Schizophrenia is a chronic, severe, and disabling mental disorder characterized by deficits in thought processes, perceptions, and emotional responsiveness. People with the disorder may hear voices other people don’t hear, or see things that others don’t see. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. They may sit for hours without moving or talking. These symptoms make holding a job, forming relationships, and other day-to-day functions especially difficult for people with schizophrenia.
Schizophrenia interferes with a person’s ability to think clearly, manage emotions, make decisions, and relate to others. Specific abnormalities that can be noted in individuals with schizophrenia include:
delusions and hallucinations;
alterations of the senses;
an inability to sort and interpret incoming sensations, and an inability therefore to respond appropriately;
an altered sense of self; and
changes in emotions, movements and behavior.
Schizophrenia is a neurological brain disorder that affects 2.2 million Americans today, or approximately one percent of the population. Schizophrenia can affect anyone at any age, but most cases develop between ages 16 and 30.
Symptoms of Schizophrenia
In healthy people, the brain functions in such a way that incoming stimuli are sorted and interpreted, followed by a logical response (e.g., saying “thank you” after a gift is given, realizing the potential outcome of arriving late to work, etc.). Conversely, the inability of patients with schizophrenia to sort and interpret stimuli and select appropriate responses is one of the hallmarks of the disease.
The symptoms of schizophrenia are generally divided into three categories, including positive, disorganized, and negative symptoms.
Overt Symptoms, or “psychotic” symptoms, include delusions, hallucinations and disorganized thinking because the patient has lost touch with reality in certain important ways. Delusions cause the patient to believe that people are reading their minds or plotting against them, that others are secretly monitoring and threatening them, or that they can control other people’s thoughts. Hallucinations cause people to hear or see things that are not there. Approximately three-fourths of individuals with schizophrenia will hear voices (auditory hallucinations) at some time during their illness.
Disorganized thinking, speech, and behavior affect most people with this illness. For example, people with schizophrenia sometimes have trouble communicating in coherent sentences or carrying on conversations with others; move more slowly, repeat rhythmic gestures or make movements such as walking in circles or pacing; and have difficulty making sense of everyday sights, sounds and feelings.
Negative symptoms include emotional flatness or lack of expression, an inability to start and follow through with activities, speech that is brief and lacks content, and a lack of pleasure or interest in life. “Negative” does not, therefore, refer to a person’s attitude, but to a lack of certain characteristics that should be there.
To be diagnosed with schizophrenia, a patient must have psychotic, “loss-of-reality” symptoms for at least six months and show increasing difficulty in functioning normally. Before the six-month period is reached, the person is diagnosed as having a schizophreniform disorder.
Prior to a medical diagnosis, it is critically important that a doctor rule out other problems that may mimic schizophrenia, such as psychotic symptoms caused by the use of drugs or other medical illnesses; major depressive episode or manic episode with psychotic features; delusional disorder (no hallucinations, disorganized speech or thought or “flattened” emotions) and autistic disorder or personality disorders (especially schizotypal, schizoid, or paranoid personality disorders). Schizoaffective disorder is a diagnosis used to indicate that the person has an illness with a mix of symptoms of both schizophrenia and bipolar disorder.
Although the cause of schizophrenia has not yet been identified, recent research suggests that schizophrenia is linked to abnormalities of brain chemistry and brain structure. Genes play some role, but the magnitude of that role remains to be ascertained. Abnormalities of neurotransmitters (e.g., dopamine, serotonin) and viruses also are under investigation. The brain changes in some cases are suspected to date to childhood. Brain-imaging technology has demonstrated that schizophrenia is as much an organic brain disorder as is multiple sclerosis, Parkinson’s or Alzheimer’s disease.
While there is no cure for schizophrenia, it is a highly treatable disorder. In fact, according to the National Advisory Mental Health Council, the treatment success rate for schizophrenia is comparable to the treatment success rate for heart disease.
It is important to diagnose and treat schizophrenia as early as possible to help people avoid or reduce frequent relapses and re-hospitalizations. Several promising, large-scale studies suggest early intervention may forestall the worst long-term outcomes of this devastating brain disorder.
People who experience acute symptoms of schizophrenia may require intensive treatment, sometimes including hospitalization. Hospitalization is necessary to treat severe delusions or hallucinations, serious suicidal inclinations, inability to care for oneself, or severe problems with drugs or alcohol.
It is critical that people with schizophrenia stay in treatment even after recovering from an acute episode. About 80 percent of those who stop taking their medications after an acute episode will have a relapse within one year, whereas only 30 percent of those who continue their medications will experience a relapse in the same time period.
Medication appears to improve the long-term prognosis for many people with schizophrenia. Studies show that after 10 years of treatment, one-fourth of those with schizophrenia have recovered completely, one-fourth have improved considerably, and one-fourth have improved modestly. Fifteen percent have not improved, and 10 percent are dead.
