Schizophrenia is a complex, difficult to manage disorder whose sufferers deal with a fractured and distorted view of the world around them. To the untrained eye, Schizophrenia can take many different forms because the themes of patient’s hallucinations and delusions vary widely. However, each case shares the common threads of odd beliefs, general disorganization, and bizarre behavior. Symptoms usually begin between the late adolescent years and the early 30s. Most commonly, the earliest signs that other people will notice are when patients appear depressed and withdraw from their social life. They will often have low energy and appear bored or unmotivated, and they stop participating in hobbies they used to enjoy. Problems with attention, information processing, and problem-solving also tend to appear early, usually as trouble functioning in school or work.
The profound nature of the disturbance becomes much more apparent when hallucinations, delusions, and disorganized thought patterns emerge. People respond to things they hear and see that are not real. They can develop complex beliefs and ideas about others trying to contact them, monitor them, or control their minds or behaviors. Their speech patterns become odd and difficult to follow, and they see connections between completely unrelated subjects. Although some people respond well to medication and are able to manage their symptoms well, most struggle chronically with the disorder and need ongoing assistance with multiple aspects of their lives. As people age, most symptoms progressively become less and less intense. However, negative symptoms and mood problems tend to persist the most, resist medication treatment, and lead to long-term impairments.
Causes and Risk Factors
The rate of Schizophrenia in the general population is roughly 0.5%. It is slightly more common in men and starts at an earlier age in men than in women.
Genetic and prenatal contributions
Having a parent or sibling with a psychotic disorder increases the risk of developing Schizophrenia to about 10%. A second degree relative (like an aunt, uncle, or grandparent) with Schizophrenia makes the risk about 3%. An identical twin of someone with Schizophrenia has a 50% risk. Older parents, exposure to prenatal infections, and oxygen deprivation during birth also increase the risk of Schizophrenia. Low birth weight, high stress levels, and maternal diabetes of pregnancy contribute as well.
Adolescent marijuana use
Natural genetic variations in parts of the brain that manage the neurotransmitter dopamine set the stage for a connection between adolescent marijuana use and the development of Schizophrenia. Earlier and more frequent use of marijuana increase the risk of developing the disorder and can contribute to it starting at a younger age. In patients with these genetic variations, using marijuana on a daily basis can raise the risk of developing Schizophrenia to seven times greater than average. Marijuana use in people who already have Schizophrenia can significantly worsen the course of the disorder and can trigger psychotic episodes.
Substance use disorders strike roughly half of patients with Schizophrenia, putting these patients at higher risk of relapse, stopping medication, violence, and suicide. This is in addition to tobacco use, which also appears in a large percentage of these patients and can reduce the efficacy of antipsychotic medications. Depression also appears in half of Schizophrenia patients, and these patients have more frequent and more severe psychotic episodes. Panic Disorder, Post Traumatic Stress Disorder, and Obsessive Compulsive Disorder are also quite common in Schizophrenic patients.
People with Schizophrenia display at least two of several unique symptoms that are characteristic of all psychotic disorders. These include delusions, hallucinations, disorganized thoughts, speech, or behavior, catatonia, and negative symptoms. The first three of these symptoms are the most important, and at least one of those must be present to make the diagnosis. These symptoms disturb functioning in at least one major life domain, such as work, relationships, or the patient’s ability to take care of him or herself. If the disorder begins in childhood or adolescence, the patient will likely have problems in school as well. Mood problems such as depression and mania can only appear for a small portion of this time. If they last longer, that would suggest a diagnosis of Schizoaffective Disorder.
These problems last at least six months. Symptoms naturally increase and decrease in severity over time. The most severe periods are preceded by milder symptoms, except for negative symptoms, which can be significant and are frequently the first signs of the disorder that appear. The times following the worst periods are similar.
Insight is when patients understand that the symptoms they are experiencing are part of a disorder and need to be treated. Lack of insight is a frequent problem accompanying Schizophrenia. It is a common reason that patients resist treatment and stop their medications without talking to their doctors. These patients have more hospitalizations, lower functioning, and worse overall courses of their illness.
People with Schizophrenia can have cognitive problems, such as slower problem-solving, impaired memory, problems with planning and organizing thoughts, and language difficulties. These issues extend to the social sphere, where patients struggle with implied forms of communication, like body language. They often react oddly during social situations, such as laughing at things that aren’t funny.
Roughly half of patients with Schizophrenia will need to have a temporary stay in a psychiatric hospital when they are first diagnosed. This is true both for patients whose symptoms come on all at once and for patients whose problems have slowly grown over several months or years. People usually need to stay in a hospital when their behavior is unmanageable and if they are a danger to themselves or others.
