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What is schizophrenia?
Schizophrenia is a chronic, severe,
and disabling brain disorder that has been recognized throughout
recorded history. It affects about 1 percent of Americans.
People
with schizophrenia may hear voices other people don't hear
or they may believe that others are reading their minds,
controlling their thoughts, or plotting to harm them. These
experiences are terrifying and can cause fearfulness, withdrawal,
or extreme agitation. People with schizophrenia may not make
sense when they talk, may sit for hours without moving or
talking much, or may seem perfectly fine until they talk
about what they are really thinking. Because many people
with schizophrenia have difficulty holding a job or caring
for themselves, the burden on their families and society
is significant as well.
Available treatments can relieve many of the disorder's
symptoms, but most people who have schizophrenia must cope
with some residual symptoms as long as they live. Nevertheless,
this is a time of hope for people with schizophrenia and
their families. Many people with the disorder now lead rewarding
and meaningful lives in their communities. Researchers are
developing more effective medications and using new research
tools to understand the causes of schizophrenia and to find
ways to prevent and treat it.
This brochure presents information on the symptoms of schizophrenia,
when the symptoms appear, how the disease develops, current
treatments, support for patients and their loved ones, and
new directions in research.
What are the symptoms of schizophrenia?
The symptoms of schizophrenia fall into three broad categories:
Positive symptoms are
unusual thoughts or perceptions, including hallucinations,
delusions, thought disorder, and disorders of movement.
Negative symptoms represent a loss
or a decrease in the ability to initiate plans, speak, express
emotion, or find pleasure in everyday life. These symptoms
are harder to recognize as part of the disorder and can be
mistaken for laziness or depression.
Cognitive
symptoms (or cognitive
deficits) are problems with attention, certain types of memory,
and the executive functions that allow us to plan and organize.
Cognitive deficits can also be difficult to recognize as
part of the disorder but are the most disabling in terms
of leading a normal life.
Positive symptoms
Positive symptoms
are easy-to-spot behaviors not seen in healthy people and
usually involve a loss of contact with reality. They include
hallucinations, delusions, thought disorder, and disorders
of movement. Positive symptoms can come and go. Sometimes
they are severe and at other times hardly noticeable, depending
on whether the individual is receiving treatment.
Hallucinations .A hallucination
is something a person sees, hears, smells, or feels that
no one else can see, hear, smell, or feel. "Voices" are
the most common type of hallucination in schizophrenia.
Many people with the disorder hear voices that may comment
on their behavior, order them to do things, warn them of
impending danger, or talk to each other (usually about
the patient). They may hear these voices for a long time
before family and friends notice that something is wrong.
Other types of hallucinations include seeing people or objects
that are not there, smelling odors that no one else detects
(although this can also be a symptom of certain brain tumors),
and feeling things like invisible fingers touching their
bodies when no one is near.
Delusions. Delusions are false
personal beliefs that are not part of the person's culture
and do not change, even when other people present proof that
the beliefs are not true or logical. People with schizophrenia
can have delusions that are quite bizarre, such as believing
that neighbors can control their behavior with magnetic waves,
people on television are directing special messages to them,
or radio stations are broadcasting their thoughts aloud to
others. They may also have delusions of grandeur and think
they are famous historical figures. People with paranoid
schizophrenia can believe that others are deliberately cheating,
harassing, poisoning, spying upon, or plotting against them
or the people they care about. These beliefs are called delusions
of persecution.
Thought Disorder. People with
schizophrenia often have unusual thought processes. One
dramatic form is disorganized thinking, in which the person
has difficulty organizing his or her thoughts or connecting
them logically. Speech may be garbled or hard to understand.
Another form is "thought blocking," in
which the person stops abruptly in the middle of a thought.
When asked why, the person may say that it felt as if the
thought had been taken out of his or her head. Finally, the
individual might make up unintelligible words, or "neologisms."
Disorders
of Movement. People with
schizophrenia can be clumsy and uncoordinated. They may also
exhibit involuntary movements and may grimace or exhibit
unusual mannerisms. They may repeat certain motions over
and over or, in extreme cases, may become catatonic. Catatonia
is a state of immobility and unresponsiveness. It was more
common when treatment for schizophrenia was not available;
fortunately, it is now rare.
