Schizophrenia is a chronic,
severe, and disabling brain disorder that has been
recognized throughout recorded history.
with schizophrenia may hear voices other people
don't hear or they may believe that others are
reading their minds, controlling their thoughts, or
plotting to harm them. These experiences are
terrifying and can cause fearfulness, withdrawal, or
extreme agitation. People with schizophrenia may not
make sense when they talk, may sit for hours without
moving or talking much, or may seem perfectly fine
until they talk about what they are really thinking.
Because many people with schizophrenia have
difficulty holding a job or caring for themselves,
the burden on their families and society is
significant as well.
treatments can relieve many of the disorder's
symptoms, but most people who have schizophrenia
must cope with some residual symptoms as long as
they live. Nevertheless, this is a time of hope for
people with schizophrenia and their families. Many
people with the disorder now lead rewarding and
meaningful lives in their communities. Researchers
are developing more effective medications and using
new research tools to understand the causes of
schizophrenia and to find ways to prevent and treat
The symptoms of schizophrenia fall into three
are unusual thoughts or perceptions, including
hallucinations, delusions, thought disorder, and
disorders of movement.
represent a loss or a decrease in the ability to
initiate plans, speak, express emotion, or find pleasure
in everyday life. These symptoms are harder to recognize
as part of the disorder and can be mistaken for laziness
(or cognitive deficits) are problems with attention,
certain types of memory, and the executive functions
that allow us to plan and organize. Cognitive deficits
can also be difficult to recognize as part of the
disorder but are the most disabling in terms of leading
a normal life.
Positive symptoms are easy-to-spot behaviors not seen in
healthy people and usually involve a loss of contact
with reality. They include hallucinations, delusions,
thought disorder, and disorders of movement. Positive
symptoms can come and go. Sometimes they are severe and
at other times hardly noticeable, depending on whether
the individual is receiving treatment.
A hallucination is something a person sees, hears,
smells, or feels that no one else can see, hear, smell,
or feel. "Voices" are the most common type of
hallucination in schizophrenia. Many people with the
disorder hear voices that may comment on their behavior,
order them to do things, warn them of impending danger,
or talk to each other (usually about the patient). They
may hear these voices for a long time before family and
friends notice that something is wrong. Other types of
hallucinations include seeing people or objects that are
not there, smelling odors that no one else detects
(although this can also be a symptom of certain brain
tumors), and feeling things like invisible fingers
touching their bodies when no one is near.
Delusions are false personal beliefs that are not part
of the person's culture and do not change, even when
other people present proof that the beliefs are not true
or logical. People with schizophrenia can have delusions
that are quite bizarre, such as believing that neighbors
can control their behavior with magnetic waves, people
on television are directing special messages to them, or
radio stations are broadcasting their thoughts aloud to
others. They may also have delusions of grandeur and
think they are famous historical figures. People with
paranoid schizophrenia can believe that others are
deliberately cheating, harassing, poisoning, spying
upon, or plotting against them or the people they care
about. These beliefs are called delusions of
People with schizophrenia often have unusual thought
processes. One dramatic form is disorganized thinking,
in which the person has difficulty organizing his or her
thoughts or connecting them logically. Speech may be
garbled or hard to understand. Another form is "thought
blocking," in which the person stops abruptly in the
middle of a thought. When asked why, the person may say
that it felt as if the thought had been taken out of his
or her head. Finally, the individual might make up
unintelligible words, or "neologisms."
Disorders of Movement.
People with schizophrenia can be clumsy and
uncoordinated. They may also exhibit involuntary
movements and may grimace or exhibit unusual mannerisms.
They may repeat certain motions over and over or, in
extreme cases, may become catatonic. Catatonia is a
state of immobility and unresponsiveness. It was more
common when treatment for schizophrenia was not
available; fortunately, it is now rare.
The term "negative symptoms" refers to reductions in
normal emotional and behavioral states. These include
flat affect (immobile facial expression, monotonous
lack of pleasure in everyday life,
diminished ability to initiate and sustain planned
speaking infrequently, even when forced to interact.
People with schizophrenia often neglect basic hygiene
and need help with everyday activities. Because it is
not as obvious that negative symptoms are part of a
psychiatric illness, people with schizophrenia are often
perceived as lazy and unwilling to better their lives.
Cognitive symptoms are subtle and are often detected
only when neuropsychological tests are performed. They
include the following:
poor "executive functioning" (the ability to absorb and
interpret information and make decisions based on that
inability to sustain attention, and
problems with "working memory" (the ability to keep
recently learned information in mind and use it right
Cognitive impairments often interfere with the patient's
ability to lead a normal life and earn a living.
They can cause great emotional distress.
Psychotic symptoms (such as hallucinations and
delusions) usually emerge in men in their late teens and
early 20s and in women in their mid-20s to early 30s.
