Causes and Symptoms (Magill’s Medical Guide, Sixth Edition)
Schizophrenia is a disorder affecting the brain and mind. Eugen Bleuler (1857-1939), a Swiss psychiatrist, first named the disease in a 1908 paper that he wrote titled “Dementia Praecox: Or, The Group of Schizophrenias.” In 1911, he published a book with the same title describing the disease in more detail. Bleuler served as the head of an eight hundred-bed mental hospital in Switzerland and treated the worst and most chronic cases. Beginning in 1896, he embarked on a project to understand the inner world of the mentally ill. He developed work therapy programs for his patients, and he visited them and talked to them almost every day. Bleuler insisted that the hospital staff show the same kind of dedication and support for his clients that he did.
Bleuler’s discoveries challenged the traditional view of the causes and treatment of the disease. The traditional view, based on the work of the great German psychiatrist Emil Kraepelin (1856-1926), held that dementia, as it was called, always got worse and that the patient’s mind continued to degenerate until death. Kraepelin suggested that the disease, which he called dementia praecox, was hereditary and was the result of a poisonous substance that destroyed brain cells. Bleuler’s investigation of living victims led him to reject this view. Instead, he argued, continuing deterioration does not always take place because the disease can stop or go into remission at any...
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Treatment and Therapy (Magill’s Medical Guide, Sixth Edition)
Since the 1950’s, many medications have been developed that are very effective in treating the symptoms of schizophrenia. Psychotherapy can also be effective and beneficial to many patients. Drugs can be used to treat both positive and negative symptoms. Some, such as Haldol, Mellaril, Prolixin, Navane, Stelazine, and Thorazine, are used to treat positive symptoms. Clozapine and Risperidone can be used for both positive and negative symptoms. These medications work by blocking the production of excess dopamine, which may cause the positive symptoms, or by stimulating the production of the neurotransmitter, which reduces negative symptoms. Clozapine blocks both dopamine and serotonin, which apparently makes it more effective than any of the other drugs. These drugs are nonaddictive and do not provide a high or euphoric effect of any kind.
The chief problem resulting from the use of such drugs is the terrible side effects that they can produce. The most dreaded side effect, from the point of view of the patient, is tardive dyskinesia (TD). This problem emerges only after many years of use. TD is characterized by involuntary movement of muscles, frequent lip-smacking, facial grimaces, and constant rocking back and forth of the arms and the body. It is completely uncontrollable.
Dystonias are another side effect. Symptoms include the abrupt stiffening of muscles, such as the sudden contraction of muscles in the...
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Perspective and Prospects (Magill’s Medical Guide, Sixth Edition)
Hopes for improving the treatment of schizophrenia rest mainly on the continuing development of new drugs. Several studies suggest that psychotherapy directed at improving social skills and reducing stress helps many people with the disease improve the quality of their lives. It is known that stress-related emotions lead to increases in delusions, hallucinations, social withdrawal, and apathy. Therapists can help patients find ways of dealing with stress and living in communities. They encourage their patients to deal with feelings of hostility, rage, and distrust of other people. Family therapy can teach all members of a family how to live with a mentally ill family member. Such therapy, along with medication, can produce marvelous results.
One study of ninety-seven victims of schizophrenia who lived with their families, received individual therapy, and took their medications showed far fewer recurrences of acute symptoms than did a group that did not get such help. Among those fifty-four individuals who received therapy but lived alone or with nonfamily members, schizophrenia symptoms reappeared or worsened over the same three-year period of the study. People living alone usually had more severe symptoms to start out with and found it difficult to find housing, food, or clothing, even with therapy. The demands of life and therapy apparently were too much for them. The major problem with this kind of treatment,...
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For Further Information: (Magill’s Medical Guide, Sixth Edition)
Barlow, David H., ed. Clinical Handbook of Psychological Disorders. 4th ed. New York: Guilford Press, 2008. This collection defines and describes psychological disorders and uses case histories as illustrations for treatment.
Gorman, Jack M. The New Psychiatry: The Essential Guide to State-of-the-Art Therapy, Medication, and Emotional Health. New York: St. Martin’s Press, 1996. A well-written, easy-to-understand book by a doctor and researcher that provides the latest information concerning the development of new medications, treatments, and therapies. Valuable information on the new antipsychotic drugs, how they work, and what their possible side effects are.
Gottesman, Irving I. Schizophrenia Genesis: The Origins of Madness. New York: W. H. Freeman, 1991. The author, a leading researcher into the genetic causes of schizophrenia, describes recent discoveries on the origins of the disease. He also evaluates different treatments and the many kinds of counseling and therapeutic techniques.
Johnstone, Eve C., et al. Schizophrenia: Concepts and Clinical Management. New York: Cambridge University Press, 1999. Written in conjunction with colleagues from Edinburgh, Eve Johnstone’s book is a useful summary of current knowledge. The suggestion that psychosis can be thought of as occurring along three dimensions—positive, negative, and disorganized—with distinct...
(The entire section is 449 words.)
Risk Factors (Genetics & Inherited Conditions)
Factors that increase an individual’s risk of schizophrenia include having a parent or sibling with schizophrenia and having an abnormal brain structure. Risks for individuals in the Northern Hemisphere include being born during winter months and being born in the city. Additional risk factors include oxygen deprivation during pregnancy and issues at birth, such as a long labor, bleeding during pregnancy, prematurity, a low birth weight, maternal malnutrition, and infections during pregnancy. Loss of a parent during childhood is another risk factor.
Men typically develop symptoms in their late teens or early twenties, while onset for women tends to occur in their twenties or thirties. In rare cases, schizophrenia is seen in childhood.
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Etiology and Genetics (Genetics & Inherited Conditions)
Schizophrenia is an extraordinarily complex and variable clinical condition, and its etiology no doubt depends on a host of both genetic and environmental factors. It is safe to assume that there are many genes that contribute either to the susceptibility or the pathology of schizophrenia, but there is no single gene or mutation that exerts an overriding or self-sufficient effect in determining the development of the disease. Online Mendelian Inheritance in Man (http://www.ncbi.nlm.nih.gov/omim/), an authoritative database maintained by the National Center for Biotechnology Information, lists thirty-one genes scattered throughout the human genome that may be associated with susceptibility to schizophrenia.
In the summer of 2009, three research consortia reported results of their genomewide association studies on the genetics of schizophrenia, and all identified a region of particular importance on the short arm of chromosome 6 (at position 6p22.1). This region is known to contain a large cluster of genes (the major histocompatibility complex) that helps determine immunity and that also codes for proteins that are important for turning other genes on and off. Since mutations in this region are known to influence susceptibility to several autoimmune diseases, it may be likely that schizophrenia has an autoimmune component as well. Genetic variation in the control of such regulatory mechanisms might also account for the...
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Symptoms (Genetics & Inherited Conditions)
Symptoms usually start in adolescence or early adulthood. They often appear slowly and become more disturbing and bizarre over time, or they may occur in a matter of weeks or months.