Negative symptoms
The term "negative symptoms" refers
to reductions in normal emotional and behavioral states.
These include the following:
- flat affect (immobile facial expression, monotonous voice),
- lack of pleasure in everyday life,
- diminished ability to initiate and sustain planned activity,
and
- speaking infrequently, even when forced to interact.
People with schizophrenia often neglect basic hygiene and
need help with everyday activities. Because it is not as
obvious that negative symptoms are part of a psychiatric
illness, people with schizophrenia are often perceived as
lazy and unwilling to better their lives.
Cognitive symptoms
Cognitive symptoms are subtle and are often detected only
when neuropsychological tests are performed. They include
the following:
- poor "executive functioning" (the
ability to absorb and interpret information and make decisions
based on that information),
- inability to sustain attention, and
- problems with "working memory" (the ability to
keep recently learned information in mind and use it right
away)
Cognitive impairments often interfere
with the patient's ability to lead a normal life and earn
a living. They can cause great emotional distress.
When does it start and who gets it?
Psychotic symptoms (such
as hallucinations and delusions) usually emerge in men
in their late teens and early 20s and in women in their
mid-20s to early 30s. They seldom occur after age 45 and
only rarely before puberty, although cases of schizophrenia
in children as young as 5 have been reported. In adolescents,
the first signs can include a change of friends, a drop
in grades, sleep problems, and irritability. Because many
normal adolescents exhibit these behaviors as well, a diagnosis
can be difficult to make at this stage. In young people
who go on to develop the disease, this is called the "prodromal" period.
Research has shown that schizophrenia affects men and women
equally and occurs at similar rates in all ethnic groups
around the world.
Are people with schizophrenia violent?
People with schizophrenia are not
especially prone to violence and often prefer to be left
alone. Studies show that if people have no record of criminal
violence before they develop schizophrenia and are not substance
abusers, they are unlikely to commit crimes after they become
ill. Most violent crimes are not committed by people with
schizophrenia, and most people with schizophrenia do not
commit violent crimes. Substance abuse always increases violent
behavior, regardless of the presence of schizophrenia (see
sidebar). If someone with paranoid schizophrenia becomes
violent, the violence is most often directed at family members
and takes place at home.
What about suicide?
People with schizophrenia attempt
suicide much more often than people in the general population.
About 104 5 percent (especially young adult males) succeed.
It is hard to predict which people with schizophrenia are
prone to suicide, so if someone talks about or tries to commit
suicide, professional help should be sought right away.
What
causes schizophrenia?
Like many other illnesses, schizophrenia is believed to
result from a combination of environmental and genetic factors.
All the tools of modern science are being used to search
for the causes of this disorder.
Can schizophrenia be inherited?
Scientists
have long known that schizophrenia runs in families. It occurs
in 1 percent of the general population but is seen in 10
percent of people with a first-degree relative (a parent,
brother, or sister) with the disorder. People who have second-degree
relatives (aunts, uncles, grandparents, or cousins) with
the disease also develop schizophrenia more often than the
general population. The identical twin of a person with schizophrenia
is most at risk, with a 40 to 65 percent chance of developing
the disorder.7
Our genes are located on 23 pairs of chromosomes that are
found in each cell. We inherit two copies of each gene, one
from each parent. Several of these genes are thought to be
associated with an increased risk of schizophrenia, but scientists
believe that each gene has a very small effect and is not
responsible for causing the disease by itself. It is still
not possible to predict who will develop the disease by looking
at genetic material.
Although there is a genetic risk for schizophrenia, it is
not likely that genes alone are sufficient to cause the disorder.
Interactions between genes and the environment are thought
to be necessary for schizophrenia to develop. Many environmental
factors have been suggested as risk factors, such as exposure
to viruses or malnutrition in the womb, problems during birth,
and psychosocial factors, like stressful environmental conditions.
Do people with schizophrenia have faulty brain chemistry?
It is likely that an imbalance in the complex, interrelated
chemical reactions of the brain involving the neurotransmitters
dopamine and glutamate (and possibly others) plays a role
in schizophrenia. Neurotransmitters are substances that allow
brain cells to communicate with one another. Basic knowledge
about brain chemistry and its link to schizophrenia is expanding
rapidly and is a promising area of research.
