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Schizophrenia

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Schizophrenia
SpecialtyPsychiatry, clinical psychology Edit this on Wikidata

Schizophrenia (from the Greek word σχιζοφρένεια, or schizophreneia, meaning "split mind") is a psychiatric diagnosis characterized by impairments in the perception or expression of reality, most commonly manifest as auditory hallucinations, paranoid or bizarre delusions or disorganized speech and thinking in the context of significant social or occupational dysfunction. Five subtypes are recognised, classified on the basis of predominant features. Onset of symptoms typically occurs in young adulthood,[1] with approximately 0.4–0.6%[2][3] of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia exists.

Studies suggest that genetics, early environment, neurobiology and psychological and social processes are important contributory factors. Current psychiatric research often focuses on the role of neurobiology, although a clear organic cause has not been found. Due to the many possible combinations of symptoms, heated debates are ongoing about whether the diagnosis represents a single disorder, or a number of discrete syndromes. For this reason, Eugen Bleuler termed the disease "the schizophrenias" (plural) when he coined the present name. Despite its etymology, "schizophrenia" is not synonymous with dissociative identity disorder, previously known as multiple personality disorder or "split personality"; in popular culture the two are often confused.

One of the more consistent findings is the overactivity of the receptor dopamine in mesolimbic pathway of the brain. The mainstay of treatment is pharmacotherapy with antipsychotic medications; these primarily work by suppressing dopamine activity. Lower doses are now generally used than in the early decades of their use. Psychotherapy, vocational and social rehabilitation are also important. In more serious cases where there is risk to self and others involuntary hospitalization may be necessary, though in general people are hospitalized a lot less frequently and for much shorter periods than they were in previous years.

Although the disorder is primarily thought to affect cognition, it also usually contributes to chronic problems with behavior and emotion. Patients suffering from schizophrenia are likely to be diagnosed with comorbid conditions; these include clinical depression and anxiety disorders, while the lifetime prevalence of substance abuse is typically around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common and life expectancy is decreased; patients typically living ten to twelve years less than those without the disorder, owing to increased physical health problems and a high suicide rate.

History

Accounts that may relate to symptoms of schizophrenia date back as far as 2000 BC in the Book of Hearts, part of the ancient Ebers papyrus. However, a recent study into the ancient Greek and Roman literature showed that although the general population probably had an awareness of psychotic disorders, there was no recorded condition that would meet the modern criteria for schizophrenia.[4]

Emil Kraepelin (1856–1926) refined the concept of psychosis.

Although a broad concept of "madness" has existed for thousands of years, schizophrenia was only classified as a distinct mental disorder by Emil Kraepelin in 1893. He was the first to make a distinction in the psychotic disorders between what he called dementia praecox (a term first used by psychiatrist Bénédict Morel 1809–1873) and manic depression. Kraepelin believed that dementia praecox was primarily a disease of the brain,[5] and particularly a form of dementia. Kraepelin named the disorder 'dementia praecox' (early dementia) to distinguish it from other forms of dementia, such as Alzheimer's disease, which occur late in life.[6]

The word "schizophrenia", which translates roughly as "splitting of the mind" and comes from the Greek σχίζω (or schizo, "to split" or "to divide") and φρήν (or phrēn, "mind"),[7] was coined by Eugene Bleuler in 1908 and was intended to describe the separation of function between personality, thinking, memory, and perception. Bleuler described the main symptoms as 4 "A"'s: flattened Affect, Autism, impaired Association of ideas and Ambivalence.[8] Bleuler realized that the illness was not a dementia as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead.

The term 'schizophrenia' is commonly misunderstood to mean that affected persons have a "split personality". Although some people diagnosed with schizophrenia may hear voices and may experience the voices as distinct personalities, schizophrenia does not involve a person changing among distinct multiple personalities. The confusion perhaps arises in part due to the meaning of Bleuler's term 'schizophrenia' (literally 'split' or 'shattered mind'). The first known misuse of "schizophrenia" to mean "split personality" was in an article by the poet T. S. Eliot in 1933.[9]

In the first half of the twentieth century schizophrenia was considered by many to be a "hereditary defect", and individuals affected by schizophrenia became subject to eugenics in many countries. Hundreds of thousands were sterilized, with or without consent, the majority in Nazi Germany, the United States, and Scandinavian countries,[10][11] Many people diagnosed with schizophrenia, together with other people labeled "mentally unfit", were murdered in the Nazi "Operation T-4" program.[citation needed]

The diagnostic description of schizophrenia has changed over time. It became clear after the 1971 'US-UK diagnostic study' that schizophrenia was diagnosed to a far greater extent in America than in Europe.[12] This was partly due to the difference in diagnostic systems with respect to their criteria for schizophrenia, the US using the DSM-II manual and Europe the ICD-9. This was one of the factors in leading to the revision not only of the diagnosis of schizophrenia, but the revision of the whole DSM manual, resulting in the publication of the DSM-III.[13]