Symptoms include hallucinations—seeing or hearing things/voices that are not there, and delusions—and strong but false personal beliefs that are not based in reality. Disorganized thinking; disorganized speech and a lack of ability to speak in a way that makes sense or to carry on a conversation; catatonic behavior, such as slow movement, repeating rhythmic gestures, pacing, walking in circles, negativism, and repetitive speech; emotional flatness, including flat speech, lack of facial expression, and general disinterest and withdrawal; paranoia, a psychosis characterized by systematized delusions of persecution or grandeur; inappropriate laughter; and poor hygiene and self-care are also symptoms. Associated conditions include obsessive-compulsive disorder, substance abuse (of drugs, alcohol, caffeine, or nicotine), and self-injury, including suicide.
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Screening and Diagnosis (Genetics & Inherited Conditions)
Early diagnosis is extremely important. Patients who are diagnosed early are able to stabilize their symptoms, decrease the risk of suicide, decrease alcohol and substance abuse, and reduce the chance of relapse and/or hospitalization.
A person must have active symptoms for at least two weeks and other symptoms for at least six months before a diagnosis can be made. The doctor will rule out other causes, such as drug use, medical illness, or a different mental condition.
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Treatment and Therapy (Genetics & Inherited Conditions)
Schizophrenia is not curable, but it is highly treatable. Hospitalization may be required during acute episodes. Symptoms are usually controlled with antipsychotic medications. These medications work by blocking certain chemicals in the brain, which helps control the abnormal thinking that occurs in people with schizophrenia. Determining a medication plan can be a complicated process. Often medications or dosages need to be changed until the right balance is found. This can take months or even years. Examples of medications include haloperidol (Haldol), thioridazine, or fluphenazine.
Relapse is common, even for patients taking medication. Treatment compliance can be a challenge, since people often stop taking their medication when they are feeling better. The side effects of traditional antipsychotics can also cause patients to discontinue treatment. The most common are physical side effects, such as slow and stiff movements, restlessness, facial tics, and protruding tongue.
New medications, called atypical antipsychotics, have fewer side effects and are better tolerated over long periods of time. However, they may cause weight gain, elevated blood sugar, and elevated serum cholesterol. Examples of these medications include aripiprazole (Abilify), clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), paliperidone (Invega), quetiapine (Seroquel), and ziprasidone (Geodon).
Medications may also...
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Prevention and Outcomes (Genetics & Inherited Conditions)
Further Reading (Genetics & Inherited Conditions)
EBSCO Publishing. Health Library: Schizophrenia. Ipswich, Mass.: Author, 2009. Available through http://www.ebscohost.com.
Frith, Christopher D., and Eve C. Johnstone. Schizophrenia: A Very Short Introduction. Oxford, England: Oxford University Press, 2003.
Moore, David P., and James W. Jefferson. Handbook of Medical Psychiatry. 2d ed. Philadelphia: Elsevier Mosby, 2004.
Temes, Roberta. Getting Your Life Back Together When You Have Schizophrenia. Oakland, Calif.: New Harbinger, 2002.
Torrey, E. Fuller. Surviving Schizophrenia: A Manual for Families, Consumers, and Providers. 4th ed. New York: Quill, 2001.
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Web Sites of Interest (Genetics & Inherited Conditions)
American Psychiatric Association. http://www.psych.org
Canadian Psychiatric Association. http://www.cpa-apc.org
Cochrane Reviews: “Electroconvulsive Therapy for Schizophrenia”. http://www.cochrane.org/reviews/en/ab000076.html
Mayo Clinic.com: Schizophrenia. http://www.mayoclinic.com/health/schizophrenia/DS00196
Mental Health Canada. http://www.mentalhealthcanada.com
National Institute of Mental Health. = http://www.nimh.nih.gov
World Fellowship for Schizophrenia and Allied Disorders. http://world-schizophrenia.org
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Schizophrenia (Encyclopedia of Genetic Disorders)
Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people and lose their ability to take care of personal needs and grooming.
The course of schizophrenia in adults can be divided into three phases or stages. In the acute phase, the patient has an overt loss of contact with reality (psychotic episode) that requires intervention and treatment. In the second or stabilization phase, the initial psychotic symptoms have been brought under control but the patient is at risk for relapse if treatment is interrupted. In the third or maintenance phase, the patient is relatively stable and can be kept indefinitely on antipsychotic medications. Even in the maintenance phase, however, relapses are not unusual and patients do not always return to full functioning.
The term schizophrenia comes from two Greek words that mean "split mind." It was observed around 1908, by a Swiss doctor named Eugen Bleuler, to...
(The entire section is 2947 words.)
Schizophrenia (Encyclopedia of Medicine)
Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming.
The course of schizophrenia in adults can be divided into three phases or stages. In the acute phase, the patient has an overt loss of contact with reality (psychotic episode) that requires intervention and treatment. In the second or stabilization phase, the initial psychotic symptoms have been brought under control but the patient is at risk for relapse if treatment is interrupted. In the third or maintenance phase, the patient is relatively stable and can be kept indefinitely on antipsychotic medications. Even in the maintenance phase, however, relapses are not unusual and patients do not always return to full functioning.
The term schizophrenia comes from two Greek words that mean "split mind." It was observed around 1908, by a Swiss doctor named Eugen Bleuler, to describe the splitting apart of mental functions that he regarded as the central...
(The entire section is 3443 words.)
Schizophrenia (Encyclopedia of Neurological Disorders)
Schizophrenia is a collection of related psychiatric disorders of unknown etiology that follow a specific pattern of behavior. Typical behavior seen in schizophrenia includes psychotic episodes in which there is a severe mental disturbance and perceptions of reality are distorted. Psychotic episodes may also involve hallucinations. Schizophrenics often have delusions about personal identity, immediate surroundings or society, and paranoia. Schizophrenia has a component of heredity, but many factors other than genetics are involved. Schizophrenia is treated with antipsychotic medication.
Schizophrenia involves a specific type of disordered thinking and behavior. It could be described as the splitting of the mind's cognitive functions pertaining to thought, perception, and reasoning from the appropriate emotional responses. Family history of schizophrenia increases an individual's chance of having the disorder, but the exact mode of inheritance is unknown. Only some schizophrenic patients have detectable anatomical brain abnormalities. The cause of schizophrenia has not been determined, yet drugs effective in its treatment have been identified. Schizophrenia is treated with antipsychotic drugs that primarily act on receptors in the brain for the neurotransmitters dopamine and serotonin. These neurotransmitters...
(The entire section is 1860 words.)
Schizophrenia (Encyclopedia of Mental Disorders)
Schizophrenia is the most chronic and disabling of the severe mental disorders, associated with abnormalities of brainstructure and function, disorganized speech and behavior, delusions, and hallucinations. It is sometimes called a psychotic disorder or a psychosis.
