Schizophrenia

Schizophrenia is a serious mental illness that interferes with a person’s ability to think clearly, manage emotions, make decisions and relate to others. It is a complex, long-term medical illness, affecting about 1% of Americans. Although schizophrenia can occur at any age, the average age of onset tends to be in the late teens to the early 20s for men, and the late 20s to early 30s for women. It is uncommon for schizophrenia to be diagnosed in a person younger than 12 or older than 40. It is possible to live well with schizophrenia.

Symptoms

It can be difficult to diagnose schizophrenia in teens. This is because the first signs can include a change of friends, a drop in grades, sleep problems, and irritability—common and nonspecific adolescent behavior. Other factors include isolating oneself and withdrawing from others, an increase in unusual thoughts and suspicions, and a family history of psychosis. In young people who develop schizophrenia, this stage of the disorder is called the “prodromal” period.

With any condition, it’s essential to get a comprehensive medical evaluation in order to obtain the best diagnosis. For a diagnosis of schizophrenia, some of the following symptoms are present in the context of reduced functioning for a least 6 months:

Hallucinations. These include a person hearing voices, seeing things, or smelling things others can’t perceive. The hallucination is very real to the person experiencing it, and it may be very confusing for a loved one to witness. The voices in the hallucination can be critical or threatening. Voices may involve people that are known or unknown to the person hearing them.

Delusions. These are false beliefs that don’t change even when the person who holds them is presented with new ideas or facts. People who have delusions often also have problems concentrating, confused thinking, or the sense that their thoughts are blocked.

Negative symptoms are ones that diminish a person’s abilities. Negative symptoms often include being emotionally flat or speaking in a dull, disconnected way. People with the negative symptoms may be unable to start or follow through with activities, show little interest in life, or sustain relationships. Negative symptoms are sometimes confused with clinical depression.

Cognitive issues/disorganized thinking. People with the cognitive symptoms of schizophrenia often struggle to remember things, organize their thoughts or complete tasks. Commonly, people with schizophrenia have anosognosia or “lack of insight.” This means the person is unaware that he has the illness, which can make treating or working with him much more challenging.

Causes

Research suggests that schizophrenia may have several possible causes:

  • Genetics. Schizophrenia isn’t caused by just one genetic variation, but a complex interplay of genetics and environmental influences. While schizophrenia occurs in 1% of the general population, having a history of family psychosis greatly increases the risk. Schizophrenia occurs at roughly 10% of people who have a first-degree relative with the disorder, such as a parent or sibling. The highest risk occurs when an identical twin is diagnosed with schizophrenia. The unaffected twin has a roughly 50% chance of developing the disorder.
  • Environment. Exposure to viruses or malnutrition before birth, particularly in the first and second trimesters has been shown to increase the risk of schizophrenia. Inflammation or autoimmune diseases can also lead to increased immune system
  • Brain chemistry. Problems with certain brain chemicals, including neurotransmitters called dopamine and glutamate, may contribute to schizophrenia. Neurotransmitters allow brain cells to communicate with each other. Networks of neurons are likely involved as well.
  • Substance use. Some studies have suggested that taking mind-altering drugs during teen years and young adulthood can increase the risk of schizophrenia. A growing body of evidence indicates that smoking marijuana increases the risk of psychotic incidents and the risk of ongoing psychotic experiences. The younger and more frequent the use, the greater the risk. Another study has found that smoking marijuana led to earlier onset of schizophrenia and often preceded the manifestation of the illness.

Diagnosis

Diagnosing schizophrenia is not easy. Sometimes using drugs, such as methamphetamines or LSD, can cause a person to have schizophrenia-like symptoms. The difficulty of diagnosing this illness is compounded by the fact that many people who are diagnosed do not believe they have it. Lack of awareness is a common symptom of people diagnosed with schizophrenia and greatly complicates treatment.

While there is no single physical or lab test that can diagnosis schizophrenia, a health care provider who evaluates the symptoms and the course of a person’s illness over six months can help ensure a correct diagnosis. The health care provider must rule out other factors such as brain tumors, possible medical conditions and other psychiatric diagnoses, such as bipolar disorder.

To be diagnosed with schizophrenia, a person must have two or more of the following symptoms occurring persistently in the context of reduced functioning:

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Disorganized or catatonic behavior
  • Negative symptoms

Delusions or hallucinations alone can often be enough to lead to a diagnosis of schizophrenia. Identifying it as early as possible greatly improves a person’s chances of managing the illness, reducing psychotic episodes, and recovering. People who receive good care during their first psychotic episode are admitted to the hospital less often, and may require less time to control symptoms than those who don’t receive immediate help. The literature on the role of medicines early in treatment is evolving, but we do know that psychotherapy is essential.

