Schizophrenia – Types, Causes, Symptoms, and Treatment

Introduction of Schizophrenia:

Schizophrenia is a severe mental disorder, characterized by profound disruptions in thinking, affecting language, perception, and the sense of self. It often includes psychotic experiences, such as hearing voices or delusions. It can impair functioning through the loss of an acquired capability to earn a livelihood or the disruption of studies. It typically begins in late adolescence or early adulthood. Schizophrenia is a serious brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others. It can leave its sufferer frightened and withdrawn. It is a lifelong disorder that cannot be cured, but usually can be controlled with proper treatment. Contrary to popular belief, schizophrenia is not a split personality or multiple personalities. The word “schizophrenia” does mean “split mind,” but it refers to a disruption of the usual balance of emotions and thinking. The behavior of people with schizophrenia may be very strange and even shocking. A sudden change in personality and behavior occurs when schizophrenia sufferers lose touch with reality, which is called a psychotic episode. It varies in severity from person to person. Some people have only one psychotic episode while others have many episodes during a lifetime but lead relatively normal lives between episodes. Schizophrenia symptoms seem to worsen and improve in cycles known as relapses and remissions.

Epidemiology:

It affects around 0.3–0.7% of people at some point in their life. It occurs 1.4 times more frequently in males than females and typically appears earlier in men but the peak ages of onset are 25 years for males and 27 years for females. Onset in childhood is much rarer, as is onset in middle or old age.

The prevalence rate for schizophrenia is approximately 1.1% of the population over the age of 18.

Types of Schizophrenia:

It is a term given to a complex group of mental disorders. However, different types of schizophrenia may have some of the same symptoms. There are several subtypes of schizophrenia based on symptoms:

Paranoid schizophrenia: People with this type, are preoccupied with false beliefs (delusions) about being persecuted or being punished by someone. Their thinking, speech, and emotions, however, remain fairly normal.

Disorganized schizophrenia: People of this type often are confused and incoherent and have jumbled speech. Their outward behavior may be emotionless or flat or inappropriate, even silly or childlike. Often they have disorganized behavior that may disrupt their ability to perform normal daily activities such as showering or preparing meals.

Catatonic schizophrenia: The most striking symptoms of this type are physical. People with catatonic schizophrenia are generally immobile and unresponsive to the world around them. They often become very rigid and stiff and unwilling to move. Occasionally, these people have peculiar movements like grimacing or assume bizarre postures or they might repeat a word or phrase just spoken by another person. At times, the opposite may be true and these individuals appear to engage in restless ongoing activity with no specific purpose or desired outcome, for example, walking a straight line over and over; repeatedly jumping in place. People with catatonic schizophrenia generally go back and forth between more sedentary behaviors, the restless, purposeless behaviors and are at increased risk of malnutrition, exhaustion, or self-inflicted injury.

Undifferentiated schizophrenia: This subtype is diagnosed when the person’s symptoms do not represent one of the other three subtypes.

Residual Schizophrenia: In this type of schizophrenia, the severity of schizophrenia symptoms has decreased. Hallucinations, delusions, or other symptoms may still be present but are considerably less than when the schizophrenia was originally diagnosed. In addition, there must still be evidence of the disturbance as indicated by the presence of some negative symptoms (for example, inexpressive faces, blank looks, monotone speech, seeming lack of interest in the world and other people, inability to feel pleasure).

Causes of Schizophrenia:

The exact cause of schizophrenia is not yet known. It is known, however, that schizophrenia-like cancer and diabetes is a real illness with a biological basis. It is not the result of bad parenting or personal weakness. But researchers believe that a combination of genetics and environment contributes to the development of the disorder.

Genetics (heredity): It tends to run in families, which means a greater likelihood of developing schizophrenia may be passed on from parents to their children.

Brain chemistry: People with schizophrenia may have an imbalance of certain chemicals in the brain. They may be either very sensitive to or produce too much of a brain chemical called dopamine.

Dopamine is a neurotransmitter, a substance that helps nerve cells in the brain to send messages to each other. An imbalance of dopamine affects the way the brain reacts to certain stimuli, such as sounds, smells, and sights, and can lead to hallucinations and delusions.

