Schizophrenia Overview

In memory of a dear friend whom I haven't seen for 20 years


The term "schizophrenia" refers to one of the most debilitating and
baffling mental illnesses known. Though it has a specific set of
symptoms, this illness varies in its severity from individual to
individual, and even within any one afflicted individual from one
time period to another.

Schizophrenia generally can be controlled with treatment and, in
more than 50 percent of individuals given access to continuous
treatment and rehabilitation over many years, recovery is often
possible. Though researchers and mental health professionals
don't know what causes the disorder, they have developed
treatments that allow most persons with schizophrenia to work,
live with their families and enjoy friends. But like those with
diabetes, people with schizophrenia probably will be under medical
care for the rest of their lives.

Symptoms

Generally, schizophrenia begins during adolescence or young
adulthood. Its symptoms appear gradually and family and friends
may not notice them as the illness takes initial hold. Often, the
young man or woman feels tense, can't concentrate or sleep, and
withdraws socially. But at some point, loved ones realize the
patient's personality has changed. Work performance, appearance
and social relationships may begin to deteriorate.

As the illness progresses, the symptoms often become more
bizarre. The patient develops peculiar behavior, begins talking in
nonsense, and has unusual perceptions. This is the beginning of
psychosis. Psychiatrists diagnose schizophrenia when a patient has
had active symptoms of the illness (such as a psychotic episode)
for at least two weeks, with other symptoms lasting six months. In
many cases, patients experience psychotic symptoms for many
months before seeking help. Schizophrenia seems to worsen and
become better in cycles known as relapse and remission,
respectively. At times, people suffering from schizophrenia
appear relatively normal. However, during the acute or psychotic
phase, people with schizophrenia cannot think logically and may
lose all sense of who they and others are. They suffer from
delusions, hallucinations or disordered thinking and speech.

Delusions are thoughts that are fragmented, bizarre and have no
basis in reality. For example, people suffering from schizophrenia
might believe that someone is spying on or planning to harm them
or that someone can "hear" their thoughts, insert thoughts into
their minds, or control their feelings, actions or impulses. Patients
might believe they are Jesus, or that they have unusual powers
and abilities.

People suffering from schizophrenia also have hallucinations. The
most common hallucination in schizophrenia is hearing voices that
comment on the patient's behavior, insult the patient or give
commands. Visual hallucinations,such as seeing nonexistent
things, and tactile hallucinations, such as a burning or itching
sensation, also can occur.

Patients also suffer disordered thinking in which the associations
among their thoughts are very loose. They may shift from one
topic to another completely unrelated topic without realizing they
are making no logical sense. They may substitute sounds or
rhymes for words or make up their own words, which have no
meaning to others.

These symptoms don't mean people with schizophrenia are
completely out of touch with reality. They know, for example, that
people eat three times a day, sleep at night and use the streets for
driving vehicles. For that reason, their behavior may appear quite
normal much of the time.

However, their illness does severely distort their ability to know
whether an event or situation they perceive is real. A person with
schizophrenia waiting for a green light at a crosswalk doesn't
know how to react when he hears a voice say, "You really smell
bad." Is that a real voice, spoken by the jogger standing next to
him, or is it only in his head? Is it real or a hallucination when he
sees blood pouring from the side of the person next to him in a
college classroom? This uncertainty adds to the terror already
created by the distorted perceptions.

Psychotic symptoms of schizophrenia may lessen--a period during
which doctors say the patient is in the residual stage or remission.
Other symptoms, such as social withdrawal, inappropriate or
blunted emotions, and extreme apathy, may continue during both
these periods of remission and periods when psychosis returns--a
period called relapse, and may persist for years. People with
schizophrenia who are in remission still may not be mentally able
to bathe or dress appropriately. They may speak in a monotone
and report that they have no emotions at all. They appear to
others as strange, disconcerting people who have odd speech
habits and who live socially marginal lives.

