.
These medications can also interfere with reproductive hormones, affecting a woman's menstrual cycles and fertility or causing breast enlargement, milk secretion or sexual side effects in both men and women. Sedation and dizziness are also relatively common side effects.
Because of the potential side effects associated with these medications, it is important that any medication regimen is tailored to the individual. You should work closely with your doctor to achieve the most benefit with the fewest problems from the medication. Sometimes adding another drug can help reduce certain antipsychotic-related side effects and possibly improve their effectiveness.
Examples of older "typical" antipsychotic medications include chlorpromazine (Thorazine), haloperidol (Haldol), perphenazine (Trilafon) and fluphenazine (Prolixin).
Over the past 20 years, pharmaceutical manufacturers have introduced a newer generation of antipsychotic drugs known as novel or "atypical" antipsychotics. The major advantage of these medications is a decreased risk of some side effects, such as EPS. These medications include clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon), paliperidone (Invega) and aripiprazole (Abilify).
Clozapine is unique in that it is the most effective antipsychotic medication and is not typically associated with EPS or TD. However, patients taking clozapine must be monitored closely with regular blood tests because the medicine can cause a blood disorder called agranulocytosis, a disorder in which there are an insufficient number of white blood cells. Although it only occurs in a very small percentage of those taking clozapine, it can prove fatal if not caught and treated immediately.
Studies find the atypical antipsychotics are about as effective as the older conventional medications but have fewer extrapyramidal side effects. It has also been suggested that the atypical antipsychotics may improve anxiety, depression and cognitive symptoms. As a result, these newer drugs have replaced older drugs as "first line" therapy in the United States.
However, this new generation of medications has its own potential side effects, including sedation, significant weight gain and sexual dysfunction. Some are associated with a higher incidence of diabetes or high cholesterol, particularly in those who gain weight. While they don't typically interfere with menstruation as much as the typical antipsychotics, there is little information about the safety or impact of antipsychotic treatment during pregnancy and breastfeeding. If you are taking these medications and considering getting pregnant, talk to your health care professional first.
Perhaps the biggest challenge facing people with schizophrenia and their families is the high rate at which many stop taking their medication. Some stop treatment because they don't really believe they are ill. Others have such extreme disorganized thinking they can't remember to take their regular medication doses. Injectable medications that last for several weeks can sometimes help in these situations.
Patients also stop taking their medication because of difficulties with side effects. Substance abuse can also interfere with the efficacy of the medication, influencing patients' compliance. Finally, uninformed family members may suggest patients stop taking their medication because the symptoms seem to have disappeared. That's why it's important for a health care professional to stay involved in the treatment of someone with schizophrenia, even if they seem to be doing fine.
In unusual circumstances, electroconvulsive therapy (ECT) can be used to treat schizophrenia. During ECT, an electrical current passes through the patient's brain inducing a seizure. This treatment may be used if the person hasn't responded to antipsychotic medication or, in some circumstances, for those in catatonic states.
Once the delusions and hallucinations of schizophrenia subside, patients also can benefit from psychosocial therapies that help them improve their social skills and teach them how to live independently. These sessions can be provided in group, family or individual settings. Many therapists use behavioral learning techniques, including coaching, modeling and positive reinforcement, all of which can make a big difference in helping patients cope with other stresses in their lives that could contribute to relapses.
Psychoeducational family therapy is another segment of treatment that many psychiatrists see as necessary to help prevent relapses. These family education training sessions teach family members and close friends how to recognize the early warning signs of a relapse and what to do before the situation worsens. Improving communication and problem-solving skills among family members and the person with schizophrenia can help reduce the potential for relapse.
For individuals suffering from schizophrenia who need community services for support, clinical case managers can coordinate the necessary services and make sure medical and psychiatric treatments are addressed. These case managers can also play a key role in crisis management if the person doesn't have a support network of family and friends.
Facts to Know
- About 1 percent of the population has schizophrenia, according to the National Institute of Mental Health.
- The number of reported cases is split between men and women, although schizophrenia tends to appear earlier for men—usually in the late teens or early 20s—compared to women, who generally begin to show signs of trouble in their 20s or early 30s. Onset of schizophrenia is rare before puberty and uncommon after age 45.
