Schizophrenia: Understanding the Mental Illness

Young Asian woman talks in support group
 Steve Debenport/istock

Schizophrenia is a type of mental illness that affects how the brain works. This leads to chronic problems with strange thoughts and behaviors. It usually requires lifelong care and treatment.

Researchers estimate that schizophrenia affects approximately 0.3 percent to 0.7 percent of people (between 3 in 1000 and 7 in 1000). Schizophrenia affects people from all racial backgrounds and ethnicities. Schizophrenia is slightly more common in men compared to women.

Causes

The causes of schizophrenia are complex and not completely understood. Genetics seem to play a role. You are more likely to have schizophrenia if you inherited variations of certain genes (portions of DNA) from your parents. People who have a relative with schizophrenia have a somewhat increased risk of also having schizophrenia or a related disorder, like schizoaffective disorder. Identical twins (who share identical DNA) are more likely to have schizophrenia than fraternal twins (who do not). This implies that genetics play a role in triggering schizophrenia, probably through several different genes.

However, this is only one part of the picture. Schizophrenia can occur in people who have no history of it in their family. And just because you have schizophrenia in your family, doesn’t mean you will have it yourself.

Various environmental factors have been linked to increased risk of schizophrenia.

 Some of these include:

  • Obstetric complications at your birth
  • Infection of the central nervous system in early childhood
  • Childhood trauma
  • Social stressors, like economic adversity

However, many people with schizophrenia have none of these risk factors. Schizophrenia probably emerges as a complex result of a variety of genetic, environmental, social, and psychological factors that are not yet well understood.

Symptoms

Two of the major categories of schizophrenia symptoms are “positive” or “negative” symptoms. This doesn’t refer to whether these symptoms are good or bad. Positive symptoms simply refer to active problems that shouldn’t be present (like hallucinations). On the other hand, negative symptoms refer to the absence of specific characteristics that a healthy human being should have. More people tend to be familiar with the positive symptoms of schizophrenia, which are generally more obvious. But both positive and negative symptoms constitute real and difficult problems in schizophrenia.

Some of the positive symptoms of schizophrenia include:

During a hallucination, a person hears, sees, feels, or smells something that is not actually present. Most often this occurs in the form of hearing voices that others do not hear. These voices may be reassuring, threatening, or anything in between. Sometimes a person experiences these only as intrusive thoughts, but often they seem to come from outside the self.

Delusions are false beliefs held by a person that are not shared by other people. Someone with a delusion has a very fixed view of a situation and cannot be talked out of it with reason.

For example, someone with schizophrenia might believe he is the subject of a government conspiracy, or that aliens are trying to monitor his activities.

People with disorganized speech may be difficult to understand because their sentences are unconnected or because the person is frequently switching topics in a way that doesn’t make sense to the listener. However, the speech may have meaning for the individual in a way that is connected to their internal experience.

On the other hand, negative symptoms of schizophrenia can include:

    People may also have additional cognitive symptoms like problems concentrating, remembering, or planning activities. People with schizophrenia may also have poor self-care and poor interpersonal, school, or career functioning. The illness also make it more challenging for the individual to join in social events and participate in meaningful relationships.

    Symptoms may have periods of worsening and periods of improvement. Periods of worsening symptoms are called flares or relapses. With treatment, most of these symptoms may diminish or go away (especially "positive" symptoms). Disease remission refers to periods of six months or longer in which a person experiences no symptoms or only mild symptoms. On the whole, negative symptoms tend to be harder to treat than positive ones.

    In the traditional biomedical model of schizophrenia, these symptoms are purely pathological. However, people in the hearing voices movement argue that hearing voices is sometimes a meaningful human experience, and that it shouldn't be seen purely as a sign of illness. 

    When Do Symptoms of Schizophrenia First Start to Appear?

    The early symptoms of schizophrenia often start to appear gradually and then become more severe and obvious to others. Typically, symptoms of schizophrenia first appear some time between adolescence and a person’s mid-30s. However, sometimes symptoms appear earlier or later. In women, symptoms tend to begin at a later age than in men.

    Brain Changes in Schizophrenia

    There is still much that scientists are learning about how brain changes lead to the symptoms of schizophrenia. Schizophrenia is also associated with a number of alterations in how the brain functions. These brain changes reflect the specific symptoms of the disease. Alterations are found both in the brain’s gray matter (containing mostly nerve cell bodies) and white matter (containing mostly axons). The following are some of the brain regions thought to have disordered functioning in schizophrenia:

    • Medial temporal lobe (causing problems with working memory)
    • Superior temporal lobe (causing problems processing auditory information)
    • Prefrontal lobe (causing problems with decision making and inhibition)

    Schizophrenia also probably results from disrupted connectivity between certain areas of the brain. Changes in neurotransmitters (signaling molecules in the brain) probably also play a role in the disease.

    Diagnosis 

    There isn’t a simple blood test or brain scan that health providers can use to diagnose schizophrenia. Instead, health providers must assess a person’s symptoms and rule out other medical conditions. To diagnose schizophrenia, a physician takes a thorough medical history and performs a medical exam. A clinician will need to rule out other psychiatric conditions that can cause hallucinations or delusions. People with schizoaffective disorder, for instance, have many of the same symptoms of schizophrenia, but they also have specific problems with their mood and emotions. 

