Article updated and reviewed by Christos Ballas, MD, Attenting Psychiatrist, Inpatient and Consult/Liaison Psychiatry, Hospital of the University of Pennsylvania. Editorial review provided by VeriMed Healthcare Network on May 11, 2005.
Schizophrenia is a severe mental disorder characterized by two kinds of symptoms; positive psychotic symptoms - thought disorder, hallucinations, delusions, and paranoia - and negative symptoms – impairment in emotional range, energy, and enjoyment of activities. For a formal diagnosis, these symptoms must persist for at least one month and usually result in severe impairment in job and/or social functioning.
Schizophrenia is a particular form of psychosis, a term encompassing several severe mental disorders that result in the loss of contact with reality along with major personality derangements.
The illness can be described as a collection of particular symptoms that usually fall into four basic categories: formal thought disorder, perception disorder, feeling/emotional disturbance, and behavior disorders.
Formal thought disorder. People with schizophrenia describe strange or unrealistic thoughts. In many instances, their speech is hard to follow due to disordered thinking. Common forms of thought disorder include circumstantiality (talking in circles around the issue), looseness of associations (moving from one topic to the next without any logical connection between them), and tangentiality (moving from one topic to another where the logical connection is visible, but not relevant to the issue at hand).
Many schizophrenics feel they possess extraordinary powers, superhuman strength, or superior insights. They may believe that their thoughts are being controlled by others or are being broadcast over the public airways, or that outside thoughts are being implanted in their heads. When such ideas are persistent, organized, and maintained in spite of evidence to the contrary, they are called delusions.
Perception disorder. Those with schizophrenia regularly report unusual sensory experience, especially when the illness is in an acute stage. Most often these experiences are in the form of hearing voices, or auditory hallucinations.
Persons may hear one or two (and sometimes more) voices making comments on their behavior. They may not know the voice, or they may believe that it is the voice of God, the devil, or a friend or relative. Importantly, these voices are perceived to be either real or from outside the individual, and not as their own voice or conscience. People experiencing these hallucinations often perform behaviors or habits in order to quiet or eliminate the voices. A typical example is turning on the radio or television to static in order to drown out the voices.
Feeling/Emotional Disturbance. People with schizophrenia may exhibit flat or restricted affect. This means that they do not respond emotionally to events which would ordinarily elicit some feeling. For example, they do not display feelings of sadness, happiness, or humor, even though they may be able to understand that these things are supposed to be sad, happy, or funny. Their facial expressions and vocal intonations remain the same regardless of what happens around them. Emotional disturbances frequently result in social withdrawal. People with schizophrenia often avoid contact with friends and lose interest in daily life and events. This withdrawal often leads to significant impairment in the person’s quality of life and can lead to the person being expelled from school or fired from a job.
Behavior disorders. Certain forms of schizophrenia are associated with particular movements or behaviors. Lack of blinking and repetitive movements can be seen. Catatonic behavior, where the person appears frozen and motionless, can also be observed. Though catatonia is a symptom of schizophrenia, it often requires a different class of medications—benzodiazepines—which are not routinely used in schizophrenia.
Researchers suspect a biological (either genetically or environmentally) basis for schizophrenia, possibly an imbalance in brain chemicals that regulate thought and emotion. A sibling or a parent with schizophrenia increases the likelihood that a person will have the disease.
Schizophrenia usually has its onset in late adolescence to the mid-20s in men and late-20s in women.
There are an array of symptoms associated with schizophrenia. The first signs are usually disruption in one's social and family relationships - withdrawing into oneself and developing illogical thought processes. This is followed by slow deterioration in other areas, such as the ability to perform in school or at work, and finally, to care for oneself. Additionally, the person may experience delusions, hallucinations, and disorganized or altered speech.
Diagnosis is based upon the clinical history and presentation of the patient. It is also based upon ruling out organic causes of mental illness, such as the influence of drugs or toxic substances, or neurological problems such as brain tumors, syphilis, or infections.
Patients with schizophrenia often do not respond to treatment or only partially improve and remain functionally impaired. While medication has been found to be effective for the treatment of “positive” symptoms of the disease, treatment of the “negative symptoms” of depression (including lack of energy, motivation, and emotional range) has historically not been very successful. In nearly 25 percent of those patients, the condition is so refractory to neuroleptic pharmacotherapy that they require custodial care.
Prevention of psychotic relapse in schizophrenic patients is a primary long-term clinical goal. The duration of psychotic episodes predicts the risk of relapse. Patients who have been psychotic for more than a year are rehospitalized for recurrence more often than those ill for less than a year. Neuroleptic drug therapy greatly shortens episodes of psychosis.
Antipsychotic drugs, also referred to as neuroleptics, are essential to the management of schizophrenia. With the exception of clozapine (Clozaril), all antipsychotic medications are equally effective overall. Older medications known as ‘typical’ antipsychotics are known to generally have more severe side effects than newer ‘atypical’ antipsychotics, specifically extrapyramidal symptoms like tremors, restlessness, and muscle spasms.
Atypical antipsychotic medications include risperidone (Risperdal), olanzapine (Zyprexa), ziprasidone (Geodon), quetiapine (Seroquel), and aripiprazole (Abilify). Typical antipsychotic mediations include haloperidol, chlorpromazine, thioridazine (Mellaril), trifluoperazine (Stelazine), and thiothixene (Navane).
Clozapine (Clozaril) has been shown to be more effective than any other treatment for schizophrenia, especially in refractory cases. It is effective for both positive and negative symptoms of the disease and has a low incidence of extrapyramidal side effects. However because of the risk of agranulocytosis, a disorder of suppressed white blood cells, it is rarely used as a first line agent.
As compliance with daily medication is an obstacle to care in schizophrenia, there are several long acting forms of antipsychotic medication that only have to be administered every week or every few weeks. Some of these long term medications include haloperidol deconate (Haldol Decanoate), fluphenazine deconate (Prolixin Decanoate), and Risperdal Consta.
Other drugs used include lithium and the benzodiazepines. Lithium alone is inferior to neuroleptic agents in inducing remission of psychosis.