There are many types of schizophrenia. For example, a person
whose symptoms are most often colored by feelings of
persecution is said to have "paranoid schizophrenia;" a person
who is often incoherent but has no delusions is said to have
"disorganized schizophrenia." Even more disabling than the
delusions and hallucinations are the symptoms of "negative" or
"deficit" schizophrenia. Negative or deficit schizophrenia refers to
the lack or absence of initiative, motivation, social interest,
enjoyment and emotional responsiveness. Because schizophrenia
can vary from person to person in intensity, severity and
frequency of both psychotic and residual symptoms, many
scientists use the word "schizophrenia" to describe a spectrum of
illnesses that range from relatively mild to severe. Others think of
schizophrenia as a group of related disorders, much as "cancer"
describes many different but related illnesses.

Some Numbers

Schizophrenia affects men and women equally, however its onset
in women is typically five years later than with men. About 150 of
every 100,000 persons will develop schizophrenia. Though it is a
relatively rare illness, its early age of onset and the lifelong
disability, emotional and financial devastation it brings to its
victims and their families make schizophrenia one of the most
catastrophic mental illnesses. Schizophrenia fills more hospital
beds than almost any other illness, and Federal figures reflect the
cost of schizophrenia to be from $30 billion to $48 billion in direct
medical costs, lost productivity and Social Security pensions.

Theories About Causes

Theories about the causes of schizophrenia abound, but research
hasn't pinpointed the origins.

In years past, psychiatric researchers theorized that schizophrenia
arose from bad parenting. A cold, distant and unfeeling mother
was called "schizophrenigenic" because it was believed that such
a mother could, through inadequate care, cause the symptoms of
schizophrenia. This theory has been discredited today.

Most scientists now suspect that people inherit a susceptibility to
the illness, which can be triggered by environmental events such
as a viral infection that changes the body's chemistry, a highly
stressful situation in adult life, or a combination of these.

While scientists have long known that the illness runs in families
and much recent research evidence supports the linking of
schizophrenia to heredity. For example, studies show that children
with one parent suffering from schizophrenia have an eight to 18
percent chance of developing the illness, even if they were
adopted by mentally healthy parents. If both parents suffer from
schizophrenia, the risk rises to between 15 and 50 percent.
Children whose biological parents are mentally healthy but whose
adoptive parentssuffer from schizophrenia have a one percent
chance of developing the disease, the same rate as the general
population.

Moreover, if one identical twin suffers from schizophrenia, there
is a 50 to 60 percent chance that the sibling--who has identical
genetic make-up also has schizophrenia.

But people don't inherit schizophrenia directly, as they inherit the
color of their eyes or hair. Like many genetically related illnesses,
schizophrenia appears when the body is undergoing the hormonal
and physicalchanges of adolescence. Genes govern the brain's
structure and biochemistry. Because structure and biochemistry
change dramatically in teen and young adult years, some
researchers suggest that schizophrenia lies "dormant" during
childhood. It emerges as the body and brain undergo changes
during puberty.

Certain genetic combinations could mean a person doesn't
produce a certain enzyme or other biochemical, and that
deficiency produces illnesses ranging from cystic fibrosis to,
possibly, diabetes. Other genetic combinationscould mean that
specific nerves don't develop correctly or completely, giving rise
to genetic deafness. Similarly, a genetically determined sensitivity
could mean the brain of a person with schizophrenia is more
prone to be affected by certain biochemicals, or that it produces
inadequate or excessive amounts of biochemicals needed to
maintain mental health. Genetically determined triggers could also
the development of part of the brain of a person with
schizophrenia, or could cause problems with the way the person's
brain screens stimuli, so that the person with schizophrenia is
overwhelmed by sensory information which normal people can
easily handle.

These theories arise from the ability of researchers to see the
structure and activity of the brain through very sophisticated
medical technology. For example:

Using computer images of brain activity, scientists have
learned that a part of the brain called the prefrontal
cortex--which governs thought and higher mental
functions--"lights up" when healthy people are given an
analytical task. This area of the brain remains quiet in
those with schizophrenia who are given the same task.
Magnetic resonance imaging (MRI) and other techniques
have suggested that the neural connections and circuits
between the temporal lobe structures and the prefrontal
cortex may be have an abnormal structure or may function
abnormally. 

