Schizophrenia: Symptoms, Types, Causes, Treatment

Schizophrenia is a chronic, severe, debilitating mental illness characterized by disordered thoughts, abnormal behaviors, and anti-social behaviors. It is a psychotic disorder, meaning the person with schizophrenia does not identify with reality at times.

• Schizophrenia affects about 1.1% of the world's population
• 3.5 million Americans have schizophrenia
• Schizophrenia is most commonly diagnosed between the ages of 16 to 25
• Schizophrenia can be hereditary (runs in families)
• It affects men 1.5 times more commonly than women
• Schizophrenia and its treatment have an enormous effect on the economy, costing between $32.5-$65 billion each year

Schizophrenia in young children is rare. The National Institute of Mental Health (NIMH) estimates only 1 in 40,000 children experience the onset of schizophrenia symptoms before the age of 13.

There are five types of schizophrenia (discussed in the following slides). They are categorized by the types of symptoms the person exhibits when they are assessed:

• Paranoid schizophrenia
• Disorganized schizophrenia
• Catatonic schizophrenia
• Undifferentiated schizophrenia
• Residual schizophrenia

Paranoid-type schizophrenia is distinguished by paranoid behavior, including delusions and auditory hallucinations. Paranoid behavior is exhibited by feelings of persecution, of being watched, or sometimes this behavior is associated with a famous or noteworthy person a celebrity or politician, or an entity such as a corporation. People with paranoid-type schizophrenia may display anger, anxiety, and hostility. The person usually has relatively normal intellectual functioning and expression of affect.

A person with disorganized-type schizophrenia will exhibit behaviors that are disorganized or speech that may be bizarre or difficult to understand. They may display inappropriate emotions or reactions that do not relate to the situation at-hand. Daily activities such as hygiene, eating, and working may be disrupted or neglected by their disorganized thought patterns.

Disturbances of movement mark catatonic-type schizophrenia. People with this type of schizophrenia may vary between extremes: they may remain immobile or may move all over the place. They may say nothing for hours, or they may repeat everything you say or do. These behaviors put these people with catatonic-type schizophrenia at high risk because they are often unable to take care of themselves or complete daily activities.

Undifferentiated-type schizophrenia is a classification used when a person exhibits behaviors which fit into two or more of the other types of schizophrenia, including symptoms such as delusions, hallucinations, disorganized speech or behavior, or catatonic behavior.

When a person has a past history of at least one episode of schizophrenia, but the person currently has no symptoms (delusions, hallucinations, disorganized speech or behavior), they are considered to have residual-type schizophrenia. The person may be in complete remission, or may at some point resume symptoms.

Schizophrenia has multiple, intermingled causes which may differ from person to person, including:

• Genetics (runs in families)
• Environment
• Brain chemistry
• History of abuse or neglect

Schizophrenia has a genetic component. While schizophrenia occurs in only 1% of the general population, it occurs in 10% of people with a first-degree relative (parent, sibling) with the disorder. The risk is highest if an identical twin has schizophrenia. It is also more common in people with a second-degree relative (aunts, uncles, cousins, grandparents) with the disorder.

Many people with schizophrenia do not appear ill. However, many behavioral changes will cause the person to seem 'off' as the disease progresses. Symptoms include:

• Social withdrawal
• Anxiety
• Delusions
• Hallucinations
• Paranoid feelings or feelings of persecution
• Loss of appetite or neglecting to eat
• Loss of hygiene

Symptoms may also be grouped into categories, discussed in the following slides.

The "positive," or overtly psychotic, symptoms are symptoms not seen in healthy people, include:

• Delusions
• Hallucinations
• Disorganized speech or behavior
• Dysfunctional thinking
• Catatonia or other movement disorders

"Negative" symptoms disrupt normal emotions and behaviors and include:

• Social withdrawal
• "Flat affect," dull or monotonous speech, and lack of facial expression
• Difficulty expressing emotions
• Lack of self-care
• Inability to feel pleasure (anhedonia)

Cognitive symptoms may be most difficult to detect and these include:

• Inability to process information and make decisions
• Difficulty focusing or paying attention
• Problems with memory or learning new tasks

Affective symptoms refer to those which affect mood. Patients with schizophrenia often have overlapping depression and may have suicidal thoughts or behaviors.