Do the brains of people with schizophrenia
look different?
The brains of people with schizophrenia look
a little different than the brains of healthy people, but
the differences are small. Sometimes the fluid-filled cavities
at the center of the brain, called ventricles, are larger
in people with schizophrenia; overall gray matter volume
is lower; and some areas of the brain have less or more metabolic
activity.3 Microscopic studies of brain tissue after death
have also revealed small changes in the distribution or characteristics
of brain cells in people with schizophrenia. It appears that
many of these changes were prenatal because they are not
accompanied by glial cells, which are always present when
a brain injury occurs after birth.3 One theory suggests that
problems during brain development lead to faulty connections
that lie dormant until puberty. The brain undergoes major
changes during puberty, and these changes could trigger psychotic
symptoms.
The only way to answer these questions is to conduct more
research. Scientists in the United States and around the
world are studying schizophrenia and trying to develop new
ways to prevent and treat the disorder.
How is schizophrenia treated?
Because the causes of schizophrenia
are still unknown, current treatments focus on eliminating
the symptoms of the disease.
Antipsychotic medications
Antipsychotic
medications have been available since the mid-1950s. They
effectively alleviate the positive symptoms of schizophrenia.
While these drugs have greatly improved the lives of many
patients, they do not cure schizophrenia.
Everyone responds differently to antipsychotic medication.
Sometimes several different drugs must be tried before the
right one is found. People with schizophrenia should work
in partnership with their doctors to find the medications
that control their symptoms best with the fewest side effects.
The older antipsychotic medications
include chlorpromazine (Thorazine®), haloperidol (Haldol®), perphenazine
(Etrafon®, Trilafon®), and fluphenzine (Prolixin®).
The older medications can cause extrapyramidal side effects,
such as rigidity, persistent muscle spasms, tremors, and
restlessness.
In the 1990s, new drugs,
called atypical antipsychotics, were developed that rarely
produced these side effects. The first of these new drugs
was clozapine (Clozaril®). It
treats psychotic symptoms effectively even in people who
do not respond to other medications, but it can produce a
serious problem called agranulocytosis, a loss of the white
blood cells that fight infection. Therefore, patients who
take clozapine must have their white blood cell counts monitored
every week or two. The inconvenience and cost of both the
blood tests and the medication itself has made treatment
with clozapine difficult for many people, but it is the drug
of choice for those whose symptoms do not respond to the
other antipsychotic medications, old or new.
Some of the drugs that were
developed after clozapine was introduced—such as risperidone (Risperdal®), olanzapine
(Zyprexa®), quietiapine (Seroquel®), sertindole (Serdolect®),
and ziprasidone (Geodon®)—are effective and rarely
produce extrapyramidal symptoms and do not cause agranulocytosis;
but they can cause weight gain and metabolic changes associated
with an increased risk of diabetes and high cholesterol.8
People respond individually to antipsychotic medications,
although agitation and hallucinations usually improve within
days and delusions usually improve within a few weeks. Many
people see substantial improvement in both types of symptoms
by the sixth week of treatment. No one can tell beforehand
exactly how a medication will affect a particular individual,
and sometimes several medications must be tried before the
right one is found.
When people first start to take atypical antipsychotics,
they may become drowsy; experience dizziness when they change
positions; have blurred vision; or develop a rapid heartbeat,
menstrual problems, a sensitivity to the sun, or skin rashes.
Many of these symptoms will go away after the first days
of treatment, but people who are taking atypical antipsychotics
should not drive until they adjust to their new medication.
If people with schizophrenia become depressed, it may be
necessary to add an antidepressant to their drug regimen.
A large clinical trial funded
by the National Institute of Mental Health (NIMH), known
as CATIE (Clinical Antipsychotic Trials of Intervention
Effectiveness), compared the effectiveness and side effects
of five antipsychotic medications—both
new and older antipsychotics—that are used to treat
people with schizophrenia. For more information, visit the
NIMH CATIE page.
Length of
Treatment. Like diabetes or high blood pressure,
schizophrenia is a chronic disorder that needs constant management.
