Schizophrenia was earlier known as dementia praecox. It was later renamed as schizophrenia by a Swiss psychiatrist Eugen Bleuler in 1911. It is derived from two Greek words, Schizein (to split) and Phren (mind).
Schizophrenia affects nearly 22 million people across the world, mostly in the age group of 15-35 years. In US, it afflicts approximately 2.5 million people. The disease generally starts between 15 to 25 years of age. The average age of onset of the disease is 18 years in men and 25 years in women. Schizophrenia effects rarely in children below 10 years and in men above 40 years.
Most patients go through three stages or phases of schizophrenia as described below.
- In the first phase, known as acute phase, the patient shows psychotic symptoms and may lose contact with reality. Patients suffer from hallucinations such as hearing voices or believing that God is communicating with them. Patients in this phase require intervention and treatment.
- In the second phase, known as stabilization phase, the patient shows marked improvement, and the psychotic symptoms are brought under control. However, if treatment is interrupted, the patient is at risk of going into relapse.
- In the third phase, known as maintenance phase, stability returns to the patient. However, in this case too, the patient may go into relapse.
Schizophrenia can be classified into two types as follows.
Type I or positive schizophrenia
- Persons with this type of schizophrenia suffer from positive symptoms such as delusions, hallucinations, and disorganized speech, thinking and behavior. The onset of the disease is acute (rapid), and the patient responds well to the treatment. Positive symptoms respond positively to the treatment and reflect the excess or distortion of normal functions.
Type II or negative schizophrenia
- Persons with this type of schizophrenia suffer from negative symptoms such as social isolation, lack of energy and emotions, alogia (poor speech), lack of interest in life, poor social skills and inability to make friends. The onset of negative symptoms is gradual and reflects the reduction or loss of normal functions. The symptoms are difficult to evaluate as they are not as abnormal or excessive as positive symptoms. At present, there is no treatment that can cure negative symptoms consistently.
According to Diagnostic and Statistical Manual of Mental Disorders, Edition IV, 1994 (DSM-IV) schizophrenia is of five subtypes.
The characteristic features of paranoid schizophrenics are as follows:
- auditory hallucinations or hearing voices
- delusions or false beliefs
- suspicious nature
- high opinion and exaggerated importance of themselves
- feeling of extreme religiosity and jealousy
- belief that others are scheming against them
- belief that others are harming or persecuting them
- violent and suicidal tendencies
- nearly normal emotions and cognitive abilities
- function at higher level than other subtypes
Disorganized or Hebephrenic:
The characteristic features of disorganized schizophrenia are as follows:
- disorganized and incoherent speech, thinking and behavior
- absence of hallucination in most cases
- incongruous, emotionless or silly behavior
- intellectual deterioration
- inappropriate or flat emotional response to situations
- extreme social withdrawal
- weak personality
The characteristic features of catatonic schizophrenia are as follows:
- extremely isolated and socially withdrawn
- imitates other’s actions, movements and speech
- psychomotor disturbances, including bad posturing, stupor, rigidity and agitation
- risk of self-injury, malnutrition and exhaustion
- not so common in Europe and US
The characteristic features of undifferentiated schizophrenia are as follows:
- display general symptoms of schizophrenia (positive and negative symptoms)
- symptom’s criteria not conforming exclusively to any other subtypes
- exhibits some features of other subtypes but without a clear dominance of anyone
The characteristic features of residual schizophrenia are as follows:
- lack of motivation
- lack of interest in day-to-day activities
- faced at least one acute schizophrenic episode
- absence of strong positive symptoms such as delusion and hallucination
- presence of negative symptoms
Causes of Schizophrenia:
Experts believe that schizophrenia results from the combination of genetic, social, environmental, and neurobiological causes. However, these causes are not yet completely understood.
Neurobiological or Dysregulation hypothesis:
According to this hypothesis, there is a connection between schizophrenia and the excessive secretion of neurotransmitters such as serotonin and dopamine.
