Schizophrenia

Definition

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

Causes

Schizophrenia is a complex and puzzling illness. Even the experts in the field are not exactly sure what causes it. Some doctors think that the brain may not be able to process information correctly.

Genetic factors appear to play a role, as people who have family members with schizophrenia may be more likely to get the disease themselves. Some researchers believe that events in a person's environment may trigger schizophrenia. For example, problems during intrauterine development (infection) and birth may increase the risk for developing schizophrenia later in life.

Psychological and social factors may also play some role in its development. However, the level of social and familial support appears to influence the course of illness and may be protective against relapse.

There are 5 recognized types of schizophrenia: catatonic, paranoid, disorganized, undifferentiated, and residual. Features of schizophrenia include its typical onset before the age of 45, continuous presence of symptoms for 6 months or more, and deterioration from a prior level of social and occupational functioning.

People with schizophrenia may show a variety of symptoms. Usually the illness develops slowly over months or even years. At first, the symptoms may not be noticed. For example, people may feel tense, may have trouble sleeping, or have trouble concentrating. They become isolated and withdrawn, and they do not make or keep friends. As the illness progresses, psychotic symptoms develop:

• Delusions - false beliefs or thoughts with no basis in reality
• Hallucinations - hearing, seeing, or feeling things that are not there
• Disordered thinking - thoughts "jump" between completely unrelated topics (the person may talk nonsense)
• Catatonic behavior - bizarre motor behavior marked by a decrease in reactivity to the environment, or hyperactivity that is unrelated to stimulus
• Flat affect - an appearance or mood that shows no emotion

No single characteristic is present in all types of schizophrenia. The risk factors include a family history of schizophrenia. Schizophrenia is thought to affect about 1% of the population worldwide.

Schizophrenia appears to occur in equal rates among men and women, but women have a later onset. For this reason, males tend to account for more than half of patients in services with high proportions of young adults. Although the onset of schizophrenia is typically in young adulthood, cases of the disorder with a late onset (over 45 years) are known.

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

Symptoms

Catatonic type:

• Motor disturbances
• Stupor
• Negativism
• Rigidity
• Agitation
• Inability to take care of personal needs
• Decreased sensitivity to painful stimulus

Paranoid type:

• Delusional thoughts of persecution or of a grandiose nature
• Anxiety
• Anger
• Violence
• Argumentativeness

Disorganized type:

• Incoherence (not understandable)
• Regressive behavior
• Flat affect
• Delusions
• Hallucinations
• Inappropriate laughter
• Repetitive mannerisms
• Social withdrawal

Undifferentiated type: Patient may have symptoms of more than one subtype of schizophrenia.

Residual type: Prominent symptoms of the illness have abated, but some features - such as hallucinations and flat affect - may remain.

Exams and Tests

Because other diseases can also cause symptoms of psychosis, psychiatrists should make the final diagnosis. The diagnosis is made based on a thorough psychiatric interview of the person and family members. As yet, there are no defining medical tests for schizophrenia. The following factors may suggest a schizophrenia diagnosis, but do not confirm it:

• Developmental background
• Genetic and family history
• Changes from level of functioning prior to illness
• Course of illness and duration of symptoms
• Response to pharmacological therapy

CT scans of the head and other imaging techniques may identify some changes associated with schizophrenia in the research literature and may rule out other neurophysiological disorders.

Treatment

During an acute episode of schizophrenia, hospitalization is often required to promote safety, and to provide for the person's basic needs such as food, rest, and hygiene.

Antipsychotic or neuroleptic medications work by changing the balances of chemicals in the brain and are used to control the symptoms of the illness. These medications are effective, but are also associated with side effects that may discourage a patient from taking them regularly. However, many of these side effects can be addressed, and should not prevent people from seeking treatment for this serious condition.

Common side effects from traditional antipsychotics may include sedation and weight gain. Other side effects are known as extrapyramidal symptoms (muscle contractions, problems of movement and gait, and feelings of restlessness or "jitters").

Long-term risks include a movement disorder called tardive dyskinesia, which involves involuntary movements. Newer agents known as atypical antipsychotics, appear to have a somewhat safer regarding side effects. They also appear to help people who have not benefited from the older traditional medications. Ongoing treatment with medications is usually necessary to prevent a return of symptoms.

Supportive and problem-focused forms of psychotherapy may be helpful for many individuals. Behavioral techniques, such as social skills training, can be used in a therapeutic setting, or in the patient's natural environment to promote social and occupational functioning.

Family interventions that combine support and education about schizophrenia (psychoeducation) appear to help families cope and reduce relapse. Patients who lack family and social support may be helped by intensive case management programs that emphasize active outreach and linkage to a range of community support services.

Outlook (Prognosis)

There are many different potential outcomes of schizophrenia. Most people with schizophrenia find that their symptoms improve with medication, and some achieve substantial control of the symptoms over time. However, others experience functional disability and are at risk for repeated acute episodes, particularly during the early stages of the illness.

Supported housing, vocational rehabilitation, and other community support programs may be essential to their community tenure. People with the most severe forms of this disorder may remain too disabled to live independently, requiring group homes or other long-term, structured living environments.

Possible Complications

• Noncompliance with medication will frequently lead to a relapse of symptoms.
• Physical illness occurs at high rates among people with schizophrenia due to psychiatric treatment itself (side effects from medication) and living conditions associated with chronic disability. These may go undetected because of poor access to medical care and because of difficulties communicating with health care providers.
• Persons with schizophrenia have a high risk of developing a coexisting substance abuse problem, and use of alcohol or other drugs increases the risk of relapse.

When to Contact a Medical Professional

Call your health care provider if:

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

Prevention

The best way to prevent relapses is to continue to take the prescribed medication. Because side effects are one of the most important reasons why people with schizophrenia stop taking their medication, it is very important to find the medication that controls symptoms without causing side effects. Always talk to your doctor about any adjustments in your medications, or your wish to discontinue them

Rakel RE. Textbook of Family Practice. 6th ed. Philadelphia, Pa: WB Saunders; 2005:115-124.

Marx J. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002:1541-1548.