Signs and symptoms

A person experiencing schizophrenia may demonstrate a variety of symptoms; these may include disorganized thinking, auditory hallucinations and delusions. In severe cases the person may be mute or almost mute and remain motionless in bizarre postures or exhibit purposeless agitation. This is known as catatonia. The current classification of psychoses holds that symptoms need to have been present for at least one month in a period of at least six months of disturbed functioning. A psychosis of shorter duration is termed a schizophreniform disorder.[14] Onset of schizophrenia typically occurs in late adolescence or early adulthood, with males tending to show symptoms earlier than females.[15] No one symptom is diagnostic of schizophrenia, and all can occur in various other medical or psychiatric conditions.[16]

Some symptoms, such as social isolation, may be caused by a number of factors. One possible factor is impairment in social cognition, which is associated with schizophrenia, but isolation may also result from an individual reacting to psychotic symptoms (such as paranoia) or avoiding potentially stressful social situations which may exacerbate mental distress in some people.[17]

Much work in recent years has gone into the prodromal (pre-onset) phase of the illness, which has been detected up to 30 months prior to the onset of symptoms although may be present for longer.[18] Many people later diagnosed with schizophrenia experience difficulties including nonspecific symptoms of social withdrawal, irritability and dysphoria[19] as well as transient or self-limiting psychotic symptoms.[20]

Schneiderian classification

The psychiatrist Kurt Schneider attempted to list the particular forms of psychotic symptoms that he thought were particularly useful in distinguishing between schizophrenia and other disorders that could produce psychosis. These are called first rank symptoms or Schneiderian first rank symptoms and include delusions of being controlled by an external force, the belief that thoughts are being inserted into or withdrawn from one's conscious mind, the belief that one's thoughts are being broadcast to other people and hearing hallucinatory voices which comment on one's thoughts or actions, or may have a conversation with other hallucinated voices.[21] The reliability of 'first rank symptoms' has been questioned,[22] although they have contributed to the current diagnostic criteria.

Positive and negative symptoms

Schizophrenia is often described in terms of "positive" (or productive) and "negative" (or deficit) symptoms. Positive symptoms include delusions, auditory hallucinations and thought disorder and are typically regarded as manifestations of psychosis. Negative symptoms are so named because they are considered to be the loss or absence of normal traits or abilities, and include features such as flat, blunted or constricted affect and emotion, poverty of speech and lack of motivation. Additionally, a 'disorganization syndrome' and neurocognitive deficits may be present. These may take the form of reduced or impaired psychological functions such as memory, attention, problem-solving, executive function or social cognition. A third symptom grouping, the so-called 'disorganization syndrome', includes disorganized speech (thought disorder) and related disorganized behavior.[16]

Diagnosis

Diagnosis is based on the self-reported experiences of the patient as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, social worker, clinical psychologist or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizophrenia, tests are carried out to exclude medical illnesses which may rarely present with psychotic schizophrenia-like symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions. It is important to rule out a delirium which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness and indicates an underlying medical illness. There are several psychiatric illnesses which may present with psychotic symptoms other than schizophrenia . These include bipolar disorder,[23] borderline personality disorder,[24] drug intoxication, brief drug-induced psychosis, and schizophreniform disorder.

Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, liver function tests if chlorpromazine or CPK to exclude neuroleptic malignant syndrome. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.

The most widely used criteria for diagnosing schizophrenia are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian 'first rank symptoms' although, in practice, agreement between the two systems is high.[25] The WHO has developed the tool SCAN (Schedules for Clinical Assessment in Neuropsychiatry) which can be used for diagnosing a number of psychiatric conditions, including schizophrenia.

DSM IV-TR Criteria

To be diagnosed with schizophrenia, a person must display:[26]

  • Characteristic symptoms: Two or more of the following, each present for a significant portion of time during a one-month period (or less, if successfully treated)
Note: Only one of these symptoms is required if delusions are bizarre or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other.
  • Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset.
  • Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if successfully treated).

Additional criteria are also given that exclude the diagnosis; thus schizophrenia cannot be diagnosed if symptoms of mood disorder or pervasive developmental disorder are present, or the symptoms are the direct result of a substance (e.g., abuse of a drug, medication) or a general medical condition.