People diagnosed with schizophrenia do not always have the same set of symptoms; in addition, a given patient's symptoms may change over time. Since the nineteenth century, doctors have recognized different subtypes of the disorder, but no single classification system has gained universal acceptance. Some psychiatrists prefer to speak of schizophrenia as a group or family of disorders ("the schizophrenias") rather than as a single entity. A standard professional reference, The Diagnostic and Statistical Manual of Mental Disorders(also known as the DSM-IV-TR)acknowledges that its present classification of subtypes is not fully satisfactory for either clinical or research purposes, and states that "alternative subtyping schemes are being actively investigated."
The symptoms of schizophrenia can appear at any time after age six or seven, although onset during adolescence and early adult life is the most common...
(The entire section is 5409 words.)
Schizophrenia (Encyclopedia of Science)
Schizophrenia (pronounced skiht-zo-FREH-nee-uh) is a severe mental condition that interferes with normal thought processes, causing delusions, hallucinations, and mental disorganization. As the most common of the extremely serious mental disorders known as psychosis (pronounced sy-KO-sis), it affects men and women equally, is found all over the world, and is usually a long-term illness with no definite cure.
Schizophrenia is described by the National Institute of Mental Health (NIMH) as a "chronic, severe, and disabling brain disease." NIMH estimates that approximately 1 percent of the American population at some point suffers from schizophrenia, meaning that more than two million Americans are considered to be schizophrenic in any given year. Others estimate that as many as half the patients in U.S. mental hospitals are schizophrenics. Although it occurs in women as often as in men, it seems to appear earlier in men, usually in their late teens or early twenties. Very young people, however, can sometimes be affected.
To be schizophrenic is to suffer from a profound disruption of cognition, meaning that the schizophrenic individual has a major problem with knowing and thinking. Some describe this condition as a thought disorder, and once we understand the sometimes terrifying symptoms that schizophrenics experience in their minds,...
(The entire section is 1910 words.)
Schizophrenia (Encyclopedia of Psychology)
A mental illness characterized by disordered thinking, delusions, hallucinations, emotional disturbance, and withdrawal from reality.
Some experts view schizophrenia as a group of related illnesses with similar characteristics. The condition affects between one-half and one percent of the world's population, occurring with equal frequency in males and females (although the onset of symptoms is usually earlier in males). Between 1 and 2% of Americans are thought to be afflicted with schizophreniat least 2.5 million at any given time, with an estimated 100,000 to 200,000 new cases every year. Although the name "schizophrenia," coined in 1911 by Swiss psychologist Eugene Bleuler (1857-1939), is associated with the idea of a "split" mind, the disorder is different from a "split personality" (dissociative identity disorder), with which it is frequently confused. Schizophrenia is commonly thought to disproportionately affect people in the lowest socioeconomic groups, although some claim that socially disadvantaged persons with schizophrenia are only more visible than their more privileged counterparts, not more numerous. In the United States, schizophrenics occupy more hospital beds than patients suffering from cancer, heart disease, or diabetes. At any given time, they account for up to half the beds in long-term care facilities. With the aid of...
(The entire section is 1806 words.)
Schizophrenia (Encyclopedia of Children's Health)
Schizophrenia is a mental illness characterized by disordered thinking, delusions, hallucinations, emotional disturbance, and withdrawal from reality.
Some experts view schizophrenia as a group of related illnesses with similar characteristics. Although the term, coined in 1911 by Swiss psychologist Eugene Bleuler (1857939), is associated with the idea of a "split" mind, the disorder is different from a "split personality" (dissociative identity disorder), with which it is frequently confused. In the United States, schizophrenics occupy more hospital beds than patients suffering from cancer, heart disease, or diabetes. At any given time, they account for up to half the beds in long-term care facilities and 40 percent of the treatment days.
The incidence of childhood schizophrenia is thought to be one in 10,000 births. In comparison, the incidence among adolescents and adults is approximately one in 100. The condition occurs with equal frequency in males and females (although the onset of symptoms is usually earlier in males). At least 2.5 million Americans are thought to be afflicted with schizophrenia, with an...
(The entire section is 2425 words.)
Schizophrenia (Encyclopedia of Alternative Medicine)
Schizophrenia is a psychotic disorder (or group of disorders) marked by severely impaired thinking, emotions, and behaviors. The term schizophrenia comes from two Greek words that mean "split mind." It was coined around 1908 by a Swiss doctor named Eugen Bleuler to describe the splitting apart of mental functions that he regarded as the central characteristic of schizophrenia. (Note that the splitting apart of mental functions in schizophrenia differs from the split personality of people with multiple personality disorder.) Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming.
Although schizophrenia was described by doctors as far back as Hippocrates (500 B.C.), it is difficult to classify. Many writers prefer the plural terms schizophrenias or schizophrenic disorders to the singular schizophrenia because of the lack of agreement in classification, as well as the possibility that different subtypes may eventually be shown to have different causes.
The schizophrenic disorders are a major social tragedy because of the large...
(The entire section is 3048 words.)
Schizophrenia (Encyclopedia of Nursing & Allied Health)
Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. Schizophrenic persons are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming.
The course of schizophrenia in adults can be divided into three phases or stages. In the acute phase, a person has an overt loss of contact with reality (psychotic episode) that requires intervention and treatment. In the second or stabilization phase, the initial psychotic symptoms have been brought under control but the person is at risk for relapse if treatment is interrupted. In the third or maintenance phase, an individual is relatively stable and can be kept indefinitely on antipsychotic medications. Even in the maintenance phase, however, relapses are not unusual and people do not always return to full functioning.
The term schizophrenia comes from two Greek words that mean split mind. It was first used by a Swiss doctor named Eugen Bleuler in 1908 to describe the splitting apart of mental functions that he regarded as the central characteristic of schizophrenia.
Recently, some psychotherapists have begun to use a classification of schizophrenia based on two main types. People with Type I, or positive schizophrenia, have a rapid (acute) onset of symptoms and tend to respond well to drugs. They also tend to suffer more from so-called positive symptoms, such as delusions and hallucinations. People with Type II, or negative schizophrenia, are usually described as poorly adjusted before their schizophrenia slowly overtakes them. They have predominantly negative symptoms, such as withdrawal from others and a slowing of mental and physical reactions (psychomotor retardation).
The fourth (1994) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) specifies five subtypes of schizophrenia.
PARANOID. The key feature of this subtype of schizophrenia is the combination of false beliefs (delusions) and hearing voices (auditory hallucinations), with more nearly normal emotions and cognitive functioning (cognitive functions include reasoning, judgment, and memory). The delusions of paranoid schizophrenics usually involve thoughts of being persecuted or harmed by others or exaggerated opinions of their own importance, but may also reflect feelings of jealousy or excessive religiosity. The delusions are typically organized into a coherent framework. Paranoid schizophrenics function at a higher level than other subtypes, but are at risk for suicidal or violent behavior under the influence of their delusions.
DISORGANIZED. Disorganized schizophrenia (formerly called hebephrenic schizophrenia) is marked by disorganized speech, thinking, and behavior by an affected person, coupled with flat or inappropriate emotional responses to a situation (affect). An individual may act silly or withdraw socially to an extreme extent. Most people in this category have weak personality structures prior to their initial acute psychotic episode.
