SCHIZOPHRENIA

• DEFINITION

Schizophrenia is a group of serious brain disorders in which reality is interpreted abnormally. Schizophrenia results in hallucinations, delusions, and disordered thinking and behavior. People with schizophrenia withdraw from the people and activities in the world around them, retreating into an inner world marked by psychosis.

Contrary to popular belief, schizophrenia isn't the same as a split personality or multiple personality. While the word "schizophrenia" does means "split-mind," it refers to a disruption of the usual balance of emotions and thinking.

Schizophrenia is a chronic condition, requiring lifelong treatment. But thanks to new medications, schizophrenia symptoms can often be successfully managed, allowing people with the condition to lead productive, enjoyable lives.

• SYMPTOMS

There are several types of schizophrenia, so signs and symptoms vary. In general, schizophrenia symptoms include:

• Beliefs not based on reality (delusions), such as the belief that there's a conspiracy against you
• Seeing or hearing things that don't exist (hallucinations), especially voices
• Incoherent speech
• Neglect of personal hygiene
• Lack of emotions
• Emotions inappropriate to the situation
• Angry outbursts
• Catatonic behavior
• A persistent feeling of being watched
• Trouble functioning at school and work
• Social isolation
• Clumsy, uncoordinated movements

Schizophrenia ranges from mild to severe. Some people may be able to function well in daily life, while others need specialized, intensive care. In some cases, schizophrenia symptoms seem to appear suddenly. Other times, schizophrenia symptoms seem to develop gradually over months, and they may not be noticeable at first.

Over time, it becomes difficult to function in daily life. You may not be able to go to work or school. You may have troubled relationships, partly because of difficulty reading social cues or others' emotions. You may lose interest in activities you once enjoyed. You may be distressed or agitated or fall into a trance-like state, becoming unresponsive to others.

In addition to the general schizophrenia symptoms, symptoms are often categorized in three ways to help with diagnosis and treatment:

Negative signs and symptoms
Negative signs and symptoms represent a loss or decrease in emotions or behavioral abilities. They may include:

• Loss of interest in everyday activities
• Appearing to lack emotion
• Reduced ability to plan or carry out activities
• Neglecting hygiene
• Social withdrawal
• Loss of motivation

Positive signs and symptoms
Positive signs and symptoms are unusual thoughts and perceptions that often involve a loss of contact with reality. These symptoms may come and go. They may include:

• Hallucinations, or sensing things that aren't real. In schizophrenia, hearing voices is a common hallucination. These voices may seem to give you instructions on how to act, and they sometimes may include harming others.
• Delusions, or beliefs that have no basis in reality. For example, you may believe that the television is directing your behavior or that outside forces are controlling your thoughts.
• Thought disorders, or difficulty speaking and organizing thoughts, such as stopping in midsentence or jumbling together meaningless words, sometimes known as "word salad."
• Movement disorders, such as repeating movements, clumsiness or involuntary movements.

Cognitive signs and symptoms
Cognitive symptoms involve problems with memory and attention. These symptoms may be the most disabling in schizophrenia because they interfere with the ability to perform routine daily tasks. They include:

• Problems making sense of information
• Difficulty paying attention
• Memory problems

• CAUSES

It's not known what causes schizophrenia. However, researchers believe that an interaction of genetics and environment may cause schizophrenia. Problems with certain naturally occurring brain chemicals, including the neurotransmitters dopamine and glutamate, also may contribute to schizophrenia. Neuroimaging studies show differences in the brain structure and central nervous system of people with schizophrenia. While researchers aren't fully certain about the significance of these changes, they support evidence that schizophrenia is a brain disease.

• RISK FACTORS

Schizophrenia affects about 1 percent of the general population. In people who have close relatives with schizophrenia, the illness is much more common — about 10 percent. In men, schizophrenia symptoms typically start in the teens or 20s. In women, schizophrenia symptoms typically begin in the 20s or early 30s.

Although the precise cause of schizophrenia isn't known, researchers have identified certain factors that seem to increase the risk of developing or triggering schizophrenia, including:

• Having a family history of schizophrenia
• Exposure to viruses while in the womb
• Malnutrition while in the womb
• Stressful life circumstances
• Older paternal age
• Taking psychoactive drugs during adolescence

• TEST AND DIAGNOSIS

When doctors suspect someone has schizophrenia, they typically run a battery of medical and psychological tests and exams. These can help rule out other problems that could be causing your symptoms, pinpoint a diagnosis and also check for any related complications. These exams and tests generally include:

• Physical exam. This may include measuring height and weight; checking vital signs, such as heart rate, blood pressure and temperature; listening to the heart and lungs; and examining the abdomen.
• Laboratory tests. These may include a complete blood count (CBC), screening for alcohol and drugs, and imaging studies, such as an MRI or CT scan.
• Psychological evaluation. A doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. He or she will ask about delusions or hallucinations and check for signs of psychosis. You may also fill out psychological self-assessments and questionnaires. You may be asked about substance or alcohol abuse. And with your permission, family members or close friends may be asked to provide information about your symptoms.

Diagnostic criteria for schizophrenia
To be diagnosed with schizophrenia, you must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Diagnostic criteria for schizophrenia are:

• Presence of at least two of these: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or presence of negative symptoms
• Significant impairment in the ability to work, attend school or perform normal daily tasks
• Signs last for at least six months
• Other mental health disorders have been ruled out

You may be diagnosed with one of the five subtypes of schizophrenia, although not all people easily fit into a specific category. The five subtypes are:

• Paranoid
• Catatonic
• Disorganized
• Undifferentiated
• Residual

Talk to your doctor about which type of schizophrenia you have so that you can learn more about your specific situation and its treatments.