The diagnosis of schizophrenia is made both by ruling out other medical disorders that can cause the behavioral symptoms (exclusion), and by observation of the presence of characteristic symptoms of the disorder. The doctor will look for the presence of delusions, hallucinations, disorganized speech or behavior, and/or negative symptoms, along with social withdrawal and/or dysfunction at work or in daily activities for at least six months.

The doctor may use physical examination, psychological evaluation, laboratory testing of blood, and imaging scans to produce a complete picture of the patient's condition.

Mental health screening and evaluation is an important part of the diagnosis process for schizophrenia. Many other mental illnesses such as bipolar disorder, schizoaffective disorder, anxiety disorders, severe depression, and substance abuse may mimic symptoms of schizophrenia. A doctor will perform an assessment to rule out these other conditions.

Antipsychotic medications are the first-line treatment for many patients with schizophrenia. Medications are often used in combination with other types of drugs to decrease or control the symptoms associated with schizophrenia. Some antipsychotic medications include:

• olanzapine (Zyprexa)
• risperidone (Risperdal)
• quetiapine (Seroquel)
• ziprasidone (Geodon)
• aripiprazole (Abilify)
• paliperidone (Invega)

Mood swings and depression are common in patients with schizophrenia. In addition to antipsychotics, other types of medications are used.

Mood stabilizers include:

• lithium (Lithobid)
• divalproex (Depakote)
• carbamazepine (Tegretol)
• lamotrigine (Lamictal)

Antidepressants include:

• fluoxetine (Prozac)
• sertraline (Zoloft)
• paroxetine (Paxil)
• citalopram (Celexa)
• escitalopram (Lexapro)
• venlafaxine (Effexor)
• desvenlafaxine (Pristiq)
• duloxetine (Cymbalta)
• bupropion (Wellbutrin)

Family psycho-education: It is important to include psychosocial interventions in the treatment of schizophrenia. Including family members to support patients decreases the relapse rate of psychotic episodes and improves the person's outcomes. Family relationships are improved when everyone knows how to support their loved one dealing with schizophrenia.

Assertive community treatment (ACT): Another form of psychosocial intervention includes use of out-patient support groups. Support teams including psychiatrists, nurses, case managers, and other counselors, meet regularly with the schizophrenic patient to help reduce the need for hospitalization or a decline in their mental status.

Substance abuse treatment: Many people with schizophrenia (up to 50%) also have substance abuse issues. These substance abuse issues worsen the behavioral symptoms of schizophrenia and need to be addressed for better outcomes.

Social skills training: Patients with schizophrenia may need to re-learn how to appropriately interact in social situations. This kind of psychosocial intervention involves rehearsing or role-playing real-life situations so the person is prepared when they occur. This type of training can reduce drug use, and improve relationships.

Supported employment: Many people with schizophrenia have difficulty entering or re-entering the work force due to their condition. This type of psychosocial intervention helps people with schizophrenia to construct resumes, interview for jobs, and even connects them with employers willing to hire people with mental illness.

Cognitive behavioral therapy (CBT): This type of intervention can help patients with schizophrenia change disruptive or destructive thought patterns, and enable them to function more optimally. It can help patients "test" the reality of their thoughts to identify hallucinations or "voices" and ignore them. This type of therapy may not work in actively psychotic patients, but it can help others who may have residual symptoms that medication does not alleviate.

Weight management: Many anti-psychotic and psychiatric drugs cause weight gain as a side effect. Maintaining a healthy weight, eating a well-balanced diet, and exercising regularly helps prevent or alleviate other medical issues.

The prognosis for people with schizophrenia can vary depending on the amount of support and treatment the patients receives. Many people with schizophrenia are able to function well and lead normal lives. However, people with schizophrenia have a higher death rate and higher incidence of substance abuse. When medications are taken regularly and the family is supportive, patients can have better outcomes.