Schizophrenia is a mental disorder characterized by abnormal social behavior and failure to understand reality. Common symptoms include false beliefs, unclear or confused thinking, hearing voices that others do not, reduced social engagement and emotional expression, and a lack of motivation. People with schizophrenia often have additional mental health problems such as anxiety, depressive, or substance-use disorders. Symptoms typically come on gradually, begin in young adulthood, and last a long time.
Subtypes of Schizophrenia
With the publication of DSM-5, the APA removed all sub-classifications of schizophrenia. The five sub-classifications included in DSM-IV-TR were
- Paranoid type – Delusions or auditory hallucinations are present, but thought disorder, disorganized behavior, or affective flattening are not. Delusions are persecutory and/or grandiose, but in addition to these, other themes such as jealousy, religiosity, or somatization may also be present.
- Disorganized type – Named hebephrenic schizophrenia in the ICD. Where thought disorder and flat affect are present together.
- Catatonic type – The subject may be almost immobile or exhibit agitated, purposeless movement. Symptoms can include catatonic stupor and waxy flexibility.
- Undifferentiated type – Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met.
- Residual type – Where positive symptoms are present at a low intensity only.
The ICD-10 defines additional subtypes
- Post-schizophrenic depression – A depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present.
- Simple schizophrenia – Insidious and progressive development of prominent negative symptoms with no history of psychotic episodes.
- Other schizophrenia – include cenesthopathic schizophrenia and schizophreniform disorder NOS.
Causes of Schizophrenia
While the causes of schizophrenia are not fully known, it seems to result from a complex interaction between genetic and environmental factors.
- Genetic causes – While schizophrenia runs in families, about 60% of schizophrenics have no family members with the disorder. Furthermore, individuals who are genetically predisposed to schizophrenia don’t always develop the disease, which shows that biology is not destiny.
- 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.
Studies suggest that inherited genes make a person vulnerable to schizophrenia and then environmental factors act on this vulnerability to trigger the disorder.
More and more research is pointing to stress, either during pregnancy or at a later stage of development, as a major environmental factor. Stress-inducing factors could include:
- Prenatal exposure to a viral infection
- Low oxygen levels during birth (from prolonged labor or premature birth
- Exposure to a virus during infancy
- Early parental loss or separation
- Physical or sexual abuse in childhood
Abnormal brain structure
In addition to abnormal brain chemistry, abnormalities in brain structure may also play a role in schizophrenia. However, it is highly unlikely that schizophrenia is the result of any one problem in any one region of the brain
Behaviors that are early warning signs of schizophrenia include
- Hearing or seeing something that isn’t there
- A constant feeling of being watched
- The peculiar or nonsensical way of speaking or writing
- Strange body positioning
- Feeling indifferent to very important situations
- Deterioration of academic or work performance
- A change in personal hygiene and appearance
- A change in personality
- Increasing withdrawal from social situations
- Irrational, angry or fearful response to loved ones
- Inability to sleep or concentrate
- Inappropriate or bizarre behavior
- Extreme preoccupation with religion or the occult
Anyone who experiences several of these symptoms for more than two weeks should seek help immediately.
Symptoms of Schizophrenia
Positive major symptoms are disturbances that are “added” to the person’s personality.
- Delusions – the patient displays false beliefs, which can take many forms, such as delusions of persecution, or delusions of grandeur. They may feel others are attempting to control them remotely. Or, they may think they have extraordinary powers and abilities.
- Hallucinations – hearing voices is much more common than seeing, feeling, tasting, or smelling things which are not there, however, people with schizophrenia may experience a wide range of hallucinations.
- Thought disorder – the person may jump from one subject to another for no logical reason. The speaker may be hard to follow or erratic.
- Disordered thinking and speech –moving from one topic to another, in a nonsensical fashion. Individuals may also make up their own words or sounds, rhyme in a way that doesn’t make sense or repeats words and ideas.