Subtypes

Historically, schizophrenia in the West was classified into simple, catatonic, hebephrenic (now known as disorganized), and paranoid. The DSM contains five sub-classifications of schizophrenia:

  • paranoid type: where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent (DSM code 295.3/ICD code F20.0)
  • disorganized type: named 'hebephrenic schizophrenia' in the ICD. Where thought disorder and flat affect are present together (DSM code 295.1/ICD code F20.1)
  • catatonic type: prominent psychomotor disturbances are evident. Symptoms can include catatonic stupor and waxy flexibility (DSM code 295.2/ICD code F20.2)
  • undifferentiated type: psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met (DSM code 295.9/ICD code F20.3)
  • residual type: where positive symptoms are present at a low intensity only (DSM code 295.6/ICD code F20.5)

The ICD-10 recognises a further two subtypes:

  • post-schizophrenic depression: a depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present (ICD code F20.4)
  • simple schizophrenia: insidious but progressive development of prominent negative symptoms with no history of psychotic episodes (ICD code F20.6)


Diagnostic issues and controversies

Schizophrenia as a diagnostic entity has been criticised as lacking in scientific validity or reliability,[27][28] part of a larger criticism of the validity of psychiatric diagnoses in general. One alternative suggests that the issues with the diagnosis would be better addressed as individual dimensions along which everyone varies, such that there is a spectrum or continuum rather than a cut-off between normal and ill. This approach appears consistent with research on schizotypy and of a relatively high prevalence of psychotic experiences[29][30] and often non-distressing delusional beliefs[31] amongst the general public.[32]

Another criticism is that the definitions used for criteria lack consistency;[33] this is particularly relevant to the evaluation of delusions and thought disorder. More recently, it has been argued that psychotic symptoms are not a good basis for making a diagnosis of schizophrenia as "psychosis is the 'fever' of mental illness — a serious but nonspecific indicator".[34]

Perhaps because of these factors, studies examining the diagnosis of schizophrenia have typically shown relatively low or inconsistent levels of diagnostic reliability. Most famously, David Rosenhan's 1972 study, published as On being sane in insane places, demonstrated that the diagnosis of schizophrenia was (at least at the time) often subjective and unreliable.[35] More recent studies have found agreement between any two psychiatrists when diagnosing schizophrenia tends to reach about 65% at best.[36] This, and the results of earlier studies of diagnostic reliability (which typically reported even lower levels of agreement) have led some critics to argue that the diagnosis of schizophrenia should be abandoned.[37]

In 2004 in Japan, Japanese term of schizophrenia was changed from Seishin-Bunretsu-Byo (mind-split-disease) to Tōgō-shitchō-shō (integration disorder).[38] In 2006, campaigners in the UK, under the banner of Campaign for Abolition of the Schizophrenia Label, argued for a similar rejection of the diagnosis of schizophrenia and a different approach to the treatment and understanding of the symptoms currently associated with it.[39]

Alternatively, other proponents have put forward using the presence of specific neurocognitive deficits to make a diagnosis. These take the form of a reduction or impairment in basic psychological functions such as memory, attention, executive function and problem solving. It is these sorts of difficulties, rather than the psychotic symptoms (which can in many cases be controlled by antipsychotic medication), which seem to be the cause of most disability in schizophrenia. However, this argument is relatively new and it is unlikely that the method of diagnosing schizophrenia will change radically in the near future.[40]

The diagnosis of schizophrenia has been used for political rather than therapeutic purposes; in the Soviet Union an additional sub-classification of sluggishly progressing schizophrenia was created. Particularly in the RSFSR (Russian Soviet Federated Socialist Republic), this diagnosis was used for the purpose of silencing political dissidents or forcing them to recant their ideas by the use of forcible confinement and treatment.[41] In 2000 there were similar concerns regarding detention and 'treatment' of practitioners of the Falun Gong movement by the Chinese government. This led the American Psychiatric Association's Committee on the Abuse of Psychiatry and Psychiatrists to pass a resolution to urge the World Psychiatric Association to investigate the situation in China.[42]

Epidemiology

Schizophrenia is typically diagnosed in late adolescence or early adulthood. The peak ages of onset are 20–28 years for men and 26–32 years for women.[1] It is found approximately equally in men and women, though its onset is later on average in women, who tend to experience a better course and outcome.[15] Relatively rare are instances of childhood-onset schizophrenia and late-onset schizophrenia (occurring in old age).[43] The lifetime prevalence of schizophrenia—that is, the proportion of individuals expected to experience the disease at any time in their lives—is commonly given at 1%. A 2002 systematic review of many studies, however, found a lifetime prevalence of 0.55%.[3] The same study found that prevalence may vary greatly among countries, despite the received wisdom that schizophrenia occurs at similar rates throughout the world. Due to this high, although variable incidence, schizophrenia is a major cause of disability. In a 1999 study of 14 countries, active psychosis was ranked the third-most-disabling condition, after quadriplegia and dementia and before paraplegia and blindness.[44]

One particularly stable and replicable finding has been the association between living in an urban environment and schizophrenia diagnosis, even after factors such as drug use, ethnic group and size of social group have been controlled for.[45]

Causes

Main article: Causes of schizophrenia
Data from a PET study[46] suggests that the less the frontal lobes are activated (red) during a working memory task, the greater the increase in abnormal dopamine activity in the striatum (green), thought to be related to the neurocognitive deficits in schizophrenia.