CATATONIC. Catatonic schizophrenia is characterized by disturbances of movement that may include rigidity, stupor, agitation, bizarre posturing, and repetitive imitations of the movements or speech of other people. These people are at risk for malnutrition, exhaustion, or self-injury. This subtype is presently uncommon in Europe and the United States. Catatonia as a symptom is most commonly associated with mood disorders.
UNDIFFERENTIATED. Persons in this category have the characteristic positive and negative symptoms of schizophrenia but do not meet the specific criteria for the paranoid, disorganized, or catatonic subtypes.
RESIDUAL. This category is used for persons who have had at least one acute schizophrenic episode but do not presently have strong positive psychotic symptoms, such as delusions and hallucinations. They may have negative symptoms, such as withdrawal from others, or mild forms of positive symptoms, which indicate that the disorder has not completely resolved.
The risk of schizophrenia among first-degree biological relatives is 10 times greater than that observed in the general population. Furthermore the presence of the same disorder is higher in monozygotic (identical) twins than in dizygotic (non-identical) twins. Research concerning adoption studies and identical twins also supports the notion that environmental factors are important, because not all relatives have the disorder or express it. There are several chromosomes and loci (specific areas on chromosomes that contain mutated genes) that have been identified. Research is ongoing to elucidate the causes, types and variations of these mutations.
A number of studies indicate that about 1% of the world's population is affected by schizophrenia, without regard to race, social class, level of education, or cultural influences. The outcome may vary from culture to culture, depending on the familial support of an affected person. Most people are diagnosed in their late teens or early twenties, but the symptoms of schizophrenia can emerge at any age in the life cycle. The male to female ratio in adults is about 1.2:1. Males typically have their first acute episode in their early twenties, while females are usually closer to age 30 when they are recognized with active symptoms.
Schizophrenia is rarely diagnosed in preadolescent children, although individuals as young as five or six have been reported. Childhood schizophrenia is at the upper end of the spectrum of severity and shows a greater gender disparity. It affects one or two children in every 10,000; the male to female ratio is 2:1.
Causes and symptoms
Theories of causality
One of the reasons for the ongoing difficulty in classifying schizophrenic disorders is incomplete understanding of their causes. As of 2001, it is thought that these disorders are the end result of a combination of genetic, neurobiological, and environmental causes. A leading neurobiological hypothesis emphasizes the connection between the disease and excessive levels of dopamine, a chemical that transmits signals in the brain (neurotransmitter). The genetic factor in schizophrenia has been underscored by recent findings that first-degree biological relatives of schizophrenics are 10 times more likely to develop the disorder than are members of the general population.
Prior to recent findings of abnormalities in the brain structure of schizophrenic persons, several generations of psychotherapists advanced a number of psychoanalytic and sociological theories about the origins of schizophrenia. These theories ranged from hypotheses about a person's problems with anxiety or aggression to theories about stress reactions or interactions with disturbed parents. Psychosocial factors are now thought to influence the expression or severity of schizophrenia, rather than directly cause it.
Another hypothesis suggests that schizophrenia may be caused by a virus that attacks the hippocampus, a part of the brain that processes sense perceptions. Damage to the hippocampus would account for a schizophrenic person's vulnerability to sensory overload. As of mid-2001, researchers are testing antiviral medications on schizophrenics.
Symptoms of schizophrenia
People with a possible diagnosis of schizophrenia are evaluated on the basis of a set or constellation of symptoms. There is no single symptom that is unique to schizophrenia. In 1959, the German psychiatrist Kurt Schneider proposed a list of so-called first-rank symptoms, which he regarded as diagnostic of the disorder.
These symptoms include:
- somatic hallucinations
- hearing voices commenting on a person's behavior
- thought insertion or thought withdrawal
Somatic hallucinations refer to sensations or perceptions concerning body organs that have no known medical cause or reason, such as the notion that one's brain is radioactive. Thought insertion and/or withdrawal refer to delusions that an outside force (for example, the FBI, the CIA, Martians, etc.) has the power to put thoughts into one's mind or remove them.
POSITIVE SYMPTOMS. The positive symptoms of schizophrenia are those that represent an excessive or distorted version of normal functions. Positive symptoms include Schneider's first-rank symptoms as well as disorganized thought processes (reflected mainly in speech) and disorganized or catatonic behavior. Disorganized thought processes are marked by such characteristics as looseness of association, in which a person rambles from topic to topic in a disconnected way; tangentiality, which means that an individual gives unrelated answers to questions; and flights of ideas or "word salad," in which a person's speech is so incoherent that it makes no grammatical or linguistic sense. Disorganized behavior means that a person has difficulty with any type of purposeful or goal-oriented behavior, including personal self-care or preparing meals. Other forms of disorganized behavior may include dressing in odd or inappropriate ways, sexual self-stimulation in public, or agitated shouting or cursing.
NEGATIVE SYMPTOMS. The DSM-IV definition of schizophrenia includes three so-called negative symptoms. They are called negative because they represent the lack or absence of behaviors. The negative symptoms that are considered diagnostic of schizophrenia are a lack of emotional response (affective flattening), poverty of speech, and absence of volition or will. In general, the negative symptoms are more difficult for doctors to evaluate than the positive symptoms.
A doctor must make a diagnosis of schizophrenia on the basis of a standardized list of outwardly observable symptoms, not on the basis of internal psychological processes. There are no specific laboratory tests that can be used to diagnose schizophrenia. Researchers have, however, discovered that persons with schizophrenia have certain abnormalities in the structure and functioning of the brain compared to normal test subjects. These discoveries have been made with the help of imaging techniques such as computed tomography scans (CT scans).
When a psychiatrist assesses an individual for schizophrenia, the doctor will begin by excluding physical conditions that can cause abnormal thinking and some other behaviors associated with schizophrenia. These conditions include organic brain disorders (including traumatic injuries of the brain), temporal lobe epilepsy, Wilson's disease, Huntington's chorea, and encephalitis. The doctor will also need to rule out substance abuse disorders, especially amphetamine use.
After ruling out organic disorders, a clinician will consider other psychiatric conditions that may include psychotic symptoms or symptoms resembling psychosis. These disorders include mood disorders with psychotic features; delusional disorder; dissociative disorder not otherwise specified (DDNOS) or multiple personality disorder; schizotypal, schizoid, or paranoid personality disorders; and atypical reactive disorders. In the past, many individuals were incorrectly diagnosed as being schizophrenic. Some people who were diagnosed prior to the changes in categorization introduced by DSM-IV should have their diagnoses, and treatment, reevaluated. In children, a doctor must distinguish between psychotic symptoms and a vivid fantasy life, and also identify learning problems or disorders. After other conditions have been ruled out, a person must meet a set of criteria specified by DSM-IV:
- Characteristic symptoms. To make a diagnosis of schizophrenia, a person must exhibit two (or more) of the following symptoms during a one-month period: delusions; hallucinations; disorganized speech; disorganized or catatonic behavior; negative symptoms.