- Disorganized behavior –this can range from having problems with routine behaviors like hygiene or choosing appropriate clothing for the weather, to unprovoked outbursts, too impulsive and uninhibited actions. A person may also have movements that seem anxious, agitated, tense or constant without any apparent reason.
The symptoms are classified into four categories
- Positive symptoms – also known as psychotic symptoms. For example, delusions and hallucinations.
- Negative symptoms – these refer to elements that are taken away from the individual. For example, the absence of facial expressions or lack of motivation.
- Cognitive symptoms – these affect the person’s thought processes. They may be positive or negative symptoms, for example, poor concentration is a negative symptom.
- Emotional symptoms – these are usually negative symptoms, such as blunted emotions.
Other symptoms may include
- Lack of motivation (avolition) – the patient loses their drive. Everyday actions, such as washing and cooking, are neglected.
- Poor expression of emotions – responses to happy or sad occasions may be lacking, or inappropriate.
- Social withdrawal – when a patient with schizophrenia withdraws socially, it is often because they believe somebody is going to harm them.
- Unawareness of illness – as the hallucinations and delusions seem so real for patients, many of them may not believe they are ill. They may refuse to take medication for fear of side effects, or for fear that the medication may be poison, for example.
- Cognitive difficulties – the patient’s ability to concentrate, recall things, plan ahead, and to organize their life are affected. Communication becomes more difficult.
Negative symptoms are capabilities that are “lost” from the person’s personality.
- Social withdrawal
- Extreme apathy (lack of interest or enthusiasm)
- Lack of drive or initiative
- Emotional flatness
Diagnosis of Schizophrenia
Determining a diagnosis of schizophrenia may include
- Physical exam – This may be done to help rule out other problems that could be causing symptoms and to check for any related complications.
- Tests and screenings – These may include tests that help rule out conditions with similar symptoms, and screening for alcohol and drugs. The doctor may also request imaging studies, such as an MRI or CT scan.
- Psychiatric evaluation – A doctor or mental health professional checks mental status by observing appearance and demeanor and asking about thoughts, moods, delusions, hallucinations, substance use, and potential for violence or suicide. This also includes a discussion of family and personal history.
- Diagnostic criteria for schizophrenia – A doctor or mental health professional may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.
Treatment of Schizophrenia
The most common schizophrenia medications are
- Risperidone (Risperdal) – less sedating than other atypical antipsychotics. Weight gain and diabetes are possible side effects, but are less likely to happen, compared with Clozapine or Olanzapine.
- Olanzapine (Zyprexa) – may also improve negative symptoms. However, the risks of serious weight gain and the development of diabetes are significant.
- Quetiapine (Seroquel) – the risk of weight gain and diabetes, however, the risk is lower than Clozapine or Olanzapine.
- Ziprasidone – the risk of weight gain and diabetes is lower than other atypical antipsychotics. However, it might contribute to cardiac arrhythmia.
- Clozapine (Clozaril) – effective for patients who have been resistant to treatment. It is known to lower suicidal behaviors in patients with schizophrenia. The risk of weight gain and diabetes is significant.
- Haloperidol – an antipsychotic used to treat schizophrenia. It has a long-lasting effect (weeks).
- Schizophrenia requires long-term treatment. Most people with schizophrenia need to continue treatment even when they’re feeling better to prevent new episodes and stay symptom-free. Treatment can change over time, though, so your doctor may be able to lower the dosage or change medication as your symptoms improve.
- Therapy – can help you improve coping and life skills, manage stress, address relationship issues, and improve communication. Group therapy can also connect you to others who are in a similar situation and gain valuable insight into how they’ve overcome challenges.
The 7 keys to self-help
Seek social support – Not only are friends and family vital to helping you get the right treatment and keeping your symptoms under control, regularly connecting with others face-to-face is the most effective way to calm your nervous system and relieve stress. Stay involved with others by continuing your work or education-or if that’s not possible, consider volunteering, joining a schizophrenia support group, or taking a class or joining a club to spend time with people who have common interests. As well as keeping you socially connected, it can help you feel good about yourself.