While the reliability of the diagnosis introduces difficulties in measuring the relative effect of genes and environment (for example, symptoms overlap to some extent with severe bipolar disorder or major depression), evidence suggests that genetic vulnerability and environmental stressors can act in combination to result in onset of schizophrenia.[47] However, the proportion of these factors' influence is widely and hotly debated.

The idea of an inherent vulnerability (or diathesis) in some people which can be unmasked by a biological, psychological or environmental stressor is known as the stress-diathesis model.[48] Evidence suggests that the diagnosis of schizophrenia has a significant heritable component,[49] although this may be significantly influenced by subsequent environmental factors or stressors which trigger or cause illness onset.[50] As an example, monozygotic twins, who have identical genetic material, have a 50% chance of concordance.[49]

Genetic

Schizophrenia is likely a condition of complex inheritance; it is likely that several genes interact to generate risk for schizophrenia or for the separate components that can co-occur to lead to a diagnosis.[51] This, combined with disagreements over which research methods are best, or how data from genetic research should be interpreted, has led to differing estimates over genetic contribution. Molecular genetic studies of schizophrenia attempt to identify specific genes which may increase risk; genes that are thought to be most involved change as new evidence is gathered.[47][51][52]

Enviromental

Living in an urban environment is one of the strongest environmental risk factors for schizophrenia.[53] Being a first or second generation immigrant is also a strong risk factor for schizophrenia, for which social adversity, racial discrimination, family dysfunction, unemployment and poor housing conditions have been proposed as contributing factors.[54] Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life.[55][56]

Prenatal

It is thought that causal factors can initially come together in early neurodevelopment, including during pregnancy, to increase the risk of later developing schizophrenia. One curious finding is that people diagnosed with schizophrenia are more likely to have been born in winter or spring, (at least in the northern hemisphere).[57] There is now evidence that prenatal exposure to infections increases the risk for developing schizophrenia later in life, providing additional evidence for a link between in utero developmental pathology and risk of developing the condition.[58]

Substance use

The relationship between schizophrenia and drug use is complex, meaning that a clear causal connection between drug use and schizophrenia has been difficult to tease apart. There is strong evidence that using certain drugs can trigger either the onset or relapse of schizophrenia in some people. It may also be the case, however, that people with schizophrenia use drugs to overcome negative feelings associated with both the commonly prescribed antipsychotic medication and the condition itself, where negative emotion, paranoia and anhedonia are all considered to be core features.[59] Amphetamines trigger the release of dopamine and excessive dopamine function is believed to be responsible for many symptoms of schizophrenia (known as the dopamine hypothesis of schizophrenia), amphetamines may worsen schizophrenia symptoms.[60] Schizophrenia can be triggered by heavy use of hallucinogenic or stimulant drugs.[61] There is evidence that cannabis use can contribute to schizophrenia.[62]

Pathophysiology

Functional magnetic resonance imaging and other brain imaging technologies allow for the study of differences in brain activity among people diagnosed with schizophrenia.

Early findings of differences in the size and structure of certain brain areas came from the discovery of ventricular enlargement in people diagnosed with schizophrenia with negative symptoms most prominent.[63] However, this has not proven particularly reliable on the level of the individual person, with considerable variation between patients. More recent studies have shown a large number of differences in brain structure between people with and without diagnoses of schizophrenia.[64] However, as with earlier studies, many of these differences are only reliably detected when comparing groups of people, and are unlikely to predict any differences in brain structure of an individual person with schizophrenia.

Studies using neuropsychological tests and brain imaging technologies such as fMRI and PET to examine functional differences in brain activity have shown that differences seem to most commonly occur in the frontal lobes, hippocampus, and temporal lobes.[65] These differences are heavily linked to the neurocognitive deficit often associated with schizophrenia, particularly in areas of memory, attention, problem solving, executive function, and social cognition.[66]

Dopamine

Main article: Dopamine hypothesis of schizophrenia

Particular focus has been placed upon the function of dopamine in the mesolimbic pathway of the brain. This focus largely resulted from the accidental finding that a drug group which blocks dopamine function, known as the phenothiazines, could reduce psychotic symptoms. An influential theory—the "dopamine hypothesis of schizophrenia"—proposed that a malfunction involving dopamine pathways was the cause of (the positive symptoms of) schizophrenia. This theory is now thought to be overly simplistic as a complete explanation, partly because newer antipsychotic medication (called atypical antipsychotic medication) can be equally effective as older medication (called typical antipsychotic medication), but also affects serotonin function and may have slightly less of a dopamine blocking effect.[67]

Glutamate

Interest has also focused on the neurotransmitter glutamate and the reduced function of the NMDA glutamate receptor in schizophrenia. This has largely been suggested by abnormally low levels of glutamate receptors found in postmortem brains of people previously diagnosed with schizophrenia[68] and the discovery that the glutamate blocking drugs such as phencyclidine and ketamine can mimic the symptoms and cognitive problems associated with the condition.[69] The fact that reduced glutamate function is linked to poor performance on tests requiring frontal lobe and hippocampal function and that glutamate can affect dopamine function, all of which have been implicated in schizophrenia, have suggested an important mediating (and possibly causal) role of glutamate pathways in schizophrenia.[70] Further support of this theory has come from preliminary trials suggesting the efficacy of coagonists at the NMDA receptor complex in reducing some of the positive symptoms of schizophrenia.[71]

Treatment and services

Molecule of chlorpromazine, which revolutionized treatment of schizophrenia in the 1950s.