Experts believe that persons with schizophrenic biological relatives are 10 times at more risk of being schizophrenic than the general population. Further, 70% of schizophrenic patients were found to have a genetic basis for the disease.
The following table shows the relationships and the risks:
|Fraternal twin||15 % risk|
|Identical twin||50 % risk|
|Sibling||10 % risk|
|One parent affected||15% risk|
|Both parents affected||35% risk|
|None affected relative||1% risk|
As per this hypothesis, prenatal exposure to the influenza virus during the second semester of pregnancy may cause schizophrenia. Further, experts agree that viral infection of the hippocampus, a brain area that deals with sense perceptions, may also cause schizophrenia.
Many psychotherapists believe that stress due to poverty, anxiety, environment, family, and society may lead to schizophrenia. However, some experts do not subscribe to this theory and think that stress does not cause the disease, but only influences the severity or expression of it.
It is also important to know that the following does NOT cause schizophrenia:
- Poor family relations
- Inadequate and bad parenting
- Overzealous parents
Further, schizophrenia is NOT same as the split personality disorder.
Some of the common triggers of schizophrenia are as follows:
- social isolation
- aggressive environment
- improper social skills
- chronic negative attitude
Symptoms of Schizophrenia:
There is no single symptom, which can be precisely identified with schizophrenia in an individual. Diagnosis is carried out based on a set or group of symptoms.
According to Eugene Bleuler (the Swiss psychiatrist who coined the term schizophrenia), schizophrenic patients display a set of four primary symptoms, including:
- associations – disturbing thoughts
- affect – flattened or inappropriate emotional response
- ambivalence – conflicting feeling towards others
- autism – social withdrawal
Eugene Bleuler considered delusion and hallucinations as secondary symptoms.
In 1959, the German psychiatrist Kurt Schneider proposed two sets of symptoms: first rank symptoms and second rank symptoms.
According to Schneider, first rank symptoms are the most important and central symptoms that are unique to schizophrenia. Such symptoms include:
- thought insertions or withdrawals (e.g., believing that external agents such as FBI, CIA, Aliens, etc., has the power to put or remove thoughts from one’s mind)
- somatic hallucinations (e.g., believing that one’s brain is radioactive)
- hearing voices
Recent studies, however, revealed that some of the first rank symptoms were found in other disorders such as bipolar disorders.
Second rank symptoms (e.g., disturbances in mood and thoughts) are those that may be present in other disorders.
These symptoms are those that represent or reflect an excessive or distorted version of normal functions. The symptoms include Schneider’s first rank symptoms such as delusions and hallucinations, and disorganized thought process. Positive symptoms show a positive response to some treatments.
The individual may show symptoms including:
- that he is being followed or watched
- that he is being persecuted or harmed
- belief that someone is sending him/her messages through TV and Radio
The symptoms include:
- hearing voices in thoughts
- visual hallucinations
- somatic hallucinations
3) Disorganized thinking:
The characteristic symptoms include:
- loose associations, which means the patient rambles from one topic to another without any connection
- tangential speech in which patient gives unrelated answers to questions
- incoherent speech, which means the patient talks so incoherently that it does not make any linguistic or grammatical sense
4) Disorganized behavior:
The symptoms may include:
- purposeless behavior
- silly behavior
- difficulty in taking self-care or doing day-to-day activities
- odd or inappropriate dressing
- sexual self-simulation in public
- shouting, agitation or cursing in public
5) Catatonic behavior:
The patient may display the following symptoms:
- bizarre or rigid postures
- unaware of surrounding environment
- purposeless motor activity such as pacing and rocking
These symptoms are those that represent or reflect diminution or absence or lack of normal functions. Negative symptoms are difficult to treat because they are difficult to evaluate.