    Physicians also need to rule out other medical conditions that can cause some similar symptoms to schizophrenia. Some of these include:

    • Substance-related disorders
    • Dementia
    • Endocrine and inflammatory conditions
    • Brain tumor
    • Delirium

    In some cases, an individual might need additional tests to rule out other conditions like these.

    The time period of symptoms is also important in diagnosis. To be diagnosed with schizophrenia, a person must display at least a six-month period of symptoms. A person who has had symptoms for less than a month might be diagnosed with something called brief psychotic disorder. Someone who has had symptoms for more than a month but less than six months might be diagnosed with something called schizophreniform disorder. Sometimes people with these conditions have persistent symptoms and are later officially diagnosed with schizophrenia.

    Subtypes 

    You may have heard of various types of schizophrenia, such as paranoid schizophrenia or catatonic schizophrenia. Mental health providers used to diagnose people with these different subtypes based on their different symptoms. However, in 2013, psychiatrists decided to stop classifying people with schizophrenia in this way. They concluded that these categories didn’t really help them understand schizophrenia any better and they didn’t help clinicians provide better care to patients. 

    Treatment

    Ideally, treatment for schizophrenia combines a multidisciplinary approach from a collaborative team of health professionals. Early treatment can help improve the chances of a fuller recovery.

    Elements of treatment should include:

    • Psychiatric medication
    • Psychological treatment
    • Social support

    Many people with schizophrenia will need to initially be hospitalized for psychiatric treatment so that doctors can stabilize their condition.

    Psychiatric Medications

    Antipsychotic medications form a very important part of treatment for schizophrenia. These medications help reduce the symptoms of schizophrenia and help prevent relapse. First generation anti-psychotic medications describe a class of drugs that were developed in the 1950s. These are also called typical antipsychotics. Some of these include:

    • haloperidol (HaldolTM)
    • chlorpromazine (ThorazineTM)

    This group of antipsychotics tend to have similar side effects like problems with movement (known as extrapyramidal symptoms), drowsiness, and dry mouth.

    Scientists later developed a newer groups of antipsychotics, often called second generation antipsychotics or atypical antipsychotics. Some of these antipsychotic drugs include the following:

    • aripiprazole (AbilifyTM)
    • clozapine (ClozarilTM)
    • olazapine (ZyprexaTM)
    • quetiapine (SeroquelTM)

    These drugs don’t usually cause the movement problems of typical anti-psychotic drugs. However, they are more likely to cause weight gain and other problems with metabolism, among other side effects.

    Support

    Increasingly, mental health providers are realizing the important role of psycho-social treatment in addressing schizophrenia. For example, various forms of psychotherapy can be very helpful. One form of psychotherapy called cognitive behavioral therapy helps patients learn to identify and change their dysfunctional emotions, behaviors, and thoughts. Family therapy can also help both patients and family members learn better how to cope with the condition. Many people with schizophrenia also need social skills training, which can help teach basic self-care and social skills. Support groups can also be helpful, both for people with the condition and for family members. People with schizophrenia may also need help finding work, housing, or certain other types of assistance.

    Prognosis

    The goal of treatment is to help patients achieve remission. Some people have long periods of remission with quite stable disease and minimal impairment. Other people have worsening symptoms and functioning and do not have a good response to available therapies. It is hard to know how a specific person will do after diagnosis. But the outlook for people with schizophrenia has improved over recent years, with better psychiatric medications and more comprehensive psychological and social support. 

    Unfortunately, people with schizophrenia have a much higher risk of suicide than people without the disorder. But this risk can be reduced if affected individuals receive high quality treatment and keep taking the medications that they need. People with schizophrenia also have a higher risk of certain other medical conditions, like cardiovascular and respiratory diseases. Additionally, people with schizophrenia also have a higher risk of certain other psychiatric problems, like substance-related disorders, panic disorder, and obsessive compulsive disorder.

    Most people will continue to need some form of support after their diagnosis. However, many people are able to live independently and actively participate in building their lives.

    A Word From Verywell

    Schizophrenia is often a difficult illness to fully treat, but there is hope. Through multifaceted and consistent treatment, many individuals diagnosed with schizophrenia can recover from many disease symptoms. People with schizophrenia need support from their family and community members to have the best chance of living full and active lives. If you or your family member has been diagnosed with schizophrenia, know that it isn’t your fault. Also know that there are many people to help affected individuals recover and regain control of their lives.

    Sources:

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    Holder SD, Wayhs A. Schizophrenia. Am Fam Physician. 2014;90(11):775-82.

    Karlsgodt KH, Sun D, Cannon TD. Structural and functional brain abnormalities in schizophrenia. Current directions in psychological science. 2010;19(4):226-231. doi:10.1177/0963721410377601.

    Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: overview and treatment optionsPharmacy and Therapeutics. 2014;39(9):638-645.

    Tandon R. Schizophrenia and Other Psychotic Disorders in Diagnostic and Statistical Manual of Mental Disorders (DSM)-5: Clinical Implications of Revisions from DSM-IV. Indian Journal of Psychological Medicine. 2014;36(3):223-225. doi:10.4103/0253-7176.135365.