- Decline in social, interpersonal, or occupational functioning, including self-care.
- Duration. The disturbed behavior must last for at least six months.
- Diagnostic exclusions. Mood disorders, substance abuse disorders, medical conditions, and developmental disorders have been ruled out.
The treatment of schizophrenia depends in part on an individual's stage or phase. People in the acute phase are hospitalized in most cases, to prevent harm to themselves or to others and to begin treatment with antipsychotic medications. A person having a first psychotic episode should be given a CT (computed tomography) or MRI (magnetic resonance imaging) scan to rule out structural brain abnormalities or disease.
The primary form of treatment of schizophrenia is antipsychotic medication. Antipsychotic drugs help to control almost all the positive symptoms of the disorder. They have minimal effect on disorganized behavior and negative symptoms. Between 600% of schizophrenics will respond to antipsychotics. In the acute phase of the illness, people are usually given medications by mouth or by intramuscular injection. After an affected person has been stabilized, the antipsychotic drug may be given in a long-acting form called a depot dose. Depot medications last for two to four weeks and have the advantage of protecting a person against the consequences of forgetting or skipping daily doses. In addition, some people who do not respond to oral neuroleptic medications have better results with depot form. Persons whose long-term treatment includes depot medications are introduced to the depot form gradually during their stabilization period. Most people with schizophrenia are kept on antipsychotic medications indefinitely during the maintenance phase of their disorder to minimize the possibility of relapse.
As of 2001, the most frequently used antipsychotics fall into two classes: the older dopamine receptor antagonists, or DAs, and the newer serotonin dopamine antagonists, or SDAs. Antagonists block the action of some other substance. For example, dopamine antagonists counteract the action of dopamine. The exact mechanisms of action of these medications are not known, but it is thought that they lower a person's sensitivity to sensory stimuli and so indirectly improve the person's ability to interact with others.
DOPAMINE RECEPTOR ANTAGONIST. The dopamine antagonists include the older antipsychotic (also called neuroleptic) drugs, such as haloperidol (Haldol), chlorpromazine (Thorazine), and fluphenazine (Prolixin). These drugs have two major drawbacks. It is often difficult to find the best dosage level for a given individual, and a dosage level high enough to control psychotic symptoms frequently produces extrapyramidal side effects, or EPS. EPSs include parkinsonism, in which a person cannot walk normally and usually develops a tremor; dystonia, or painful muscle spasms of the head, tongue, or neck; and akathisia, or restlessness. A type of long-term EPS is called tardive dyskinesia, which features slow, rhythmic, automatic movements. Schizophrenics with AIDS are especially vulnerable to developing EPS.
SERATONIN DOPAMINE ANTAGONISTS. The serotonin dopamine antagonists, also called atypical antipsychotics, are newer medications that include clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa). The SDAs have a better effect on the negative symptoms of schizophrenia than do the older drugs and are less likely to produce EPS than the older compounds. The newer drugs are significantly more expensive in the short term, although the SDAs may reduce long-term costs by reducing the need for hospitalization. They are also presently unavailable in injectable forms. The SDAs are commonly used to treat persons who respond poorly to the DAs. However, many psychotherapists now regard the use of these atypical antipsychotics as the treatment of first choice.
Most schizophrenics can benefit from psychotherapy once their acute symptoms have been brought under control by antipsychotic medication. Psychoanalytic approaches are not recommended. Behavior therapy, however, is often helpful in assisting people to acquire skills for daily living and social interaction. It can be combined with occupational therapy to prepare individuals for eventual employment.
Family therapy is often recommended for the families of schizophrenic patients, to relieve the feelings of guilt that they often have as well as to help them understand a schizophrenic's disorder. The family's attitude and behaviors toward the schizophrenic are key factors in minimizing relapses (for example, by reducing stress in an individual's life), and family therapy can often strengthen the family's ability to cope with the stresses caused by the schizophrenic's illness. Family therapy that focuses on communication skills and problem-solving strategies is particularly helpful. In addition to formal treatment, many families benefit from support groups and similar mutual help organizations for relatives of schizophrenics.
Affective flattening loss or lack of emotional expressiveness. It is sometimes called blunted or restricted affect.
Akathisiagitated or restless movement, usually affecting the legs and accompanied by a sense of discomfort. It is a common side effect of neuroleptic medications.
Catatonic behaviorehavior characterized by muscular tightness or rigidity and lack of response to the environment. In some persons, rigidity alternates with excited or hyperactive behavior.
Delusion fixed, false belief that is resistant to reason or factual disproof.
Depot dosage form of medication that can be stored in a person's body tissues for several days or weeks, thus minimizing the risk of forgetting daily doses. Haloperidol and fluphenazine can be given in depot form.
Dopamine receptor antagonists (DAs)he older class of antipsychotic medications, also called neuroleptics. These primarily block the site on nerve cells that normally receives the brain chemical dopamine.
Dystoniaainful involuntary muscle cramps or spasms. Dystonia is one of the extrapyramidal side effects associated with some antipsychotic medications.
Extrapyramidal symptoms (EPS) group of side effects associated with antipsychotic medications. EPS include parkinsonism, akathisia, dystonia, and tardive dyskinesia.
First-rank symptoms set of symptoms designated by Kurt Schneider in 1959 as the most important diagnostic indicators of schizophrenia. These symptoms include delusions, hallucinations, thought insertion or removal, and thought broadcasting. First-rank symptoms are sometimes referred to as Schneiderian symptoms.
Hallucination sensory experience of something that does not exist outside the mind. A person can experience a hallucination in any of the five senses. Auditory hallucinations are a common symptom of schizophrenia.
Huntington's chorea hereditary disease that typically appears in midlife, marked by gradual loss of brain function and involuntary movements. Some of its symptoms resemble those of schizophrenia.
Negative symptomsymptoms of schizophrenia that are characterized by the absence or elimination of certain behaviors. DSM-IV specifies three negative symptoms: affective flattening, poverty of speech, and loss of will or initiative.
Neurolepticnother name for the older type of antipsychotic medications given to schizophrenic persons.
Parkinsonism set of symptoms originally associated with Parkinson's disease that can occur as side effects of neuroleptic medications. The symptoms include trembling of the fingers or hands, a shuffling gait, and tight or rigid muscles.
Positive symptomsymptoms of schizophrenia that are characterized by the production or presence of behaviors that are grossly abnormal or excessive, including hallucinations and thought process disorder. DSM-IV subdivides positive symptoms into psychotic and disorganized.
Poverty of speech negative symptom of schizophrenia, characterized by brief and empty replies to questions. It should not be confused with shyness or reluctance to talk.
Psychotic disorder mental disorder characterized by delusions, hallucinations, or other symptoms of lack of contact with reality. The schizophrenias are psychotic disorders.
Serotonin dopamine antagonists (SDAs)he newer second-generation antipsychotic drugs, also called atypical antipsychotics. SDAs include clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa).