Individuals with schizophrenia die at a younger age than do healthy people. Males have a 5.1 greater than expected early mortality rate than the general population, and females have a 5.6 greater risk of early death. Suicide is the single largest contributor to this excess mortality rate, which is 10 to 13 percent higher in schizophrenia than the general population.
Suicide is in fact the number one cause of premature death among people with schizophrenia, with an estimated 10 percent to 13 percent killing themselves. The extreme depression and psychoses that can result due to lack of treatment are the usual culprits in these sad cases. These suicides rates can be compared to the general population, which is somewhere around 0.01%. Other contributors to excess mortality include:
- Accidents: Although individuals with schizophrenia do not drive as much as other people, studies have shown that they have double the rate of motor vehicle accidents per mile driven. A significant but unknown number of individuals with schizophrenia also are killed as pedestrians by motor vehicles.
- Diseases: There is some evidence that individuals with schizophrenia have more infections, heart disease, type II (adult onset) diabetes, and female breast cancer, all of which might increase their mortality rate. Individuals with schizophrenia who become sick are less able to explain their symptoms to medical personnel, and medical personnel are more likely to disregard their complaints and assume that they are simply part of the illness. There also is evidence that some persons with schizophrenia have an elevated pain threshold so they may not complain of symptoms until the disease has progressed too far to be treatable.
- Homelessness: Although it has not been well studied to date, it appears that homelessness increases the mortality rate of individuals with schizophrenia by making them even more susceptible to accidents and diseases.
One of the most effective tools in treating schizophrenia is by Programs for Assertive Community Treatment (PACT), an intensive team effort in local communities to help people stay out of the hospital and live independently. Serving as a hospital without walls, PACT professionals are available around the clock and meet their clients where they live, providing at-home support at whatever level is needed, for whatever problems need to be solved. Professionals can make sure that clients are taking their medication and help them meet the challenges of daily life – every day tasks ranging from grocery shopping and keeping doctor appointments to managing money and getting along with others.
While PACT programs are an excellent means for delivering outpatient services, research demonstrates that they improve medication compliance for some, but not all, patients. For example, a recent Baltimore study of 77 homeless individuals with severe mental illness (86 percent with schizophrenia or major affective disorder) were assigned to PACT teams and followed for one year. Medication compliance improved from 29 percent to between 50 percent and 57 percent during the remainder of the year. The study found that approximately one-third of the subjects were noncompliant at any given time during the research year.
Antipsychotic drugs are used in the treatment of schizophrenia. These medications help relieve the delusions, hallucinations, and thinking problems associated with this devastating disorder. Scientists believe the drugs work by correcting imbalances in the chemicals that help brain cells communicate with one another. As with drug treatments for other physical illnesses, many patients with severe mental illnesses may need to try several different antipsychotic medications before they find the one, or the combination of medications, that works best for them.
Conventional or Standard Antipsychotics include: chlorpromazine (Thorazine); fluphenazine (Prolixin); haloperidol (Haldol); thiothixene (Navane); trifluoperazine (Stelazine); perphenazine (Trilafon) and thioridazine (Mellaril).
Atypical Antipsychotics are newer drugs with fewer side effects and include risperidone (Risperdal); clozapine (Clozaril) and olanzapine (Zyprexa).
Since these medications do not work immediately, experts recommend that doctors give the antipsychotic time to take effect before switching to another antipsychotic, adjusting the dose, or adding another medication.
Antipsychotic drugs are usually taken daily in tablet or liquid form. Fluphenazine (Prolixin) and haloperidol (Haldol), for example, also can be given in long-acting injections (called “depot formulations”) at one- to four-week intervals. With depot formulations, medication is stored in the body and slowly released. This can be especially helpful for patients who have a hard time taking pills on a daily basis.
Possible Side Effects of Antipsychotic Medication
As a group, antipsychotic drugs are safe, and serious side effects are relatively rare. Some people may experience side effects that are inconvenient or unpleasant, but not serious.
Most common side effects: dry mouth, constipation, blurred vision, and drowsiness.
Less common side effects: decreased sexual desire, menstrual changes, and stiff muscles on one side of the neck and jaw.
More serious side effects: restlessness, muscle stiffness, slurred speech, tremors of the hands or feet. Agranulocytosis, a decrease in the production of white blood cells, which occurs only when taking clozapine, requires monitoring of the blood every two weeks.
Tardive Dyskinesia is the most unpleasant and serious side effect of antipsychotic drugs causing involuntary facial movements and sometimes jerking or twisting movements of other parts of the body. This condition usually develops in older patients, affecting 15 to 20 percent of those who have taken older antipsychotic drugs for years. In most cases, the tardive dyskinesia slowly goes away when the medication is stopped.