Treatment with medication is a key piece in the puzzle of managing Schizophrenia and should be started as soon as symptoms appear. The first choice medications belong to a group known as “second generation” or “atypical” antipsychotics (SGAs). These include Abilify (aripiprazole), Saphris (asenapine), Latuda (lurasidone), Zyprexa (olanzapine), Risperdal (risperidone), Seroquel (quetiapine), and Geodon (ziprasidone). These medications are preferred over the older “first generation” or “typical” antipsychotics (FGAs), such as Thorazine (chlorpromazine), Proxlixin (fluphenazine), and Haldol (haloperidol), which have side effects that are more difficult to manage. Clozaril (clozapine) is a last-ditch effort medication that is usually tried only after several other medications have failed because of multiple, serious potential side effects that require frequent medical monitoring. However, Clozaril is very effective at treating Schizophrenia in patients for whom several other medications have not worked, and it is especially helpful in treating these patients who also have suicidal thoughts. Medications are tried during the initial period of symptoms until one or a combination is found that works for each individual patient.
The goal in the initial few days of treatment is to reduce the most severe and disruptive symptoms. Patients who are in the midst of a psychotic episode usually are resistant to most treatment and need the help of these medications to get them out of this state. Only then will they be more amenable to communicating with providers and engaging in their own treatment process. After the worst of the symptoms have subsided, doses of medications may be changed slightly so that patients can stay on them long term. Many patients have difficulty taking medications regularly and may stop them suddenly without telling their health care providers. For these patients, long-acting injectable forms of these medications can be administered at regular appointments once every few weeks (timing varies between different medications). These improve medication compliance and reduce psychiatric hospitalizations.
Once patients are on a stable dose of a medication that keeps their severe symptoms at bay, they will be able to engage in forms of talk therapy that will help them manage the symptoms that the medications don’t fully control.
Cognitive Behavioral Therapy (CBT) helps patients deal with the residual symptoms, including hallucinations and delusions. CBT targets unhelpful thought patterns that contribute to paranoia and delusions. It also helps with negative symptoms, which medications largely fail to address. In CBT, patients will learn social skills, practice monitoring their own thought patterns, and get back into hobbies and pastimes that they enjoyed prior to the onset of their illness. CBT also decreases the chance that patients will suddenly stop their medication.
Family therapy aids families of patients in dealing with the stress that comes with a family member being diagnosed with Schizophrenia. Family therapy decreases hospitalization rates and increases patient adherence to treatment.
Assertive Community Treatment (ACT) and case management are the two major resources that provide patients with help managing the multiple areas of their lives that are affected by Schizophrenia. Patients get help not only with the medical aspects of their disorder, such as therapy and medication management, but also with finding housing and employment. This reduces hospitalizations, increases patient independence, and decreases the stress on families. ACT is a coordinated form of care for patients who need to be able to access a caregiver at any time: nights, days, weekends, or holidays. It is a team of providers that includes doctors, nurses, and social workers who all work together for each patient. Case managers usually work for state or local government and are well connected with treatment providers and other resources in their area. They will help patients navigate the system, get to the care they need, and access local resources.
Medication side effects
Antipsychotics, the major medications used in treating Schizophrenia, have several potential side effects that these patients will need help managing. First generation antipsychotics can cause multiple types of movement problems which are collectively known as “extrapyramidal symptoms”, a term that refers to a part of the brain that manages body motions. These include problems like general muscle tension, muscle spasms, tremors, and feelings of restlessness. Taking FGAs for a long time can lead to Tardive Dyskinesia, a disorder of persistent, involuntary muscle movements of the mouth, lips, and tongue. These symptoms are very unpleasant for patients and are a common reason that they stop taking these medications. Second generation antipsychotics have more manageable side effects, so they are the preferred first line medications for Schizophrenia. SGAs tend to cause weight gain, high cholesterol, and contribute to development of type II diabetes. One SGA in particular, Clozaril (clozapine), can cause agranulocytosis, which is a severely low concentration of white blood cells in the body and puts patients at higher risk of infections. This requires frequent monitoring with blood tests, especially right when a patient is starting the medication.
One in five patients with Schizophrenia will attempt suicide at least once at some point in their lives. Five percent of Schizophrenia patients will die by suicide. The risk is highest in patients who also abuse drugs and alcohol, have depressive symptoms, are unemployed, or have recently had a psychotic episode. Auditory hallucinations where patients hear a voice telling them to hurt themselves (called “command hallucinations”) are common in suicidal Schizophrenic patients.
Between 60% to 80% of Schizophrenia patients smoke tobacco, at least three times greater than the rate of smoking in the general population. They tend to be heavier smokers as well, most smoking at least a pack a day. Almost all start smoking before the onset of Schizophrenia. Smoking in Schizophrenia is associated with a younger age at first symptoms, more severe symptoms, more frequent hospitalizations, and needing higher dosages of antipsychotic medications.