The concept of a "cure" remains controversial, as there is no consensus on the definition, although some criteria for the remission of symptoms have recently been suggested.[72] The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the most common being the positive and negative syndrome scale (PANSS).[73] As with many chronic illnesses, aiming for management of symptoms and improving function is more achievable than a "cure". Treatment was revolutionized in the mid 1950s with the development and introduction of chlorpromazine.[74]

Hospitalization may occur, with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still occur.[75] Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a 'community mental health team' or Assertive Community Treatment team, supported employment[76] and patient-led support groups.

In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. The outcome for people diagnosed with schizophrenia in non-Western countries may actually be better than for people in the West.[77] The reasons for this effect are not clear, although cross-cultural studies are being conducted.

Electroconvulsive therapy is not considered a first line treatment but may be prescribed in cases where other treatments have failed. It is most effective where symptoms of catatonia are present.[citation needed] Psychosurgery has now become a rare procedure and is not a recommended treatment for schizophrenia.[78]

Medication

The mainstay of treatment for schizophrenia is an antipsychotic medication.[79] These provide symptomatic relief from the positive symptoms of psychosis. Most medications take around 7-14 days to have an antipsychotic effect but indirect symptomatic relief may occur immediately as insomnia and agitation are addressed by nonspecific sedative effects or adjunctive benzodiazepine prescription.

Risperidone (trade name Risperdal) is a common atypical antipsychotic medication.

Though expensive, the newer atypical antipsychotic drugs are usually preferred for initial treatment over the older typical antipsychotics; they are generally better tolerated and associated with lower rates of tardive dyskinesia, although they are more likely to induce weight gain and obesity-related diseases.[80] It remains unclear whether the newer antipsychotics reduce the chances of developing neuroleptic malignant syndrome, a rare but serious and potentially fatal neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs.[81]

The two classes of antipsychotics are generally thought equally effective for the treatment of the positive symptoms. Some researchers have suggested that the atypicals offer additional benefit for the negative symptoms and cognitive deficits associated with schizophrenia, although the clinical significance of these effects has yet to be established. Recent reviews have refuted the claim that atypical antipsychotics have fewer extrapyramidal side effects than typical antipsychotics, especially when the latter are used in low doses or when low potency antipsychotics are chosen.[82]

Treatment-resistant schizophrenia is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics; patients in this category may be prescribed clozapine, a medication of superior effectiveness but several potentially lethal side effects including cardiomyopathy and agranulocytosis. Monitoring for this latter complication requires weekly blood tests for several months, then monthly indefinitely afterwards. For other patients who are unwilling or unable to take medication regularly, long-acting depot preparations of antipsychotics may be given every two weeks to achieve control. America and Australia are two countries with laws allowing the forced administration of this type of medication on those who refuse but are otherwise stable and living in the community.

A novel approach to medication is the use of omega-3 fatty acids, which are found in foods such as oily fish, flax seeds, hemp seeds, walnuts and canola oil) have recently been studied as a treatment for schizophrenia. One study found omega-3 supplements to be effective when used as a dietary supplement.[83]

Psychological and social interventions

Psychotherapy may be beneficial in the treatment of schizophrenia. It has been reported that, despite evidence and recommendations, treatment is often confined to pharmacotherapy alone because of reimbursement problems or lack of training.[84] Therapy which addresses the whole family system of an individual with a diagnosis of schizophrenia, including through psychological education, has also been found to have significant benefits.[85][86]

Cognitive behavioral therapy may focus on the direct reduction of the symptoms, or on related aspects, such as issues of self-esteem, social functioning, and insight. Although the results of early trials with cognitive behavioral therapy (CBT) were inconclusive,[87] more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia.[88] There have also been advances in social skills training.[89]

Another approach is cognitive remediation therapy, a technique aimed at remediating the neurocognitive deficits sometimes present in schizophrenia. Based on techniques of neuropsychological rehabilitation, early evidence has shown it to be cognitively effective, with some improvements related to measurable changes in brain activation as measured by fMRI.[90] A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy.[91] A recent randomised controlled trial found that music therapy significantly improved symptom scores in a group of patients diagnosed with schizophrenia.[92] A notable early mention of the beneficial effect of music on mental illness was in 1621 by Robert Burton in The Anatomy of Melancholy.[93]