They seldom occur after age 45 and only rarely before
puberty, although cases of schizophrenia in children as
young as 5 have been reported. In adolescents, the first
signs can include a change of friends, a drop in grades,
sleep problems, and irritability. Because many normal
adolescents exhibit these behaviors as well, a diagnosis
can be difficult to make at this stage. In young people
who go on to develop the disease, this is called the "prodromal"
Research has shown that schizophrenia affects men and
women equally and occurs at similar rates in all ethnic
groups around the world.
Like many other illnesses,
schizophrenia is believed to result from a
combination of environmental and genetic
factors. All the tools of modern science are
being used to search for the causes of this
Can schizophrenia be
Scientists have long known
that schizophrenia runs in families. It occurs
in 1 percent of the general population but is
seen in 10 percent of people with a first-degree
relative (a parent, brother, or sister) with the
disorder. People who have second-degree
relatives (aunts, uncles, grandparents, or
cousins) with the disease also develop
schizophrenia more often than the general
population. The identical twin of a person with
schizophrenia is most at risk, with a 40 to 65
percent chance of developing the disorder.
Our genes are located on 23
pairs of chromosomes that are found in each
cell. We inherit two copies of each gene, one
from each parent. Several of these genes are
thought to be associated with an increased risk
of schizophrenia, but scientists believe that
each gene has a very small effect and is not
responsible for causing the disease by itself.
It is still not possible to predict who will
develop the disease by looking at genetic
Although there is a genetic
risk for schizophrenia, it is not likely that
genes alone are sufficient to cause the
disorder. Interactions between genes and the
environment are thought to be necessary for
schizophrenia to develop. Many environmental
factors have been suggested as risk factors,
such as exposure to viruses or malnutrition in
the womb, problems during birth, and
psychosocial factors, like stressful
Do people with schizophrenia have faulty
It is likely that an
imbalance in the complex, interrelated chemical
reactions of the brain involving the
neurotransmitters dopamine and glutamate (and
possibly others) plays a role in schizophrenia.
Neurotransmitters are substances that allow
brain cells to communicate with one another.
Basic knowledge about brain chemistry and its
link to schizophrenia is expanding rapidly and
is a promising area of research.
Do the brains of people with
schizophrenia look different?
The brains of people with
schizophrenia look a little different than the
brains of healthy people, but the differences
are small. Sometimes the fluid-filled cavities
at the center of the brain, called ventricles,
are larger in people with schizophrenia; overall
gray matter volume is lower; and some areas of
the brain have less or more metabolic activity.
Microscopic studies of brain tissue after death
have also revealed small changes in the
distribution or characteristics of brain cells
in people with schizophrenia. It appears that
many of these changes were prenatal because they
are not accompanied by glial cells, which are
always present when a brain injury occurs after
birth. One theory suggests that problems during
brain development lead to faulty connections
that lie dormant until puberty. The brain
undergoes major changes during puberty, and
these changes could trigger psychotic symptoms.
How is schizophrenia diagnosed?
The symptoms of schizophrenia
can be very frightening for the person
experiencing them, or for friends and loved ones
observing them. If you or someone you care about
experiences symptoms that suggest schizophrenia,
it’s very important to get advice from a doctor
right away. You’ll need to see a psychiatrist to
rule out or diagnose schizophrenia. The symptoms
may indicate another illness that needs to be
treated. If the diagnosis is schizophrenia it’s
very important to begin treatment as soon as
possible in order to make the best recovery.
Schizophrenia is a type of
mental illness classified as a psychotic
disorder. People with schizophrenia have
symptoms of psychosis, which make them appear to
be out of touch with reality. However, other
illnesses may also involve psychotic symptoms.
There is no blood test or brain scan to diagnose
schizophrenia. Only some one with special
training to diagnose mental illness can make an
accurate diagnosis of schizophrenia. . In order
to diagnose schizophrenia, a doctor will perform
a variety of interview and psychological tests
to determine the patient’s current beliefs and
symptoms as well as the history of the patient.
Five Types of Symptoms of
There are five basic types of
symptoms of schizophrenia that a doctor will
look for when trying to make a diagnosis. The
first four types are described as positive
symptoms, and the last type includes all
In addition to the positive
and negative symptoms, a patient may have
cognitive symptoms as well. Those symptoms are
not specific to the definition of schizophrenia
that the doctor will use to make the diagnosis.
Five Types of Schizophrenia
There are five basic subtypes
of schizophrenia, which are distinguished by the
combination of symptoms a patient experiences.
Based on psychological tests and interviews, the
formal diagnosis of schizophrenia will specify
one of these types.
Schizophrenia. Prominent features of
this diagnosis involve hallucinations or
delusions fixated on a theme that often
involves being plotted against, betrayed or
persecuted. Negative symptoms such as
flattened affect, catatonia, or disorganized
speech are not as prominent as in other
types of schizophrenia.