Wilson's disease rare hereditary disease marked by high levels of copper deposits in the brain, eyes and liver. It can cause psychiatric symptoms resembling schizophrenia.
Word saladpeech that is so disorganized that it makes no linguistic or grammatical sense.
One important prognostic sign is a person's age at onset of psychotic symptoms. People with early onset of schizophrenia are more often male, have a lower level of functioning prior to onset, a higher rate of brain abnormalities, more noticeable negative symptoms, and worse outcomes. Persons with later onset are more likely to be female, with fewer brain abnormalities and thought impairment, and more hopeful prognoses.
The average course and outcome for schizophrenics are less favorable than those for most other mental disorders, although as many as 30% of people diagnosed with schizophrenia recover completely and the majority experience some improvement. Two factors that influence outcomes are stressful life events and a hostile or emotionally intense family environment. Schizophrenics with a high number of stressful changes in their lives, or who have frequent contacts with critical or emotionally overinvolved family members, are more likely to relapse. Overall, the most important component of long-term care for schizophrenic individuals is complying with their regimen of antipsychotic medications.
Health care team roles
Physicians such as a family doctor or internist often make an initial diagnosis of schizophrenia. Psychiatrists, psychologists, or other therapists may also provide an initial diagnosis. Psychiatrists, clinical psychologists, or other trained professionals provide intervention treatment and therapy. Counselors may provide support during and after treatment. Nurses often administer medications.
With present levels of understanding about schizophrenia, there does not appear to be any way to prevent the disease. Better understanding holds the promise of prevention if specific causal factors are environmental, chemical or viral.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.
Brenner, H.D., and R. Boker. Treatment of Schizophrenia: Status and Emerging Trends. Seattle: Hogrefe & Huber, 2001.
Corrigan, Patrick W., and David L. Penn. Social Cognition and Schizophrenia. Washington, DC: American Psychological Association, 2001.
Dalton, Richard, and Marc A. Forman. "Childhood schizophrenia." In Nelson Textbook of Pediatrics, 16th ed. Edited by Richard E. Behrman et al., Philadelphia: Saunders, 2000, 88-89.
Green, Michael F. Schizophrenia Revealed: From Neurons to Social Interaction. New York: W.W. Norton, 20001.
Sharma, Tonmoy, and Philip D. Harvey. Cognition in Schizophrenia: Impairments, Importance, and Treatment Strategies. New York: Oxford University Press, 2000.
Warner, Richard. The Environment of Schizophrenia: Innovations in Practice, Policy and Communications. New York: Warner, 2001.
Mason, SE, Miller R. Bulletin of the Menninger Clinic 65, no. 2 (2001): 179-193.
Meltzer, HY. "Treatment of suicidality in schizophrenia." Annals of the New York Academy of Science 932 (2001): 44-60.
Rungreangkulkij, S, Chesla C. "Smooth a heart with water: Thai mothers care for a child with schizophrenia." Archives of Psychiatric Nursing 15, no. 3 (2001): 120-127.
Sanders, AR, Gejman PV. "Influential Ideas and Experimental Progress in Schizophrenia Genetics Research." Journal of the American Medical Association 13, 285, no. 22(2001): 2831-2833.
Thaker, G, Adami H, Gold J. "Functional deterioration in individuals with schizophrenia spectrum personality symptoms." Journal of Personality Disorders 15, no. 3 (2001): 229-234.
Wiedemann, G, Hahlweg K, Muller U, Feinstein E, Hank G, Dose M. "Effectiveness of targeted intervention and maintenance pharmacotherapy in conjunction with family intervention in schizophrenia." European Archives of Psychiatry and Clinical Neuroscience 251, no. 2 (2001): 72-84.
American Psychological Association. 750 First Street NW, Washington, DC, 20002-4242. (800) 374-2721 or (202) 336-5500. <<a href="http://www.apa.org/">http://www.apa.org/>.
National Alliance for Research on Schizophrenia and Depression. 60 Cutter Mill Road, Suite 404, Great Neck, NY 11021. (516) 829-0091. Fax: (516) 487-6930. <<a href="http://www.mhsource.com/narsad/">http://www.mhsource.com/narsad/>. firstname.lastname@example.org.
National Institute of Mental Health. 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. Fax (301) 443-4279. <<a href="http://www.nimh.nih.gov/home.cfm">http://www.nimh.nih.gov/home.cfm>. email@example.com.
National Mental Health Association. 1021 Prince Street, Alexandria, VA 22314-2971. (800) 969-6942 or (703) 684-7722. Fax: (703) 684-5968. <<a href="http://www.nmha.org/">http://www.nmha.org/>.
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L. Fleming Fallon, Jr., MD, DrPH
Schizophrenia (Encyclopedia of Public Health)
Schizophrenia, often misunderstood as split personality, is a chronic mental illness characterized by psychosis, or loss of reality testing. It is a heterogeneous disease in its presentation, course, effect on functioning, response to treatment, and possibly even etiology. In 1990, the total cost of schizophrenia in the United States, including mental health and societal costs, was estimated at $32.5 billion. The risk of suicide in schizophrenia is at least 10 percent, which is twenty times the risk in the general population. Over 70 percent of persons with schizophrenia are unemployed. An estimated 30 to 50 percent of the homeless population has schizophrenia. As one of the most chronically disabling mental illnesses, it can be devastating for those afflicted and their families, and it has a significant impact on public mental health systems.
Schizophrenia presents as a syndrome. The symptoms are organized into three major categories: positive symptoms, negative symptoms, and cognitive impairment. Positive symptoms include hallucinations, delusions, thought disorders, and bizarre behaviors. Hallucinations are most commonly auditory, usually experienced as voices talking to or about the person. Delusions are false beliefs and tend to be paranoid, grandiose, or bizarre in nature. Disorganized speech is presumed to be a manifestation of an underlying thought disorder. The flow of ideas is illogical and may range from being mildly confusing to incomprehensible. Words may be strung together based on sound rather than meaning, or entirely new words may be created. Bizarre behavior may be observed as repetitive movements, unusual mannerisms, odd ways of dressing, and disregard for social norms.
Negative symptoms include flat affect (facial expression), avolition, and apathy. A flat affect is one revealing little emotion or expression. Generally, persons with schizophrenia seem emotionally disconnected and tend to be socially withdrawn. Avolition and apathy are characterized by a lack of motivation and poor grooming and hygiene. In addition to the positive and negative symptoms of schizophrenia, cognitive impairment with deficits in attention span, memory, and information processing is often present. Persons with schizophrenia experience varying constellations and severities of symptoms resulting in a range of impaired functioning.
The prevalence of schizophrenia is approximately 0.85 percent of the population worldwide and is fairly consistent across race and geographical regions. Men and women are equally affected. Average age of onset in men is 15 to 25 years of age, while in women it is 25 to 35 years of age. No clear risk factors for developing schizophrenia have been identified except a family history of the disease. The disease course is marked by relapses and remissions. Although some persons with schizophrenia regain their premorbid functioning, most experience chronic debilitating symptoms. Acute onset, female gender, being married, and good premorbid adjustment are factors associated with a better prognosis.