In recent years the importance of service-user led recovery based movements has grown substantially throughout Europe and America. Groups such as the Hearing Voices Network and more recently, the Paranoia Network, have developed a self-help approach that aims to provide support and assistance outside of the traditional medical model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of criteria for mental illness or mental health, they aim to destigmatize the experience and encourage individual responsibility and a positive self-image. Peer-to-peer support is also developing a professional footing with partnerships between hospitals and consumer run groups becoming more common. These services work towards remediating social withdrawal, building social skills and reducing rehospitalization.[94]

Prognosis

One retrospective study has shown that about a third of people make a full recovery, about a third show improvement but not a full recovery, and a third remain ill.[95] A more recent study using stricter recovery criteria (i.e. concurrent remission of positive and negative symptoms and specific instances of adequate social / vocational functioning) reported a recovery rate of 13.7%.[96] However, the exact definition of what constitutes recovery has not been widely defined, although criteria have recently been suggested to define a remission in symptoms.[72] Therefore, this makes it difficult to give an exact estimate as recovery and remission rates are not always comparable across studies.

The World Health Organization conducted two long-term follow-up studies involving more than 2,000 people suffering from schizophrenia in different countries. These studies found patients have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (USA, UK, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia),[97] despite the fact antipsychotic drugs are typically not widely available in poorer countries, raising questions about the effectiveness of such drug-based treatments.

Several factors are associated with a better prognosis: Being female, acute (vs. insidious) onset of symptoms, older age of first episode, predominantly positive (rather than negative) symptoms, presence of mood symptoms and good premorbid functioning. [98] Most studies done on this subject, however, are correlational in nature, and a clear cause-and-effect relationship is difficult to establish. Evidence is also consistent that negative attitudes towards individuals with schizophrenia can have a significant adverse impact. In particular, critical comments, hostility, authoritarian and intrusive or controlling attitudes (termed high 'Expressed Emotion' or 'EE' by researchers) from family members have been found to correlate with a higher risk of relapse in schizophrenia across cultures.[99]

Mortality

In a study of over 168,000 Swedish citizens undergoing psychiatric treatment, schizophrenia was associated with an average life expectancy of approximately 80–85% of that of the general population. Women with a diagnosis of schizophrenia were found to have a slightly better life expectancy than that of men, and as a whole, a diagnosis of schizophrenia was associated with a better life expectancy than substance abuse, personality disorder, heart attack and stroke.[100] There is a high suicide rate associated with schizophrenia; a recent study showed that 30% of patients diagnosed with this condition had attempted suicide at least once during their lifetime.[101] Another study suggested that 10% of persons with schizophrenia die by suicide.[102]

Violence

The relationship between violent acts and the diagnosis of schizophrenia is a contentious topic. A national survey in the United States indicated that 61% of Americans judge individuals with schizophrenia as likely to commit an act of interpersonal violence, while 17% thought such an act would be committed by person described only as "troubled".[103]

Research on violence indicates a moderately increased number of violent acts by a minority of individuals with a diagnosis of schizophrenia.[104] An assessment verified by multiple sources indicated that 15% of individuals with schizophrenia had committed violent acts during the course of a year,[105] which was statistically related to substance abuse, and to the relatively poor and violent neighbourhoods in which they resided.[106] An assessment of individuals enrolled in a trial of antipsychotic medication indicated that 19% had committed violent acts in the preceding six months, with 15.5% being of a "minor" nature.[107]

Population-attributable figures indicate that a small percentage (3% in the ECA study in America) of the overall violence of a given population is attributable to people with schizophrenia, and that the majority of this risk is attributable to substance misuse, young age, other correlated variables, and social and economic contexts, rather than schizophrenia per se.[104][105] Studies suggest that 5–10% of those awaiting trial for murder in Western countries have a schizophrenia spectrum disorder,[108] with lower figures for convictions,[109][110] representing a tiny probability for a given individual with a diagnosis of schizophrenia.[104] A consistent finding from this research is that individuals with a diagnosis of schizophrenia are often the victims of violent crime—at least 14 times more often than they are perpetrators,[111] with 4.3% having been victims in a one-month period.[112] Another consistent finding is a link to substance misuse, particularly alcohol,[113] among the minority who commit violent acts.

