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Schizophrenia

Schizophrenia is a psychotic disorder (or group of disorders) marked by severely impaired thinking, emotions, and behaviors. The term schizophrenia comes from two Greek words that mean "split mind." It was coined around 1908 by a Swiss doctor named Eugen Bleuler to describe the splitting apart of mental functions that he regarded as the central characteristic of schizophrenia. (Note that the splitting apart of mental functions in schizophrenia differs from the split personality of people with multiple personality disorder.) Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming.

Although schizophrenia was described by doctors as far back as Hippocrates (500 B.C.), it is difficult to classify. Many writers prefer the plural terms schizophrenias or schizophrenic disorders to the singular schizophrenia because of the lack of agreement in classification, as well as the possibility that different subtypes may eventually be shown to have different causes.

Description

The schizophrenic disorders are a major social tragedy because of the large number of persons affected and the severity of their impairment. It is estimated that people who suffer from schizophrenia fill 50% of the hospital beds in psychiatric units and 25% of all hospital beds. A number of studies indicate that about 1% of the world's population is affected by schizophrenia, without regard to race, social class, level of education, or cultural influences. (However, outcome may vary from culture to culture, depending on the familial support of the patient.) Most patients are diagnosed in their late teens or early 20s, but the symptoms of schizophrenia can emerge at any point in the life cycle. The male/female ratio in adults is about 1.2:1. Males typically have their first acute episode in their late teens or early 20s, while females are usually well into their 20s when diagnosed.

Schizophrenia is rarely diagnosed in preadolescent children, although patients as young as five or six have been reported. Childhood schizophrenia is at the upper end of the spectrum of severity and shows a greater gender disparity. It affects one or two children in every 10,000; the male/female ratio is 2:1.

The course of schizophrenia in adults can be divided into three phases or stages. In the acute phase, the patient has an overt loss of contact with reality (psychotic episode) that requires intervention and treatment. In the second or stabilization phase, the initial psychotic symptoms have been brought under control but the patient is at risk for relapse if treatment is interrupted. In the third or maintenance phase, the patient is relatively stable and can be kept indefinitely on antipsychotic medications. Even in the maintenance phase, however, relapses are not unusual and patients do not always return to full functioning.

Recently, some psychiatrists have begun to use a classification of schizophrenia based on two main types. People with Type I, or positive schizophrenia, have a rapid (acute) onset of symptoms and tend to respond well to drugs. They also tend to suffer more from the positive symptoms, such as delusions and hallucinations. People with Type II, or negative schizophrenia, are usually described as poorly adjusted before their schizophrenia slowly overtakes them. They have predominantly negative symptoms, such as withdrawal from others and a slowing of mental and physical reactions (psychomotor retardation).

The fourth revised (2000) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) specifies five subtypes of schizophrenia:

Paranoid

The key feature of this subtype of schizophrenia is the combination of false beliefs (delusions) and hearing voices (auditory hallucinations), with more nearly normal emotions and cognitive functioning. (Cognitive functions include reasoning, judgment, and memory.) The delusions of paranoid schizophrenics usually involve thoughts of being persecuted or harmed by others or exaggerated opinions of their own importance, but may also reflect feelings of jealousy or excessive religiosity. The delusions are typically organized into a coherent framework. Paranoid schizophrenics function at a higher level than other subtypes, but are at risk for suicidal or violent behavior under the influence of their delusions.

Disorganized

Disorganized schizophrenia (formerly called hebephrenic schizophrenia) is marked by disorganized speech, thinking, and behavior on the patient's part, coupled with flat or inappropriate emotional responses to a situation (affect). The patient may act silly or withdraw socially to an extreme extent. Most patients in this category have weak personality structures prior to their initial acute psychotic episode. 

 

 

Catatonic

Catatonic schizophrenia is characterized by disturbances of movement that may include rigidity, stupor, agitation, bizarre posturing, and repetitive imitations of the movements or speech of other people. These patients are at risk for malnutrition, exhaustion, or self-injury. This subtype is presently uncommon in Europe and the United States. Catatonia as a symptom is most commonly associated with mood disorders.

Undifferentiated

Patients in this category have the characteristic positive and negative symptoms of schizophrenia but do not meet the specific criteria for the paranoid, disorganized, or catatonic subtypes.

