What is Schizophrenia?

Schizophrenia is a brain disorder that affects a person's ability to perceive the world and to process information. It occurs in 1% of the population and typically appears in adolescence or young adulthood. Schizophrenia is diagnosed by a clinical assessment that includes assessment of current and historical symptoms and functional status.

A common perception of schizophrenia is that it is a devastating disorder. Although schizophrenia can be a very serious and chronic illness, it varies greatly among individuals. Many people with schizophrenia are able to live independently, work and lead normal lives. Others may need ongoing support, but still can attain meaningful recovery.

Symptoms

The symptoms of schizophrenia tend to fall into three categories:

Positive Symptoms

• Hallucinations - Hallucinations can take a number of different forms - they can be:

1. Visual (seeing things that are not there or that other people cannot see),
2. Auditory (hearing voices that other people can't hear),
3. Tactile (feeling things that other people don't feel or something touching your skin that isn't there),
4. Olfactory (smelling things that other people cannot smell, or not smelling the same thing that other people do smell),
5. Gustatory experiences (tasting things that aren't there)

• Delusions - false beliefs strongly held in spite of invalidating evidence, especially as a symptom of mental illness: for example,

1. Paranoid delusions, or delusions of persecution, for example believing that people are "out to get" you, or the thought that people are doing things when there is no external evidence that such things are taking place.
2. Delusions of reference - when things in the environment seem to be directly related to you even though they are not. For example it may seem as if people are talking about you or special personal messages are being communicated to you through the TV, radio, or other media.
3. Somatic Delusions are false beliefs about your body - for example that a terrible physical illness exists or that something foreign is inside or passing through your body.
4. Delusions of grandeur - for example when you believe that you are very special or have special powers or abilities. An example of a grandiouse delusion is thinking you are a famous rock star.

 Negative Symptoms

• Lack of emotion - the inability to enjoy regular activities (visiting with friends, etc.) as much as before
• Low energy - the person tends to sit around and sleep much more than normal
• Lack of interest in life, low motivation
• Affective flattening - a blank, blunted facial expression or less lively facial movements, flat voice (lack of normal intonations and variance) or physical movements
• Alogia (difficulty or inability to speak)
• Inappropriate social skills or lack of interest or ability to socialize with other people
• Inability to make friends or keep friends, or not caring to have friends
• Social isolation - person spends most of the day alone or only with close family

Cognitive Symptoms

• Disorganized thinking
• Slow thinking
• Difficulty understanding
• Poor concentration
• Poor memory
• Problems with attention

What do we know about the biological basis of schizophrenia?

In the last twenty years, there has been an explosion of knowledge about how the brain works. It is clear the brain functions in a highly integrated manner, and that there are neural circuits essential to normal brain function. These circuits are not unlike a very complicated road system, where information may travel down a main road, but may also get to the appropriate destination by alternative routes. Like the "alternative routes" that one may use in a traffic jam, the "alternative routes" may not be as efficient as the main route. Throughout life, but especially during childhood and adolescence, major pruning of redundant "routes" occurs. This neural pruning prepares the individual for the tasks of adulthood, but in the course of the changes, an "alternative route" may be cut off in a person with schizophrenia unmasking the problematic "main route", and thus the symptoms of schizophrenia.

Information is transmitted through these neural circuits, or "routes", via a relay of chemicals called neurotransmitters. There are probably hundreds of neurotransmitters in the brain. Substantial research is directed at better understanding how neurotransmitter systems work in healthy brains and in brains with schizophrenia, but little is known for sure. One hypothesis that is the focus of a great deal of research is that the dopamine neurotransmitter system in a part of the brain involved in emotion and information processing, the mesolimbic system, is involved in hallucinations and delusions. A related hypothesis is that the dopamine system in another brain area--the prefrontal cortex--is involved in the decrease in experience of emotions and other negative symptoms of schizophrenia. However, there are hypotheses that many neurotransmitter systems may be involved in schizophrenia, including norepinephrine, acetylcholine, and serotonin, to name just a few.

What causes schizophrenia?

Like pneumonia, which can be caused by various bacteria, viruses, or chemicals, schizophrenia probably has multiple causes, all of which affect the brain in related ways. Research suggests that both genes and environmental factors are involved in developing schizophrenia. While 1 out of every 100 persons has schizophrenia, having a biological relative with schizophrenia increases a person's risk of developing this disorder. A person who has a genetically identical twin with schizophrenia has a 50% chance of having schizophrenia and a 50% chance of not having schizophrenia. A person with a sibling or a parent with schizophrenia has a 10% of having schizophrenia and 90% chance of not having schizophrenia. Thus, research is aimed at finding both the genetic factor that may put a person at increased risk for schizophrenia, and the environmental factors that may be involved. There is active and exciting research to find the genes that increase risk for schizophrenia. Three areas on various chromosomes have been linked to schizophrenia in more than one study; however, the actual gene that increases risk for schizophrenia has not yet been found.

The search for possible environmental factors is in very early stages. One prominent theory is that schizophrenia results from altered brain development during fetal life, occuring from in utero environmental stressors. For example, several, but not all, studies have shown that individuals who were fetuses during influenza epidemics are at increased risk of schizophrenia. A few studies have shown that indiivuduals that were fetuses and their mothers endured severe starvation during that preganancy are at increased risk for schizophrenia. Another study has shown that Rh incompatibility between mother and fetus increases risk for schizophrenia. During fetal life the brain is actively developing. The theory is that these stressors somehow interfere with brain development during a critical stage. In post-mortem studies the brains of individuals with schizophrenia have been examined. Here, several researchers have found that the organization of brain cells was more random than in the brains from mentally healthy individuals. In addition, they have found "nests" of brain cells in patients with schizophrenia in the mesolimbic areas of the brain, suggesting that these cells were somehow stopped in their programmed migration to their final resting place. These and other studies hold promise for our eventual understanding of how genes and environment may interact to cause schizophrenia. Regardless, evidence is overwhelming that schizophrenia is a biologically based illness and that the previous view that parents or families cause schizophrenia is totally without merit.

How do you treat schizophrenia?

One very important thing to remember is that schizophrenia, like many other chronic illnesses, is treatable. Antipsychotic medications are the cornerstone of treatment for pscychotic disorders. Antipsychotic medications eliminate or lessen the symptoms of schizophrenia in most patients. Without medications, symptoms will almost always occur. With each recurrence, the symptoms usually take longer to get better, and may not respond as well. When individuals with schizophrenia have repeated exacerbations of symptoms , or "relapses", they may often develop chronic symptoms that do not respond well to medication. The goal of medication treatment is to take medications when symptoms first occur, and to stay on medications even if symptoms go away entirely, to help prevent future relapses. Research now suggests that ongoing hallucinations and delusions are symptoms of a process that is toxic to the brain. Control of the symptoms may also mean that this brain damaging process is also halted. Regardless, several studies have shown that the earlier a person with schizophrenia gets treatment, the more mild the illness.

Antipsychotic medications may have troublesome side effects. It is important to find a doctor who will work with you to address problems with side effects. In addition to treatment with medications, there are many psychosocial treatments that have been shown to be effective in treating schizophrenia. These important treatments work best in combination with medication. They include supportive psychotherapy, cognitive behavioral therapy, family psychoeducation, skills training, and a variety of psychiatric rehabilitation services.
Sometimes persons with schizophrenia may have difficulty with practical life issues, such as accessing disability benefits or finding appropriate housing. Case management services can help immensely to provide ongoing assessment and support while linking people to the types of resources and supports they need.