Schizophrenia. This diagnosis describes
patients who exhibit disorganized behavior
and speech as well as negative symptoms, but
relatively fewer hallucinations or
Schizophrenia. This diagnosis is made
when the most prominent symptoms are bizarre
behavior and abnormal activity, either very
little activity or overly excited behavior.
Schizophrenia. These patients show a
mixture of psychotic symptoms (delusions,
hallucinations, disorganized speech,
disorganized behavior, and negative
symptoms), with no one type of symptoms
dominating the behavior.
Schizophrenia. This diagnosis is more
rarely used than the other four. It
describes a patient who at one time met the
criteria for one of the other four types but
who no longer has significant delusions,
hallucinations, disorganized speech or
disorganized behavior. To meet this
diagnosis, the person will either have
negative symptoms like flattened affect or
reduced activity or speech, or have greatly
reduced, residual positive symptoms like
delusions, hallucinations, or disorganized
speech or behavior.
Other Psychotic Disorders
Most of the symptoms of
schizophrenia are symptoms of psychosis, but it
is possible to have psychotic symptoms without
having schizophrenia. Other psychotic disorders
Brief Psychotic Disorder
Shared Psychotic Disorder
Psychotic Disorder Due to
a General Medical Condition
Psychotic Disorder Not
There are also disorders that
can have psychosis as a symptom:
Mood Disorder with
Cognitive Disorder with
and disorders that can
masquerade as psychosis:
How is schizophrenia treated?
Because the causes of schizophrenia are still
unknown, current treatments focus on eliminating the
symptoms of the disease.
Antipsychotic medications have
been available since the mid-1950s. They effectively
alleviate the positive symptoms of schizophrenia.
While these drugs have greatly improved the lives of
many patients, they do not cure schizophrenia.
Everyone responds differently to
antipsychotic medication. Sometimes several
different drugs must be tried before the right one
is found. People with schizophrenia should work in
partnership with their doctors to find the
medications that control their symptoms best with
the fewest side effects.
The older antipsychotic
medications include chlorpromazine (Thorazine®),
haloperidol (Haldol®), perphenazine (Etrafon®,
Trilafon®), and fluphenzine (Prolixin®). The older
medications can cause extrapyramidal side effects,
such as rigidity, persistent muscle spasms, tremors,
In the 1990s, new drugs, called
atypical antipsychotics, were developed that rarely
produced these side effects. The first of these new
drugs was clozapine (Clozaril®). It treats psychotic
symptoms effectively even in people who do not
respond to other medications, but it can produce a
serious problem called agranulocytosis, a loss of
the white blood cells that fight infection.
Therefore, patients who take clozapine must have
their white blood cell counts monitored every week
or two. The inconvenience and cost of both the blood
tests and the medication itself has made treatment
with clozapine difficult for many people, but it is
the drug of choice for those whose symptoms do not
respond to the other antipsychotic medications, old
Some of the drugs that were
developed after clozapine was introduced—such as
risperidone (Risperdal®), olanzapine (Zyprexa®),
quietiapine (Seroquel®), sertindole (Serdolect®),
and ziprasidone (Geodon®)—are effective and rarely
produce extrapyramidal symptoms and do not cause
agranulocytosis; but they can cause weight gain and
metabolic changes associated with an increased risk
of diabetes and high cholesterol.
People respond individually to
antipsychotic medications, although agitation and
hallucinations usually improve within days and
delusions usually improve within a few weeks. Many
people see substantial improvement in both types of
symptoms by the sixth week of treatment. No one can
tell beforehand exactly how a medication will affect
a particular individual, and sometimes several
medications must be tried before the right one is
When people first start to take
atypical antipsychotics, they may become drowsy;
experience dizziness when they change positions;
have blurred vision; or develop a rapid heartbeat,
menstrual problems, a sensitivity to the sun, or
skin rashes. Many of these symptoms will go away
after the first days of treatment, but people who
are taking atypical antipsychotics should not drive
until they adjust to their new medication.
If people with schizophrenia
become depressed, it may be necessary to add an
antidepressant to their drug regimen.
Length of Treatment.
Like diabetes or high blood pressure, schizophrenia
is a chronic disorder that needs constant
management. At the moment, it cannot be cured, but
the rate of recurrence of psychotic episodes can be
decreased significantly by staying on medication.
Although responses vary from person to person, most
people with schizophrenia need to take some type of
medication for the rest of their lives as well as
use other approaches, such as supportive therapy or
Relapses occur most often when
people with schizophrenia stop taking their
antipsychotic medication because they feel better,
or only take it occasionally because they forget or
don't think taking it regularly is important. It is
very important for people with schizophrenia to take
their medication on a regular basis and for as long
as their doctors recommend. If they do so, they will
experience fewer psychotic symptoms.
medication should be discontinued without talking to
the doctor who prescribed it, and it should always
be tapered off under a doctor's supervision rather
than being stopped all at once.