The occurrence of psychosis in schizophrenia has also been linked to a higher risk of violent acts. Findings on the specific role of delusions or hallucinations are inconsistent, but have included a focus on delusional jealousy and perception of threat or command hallucinations. It has also been proposed that there is a type of individual with schizophrenia characterized by a history of educational difficulties, low IQ, conduct disorder, early-onset substance misuse and offending prior to diagnosis.[108] Violence by or against individuals with schizophrenia typically occurs in the context of complex social interactions (including in atmosphere of mutually high "expressed emotion") within a family setting,[114] as well as being an issue in healthcare settings[115] and the wider community.[116]

Alternative approaches

An approach broadly known as the anti-psychiatry movement, most active in the 1960s, opposes the orthodox medical view of schizophrenia as an illness.[117] Psychiatrist Thomas Szasz argued that psychiatric patients are not ill rather individuals with unconventional thoughts and behavior that make society uncomfortable.[118] He argues that society unjustly seeks to control them by classifying their behavior as an illness and forcibly treating them as a method of social control. According to this view, "schizophrenia" does not actually exist but is merely a form of social constructionism, created by society's concept of what constitutes normality and abnormality. Szasz has never considered himself to be "anti-psychiatry" in the sense of being against psychiatric treatment, but simply believes that treatment should be conducted between consenting adults, rather than imposed upon anyone against his or her will.[citation needed] Similarly, psychiatrists R. D. Laing, Silvano Arieti, Theodore Lidz and Colin Ross[119] have argued that the symptoms of what is called mental illness are comprehensible reactions to impossible demands that society and particularly family life places on some sensitive individuals. Laing, Arieti, Lidz and Ross were notable in valuing the content of psychotic experience as worthy of interpretation, rather than considering it simply as a secondary but essentially meaningless marker of underlying psychological or neurological distress. Laing described eleven case studies of people diagnosed with schizophrenia and argued that the content of their actions and statements was meaningful and logical in the context of their family and life situations.[120] In the books Schizophrenia and the Family and The Origin and Treatment of Schizophrenic Disorders Lidz and his colleagues explain their belief that parental behaviour can result in mental illness in children. Arieti's Interpretation of Schizophrenia won the 1975 scientific National Book Award in the United States.

The concept of schizophrenia as a result of civilization has been developed further by psychologist Julian Jaynes in his 1976 book The Origin of Consciousness in the Breakdown of the Bicameral Mind; he proposed that until the beginning of historic times, schizophrenia or a similar condition was the normal state of human consciousness.[121] This would take the form of a "bicameral mind" where a normal state of low affect, suitable for routine activities, would be interrupted in moments of crisis by "mysterious voices" giving instructions, which early people characterized as interventions from the gods. This theory was briefly controversial. Continuing research has failed to either further confirm or refute the thesis.[citation needed]


The Soteria model is an alternative treatment to institutionalization and early use of antipsychotics. It is described as a milieu-therapeutic recovery method, characterized by its founder as "the 24 hour a day application of interpersonal phenomenologic interventions by a nonprofessional staff, usually without neuroleptic drug treatment, in the context of a small, homelike, quiet, supportive, protective, and tolerant social environment."[122] Newer adaptions of this model sometimes employ professional staff.[123][verification needed]

Psychiatrist Tim Crow argued in a 1997 paper that schizophrenia may be the evolutionary price we pay for a left brain hemisphere specialization for language.[124] Since psychosis is associated with greater levels of right brain hemisphere activation and a reduction in the usual left brain hemisphere dominance, our language abilities may have evolved at the cost of causing schizophrenia when this system breaks down.

Researchers into shamanism have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman;[125] the experience of having access to multiple realities is not uncommon in schizophrenia, and is a core experience in many shamanic traditions. Equally, the shaman may have the skill to bring on and direct some of the altered states of consciousness psychiatrists label as illness. Psychohistorians, on the other hand, accept the psychiatric diagnoses. However, unlike the current medical model of mental disorders they argue that poor parenting in tribal societies causes the shaman’s schizoid personalities.[126] Speculation regarding primary and important religious figures as having schizophrenia abound. Commentators such as Paul Kurtz and others have endorsed the idea that major religious figures experienced psychosis, heard voices and displayed delusions of grandeur.[127]

Alternative medicine holds the view that schizophrenia is primarily caused by imbalances in the body's reserves and absorption of dietary minerals, vitamins, fats, and/or the presence of excessive levels of toxic heavy metals.[citation needed] The branch of alternative medicine that deals with these views regarding the cause of schizophrenia is known as orthomolecular psychiatry. Some argue that schizophrenia can be treated effectively with doses of Vitamin B-3 (Niacin).[128]

The body's adverse reactions to gluten are implicated in some alternative theories. This theory—discussed by one author in three British journals in the 1970s[129]—is unproven. A 2006 literature review suggests that gluten may be a factor for a subset of patients with schizophrenia, but further study is needed to confirm the association between gluten and schizophrenia.[130]

An additional approach is suggested by the work of Richard Bandler who argues that "The usual difference between someone who hallucinates and someone who visualizes normally, is that the person who hallucinates doesn't know he's doing it or doesn't have any choice about it."[131] He suggests that because visualization is a sophisticated mental capability, schizophrenia is a skill, albeit an involuntary and dysfunctional one that is being used but not controlled. He therefore suggests that a significant route to treating schizophrenia might be to teach the missing skill—how to distinguish created reality from consensus external reality, to reduce its maladaptive impact, and ultimately how to exercise appropriate control over the vizualization or auditory process. Hypnotic approaches have been explored by the physician Milton H. Erickson as a means of facilitating this.[citation needed]