The prefrontal cortex in the brains of some schizophrenia
sufferers appears to have either atrophied or developed
abnormally. 
Computed axial tomography or CAT scans have shown
subtle abnormalities in the brains of some people suffering
from schizophrenia. The ventricles--the fluid-filled spaces
within the brain--are larger in the brains of some people
with schizophrenia. 
Successful use of medications that interfere with the
brain's production of a biochemical called dopamine
indicates that the brains of those with schizophrenia are
either extraordinarily sensitive to dopamine or produce too
much dopamine. This theory is strengthened by observing
treatment for Parkinson's disease, caused by too little
dopamine. Parkinson's patients, who are treated with
medication that helps increase the amount of dopamine,
may also develop psychotic symptoms. 

Schizophrenia is similar in several respects to "autoimmune"
illnesses -disorders like multiple sclerosis (MS) and amyotrophic
lateral sclerosis (ALS or Lou Gherig's disease), caused when the
body's immune systemattacks itself. Like the autoimmune
diseases, schizophrenia is not present at birth but develops during
adolescence or young adulthood. It comes and goes in cycles of
remission and relapse, and it runs in families. Because of these
similarities, scientists suspect schizophrenia could fall into the
autoimmune category.

Some scientists think genetics, autoimmune illness and viral
infections combine to cause schizophrenia. Genes determine the
body's immune reaction to viral infection. Instead of stopping
when the infection is over, the genes tell the body's immune
system to continue its attack on a specific part of the body. This is
similar to the theories about arthritis, in which the immune system
is thought to attack the joints.

The genes of people with schizophrenia may tell the immune
system to attack the brain after a viral infection. This theory is
supported by the discovery that the blood of people with
schizophrenia contains antibodies--immune system cells--specific
to the brain. Moreover, researchers in a National Institute of
Mental Health study found abnormal proteins in the fluid that
surrounds the brain and spinal cord in 30 percent of people with
schizophrenia but in none of the mentally healthy people they
studied. These same proteins are found in 90 percent of the
people who have suffered herpes simplex encephalitis, an
inflammation of the brain caused by the family of viruses that
causes warts and other illnesses.

Finally, some scientists suspect a viral infection during pregnancy.
Many people suffering from schizophrenia were born in late
winter or early spring. That timing means their mothers may have
suffered from a slow virus during the winter months of their
pregnancy. The virus could have infected the baby to produce
pathological changes over many years after birth. Coupled with a
genetic vulnerability, a virus could trigger schizophrenia.

Most psychiatrists today believe that the above--genetic
predisposition, environmental factors such as viral infection,
stressors from the environment such as poverty and emotional or
physical abuse--form a constellation of "stress factors" that should
be taken into account in understanding schizophrenia. An
unsupportive home or social environment and inadequate social
skills can bring on schizophrenia in those with genetic vulnerability
or cause relapse in those already suffering with the disease.
Psychiatrists also believe these stress factors can often be offset
with "protective factors" when the person with schizophrenia
receives proper maintenance doses of antipsychotic medication,
and help in creating a secure network of supportive family and
friends, in finding a steady and understanding place of
employment, and in learning necessary social and coping skills.

Treatments

Psychiatrists have found a number of antipsychotic medications
that help bring biochemical imbalances closer to normal. The
medications significantly reduce the hallucinations and delusions
and help the patient maintain coherent thoughts. Like all
medications, however, antipsychotic drugs should be taken only
under the close supervision of a psychiatrist or other physician.

Antipsychotic medications are important in reducing or eliminating
the chances of relapse. One study showed that 60 to 80 percent
of those who did not take medication as part of their treatment
had a relapse the first year after leaving the hospital. Between 20
and 50 percent of those who did take medication were
rehospitalized that first year; however, if the patients continued
taking medication beyond the first year, relapse rates fell to 10
percent.

Like virtually all other medications, antipsychotic agents have side
effects. While the patient's body adjusts to the medication during
the first few weeks, he or she may have to contend with dry
mouth, blurred vision, constipation and drowsiness. One may also
experience dizziness when standing up due to a drop in blood
pressure. These side effects usually disappear after a few weeks.

Other side effects include restlessness (which can resemble
anxiety), stiffness, tremor, and a dampening of accustomed
gestures and movements. Patients may feel muscle spasms or
cramps in the head or neck, restlessness, or a slowing and
stiffening of muscle activity in the face, body, arms and legs.
Though discomforting, these are not medically serious and are
reversible.