1) Affective flattening:
The symptoms may include:
- lack or inappropriate emotional response
- flattened facial expression
- lack of eye contact
- inappropriate body language
Alogia means poverty of speech. The symptoms may include:
- lack or reduction in speech fluency
- blocked thoughts
- empty or short replies to questions
Avolition means absence of will or volition. The patient may display the following symptoms:
- disinterest in normal things
- lack or reduced ability to initiate or persist in the goal-oriented objectives
- sitting inside house for hours or days doing nothing
- disinterested in meeting with friends
- lack of interest in doing things that used to be done enthusiastically
The psychiatrist during diagnosis shall look at outward observable symptoms and not at internal psychological features. Doctor may recommend the patient to undergo computer tomography scan (CT scan) to find any abnormalities in the brain structure associated with schizophrenia.
The doctor starts the diagnosis by excluding any physical conditions that may cause behavior similar to those associated with schizophrenia. These organic disorders include:
- Wilson disease
- temporal lobe epilepsy
- Huntington’s chorea
- organic brain disorders, including traumatic brain injuries
- substance (especially amphetamine) abuse disorders
After ruling out the above conditions, the physician will exclude other psychiatric conditions with symptoms resembling psychosis. Such conditions include:
- multiple personality disorder or dissociative disorder not otherwise specified (DDNOS)
- mood disorders with psychotic features
- schizotypal personality disorder
- schizoid personality disorder
- paranoid personality disorder
- delusional disorder
- atypical reactive disorder
After ruling out the above conditions and disorders, the patient, in order to be diagnosed with schizophrenia, must meet a set of criteria specified by DSM-IV as follows:
- Patient must display at least two of the following characteristic symptoms for a significant portion of time during the one month period
- catatonic or grossly disorganized behavior
- disorganized speech
- negative symptoms
- Decline in social or occupational or interpersonal skills
- Disturbances should persist continuously for a period of at least six months
- Conditions should not be attributed to mood disorder
- Conditions should not be attributed to substance abuse
- Conditions should not be attributed to other general medical conditions
Another set of criteria used to diagnosis schizophrenia is ICD-10 criteria. The criteria according to ICD-10 are as follows:
- Patient must display at least one of the following characteristic symptoms for a period of one month
- thought insertion or withdrawal or broadcasting
- delusions of control or influence
- voice hallucinations
- inappropriate or impossible delusions such as extreme religiosity or superhuman powers
- Patient must display at least two of the following characteristic symptoms for a period of one month
- irrelevant or incoherent speech
- catatonic behavior
- hallucinations accompanied by delusions
- negative symptoms
- Mood disorder, if present, must be preceded by one month of characteristic symptoms
- Conditions not attributed to substance abuse
- Conditions not attributed to brain disease
The aim of the treatment should be to minimize the symptoms, reduce the side effects of medicines, prevent relapse, and maximize the functions and recovery process.
Treatment depends, in part, on the phase or stage of the disease. Patients in acute stage are hospitalized to avoid any harm, they may cause to themselves or to others. Doctor starts the treatment by conducting MRI or CT scans to rule out any structural brain damage or disease. The patient may be subjected to diagnostic tests to exclude other disorders with symptoms similar to those of schizophrenia.
The treatment generally consists of three phases:
- Psychological and
This is the primary form of treatment in which the patient is administered with antipsychotic drugs (not antischizophrenic drugs). These drugs help to control almost all the positive symptoms of the disorder, but do not have much effect on negative symptoms and disorganized behavior. However, the patient can be deinstitutionalized with the use of antipsychotic drugs.
Antipsychotic drugs can be divided into two classes: the traditional dopamine receptor antagonists (Das), and the latest serotonin dopamine antagonists (SDAs). These medications reduce the patient’s sensitivity to sensory stimuli and thus help to improve the patient’s ability to interact with others.
Dopamine Receptor Antagonists:
Dopamine Receptor Antagonists drugs are conventional or traditional antipsychotic drugs. They are also known as neuroleptic drugs or major tranquilizers. The drugs include:
- chlorpromazine (Thorazine)
- haloperidol (Haldol)
- fluphenazine (Prolixin)
- trifluoperazine (Stelazine)
- perphenazine (Trilafon)
- thioridazine (Mellaril)
- thiothixene (Navane)
- mesoridazine (Serentil)
- loxapine (Loxitane)
- molidone (Moban)
- pimozide (Orap)
Neuroleptic drugs have a good effect on positive symptoms. However, they are not much helpful in treating the negative symptoms.