People can describe symptoms in a variety of ways. How a person describes symptoms often depends on the cultural lens she is looking through. African Americans and Latinos are more likely to be misdiagnosed, probably due to differing cultural or religious beliefs or language barriers. Any person who has been diagnosed with schizophrenia should try to work with a health care professional that understands his or her cultural background and shares the same expectations for treatment.

Treatment

With medication, psychosocial rehabilitation, and family support, the symptoms of schizophrenia can be reduced. People with schizophrenia should get treatment as soon as the illness starts showing, because early detection can reduce the severity of their symptoms.

Recovery while living with schizophrenia is often seen over time, and involves a variety of factors including self-learning, peer support, school and work and finding the right supports and treatment.

Medication

Typically, a health care provider will prescribe antipsychotics to relieve symptoms of psychosis, such as delusions and hallucinations. Due to lack of awareness of having an illness and the serious side effects of medication used to treat schizophrenia, people who have been prescribed them are often hesitant to take them.

First Generation (Typical) Antipsychotics

These medications can cause serious movement problems that can be short (dystonia) or long term (called tardive dyskinesia), and also muscle stiffness. Other side effects can also occur.

  • Chlorpromazine (Thorazine)
  • Fluphenazine (Proxlixin)
  • Haloperidol (Haldol)
  • Loxapine (Loxitane)
  • Perphenazine (Trilafon)
  • Thiothixene (Navane)
  • Trifluoperazine (Stelazine)

Second Generation (Atypical) Antipsychotics

These medications are called atypical because they are less likely to block dopamine and cause movement disorders. They do, however, increase the risk of weight gain and diabetes. Changes in nutrition and exercise, and possibly medication intervention, can help address these side effects.

  • Aripiprazole (Abilify)
  • Asenapine (Saphris)
  • Clozapine (Clozaril)
  • Iloperidone (Fanapt)
  • Lurasidone (Latuda)
  • Olanzapine (Zyprexa)
  • Paliperidone (Invega)
  • Risperidone (Risperdal)
  • Quetiapine (Seroquel)
  • Ziprasidone (Geodon)

One unique second generation antipsychotic medication is called clozapine. It is the only FDA approved antipsychotic medication for the treatment of refractory schizophrenia and has been the only one indicated to reduce thoughts of suicide. However, it does have multiple medical risks in addition to these benefits. Read a more complete discussion of these risk and benefits.

Psychotherapy

Cognitive behavioral therapy (CBT) is an effective treatment for some people with affective disorders. With more serious conditions, including those with psychosis, additional cognitive therapy is added to basic CBT (CBTp). CBTp helps people develop coping strategies for persistent symptoms that do not respond to medicine.

Supportive psychotherapy is used to help a person process his experience and to support him in coping while living with schizophrenia. It is not designed to uncover childhood experiences or activate traumatic experiences, but is rather focused on the here and now.

Cognitive Enhancement Therapy (CET) works to promote cognitive functioning and confidence in one’s cognitive ability. CET involves a combination of computer based brain training and group sessions. This is an active area of research in the field at this time.

Psychosocial Treatments

People who engage in therapeutic interventions often see improvement, and experience greater mental stability. Psychosocial treatments enable people to compensate for or eliminate the barriers caused by their schizophrenia and learn to live successfully. If a person participates in psychosocial rehabilitation, she is more likely to continue taking their medication and less likely to relapse. Some of the more common psychosocial treatments include:

  • Assertive Community Treatment (ACT) provides comprehensive treatment for people with serious mental illnesses, such as schizophrenia. Unlike other community-based programs that connect people with mental health or other services, ACT provides highly individualized services directly to people with mental illness. Professionals work with people with schizophrenia and help them meet the challenges of daily life. ACT professionals also address problems proactively, prevent crises, and ensure medications are taken.
  • Peer support groups like NAMI Peer-to-Peer encourage people’s involvement in their recovery by helping them work on social skills with others.

Complementary Health Approaches

Omega-3 fatty acids, commonly found in fish oil, have shown some promise for treating and managing schizophrenia. Some researchers believe that omega-3 may help treat mental illness because of its ability to help replenish neurons and connections in affected areas of the brain.

Additional Concerns

Physical Health. People with schizophrenia are subject to many medical risks, including diabetes and cardiovascular problems, and also smoking and lung disease. For this reason, coordinated and active attention to medical risks is essential.

Substance Abuse. About 25% of people with schizophrenia also abuse substances such as drugs or alcohol. Substance abuse can make the treatments for schizophrenia less effective, make people less likely to follow their treatment plans, and even worsen their symptoms.