Because some other side effects may be more serious and not
fully reversible, anyone taking these medications should be closely
monitored by a psychiatrist. One such side effect is called tardive
dyskinesia (TD), a condition that affects 20 to 30 percent of
people taking antipsychotic drugs. TD is more common among
older patients.

It begins with small tongue tremors, facial tics and abnormal jaw
movements. These symptoms may progress into thrusting and
rolling of the tongue, lip licking and smacking, pouting, grimacing,
and chewing or sucking motions. Later, the patient may develop
spasmodic movements of the hands, feet, arms, legs, neck and
shoulders.

Most of these symptoms reach a plateau and do not become
progressively worse. TD is severe in less than 5 percent of its
victims. If medication is stopped, TD also fades away among 30
percent of all patients and in 90 percent of those younger than 40.
There is also evidence that TD subsides eventually, even in
patients who continue with medication. Despite the risk of TD,
many suffering with schizophrenia accept medication because it
so effectively ends the horrifying and painful psychoses brought
on by their illness. However, the unpleasant side effects of
antipsychotic medication also leads many patients to stop using
medication against the advice of their psychiatrist. The refusal of
patients with schizophrenia to comply with psychiatrists' treatment
recommendations is a serious challenge to those specializing in the
treatment of chronically mentally ill people. Psychiatrists treating
people with schizophrenia must often practice with tolerance and
flexibility to overcome this resistance.

There is also hope that the newer generations of antipsychotic
drugs now being introduced and under development will prove to
be a great help to people with schizophrenia that has been
resistant to treatment in the past, with fewer side effects and
greater effectiveness with schizophrenia's symptoms. Clozapine
and risperidone (the first approved by the U.S. Food and Drug
Administration and the second nearing approval) provide two
examples. Clozapine doesn't list TD as one of its side effects and
has helped many whose conditions were not substantially
improved by the older generation of neuroleptic medications. Use
of clozapine is restricted, however, by an expensive medical
monitoring system made necessary by the fact that the medicine
can cause agranulocytosis, a blood disorder that occurs in one to
two percent of patients who take it and which can prove fatal if it
is not observed. Risperidone may be safer than clozapine and
have fewer of its side effects, including agranulocytosis. By
ending or reducing the painful hallucinations, delusions and thought
disorders, medications allow a patient to gain benefit from
rehabilitation and counseling aimed at promoting the individual's
functioning in society. Social skills training, which can be provided
in group, family or individual sessions, is a structured and
educational approach to learning social relationship and
independent living skills. By using behavioral learning techniques,
such as coaching, modeling and positive reinforcement, skills
trainers have been successful in overcoming the cognitive deficits
that interfere with rehabilitation. Research studies show that
social skills training improves social adjustment and equips
patients with means of coping with stressors, thereby reducing
relapse rates by up to 50 percent.

Another type of learning-based treatment that has been
documented to reduce relapse rates is behaviorally oriented,
psychoeducational family therapy. Mental health professionals
recognize the important role families play in treatment and should
maintain open lines of communication with the families as
treatment evolves over time. Providing family members, including
the patient, with a better understanding of schizophrenia and its
treatment, while helping them to improve their communication and
problem-solving skills, is becoming a standard practice in many
psychiatric clinics and mental health centers. In one study, when
psychoeducational family therapy and social skills training were
combined, the relapse rate during the first year of treatment was
zero.

Psychiatric management and supervision of regular medication
use, social skills training, behavioral and psychoeducational family
therapy, and vocational rehabilitation must be delivered within the
context of a community support program. The key personnel in
community support programs are clinical case managers who are
experienced in linking the patient to needed services, assuring that
social services as well as medical and psychiatric treatment is
delivered, forming solid and supportive long-term
helpingrelationships with the patient, and advocating for patients'
needs when there is a crisis or problem.

When continuing treatment and supportive care is available in the
community, with a partnership of family, patient and professional
caregivers, patients can learn to control their symptoms, identify
early warning signs of relapse, develop a relapse prevention plan,
and succeed in vocational and social rehabilitation programs. For
the vast majority of persons with schizophrenia, the future is
bright with optimism--new and more effective medications are on
the horizon, neuroscientists are learning more and more about the
function of the brain and how it goes awry in schizophrenia, and
psychosocial rehabilitation programs are increasingly successful in
restoring functioning and quality of life.