Residual

This category is used for patients who have had at least one acute schizophrenic episode but do not presently have such strong positive psychotic symptoms as delusions and hallucinations. They may have negative symptoms, such as withdrawal from others, or mild forms of positive symptoms, which indicate that the disorder has not completely resolved.

Causes & symptoms

One of the reasons for the ongoing difficulty in classifying schizophrenic disorders is incomplete understanding of their causes. It is thought that these disorders are the end result of a combination of genetic, neurobiological, and environmental causes. A leading neurobiological hypothesis looks at the connection between the disease and excessive levels of dopamine, a chemical that transmits signals in the brain (neurotransmitter). The genetic factor in schizophrenia has been underscored by recent findings that first-degree biological relatives of schizophrenics are 10 times as likely to develop the disorder as are members of the general population.

Prior to recent findings of abnormalities in the brain structure of schizophrenic patients, several generations of psychiatrists advanced a number of psychoanalytic and sociological theories about the origins of schizophrenia. These theories ranged from hypotheses about the patient's problems with anxiety or aggression to theories about stress reactions or interactions with disturbed parents. Psychosocial factors are now thought to influence the expression or severity of schizophrenia, rather than cause it directly.

Another hypothesis suggests that schizophrenia may be caused by a virus that attacks the hippocampus, a part of the brain that processes sense perceptions. Damage to the hippocampus would account for schizophrenic patients' vulnerability to sensory overload. As of mid-1998, researchers were preparing to test antiviral medications on schizophrenics.

In 2002, scientists at the University of Southern California (UCLA) used a special technique to determine that people with schizophrenia have significantly less gray matter in certain regions of the brain than others, even than their identical twins. This discovery shows that gray matter reductions are partly due to genetics and partly due to environmental factors. It also helps show the difficulty schizophrenic patients face in focusing and organizing information in their brains. The scientists hope that their work will eventually lead to targeting of exactly how and where gray matter loss occurs so that maybe researchers can develop methods to stop the process and prevent or reduce loss of brain function in those areas.

Patients with a possible diagnosis of schizophrenia are evaluated on the basis of a set or constellation of symptoms; there is no single symptom that is unique to schizophrenia. In 1959, the German psychiatrist Kurt Schneider proposed a list of so-called first-rank symptoms, which he regarded as diagnostic of the disorder:

  • delusions
  • somatic hallucinations
  • hearing voices commenting on behavior
  • thought insertion or withdrawal

Somatic hallucinations refer to sensations or perceptions concerning body organs that have no known medical cause or reason, such as the notion that one's brain is radioactive. Thought insertion and/or withdrawal refer to delusions that an outside force (for example, the FBI, the CIA, Martians, etc.) has the power to put thoughts into one's mind or remove them.

POSITIVE SYMPTOMS. The positive symptoms of schizophrenia are those that represent an excessive or distorted version of normal functions. Positive symptoms include Schneider's first-rank symptoms as well as disorganized thought processes (reflected mainly in speech) and disorganized or catatonic behavior. Disorganized thought processes are marked by such characteristics as looseness of associations, in which the patient rambles from topic to topic in a disconnected way; tangentiality, which means that the patient gives unrelated answers to questions; and word salad, in which the patient's speech is so incoherent that it makes no grammatical or linguistic sense. Disorganized behavior means that the patient has difficulty with any type of purposeful or goal-oriented behavior, including personal self-care or preparing meals. Other forms of disorganized behavior may include dressing in odd or inappropriate ways, sexual self-stimulation in public, or agitated shouting or cursing.

NEGATIVE SYMPTOMS. The DSM-IV definition of schizophrenia includes three so-called negative symptoms. They are called negative because they represent the lack or absence of behaviors. The negative symptoms that are considered diagnostic of schizophrenia are a lack of emotional response (affective flattening), poverty of speech, and absence of volition or will. In general, the negative symptoms are more difficult for doctors to evaluate than the positive symptoms. 

Diagnosis

A doctor must make a diagnosis of schizophrenia on the basis of a standardized list of outwardly observable symptoms, not on the basis of internal psychological processes. There are no specific laboratory tests that can be used to diagnose schizophrenia. Researchers have, however, discovered that patients with schizophrenia have certain abnormalities in the structure and functioning of the brain compared to normal test subjects. These discoveries have been made with the help of such imaging techniques as computed tomography (CT) scans, magnetic resonance imaging (MRI), and positron emission tomography (PET) scans.