At the moment, it cannot be cured, but the rate of recurrence
of psychotic episodes can be decreased significantly by staying
on medication. Although responses vary from person to person,
most people with schizophrenia need to take some type of
medication for the rest of their lives as well as use other
approaches, such as supportive therapy or rehabilitation.
Relapses occur most often when people with schizophrenia
stop taking their antipsychotic medication because they feel
better, or only take it occasionally because they forget
or don't think taking it regularly is important. It is very
important for people with schizophrenia to take their medication
on a regular basis and for as long as their doctors recommend.
If they do so, they will experience fewer psychotic symptoms.
No antipsychotic medication should be discontinued without
talking to the doctor who prescribed it, and it should always
be tapered off under a doctor's supervision rather than being
stopped all at once.
There are a variety of reasons why people with schizophrenia
do not adhere to treatment. If they don't believe they are
ill, they may not think they need medication at all. If their
thinking is too disorganized, they may not remember to take
their medication every day. If they don't like the side effects
of one medication, they may stop taking it without trying
a different medication. Substance abuse can also interfere
with treatment effectiveness. Doctors should ask patients
how often they take their medication and be sensitive to
a patient's request to change dosages or to try new medications
to eliminate unwelcome side effects.
There are many strategies to help people with schizophrenia
take their drugs regularly. Some medications are available
in long-acting, injectable forms, which eliminate the need
to take a pill every day. Medication calendars or pillboxes
labeled with the days of the week can both help patients
remember to take their medications and let caregivers know
whether medication has been taken. Electronic timers on clocks
or watches can be programmed to beep when people need to
take their pills, and pairing medication with routine daily
events, like meals, can help patients adhere to dosing schedules.
Medication
Interactions. Antipsychotic medications can produce
unpleasant or dangerous side effects when taken with certain
other drugs. For this reason, the doctor who prescribes the
antipsychotics should be told about all medications (over-the-counter
and prescription) and all vitamins, minerals, and herbal
supplements the patient takes. Alcohol or other drug use
should also be discussed.
Psychosocial treatment
Numerous
studies have found that psychosocial treatments can help
patients who are already stabilized on antipsychotic medications
deal with certain aspects of schizophrenia, such as difficulty
with communication, motivation, self-care, work, and establishing
and maintaining relationships with others. Learning and using
coping mechanisms to address these problems allows people
with schizophrenia to attend school, work, and socialize.
Patients who receive regular psychosocial treatment also
adhere better to their medication schedule and have fewer
relapses and hospitalizations. A positive relationship with
a therapist or a case manager gives the patient a reliable
source of information, sympathy, encouragement, and hope,
all of which are essential for for managing the disease.
The therapist can help patients better understand and adjust
to living with schizophrenia by educating them about the
causes of the disorder, common symptoms or problems they
may experience, and the importance of staying on medications.
Illness Management
Skills. People with schizophrenia can
take an active role in managing their own illness. Once they
learn basic facts about schizophrenia and the principles
of schizophrenia treatment, they can make informed decisions
about their care. If they are taught how to monitor the early
warning signs of relapse and make a plan to respond to these
signs, they can learn to prevent relapses. Patients can also
be taught more effective coping skills to deal with persistent
symptoms.
Integrated
Treatment for Co-occurring Substance Abuse. Substance
abuse is the most common co-occurring disorder in people
with schizophrenia, but ordinary substance abuse treatment
programs usually do not address this population's special
needs. Integrating schizophrenia treatment programs and drug
treatment programs produces better outcomes.
Rehabilitation. Rehabilitation emphasizes social and vocational
training to help people with schizophrenia function more
effectively in their communities. Because people with schizophrenia
frequently become ill during the critical career-forming
years of life (ages 18 to 35) and because the disease often
interferes with normal cognitive functioning, most patients
do not receive the training required for skilled work. Rehabilitation
programs can include vocational counseling, job training,
money management counseling, assistance in learning to use
public transportation, and opportunities to practice social
and workplace communication skills.
Family Education. Patients with schizophrenia are often
discharged from the hospital into the care of their families,
so it is important that family members know as much as possible
about the disease to prevent relapses. Family members should
be able to use different kinds of treatment adherence programs
and have an arsenal of coping strategies and problem-solving
skills to manage their ill relative effectively. Knowing
where to find outpatient and family services that support
people with schizophrenia and their caregivers is also valuable.