The etiology of schizophrenia is poorly understood. Prevailing theories propose a biological vulnerability to developing schizophrenia with both environmental and psychological factors contributing. The biological vulnerability is likely genetic and is suggested by twin studies, adoption studies, and an increased rate of schizophrenia in relatives of persons with the disorder. Immunological abnormalities, viral infections, and hypoxia have all been hypothesized as mechanisms of environmental assaults on the developing brain. Pathological theories focus on abnormalities in the neural circuitry and in neurotransmitters, particularly dopamine. The role of dopamine in schizophrenia is supported by studies showing that increased dopamine activity can induce psychotic symptoms, while blocking dopamine receptors can decrease psychosis.
Schizophrenia is a chronic illness that is managed, not cured. Treatment is most effective when elements of pharmacotherapy, supportive therapy, and psychosocial rehabilitation are integrated. Pharmacotherapy with antipsychotic medications, also called neuroleptics, is the mainstay of treatment and is crucial for diminishing the acute symptoms of schizophrenia as well as maintaining remission. The presumed mechanism of action of these medications is blockade of dopamine receptors in neural tissue. Due to the severity of symptoms and the functional impairments they produce, psychosocial supports and rehabilitation are important for individuals with schizophrenia and their families. Individual supportive therapy and group therapy can promote the development of strategies to manage psychotic symptoms and to manage stress, which can contribute to relapses. Rehabilitation targets the improvement of vocational and social skills. Case management facilitates access to social services, entitlements, housing, and medical care. Up to 25 percent of those with schizophrenia are too impaired to care for themselves in the community and require residential treatment programs or long-term hospitalization. Even when a person is able to live in the community, brief hospitalizations are often necessary to treat exacerbations of psychosis.
STUART J. EISENDRATH
(SEE ALSO: Community Metal Health Centers)
Eisendrath, S. J., and Lichtmacher, J. E. (1999). "Psychiatric Disorders." In Current Medical Diagnosis and Treatment 1999, eds. L. M. Tierney, S. J. Mcphee, and M. A. Papadakis. Stamford, CT: Appleton and Lange.
Kaplan, H. I., and Sadock, B. J. (1998). Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 6th edition. Baltimore, MD: Williams & Wilkins.
Schizophrenia (International Dictionary of Psychoanalysis)
For psychoanalysis, as for medical research and the entire field of mental health, schizophrenia is a complex, baffling, and frustrating disorder. It is not particularly rare, affecting about 1 percent of the population; its distribution is worldwide. A century after Emil Kraepelin created the diagnosis of dementia praecox and its extensive symptomologyenamed schizophrenia by Eugen Bleulert remains poorly understood. In spite of revolutionary advances in biology and neuroscience, no treatment or combination of therapies offers a reliable cure.
Like all the psychotic disorders, schizophrenia was thought from the start to have an organic basis, but Kraepelin was forced describe it as a "functional disorder." Early age of onset and absence of brain lesions such as might be found in epilepsy or tertiary syphilis, for example, encouraged early analysts to attempt treatment, especially in light of the limitations of other therapeutic modalities. It became plausible to suggest, at least tentatively, that schizophrenia was a psychological disorder that originated, like neurotic conflicts, in infancy and early childhood. The fact that some small but significant percentage of patients experienced full or partial recovery made it a target for therapies of all kinds, including psychoanalysis.
Although Freud himself was skeptical about prospects for successfully treating schizophrenia, the disorder was central to the activity of many early analysts, who often were associated with hospitals for the insane. Karl Abraham's first letters to Freud concerned psychosis; like Carl Jung, he worked at the Burgholzi Central Asylum and University Clinic in Zurich, which Bleuler directed. In the United States, where psychiatry only gradually became a primarily office practice beginning about 1920, psychiatrists influenced by Freud also worked in asylums. Adolf Meyer and William Alanson White were both hospital-based psychiatrists, as was Harry Stack Sullivan, who reported impressive results with his analytically oriented treatment beginning in the 1920s. Particularly influential, Sullivan's work led to the creation of a psychoanalytic enclave at Chestnut Lodge in Rockville, Maryland, devoted to the treatment of patients with schizophrenia and related disorders.
The rapid growth of psychoanalysis as a medical specialty in the United States after World War II affected the way that schizophrenia was perceived, understood, and treated. The broad theoretical reach of psychoanalysis, with its ambitious aims to provide a general psychology, extended to schizophrenia both as an explanatory tool and treatment modality. In retrospect it is clear that as a treatment it was not successful and that the early-childhood environmental deficit model that analysts proposed could not be sustained. At the time, however, without benefit of drugs or a significant knowledge base in neurochemistry, and in the wake of a period during which biological explanations of mental disease had favored eugenics, psychoanalysts appeared to be modern and forward-looking professionals who were making an earnest and humane effort to understand severe psychopathology in terms of developmental deficits.
Psychoanalysis was not seriously affected by the introduction of phenothiazine in the mid-1950s. But the narcoleptics and their successor drugs set the stage for the de-institutionalization of the mentally ill that began a decade later and also opened the way for the dopamine hypothesis, the first of various neurochemical pathways to be implicated in schizophrenia. By the late 1960s the authority of psychoanalysis was eroding, both as therapy and theory, and it had to compete with a diversified marketplace of competing treatments. As psychoanalysis in the United States entered a period of steep decline in the 1980s, its efforts on both a theoretical and clinical level were often held to be of no account. However, one positive outcome of analytic interest in the severe mental disorders, in fact, was a sophisticated and durable typology of what became known as the borderline and narcissistic disorders (Kernberg 1975), which developed along separate lines and found a respected place in clinical psychiatry and mental health practice more generally.
The list of analysts who studied and wrote about schizophrenia is long and includes interpersonalists, ego psychologists, Kleinians and their successors, together with any number who might be described as individualistic or idiosyncratic. Key texts included papers by Paul Federn, Melanie Klein, Harold Searles, and many others. Some analysts published books on schizophrenia that remained in print for decades, such as Frieda Fromm-Reichman's Principles of Intensive Psychotherapy (1950) and Silvano Arieti's The Interpretation of Schizophrenia (1955). Arieti served for years as editor of the voluminous American Handbook of Psychiatry.
Today, psychoanalysts view schizophrenia through a diversity of lenses. Many if not most would acknowledge the medical consensus that it is essentially a biological disorder and would not recommend the kind of intensive therapeutic efforts employed in the past. Analysts seeking an in media res would hold that analytic therapy can be beneficial while giving up earlier etiological views. A minority of analysts, post-Kleinians and others, continue to view schizophrenia as amenable in a global sense to therapeutic intervention and theoretical elaboration. Although the classic psychoanalytic model of the etiology of schizophrenia is definitively obsolete, all these currents can coexist and develop alongside the diathesis-stress model of the disorder, currently dominant in psychiatry and medicine.