Cultural references

The book and film A Beautiful Mind chronicled the life of John Forbes Nash, a Nobel-Prize-winning mathematician who was diagnosed with schizophrenia. The Marathi film Devrai (Featuring Atul Kulkarni) is a presentation of a patient with schizophrenia. The film, set in the Konkan region of Maharashtra in Western India, shows the behavior, mentality, and struggle of the patient as well as his loved-ones. It also portrays the treatment of this mental illness using medication, dedication and lots of patience of the close relatives of the patient.

In Bulgakov's Master and Margarita the poet Ivan Bezdomnyj is institutionalized and diagnosed with schizophrenia after witnessing the devil (Woland) predict Berlioz's death. The book The Eden Express by Mark Vonnegut accounts his struggle into schizophrenia and his journey back to sanity.

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  125. ^ Polimeni J, Reiss JP (2002). How shamanism and group selection may reveal the origins of schizophrenia. Medical Hypothesis, 58(3), 244–8. PMID 12018978
  126. ^ DeMause, Lloyd, "The seven stages of historical personality" in The Emotional Life of Nations (Karnac, 2002). Available at primal-page.com, Retrieved on 2007-05-17.
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  130. ^ Kalaydjian AE, Eaton W, Cascella N, Fasano A (2006). The gluten connection: the association between schizophrenia and celiac disease. Acta Psychiatr Scand. 2006 Feb;113(2):82–90. PMID 16423158
  131. ^ Bandler, Richard. Time for a Change, p107.

References

  • Sadock BJ, Sadock VA (2003). Kaplan & Sadock's Synopsis of Psychiatry, Ninth Edition. Philadelphia, PA: Lippincott, Williams & Wilkins. ISBN 0-7817-3183-6.

Further reading

  • Bentall, R. (2003) Madness explained: Psychosis and Human Nature. London: Penguin Books Ltd. ISBN 0-7139-9249-2
  • Boyle, Mary, (1993), Schizophrenia: A Scientific Delusion, Routledge, ISBN 0-415-09700-2
  • Deveson, Anne (1991), Tell Me I'm Here. Penguin. ISBN 0-14-027257-7
  • Fallon, James H. et al. (2003) The Neuroanatomy of Schizophrenia: Circuitry and Neurotransmitter Systems. Clinical Neuroscience Research 3:77–107. Available at Elsevier article locater.
  • Green, M.F. (2001) Schizophrenia Revealed: From Neurons to Social Interactions. New York: W.W. Norton. ISBN 0-393-70334-7
  • Jones, S. and Hayward, P. (2004) Coping with Schizophrenia: A Guide for Patients, Families and Caregivers. ISBN 1-85168-344-5
  • Keen, T. M. (1999) Schizophrenia: orthodoxy and heresies. A review of alternative possibilities. Journal of Psychiatric and Mental Health Nursing, 1999, 6, 415–424. PMID 10818864Full-text (PDF), Retrieved on 2007-05-17.
  • Noll, Richard (2007) The Encyclopedia of Schizophrenia and Other Psychotic Disorders, Third Edition ISBN 0-8160-6405-9
  • Read, J., Mosher, L.R., Bentall, R. (2004) Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia. ISBN 1-58391-906-6. A critical approach to biological and genetic theories, and a review of social influences on schizophrenia.
  • Shaner, A., Miller, G. F., & Mintz, J. (2004). Schizophrenia as one extreme of a sexually selected fitness indicator. Schizophrenia Research, 70(1), 101–109. PMID 15246469Full text (PDF), Retrieved on 2007-05-17.
  • Szasz, T. (1976) Schizophrenia: The Sacred Symbol of Psychiatry. New York: Basic Books. ISBN 0-465-07222-4
  • Tausk, V. : "Sexuality, War, and Schizophrenia: Collected Psychoanalytic Papers", Publisher: Transaction Publishers 1991, ISBN 0-88738-365-3 (On the Origin of the 'Influencing Machine' in Schizophrenia.)
  • Torrey, E.F., M.D. (2006) Surviving Schizophrenia: A Manual for Families, Consumers, and Providers (5th Edition). Quill (HarperCollins Publishers) ISBN 0-06-084259-8
  • Wiencke, Markus (2006) Schizophrenie als Ergebnis von Wechselwirkungen: Georg Simmels Individualitätskonzept in der Klinischen Psychologie. In David Kim (ed.), Georg Simmel in Translation: Interdisciplinary Border-Crossings in Culture and Modernity (pp. 123–155). Cambridge Scholars Press, Cambridge, ISBN 1-84718-060-5
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