Cognitive
Behavioral Therapy. Cognitive behavioral therapy is useful for patients with
symptoms that persist even when they take medication. The
cognitive therapist teaches people with schizophrenia how
to test the reality of their thoughts and perceptions,
how to "not listen" to their voices,
and how to shake off the apathy that often immobilizes them.
This treatment appears to be effective in reducing the severity
of symptoms and decreasing the risk of relapse.
Self-Help
Groups. Self-help groups for people with schizophrenia
and their families are becoming increasingly common. Although
professional therapists are not involved, the group members
are a continuing source of mutual support and comfort for
each other, which is also therapeutic. People in self-help
groups know that others are facing the same problems they
face and no longer feel isolated by their illness or the
illness of their loved one. The networking that takes place
in self-help groups can also generate social action. Families
working together can advocate for research and more hospital
and community treatment programs, and patients acting as
a group may be able to draw public attention to the discriminations
many people with mental illnesses still face in today's world.
Support groups and advocacy groups are excellent resources
for people with many types of mental disorders.
What
is the role of the patient’s
support system?
Support for those with mental disorders can
come from families, professional residential or day program
caregivers, shelter operators, friends or roommates, professional
case managers, or others in their communities or places of
worship who are concerned about their welfare. There are
many situations in which people with schizophrenia will need
help from other people.
Getting Treatment. People with schizophrenia often resist
treatment, believing that their delusions or hallucinations
are real and psychiatric help is not required. If a crisis
occurs, family and friends may need to take action to keep
their loved one safe.
The issue of civil rights enters into any attempt to provide
treatment. Laws protecting patients from involuntary commitment
have become very strict, and trying to get help for someone
who is mentally ill can be frustrating. These laws vary from
state to state, but, generally, when people are dangerous
to themselves or others because of mental illness and refuse
to seek treatment, family members or friends may have to
call the police to transport them to the hospital. In the
emergency room, a mental health professional will assess
the patient and determine whether a voluntary or involuntary
admission is needed.
A person with mental illness who does not want treatment
may hide strange behavior or ideas from a professional; therefore,
family members and friends should ask to speak privately
with the person conducting the patient's examination and
explain what has been happening at home. The professional
will then be able to question the patient and hear the patient's
distorted thinking for themselves. Professionals must personally
witness bizarre behavior and hear delusional thoughts before
they can legally recommend commitment, and family and friends
can give them the information they need to do so.
Caregiving. Ensuring that people with schizophrenia continue
to get treatment and take their medication after they leave
the hospital is also important. If patients stop taking their
medication or stop going for follow-up appointments, their
psychotic symptoms will return. If these symptoms become
severe, they may become unable to care for their own basic
needs for food, clothing, and shelter; they may neglect personal
hygiene; and they may end up on the street or in jail, where
they rarely receive the kind of help they need.
Family and friends can also help patients set realistic
goals and regain their ability to function in the world.
Each step toward these goals should be small enough to be
attainable, and the patient should pursue them in an atmosphere
of support. People with a mental illness who are pressured
and criticized usually regress and their symptoms worsen.
Telling them what they are doing right is the best way to
help them move forward.
How should you respond when someone with schizophrenia makes
statements that are strange or clearly false? Because these
bizarre beliefs or hallucinations are real to the patient,
it will not be useful to say they are wrong or imaginary.
Going along with the delusions will not be helpful, either.
It is best to calmly say that you see things differently
than the patient does but that you acknowledge that everyone
has the right to see things in his or her own way. Being
respectful, supportive, and kind without tolerating dangerous
or inappropriate behavior is the most helpful way to approach
people with this disorder.
What is the outlook for the future?
The outlook for people with schizophrenia has improved over
the last 30 years or so. Although there still is no cure,
effective treatments have been developed, and many people
with schizophrenia improve enough to lead independent, satisfying
lives.
This is an exciting time for schizophrenia research. The
explosion of knowledge in genetics, neuroscience, and behavioral
research will enable a better understanding of the causes
of the disorder, how to prevent it, and how to develop better
treatments to allow those with schizophrenia to achieve their
full potential. |