• TREATMENT AND DRUGS

Schizophrenia is a chronic condition that requires lifelong treatment, even during periods when you feel better and your symptoms have subsided. Treatment with medications and psychosocial therapy can help you take control of your condition and become an active and informed participant in your own care. During crisis periods or times of severe symptoms, hospitalization may be necessary for your safety and to make sure you're getting proper nutrition, sleep and hygiene.

Schizophrenia treatment is usually guided by a psychiatrist skilled in treating the condition. But you may have others on your treatment team as well, including psychologists, social workers and psychiatric nurses, because the condition can affect so many areas of your life. You may also have a case manager to make sure that you're getting all of the treatment you need and that your care is coordinated among all of your health care providers.

Medications
Medications are the cornerstone of schizophrenia treatment. But because medications for schizophrenia can cause serious but rare side effects, you may be reluctant to take them. Work with your psychiatrist and other health care providers to find a medication regimen that works for you, with the fewest side effects.

Antipsychotic medications are the most commonly prescribed medications to treat schizophrenia. They're thought to control symptoms by affecting the brain neurotransmitters dopamine and serotonin. There are two main types of antipsychotic medications:

• Conventional, or typical, antipsychotics. These medications have traditionally been very effective in managing the positive symptoms of schizophrenia. These medications have frequent and potentially severe neurological side effects, including the possibility of tardive dyskinesia, or involuntary jerking movements. This group of medications includes:
• Haloperidol (Haldol)
• Thioridazine
• Fluphenazine

These typical antipsychotics are often cheaper than newer counterparts, especially the generic versions, which can be an important consideration when long-term treatment is necessary.

• New generation, also called atypical antipsychotics. These newer antipsychotic medications are effective at managing both positive and negative symptoms. They include:

• Clozapine (Clozaril)
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Paliperidone (Invega)

Risperidone (Risperdal) is the only atypical antipsychotic medication that's been approved by the Food and Drug Administration (FDA) to treat schizophrenia in children ages 13 to 17. Atypical antipsychotic medications pose a risk of metabolic side effects, including weight gain, diabetes and high cholesterol.

Which medication is best for you depends on your own individual situation. It can take several weeks after first starting a medication to notice an improvement in your symptoms. In general, the goal of treatment with antipsychotic medications is to effectively control signs and symptoms at the lowest possible dosage. Other medications also may be helpful, such as antidepressants or anti-anxiety medications.

If one medication doesn't work well for you or has intolerable side effects, your doctor may recommend combining medications, switching to a different medication or adjusting your dosage. Don't stop taking your medications without talking to your doctor, even if you're feeling better. You may have a relapse of psychotic symptoms if you stop taking your medication. In addition, antipsychotic medication needs to be tapered off, rather than stopped abruptly, to avoid withdrawal symptoms.

Be aware that all antipsychotic medications have side effects and possible health risks. Certain antipsychotic medications, for instance, may increase the risk of diabetes, weight gain, high cholesterol and high blood pressure. Clozaril can cause dangerous changes in your white blood cell count. Certain antipsychotic medications can cause serious health problems in some older adults and should be avoided.

Be sure to talk to your doctor about all of the possible side effects and being monitored for health problems while you take these medications. Antipsychotic medications can also have dangerous interactions with other substances. Your doctors should know about all medications and over-the-counter substances you take, including vitamins, minerals and herbal supplements.

Psychosocial treatments
Although medications are the cornerstone of schizophrenia treatment, psychotherapy and other psychosocial treatments also are important. These treatments may include:

• Individual therapy. Psychotherapy with a skilled mental health provider can help you learn ways to cope with the daily life challenges brought on by schizophrenia. Therapy can help you improve communications skills, relationships, your ability to work and your motivation to stick to your treatment plan. Learning about schizophrenia can help you understand it better, cope with lingering symptoms, and understand the importance of taking your medications. Therapy can also help you cope with stigma surrounding schizophrenia.
• Family therapy. Both you and your family may benefit from therapy that provides support and education to families. Your symptoms have a better chance of improving if your family members understand your illness, can recognize stressful situations that might trigger a relapse, and can help you stick to your treatment plan. Family therapy can also help you and your family communicate better with each other and understand family conflicts. Family therapy can also help family members cope and reduce their distress about your condition.
• Rehabilitation. Training in social and vocational skills to live independently is an important part of recovery from schizophrenia. With the help of a therapist, you can learn such skills as good hygiene, cooking and better communication. Many communities have programs to help people with schizophrenia with jobs, housing, self-help groups and crisis situations. If you don't have a case manager to help you with these services, ask your doctors about getting one. Today, fewer people with schizophrenia require long-term hospitalization because effective treatments are available.

Treatment challenges
When you have appropriate treatment and stick to your treatment plan, you have a good chance of leading a productive life and functioning well in daily activities. But be prepared for challenges that can interfere with treatment.

For one thing, it's often difficult for people with schizophrenia to stick to their treatment plans. You may believe that you don't need medications or other treatment. Also, if you're not thinking clearly, you may forget to take your medications or to go to therapy appointments. Talk to your doctors about tips to stick to your treatment plan, such as taking a medication that's available in a long-lasting injectable form. Even with good treatment, you may have a relapse. Have a plan in place to deal with a relapse.

Many people with schizophrenia smoke, often heavily. If you smoke, you may need a higher dose of antipsychotic medication because nicotine interferes with these medications.

Similarly, using alcohol and drugs can make schizophrenia symptoms worse. If you have a problem with alcohol or substance abuse, you may benefit from treatment programs that include care for both schizophrenia and substance abuse.