There are a variety of reasons
why people with schizophrenia do not adhere to
treatment. If they don't believe they are ill, they
may not think they need medication at all. If their
thinking is too disorganized, they may not remember
to take their medication every day. If they don't
like the side effects of one medication, they may
stop taking it without trying a different
medication. Substance abuse can also interfere with
treatment effectiveness. Doctors should ask patients
how often they take their medication and be
sensitive to a patient's request to change dosages
or to try new medications to eliminate unwelcome
There are many strategies to help
people with schizophrenia take their drugs
regularly. Some medications are available in
long-acting, injectable forms, which eliminate the
need to take a pill every day. Medication calendars
or pillboxes labeled with the days of the week can
both help patients remember to take their
medications and let caregivers know whether
medication has been taken. Electronic timers on
clocks or watches can be programmed to beep when
people need to take their pills, and pairing
medication with routine daily events, like meals,
can help patients adhere to dosing schedules.
Antipsychotic medications can produce unpleasant or
dangerous side effects when taken with certain other
drugs. For this reason, the doctor who
prescribes the antipsychotics should be told about
all medications (over-the-counter and prescription)
and all vitamins, minerals, and herbal supplements
the patient takes. Alcohol or other drug use should
also be discussed.
Numerous studies have found that
psychosocial treatments can help patients
who are already stabilized on antipsychotic
medications deal with certain aspects of
schizophrenia, such as difficulty with
communication, motivation, self-care, work, and
establishing and maintaining relationships with
others. Learning and using coping mechanisms to
address these problems allows people with
schizophrenia to attend school, work, and socialize.
Patients who receive regular psychosocial treatment
also adhere better to their medication schedule and
have fewer relapses and hospitalizations. A positive
relationship with a therapist or a case manager
gives the patient a reliable source of information,
sympathy, encouragement, and hope, all of which are
essential for for managing the disease. The
therapist can help patients better understand and
adjust to living with schizophrenia by educating
them about the causes of the disorder, common
symptoms or problems they may experience, and the
importance of staying on medications.
Illness Management Skills.
People with schizophrenia can take an active role in
managing their own illness. Once they learn basic
facts about schizophrenia and the principles of
schizophrenia treatment, they can make informed
decisions about their care. If they are taught how
to monitor the early warning signs of relapse and
make a plan to respond to these signs, they can
learn to prevent relapses. Patients can also be
taught more effective coping skills to deal with
Integrated Treatment for
Co-occurring Substance Abuse.
is the most common co-occurring disorder in people
with schizophrenia, but ordinary substance abuse
treatment programs usually do not address this
population's special needs. Integrating
schizophrenia treatment programs and drug treatment
programs produces better outcomes.
Rehabilitation emphasizes social and vocational
training to help people with schizophrenia function
more effectively in their communities. Because
people with schizophrenia frequently become ill
during the critical career-forming years of life
(ages 18 to 35) and because the disease often
interferes with normal cognitive functioning, most
patients do not receive the training required for
skilled work. Rehabilitation programs can include
vocational counseling, job training, money
management counseling, assistance in learning to use
public transportation, and opportunities to practice
social and workplace communication skills.
Patients with schizophrenia are often discharged
from the hospital into the care of their families,
so it is important that family members know as much
as possible about the disease to prevent relapses.
Family members should be able to use different kinds
of treatment adherence programs and have an arsenal
of coping strategies and problem-solving skills to
manage their ill relative effectively. Knowing where
to find outpatient and family services that support
people with schizophrenia and their caregivers is
Cognitive Behavioral Therapy.
Cognitive behavioral therapy is useful for patients
with symptoms that persist even when they take
medication. The cognitive therapist teaches people
with schizophrenia how to test the reality of their
thoughts and perceptions, how to "not listen" to
their voices, and how to shake off the apathy that
often immobilizes them. This treatment appears to be
effective in reducing the severity of symptoms and
decreasing the risk of relapse.
Self-help groups for people with schizophrenia and
their families are becoming increasingly common.
Although professional therapists are not involved,
the group members are a continuing source of mutual
support and comfort for each other, which is also
therapeutic. People in self-help groups know that
others are facing the same problems they face and no
longer feel isolated by their illness or the illness
of their loved one. The networking that takes place
in self-help groups can also generate social action.
Families working together can advocate for research
and more hospital and community treatment programs,
and patients acting as a group may be able to draw
public attention to the discriminations many people
with mental illnesses still face in today's world.
Support groups and advocacy
groups are excellent resources for people with many
types of mental disorders.