Further, there are two drawbacks with traditional antipsychotic or neuroleptic drugs:
- It is difficult to find the correct dosage level for an individual.
- Dosage levels that are required to control the psychotic symptoms induce extrapyramidal side effects (EPSs). These side effects may include:
- Akathisia (restlessness, pacing and fidgeting)
- Parkinsonism (patient has difficulty in walking and may develop tremors)
- Dystonia (painful muscle cramps of tongue, head and neck)
- Tardive dyskinesia (worst form of EPS resulting in involuntary movements beginning from mouth and spreading to face, neck, and trunk). The most common movements are lip smacking, grimacing and eye blinking.
Other side effects include:
- Neuroleptic Malignant Syndrome (a rare, but life-threatening disease involving fever, muscle rigidity, delirium and autonomic instability).
- Weight gain
- Dry Mouth
- Blurry Vision
Serotonin Dopamine Antagonists:
- clozapine (Clozaril)
- olanzapine (Zyprexa)
- risperidone (Risperdal)
- quetiapine (Seroquel)
- ziprasidone (Geodon)
- aripiprazole (Abilify)
- risperidone MS (Consta)
These drugs can control the negative symptoms in a much better way than neuroleptic drugs and are less likely to produce the EPSs. They also help in alleviating cognitive and mood symptoms. However, atypical antipsychotic drugs may cause some side effects such as weight gain, ECG changes and metabolic problems.
SDAs are expensive in short term, but they reduce the long-term costs by cutting down the need for a longer hospitalization period. At present, SDAs are unavailable in injection form. Usually, SDAs are given to patients who respond poorly to the treatment by DAs. However, doctors now regard the use of atypical antipsychotic drugs as first choice.
Apart from antipsychotic drugs, psychiatrists recommend the use of anti-depressants or benzodiazephines, because most of the schizophrenic patients suffer from depression, anxiety and phobias.
In the acute phase of schizophrenia, patients are usually given medications orally or through intramuscular injections. When the patient enters the stabilized phase, the medications are given in a long-acting form called the depot dose.
Depot dose is a form of medication in which medicines are stored in patient’s body tissue for a certain period (generally two to four weeks). This will minimize the risk of the patient forgetting or skipping the daily doses of medicine. Depot dose should be introduced gradually so that the patient gets used to such type of medication.
During the maintenance phase of schizophrenia, the patient has to take the antipsychotic drugs indefinitely to minimize the risk of relapse.
Most schezophrenics can benefit from psychotherapy once their acute symptoms have been brought under control with the help of antipsychotic drugs. However, psychoanalysis is not recommended, because the patient is unable to form meaningful relationships.
Family therapy for family members of schezhophrenic patients is often recommended to help them to understand the patient’s disorder. Family members can learn about the causes, treatment and coping strategies of schizophrenia.
Family therapy also changes the family member’s attitude and behavior towards the patient and can help them to cope with the stresses caused by the patient’s illness. The therapy improves the communication skills and problem-solving strategies of family members when dealing with the patient. Further, support groups and related organizations can also aid the families of schizophrenic patients.
Social treatment involves behavior therapy to improve the patient’s social interaction skills and occupational therapy to prepare the patient for an eventful employment.
Prognosis depends upon the age of the patient at the onset of the psychotic symptoms. Patients with early onset of symptoms are more likely to be male, have higher rate of brain abnormalities, more symptoms that are negative, lower level of functioning before the onset, and worse prognosis.
Patients with later onset of symptoms are more often females, with low thought impairment and fewer brain abnormalities, and good prognosis.
Patients who have a stressful life or surrounded by hostile or emotionally intense family environment are more likely to relapse. The most important factor in the long-term care of schizophrenics is to comply with their regime of antipsychotic drugs.
At present, there is no way to prevent the onset of schizophrenia. However, research is going on to find ways to treat the disorder before the onset of its symptoms (for example, when there is suspicion of hereditary or genetic transmission).