- People with schizophrenia tend to have psychotic symptoms, such as hearing voices when no one is speaking or insisting that other people are listening to their thoughts or attempting to control them. Many people with schizophrenia have active psychotic episodes, a state where hallucinations and/or delusions occur and they lose touch with reality. Most people with schizophrenia experience at least one relapse after their first such episode. Other early signs of the disease include increasing social withdrawal and loss of interest in normal pursuits, unusual behavior or a decrease in overall functioning, often before the delusions and hallucinations begin. These are often the first warning signs that alert friends and family to a problem.
- Genetics appears to play a role in schizophrenia. However, genetics alone does not explain the disease. An identical twin of someone with schizophrenia has a 40 percent to 65 percent chance of developing the illness, while children who have a first-degree relative with the disease have about a 10 percent risk of developing it themselves. People with a second-degree relative, such as an aunt, grandparent or cousin, also have an increased risk.
- Researchers find that multiple genes are involved in the risk for schizophrenia, but they are not the only cause. Other factors, such as prenatal difficulties (including viral infections and complications around the time of birth), also appear to influence the development of the disease. Researchers suspect that the disease may be the result of inappropriate connections between neurons in the brain that form during fetal development or puberty, times of significant changes in the brain.
- There is no way to definitively diagnose schizophrenia with laboratory studies, so clinicians rely on a pattern of psychotic symptoms and functional deterioration, as well as eliminating other possible causes of symptoms, to make a diagnosis. Psychiatrists often diagnose schizophrenia when someone has had active symptoms of the disorder, such as a psychotic episode that includes delusions and hallucinations, for at least a month, with other symptoms, such as decline in functioning and disturbed thought, lasting six months or longer. Many other conditions can resemble schizophrenia, so diagnosis should be performed by an experienced mental health professional.
- Schizophrenia appears to improve and worsen in cycles. When it improves, the person suffering from the disease may appear perfectly normal. Unfortunately, this is when many people decide to stop taking their medication and relapse. However, during the acute or psychotic phase, individuals with schizophrenia think without logical reasoning and may lose perception of who they or others around them are.
- In most cases, schizophrenia is a chronic condition requiring lifelong treatment. The best treatment blends a combination of antipsychotic medications with psychosocial interventions such as supportive psychotherapy, family participation in therapy and psychosocial and vocational rehabilitation. During crisis periods or times of severe symptoms, hospitalization may be required. Schizophrenia treatment is usually guided by an experienced psychiatrist, but it may also involve psychologists, social workers, psychiatric nurses and possibly a case manager.
Questions to Ask
Review the following Questions to Ask about schizophrenia so you're prepared to discuss this important health issue with your health care professional.
- What type of medical professional cares for people with schizophrenia? What specialists should I consider visiting?
- What criteria should I use to find a psychiatrist or other specialist who will meet my needs or the needs of my family member?
- How many patients with schizophrenia have you provided care for in the last 10 years?
- What side effects might occur with the antipsychotic medication you are recommending?
- Are there any newer medications that could provide the same outcome—or better—with fewer side effects?
- Can antipsychotic medication be taken during pregnancy?
- If hallucinations or delusions return while taking antipsychotic medication, what should I (or my family member) do?
- Are there injectable (and longer-lasting) versions of this antipsychotic medication to improve the chance that it will be taken as directed? Are they just as effective as medications taken orally on a daily basis?
- Are there other treatments to consider to further reduce the potential for relapses? What about family psychotherapy sessions and other types of rehabilitation?
- Can you recommend a clinical case manager who can coordinate care and help find appropriate social services that I may need?
- What is schizophrenia?
Schizophrenia is a chronic brain disorder that is often progressively debilitating for individuals unless they seek intervention through medications, psychosocial treatments and other types of care.
- Are women at greater risk of developing the disorder compared with men?
The number of reported cases is split rather evenly between men and women, although schizophrenia tends to present itself at different ages for the two sexes. Onset of the disorder tends to occur earlier for men—usually in the late teens or early 20s—compared to women, who generally begin to show signs of trouble in their 20s or early 30s. An identical twin of someone with schizophrenia has about a 40 percent to 65 percent chance of developing the illness. Interestingly, researchers have found there is a further heightened risk for a female identical twin to develop schizophrenia if her twin has the illness. Women tend to have a less severe form of the disorder and respond better to treatment.
- Am I at greater risk of developing schizophrenia if I have a close relative who has been diagnosed with the disorder?