When a psychiatrist assesses a patient for schizophrenia, he or she will begin by excluding physical conditions that can cause abnormal thinking and some other behaviors associated with schizophrenia. These conditions include organic brain disorders (including traumatic injuries of the brain), temporal lobe epilepsy, Wilson's disease, Huntington's chorea, and encephalitis. The doctor will also need to rule out substance abuse disorders, especially amphetamine use.

After ruling out organic disorders, the doctor will consider other psychiatric conditions that may include psychotic symptoms or symptoms resembling psychosis. These disorders include mood disorders with psychotic features; delusional disorder; dissociative disorder not otherwise specified (DDNOS) or multiple personality disorder; schizotypal, schizoid, or paranoid personality disorders; and atypical reactive disorders. In the past, many individuals were incorrectly diagnosed as schizophrenic. Some patients who were diagnosed prior to the changes in categorization introduced by DSM-IV should have their diagnoses and treatment reevaluated. In children, the doctor must distinguish between psychotic symptoms and a vivid fantasy life, and also identify learning problems or disorders. After other conditions have been ruled out, the patient must meet a set of criteria specified by DSM-IV:

  • Characteristic symptoms. The patient must have two (or more) of the following symptoms during a one-month period: delusions; hallucinations; disorganized speech; disorganized or catatonic behavior; negative symptoms.
  • Decline in social, interpersonal, or occupational functioning, including self-care.
  • Duration. The disturbed behavior must last for at least six months.
  • Diagnostic exclusions. Mood disorders, substance abuse disorders, medical conditions, and developmental disorders have been ruled out.

Treatment

The treatment of schizophrenia depends in part on the patient's stage or phase. Patients in the acute phase are hospitalized in most cases, to prevent harm to the patient or others and to begin treatment with antipsychotic medications. A patient having a first psychotic episode should be given a CT or MRI scan to rule out structural brain disease.

Psychotic patients require conventional antipsychotic medications. Once a patient is stabilized and non-psychotic, other alternative treatments may be used. A 2002 study reported that patients who received ginkgo biloba extract showed enhanced effectiveness and reduced toxicity of haloperidol. This raised the possibility that ginkgo might be useful as an adjunct to antipsychotic drugs. Essential fatty acids (fish oil, flax oil, etc.), multivitamins with a high vitamin B potency, and ginseng may help to balance the mind and decrease or improve the side effects of antipsychotic medication, but should not be taken without consultation with a doctor. Grounding and stress-reducing therapies such as breathwork and movement therapy (yoga, t'ai chi, and qigong) are also beneficial. However, long-term compliance with a medication regime is critical to controlling the disorder.

Allopathic treatment

The primary form of treatment for schizophrenia is antipsychotic medication. Antipsychotic drugs help to control almost all the positive symptoms of the disorder. They have minimal effects on disorganized behavior and negative symptoms. Between 60–70% of schizophrenics will respond to antipsychotics. In the acute phase of the illness, patients are usually given medications by mouth or by intramuscular injection.

One of the most difficult challenges in treating schizophrenia patients with medications is helping them stay on medication. After the patient has been stabilized, an antipsychotic drug may be given in a long-acting form called a depot dose. Depot medications last for two to four weeks; they have the advantage of protecting the patient against the consequences of forgetting or skipping daily doses. In addition, some patients who do not respond to oral neuroleptics have better results with depot form. In 2002, scientists at the University of Pennsylvania Medical School designed an implantable device that can deliver medication to patients over a five-month period. While still in clinical trials, the device showed promise in allowing for measured, consistent doses of antipsychotic drugs to schizophrenic patients. The device can be implanted in a simple 15-minute procedure under local anesthesia. Most people with schizophrenia are kept indefinitely on antipsychotic medications during the maintenance phase of their disorder to minimize the possibility of relapse.

The most frequently used antipsychotics fall into two classes: the older dopamine receptor antagonists, or DAs, and the newer serotonin dopamine antagonists, or SDAs. (Antagonists block the action of some other substance; for example, dopamine antagonists counteract the action of dopamine.) The exact mechanisms of action of these medications are not known, but it is thought that they lower the patient's sensitivity to sensory stimuli and so indirectly improve the patient's ability to interact with others.