- Manage stress – High levels of stress are believed to trigger schizophrenic episodes by increasing the body’s production of the hormone cortisol. As well as staying socially connected, there are plenty of steps you can take to reduce your stress levels, including relaxation techniques such as meditation, yoga, or deep breathing.
- Get regular exercise – As well as all the emotional and physical benefits, exercise may help reduce symptoms of schizophrenia, improve your focus and energy, and help you feel calmer. Aim for 30 minutes of activity on most days or if it’s easier three 10-minute sessions. Try rhythmic exercise that engages both your arms and legs, such as walking, running, swimming or dancing.
- Get plenty of sleep – When you’re on medication, you most likely need even more sleep than the standard 8 hours. Many people with schizophrenia have trouble with sleep, but getting regular exercise and avoiding caffeine can help.
- Avoid alcohol, drugs, and nicotine – Substance abuse complicates schizophrenia treatment and worsens symptoms. Even smoking cigarettes can interfere with the effectiveness of some schizophrenia medications. If you have a substance abuse problem, seek help.
- Eat regular, nutritious meals – to avoid symptoms exacerbated by changes in blood sugar levels. Omega-3 fatty acids from fatty fish, fish oil, walnuts, and flaxseeds can help improve focus, banish fatigue, and balance your moods.
- Family psycho-education and support – In addition to educating family members about the symptoms, course, and treatment of schizophrenia, this form of treatment consists of providing the family with supportive therapy, problem-solving skills, and access to ongoing community supports, including care providers during times of crises. When this intervention is consistently provided for at least several months, it has been found to decrease the relapse rate for the person with schizophrenia and improve social and emotional outcomes. Also, the burden that family members experience as a result of having a loved one with schizophrenia is less, family members tend to be more knowledgeable about the disorder and feel more supported by the professionals involved, and family relationships are improved.
- Assertive community treatment (ACT) – This intervention consists of members of the person’s treatment team meeting with that individual on a daily basis, in community settings (for example, home, work, or other places the person with schizophrenia frequents) rather than in an office or hospital setting. The treatment team is made up of a variety of professionals. For example, a psychiatrist, nurse, case manager, employment counselor, and substance-abuse counselor often make up an ACT team. Over the long term, ACT tends to be successful in reducing how often people with schizophrenia are psychiatrically hospitalized or become homeless.
- Substance abuse treatment – Providing medical and psychosocial interventions that address substance abuse should be an integral part of treatment as about 50% of individuals with schizophrenia suffer from some kind of substance abuse or dependence.
- Social skills training – Also called illness management and recovery programming, social-skills training involves teaching clients ways to handle social situations appropriately. It may be conducted as part of individual or group psychotherapy and often involves the person scripting (thinking through or role-playing) situations that occur in social settings in order to prepare for those situations when they actually occur. This treatment type has been found to help people with schizophrenia resist using drugs of abuse, as well as improve their relationships with health care professionals and with people at work.
- Supported employment – This intervention provides supports like a job coach (someone who periodically or consistently counsels the client in the workplace), as well as instruction on constructing a résumé, interviewing for jobs, and education and support for employers to hire individuals with chronic mental illness. Supported employment has been found to help schizophrenia sufferers secure and maintain employment, earn more money, and increase the number of hours they are able to work.
- Cognitive behavioral therapy (CBT) – CBT is a reality-based intervention that focuses on helping a client understand and change patterns that tend to interfere with his or her ability to interact with others and otherwise function. Except for people who are actively psychotic, CBT has been found to help individuals with schizophrenia decrease symptoms and improve their ability to function socially. This intervention can be done either individually or in group therapy.
- Group therapy – Group therapy is usually supportive and expressive, in that participants are encouraged in their efforts to care for themselves and otherwise engage in healthy, appropriate behaviors in the community.
- Weight management – Educating people with schizophrenia about weight gain and related health problems that can be a side effect of some antipsychotic and other psychiatric medications have been found to be helpful in resulting in a modest weight loss. That is also true when schizophrenia sufferers are provided with behavioral interventions to help with weight loss.
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