If you have a close relative with the disease, you are more likely to develop it compared with someone who has no close relatives with schizophrenia. Your risk is also slightly elevated if you have a secondary family member with the disease, such as an aunt, uncle, grandparent or cousin.
- What are the early warning signs of schizophrenia?
Most people who develop schizophrenia begin having delusions and hallucinations. Other early signs include increasing social withdrawal, loss of pleasure in everyday life, unusual behavior or decreases in overall functioning before the delusions and hallucinations begin. Speech and behavior tend to become progressively disorganized and confused, and work performance often deteriorates.
- What are my treatment options if I am diagnosed with the disorder?
The primary mode of treatment for schizophrenia is a regimen of antipsychotic medications that make a significant difference in eliminating or significantly reducing the hallucinations and delusions. These drugs, which help restore biochemical imbalances to normal levels, also help the patient regain coherent thinking abilities. However, a major drawback to these medications is a wide array of side effects, some of them quite severe for some patients. In addition to medications, health care professionals strongly recommend patients with schizophrenia supplement their drug regimen with an array of psychosocial interventions.
- What are my chances for a relapse once I am taking medications and following a treatment plan?
When taken as directed, antipsychotic medications can make a huge difference in the long-term potential for minimizing relapses and hospitalizations. Relapses usually happen when people stop taking their medication or take it only occasionally. People often stop their medication because they feel better and don't think they need it anymore. However, you should never stop taking an antipsychotic medication without first checking with your doctor. And even if your doctor gives you the OK, you should taper the dose of your medication gradually and not stop it suddenly.
- Is there any way to prevent myself from developing schizophrenia?
Current research is being done to answer this question, and there are several clinics around the world devoted to identifying and helping "at risk" individuals. It does appear that the onset of schizophrenia can be triggered by stress or by using certain drugs such as marijuana. If a person has a family history of schizophrenia, avoiding illicit drug use is advisable, as well as reducing stress, getting adequate sleep and starting antipsychotic medications as soon as necessary.
Organizations and Support
For information and support on Schizophrenia, please see the recommended organizations, books and Spanish-language resources listed below.
American Academy of Child and Adolescent Psychiatry (AACAP)
Address: 3615 Wisconsin Ave., NW
Washington, DC 20016
American Association for Geriatric Psychiatry (AAGP)
Address: 7910 Woodmont Ave, Ste 1050
Bethesda, MD 20814
American Association of Suicidology
Address: 5221 Wisconsin Avenue, NW
Washington, DC 20015
Hotline: 1-800-273-TALK (1-800-273-8255)
American Psychiatric Association
Address: 1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209
American Psychiatric Nurses Association (APNA)
Address: 1555 Wilson Blvd., Suite 530
Arlington, VA 22209
American Psychological Association
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1 -800-374-2721
Address: The Bazelon Center for Mental Health Law
1101 15th Street NW, Suite 1212
Washington, DC 20005
International Society of Psychiatric-Mental Health Nurses (ISPN)
Address: 2810 Crossroads Drive, Suite 3800
Madison, WI 53718
Mental Health America
Address: 2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
National Alliance on Mental Illness (NAMI)
Address: Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
Hotline: 1-800-950-NAMI (1-800-950-6264)
National Institute of Mental Health
Address: Science Writing, Press and Dissemination Branch
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
National Mental Health Consumers' Self-Help Clearinghouse
Address: 1211 Chestnut St., Suite 1207
Philadelphia, PA 19107
SAMHSA's National Mental Health Information Center
Address: P.O. Box 2345
Rockville, MD 20847
Screening for Mental Health (SMH)
Address: One Washington Street, Suite 304
Wellesley Hills, MA 02481
Surviving Schizophrenia: A Manual for Families, Patients, and Providers
by E. Fuller Torrey
The Complete Family Guide to Schizophrenia: Helping Your Loved One Get the Most Out of Life
by Kim T. Mueser, Ph.D. and Susan Gingerich, MSW
Getting Your Life Back Together When You Have Schizophrenia
by Roberta Temes
I Am Not Sick, I Don't Need Help!
by Xavier Amador, Ph.D.
The Day the Voices Stopped: A Schizophrenic's Journey from Madness to Hope
by Ken Steele and Claire Berman
American Academy of Family Physicians
Medline Plus: Schizophrenia
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894