The dopamine antagonists include the older antipsychotic (also called neuroleptic) drugs, such as haloperidol (Haldol), chlorpromazine (Thorazine), and fluphenazine (Prolixin). These drugs have two major drawbacks: it is often difficult to find the best dosage level for the individual patient, and a dosage level high enough to control psychotic symptoms frequently produces extrapyramidal side effects, or EPSs. EPSs include parkinsonism, in which the patient cannot walk normally and usually develops a tremor; dystonia, or painful muscle spasms of the head, tongue, or neck; and akathisia, or restlessness. A type of long-term EPS is called tardive dyskinesia, which features slow rhythmic automatic movements. Schizophrenics with AIDS are especially vulnerable to developing EPS.

The serotonin dopamine antagonists, also called atypical antipsychotics, are newer medications that include clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa). The SDAs have a better effect on the negative symptoms of schizophrenia than do the older drugs and are less likely to produce EPS than the older compounds. These drugs are significantly more expensive in the short term, although the SDAs may reduce long-term costs by reducing the need for hospitalization.

Most schizophrenics can benefit from psychotherapy once their acute symptoms have been brought under control by antipsychotic medication. Psychoanalytic approaches are not recommended. Behavior therapy, however, is often helpful in assisting patients to acquire skills for daily living and social interaction. It can be combined with occupational therapy to prepare the patient for eventual employment.

Family therapy is often recommended for the families of schizophrenic patients, to relieve the feelings of guilt that they often have as well as to help them understand the patient's disorder. The family's attitude and behaviors toward the patient are key factors in minimizing relapses (for example, by reducing stress in the patient's life), and family therapy can often strengthen the family's ability to cope with the stresses caused by the schizophrenic's illness. Family therapy focused on communication skills and problem-solving strategies is particularly helpful. In addition to formal treatment, many families benefit from support groups and similar mutual help organizations for relatives of schizophrenics. 

Expected results

Patients with early onset of schizophrenia are more often male, have a lower level of functioning prior to onset, a higher rate of brain abnormalities, more noticeable negative symptoms, and worse outcomes. Patients with later onset are more likely to be female, with fewer brain abnormalities and thought impairment, and more hopeful prognoses.

The average course and outcome for schizophrenics are less favorable than those for most other mental disorders, although as many as 30% of patients diagnosed with schizophrenia recover completely and the majority experience some improvement. Schizophrenics with a high number of stressful changes in their lives, or who have frequent contacts with critical or emotionally involved family members, are more likely to relapse. Overall, the most important component of long-term care of schizophrenic patients is complying with their regimen of antipsychotic medications.

BOOKS

Clark, R. Barkley. "Psychosocial Aspects of Pediatrics & Psychiatric Disorders." Current Pediatric Diagnosis & Treatment. Edited by William W. Hay Jr., et al. Stamford, CT: Appleton & Lange, 1997.

Day, Max, and Elvin V. Semrad. "Schizophrenia: Comprehensive Psychotherapy." The Encyclopedia of Psychiatry, Psychology, and Psychoanalysis. Edited by Benjamin B. Wolman. New York: Henry Holt and Company, 1996.

Eisendrath, Stuart J. "Psychiatric Disorders." Current Medical Diagnosis & Treatment 1998. Edited by Lawrence M. Tierney Jr., et al. Stamford, CT: Appleton & Lange, 1997.

Marder, Stephen R. "Schizophrenia." Conn's Current Therapy. Edited by Robert E. Rakel. Philadelphia: W. B. Saunders Company, 1998.

"Schizophrenia and Other Psychotic Disorders." Diagnostic and Statistical Manual of Mental Disorders. 4th ed. rev Washington, DC: The American Psychiatric Association, 2000.

Schultz, Clarence G. "Schizophrenia: Psychoanalytic Views." The Encyclopedia of Psychiatry, Psychology, and Psychoanalysis. Edited by Benjamin B. Wolman. New York: Henry Holt and Company, 1996.

PERIODICALS

"Brain Defects Identified by UCLA Scientists." Pain & Central Nervous System Week (April 1, 2002):3.

Gaby, Alan R. "Ginkgo for Schizophrenia (Literature Review & Commentary)." Townsend Letter for Doctors and Patients. (June 2002):31.

"Implant May Stabilize Treatment." Pain & Central Nervous System Week, (June 17, 2002):2.

Winerip, Michael. "Schizophrenia's Most Zealous Foe." The New York Times Magazine. (February 22, 1998): 26-29.

Paula Ford-Martin

Teresa G. Odle

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