JOHN GALBRAITH SIMMONS
See also: Ambivalence; Anti-Oedipus: Capitalism and Schizophrenia; As if personality; Basic Problems of Ethnopsychiatry; Blank/nondelusional psychoses; Character Analysis; "Claims of Psycho-Analysis to Scientific Interest"; Collected Papers on Schizophrenia and Related Subjects; Dementia; Disintegration, feelings of, (anxieties); Ego Psychology and Psychosis; Foreclosure; Infantile schizophrenia; ; Language and disturbances of language; "Metapsychological Supplement to the Theory of Dreams"; Narcissism, secondary; Numinous (analytical psychology); "On the Origin of the 'Influencing Machine' in Schizophrenia"; Organic psychoses; Paranoia; Paranoid psychosis; Paranoid-schizoid position; Paraphrenia; Persecution; Psychological types (analytical psychology); Psychology of Dementia præcox; Psychology of the Unconscious, The;Psychoses, chronic and delusional; Psychotic/neurotic; Psychotic transference; Splitting of the ego; Symbolic equation; Symbolic realization; Thought-thinking apparatus; "Unconscious, The"; Violence of Interpretation, The: From Pictogram to Statement; Word-presentation.
Arieti, Silvano. (1955). The interpretation of schizophrenia. New York: Brunner.
Fromm-Reichmann, Freida. (1950). Principles of intensive psychotherapy. Chicago: University of Chicago Press.
Kernberg, Otto. (1975). Borderline personality disorders and pathological narcissism. New York: Jason Aronson.
Shapiro, Sue. (1981). Contemporary theories of schizophrenia: Review and synthesis. New York: McGraw-Hill.
Willick, Martin. (2001). Psychoanalysis and schizophrenia: A cautionary tale. Journal of the American Psychoanalytic Association, 49, 27-56.
Munich, R.L. (1997). Contemporary treatment of schizophrenia. Bulletin of the Menninger Clinic, 61, 189-221.
Schizophrenia (Encyclopedia of Drugs, Alcohol, and Addictive Behavior)
Schizophrenia is a psychiatric illness that can be profoundly disabling and is usually chronic in nature. The cause is not known, but there appears to be a genetic predisposition. The etiology has been conceptualized in a stress/diathesis (vulnerability) model: Biological and environmental factors (e.g., drug abuse, psychosocial stresses) interact with a genetic vulnerability to precipitate the illness. Several theories have been proposed to explain the observed biological abnormalities of the disorder, including over-activity of the dopamine neurotransmitter systems in the central nervous system, changes in brain structure (e.g., enlargement of the lateral cerebral ventricles) and brain function (e.g., decreased frontal lobe function [hypofrontality], as evidenced by diminished blood flow, and deficits in attention and sensory filtering). Psychological and social factors are considered important in the expression and course of the disorder. It is likely that schizophrenia constitutes a group of disorders rather than a single entity; these disorders present with similar clinical signs and symptoms, but the etiologies, treatment responsiveness, and course of illness in each vary.
Detailed descriptions of the illness date back to the nineteenth century. Emil Kraepelin (1856-1926) used the term dementia praecox to describe psychiatric states with an early onset and deteriorating course. Eugen Bleuler (1857-1939) coined the term schizophrenia for a "splitting of the mind," in his belief that the illness was a result of the disharmony of psychological functions. The diagnosis of schizophrenia requires observation and clinical interviewing. No sign or symptom is specific for the illness, nor do any laboratory tests exist to establish the diagnosis. The DIAGNOSTIC AND STATISTICAL MANUAL for Mental Disorders-3rd edition contains the diagnostic guidelines of the American Psychiatric Association for schizophrenia. These include: the presence of characteristic psychotic symptoms (delusions, HALLUCINATIONS, a thought disorder, inappropriate emotion); impaired work, social functioning, and selfcare; and continuous signs of the illness for at least six months. The symptoms of an affected individual can change with time, therefore longitudinal follow-up is important. It should be noted that certain of these symptoms can be indicative of other conditions (including drug abuse [cocaine, crack, PCB, amphetamines], head injury, brain tumors, as well as other psychiatric disorders). Furthermore, it is important to take into account the educational level, intellectual ability, and cultural affiliation of the individual when making a diagnosis. The onset of illness is usually in late adolescence or early adulthood and is generally insidious. The typical course of schizophrenia is characterized by exacerbations and remissions. A gradual deterioration in functioning generally occurs that eventually reaches a plateau. However, a small proportion of persons may recover. It is estimated that 20 percent to 30 percent of affected individuals can lead somewhat normal lives whereas another 20 to 30 percent continue to experience moderate symptoms.
The prevalence rates of schizophrenia vary to a limited degree worldwide, but in the United States the lifetime prevalence is estimated to be 1 percent (about one in one-hundred people). In industrialized countries, there is a disproportionate number of schizophrenic patients in the lower socioeconomic classes. Some experts feel this is due to the schizophrenic's loss of education and social opportunity, while others feel this is more a direct result of the stresses of poverty.
The management of affected individuals involves hospitalization when there is an exacerbation of the illness, plus the use of medication. The mainstay of pharmacologic treatment is the class of drugs known as ANTIPSYCHOTICS. Many antipsychotics are available and they act to control the psychotic symptoms; most of them do so by blocking the actions of the neurotransmitter, dopamine. About 75 percent of patients respond to these drugs; however, there are side effects, including muscle stiffness, tremors, and weight gain. The drugs may also cause tardive dyskinesia (TD), a disorder that causes involuntary, repetitive movements of the body, mouth, and tongue.
Some of the more commonly prescribed antipsychotics include: chlorpromazine, fluphenazine, haloperidol, olanzapine, and risperidone. The atypical antipsychotic, clozapine, has been identified as the best choice for managing resistant schizophrenia; however, up to 73 percent of patients treated with clozapine report clinically relevant side effects. These can be quite severe, and include potentially fatal neuroleptic malignant syndrome (NMS), myocarditis, cardiomyopathy, and dangerous lowering of white blood cell count (for the latter, regular and frequent blood testing is required during the treatment period). In a study following 8,000 patients in Australia who started clozapine treatment between January 1993 and March 1999, fifteen developed myocarditis, and eight developed cardiomyopathy; a total of six patients died within the six years.
After a person has recovered from an acute episode of schizophrenia, the emphasis is on practical aspects of management: living arrangements, self-care, employment, and social relationships. Education of and support made available to family members are important and can have an impact on relapse rates in the patient. Many schizophrenic patients have to remain on antipsychotic medication for prolonged periods, since the rate of relapse is high after drug discontinuation. Side effects, primarily of a neurologic nature (e.g., TD), are a source of concern, but in most cases the benefits of symptom control outweigh the risks of pharmacotherapy. Making sure that the patient complies with medication use is often a problem.
(SEE ALSO: Amphetamine; Cannabis sativa; )
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REVISED BY KIMBERLY A. MCGRATH