Brain abnormality: Research has found abnormal brain structure and function in people with schizophrenia. However, this type of abnormality does not happen in all schizophrenics and can occur in people without the disease.

Environmental factors: Evidence suggests that certain environmental factors, such as a viral infection, extensive exposure to toxins like marijuana, or highly stressful situations, may trigger schizophrenia in people who have inherited a tendency to develop the disorder. Schizophrenia more often surfaces when the body is undergoing hormonal and physical changes, such as those that occur during the teen and young adult years.

Risk Factors:

Although the precise cause of schizophrenia is unknown, certain factors seem to increase the risk of developing or triggering schizophrenia, including:

• Having a family history of schizophrenia,
• Exposure to viruses, toxins, or malnutrition while in the womb, particularly in the first and second trimesters,
• Increased immune system activation, such as from inflammation or autoimmune diseases,
• Taking mind-altering (psychoactive or psychotropic) drugs during teen years and young adulthood.

Dopamine Theory of Schizophrenia: The exact cause of schizophrenia is unknown, though genetics and environmental factors may play a role. For example, altered brain structures, such as having less gray matter than average, may contribute to the onset of the disorder. Altered brain chemistry, specifically due to the neurotransmitter dopamine, also may be a factor.

Pharmacological treatments support the idea that an overactive dopamine system may result in schizophrenia: Medications that block dopamine receptors, specifically D2 receptors, reduce schizophrenia symptoms.

Dopamine: It is a catecholamine neurotransmitter present in a wide variety of animals. In the brain, this functions as a neurotransmitter, activating the five known types of dopamine receptors – D1, D2, D3, D4, and D5.

Dopamine is also a neurohormone released by the hypothalamus. Its main function as a hormone is to inhibit the release of prolactin from the anterior lobe of the pituitary.

Evidence for the dopamine hypothesis: Amphetamine, cocaine, and similar drugs increase levels of dopamine in the brain and can cause symptoms that resemble those present in psychosis.

Similarly, those treated with dopamine-enhancing levodopa for Parkinson’s disease can experience psychotic side effects mimicking the symptoms of schizophrenia.

Up to 75% of patients with schizophrenia have increased signs and symptoms of their psychosis upon challenge with moderate doses of methylphenidate or amphetamine or other dopamine-like compounds.

Some functional neuroimaging studies have also shown that, after taking amphetamine, patients diagnosed with schizophrenia show greater levels of dopamine release than non-psychotic individuals.

However, the acute effects of dopamine stimulants include euphoria, alertness, and over-confidence; these symptoms are more reminiscent of mania than schizophrenia.

Symptoms of Schizophrenia:

In men, schizophrenia symptoms typically start in the early to mid-20s. In women, symptoms typically begin in the late 20s. It is uncommon for children to be diagnosed with schizophrenia and rare for those older than 45.

Schizophrenia involves a range of problems with thinking (cognitive), behavior, or emotions. Signs and symptoms may vary, but they reflect an impaired ability to function.

The most common symptoms of schizophrenia can be grouped into three categories:

• Positive symptoms
• Disorganized symptoms and
• Negative symptoms

Positive symptoms are disturbances that are “added” to the person’s personality.

• Delusions: “False ideas” individuals may believe that someone is spying on him or her, or that they are someone famous (or a religious figure).
• Hallucinations: These usually involve seeing, feeling, tasting, hearing, or smelling something that does not exist. The most common experience is hearing imaginary voices that give commands or comments to the individual.
• Disordered thinking and speech: Moving from one topic to another, in a nonsensical fashion. Individuals may also make up their own words or sounds, rhyme in a way that does not make sense or repeat words and ideas.
• Disorganized behavior: This can range from having problems with routine behaviors like hygiene or choosing appropriate clothing for the weather, to unprovoked outbursts, to impulsive and uninhibited actions. A person may also have movements that seem anxious, agitated, tense, or constant without any apparent reason.

Negative symptoms are capabilities that are “lost” from the person’s personality.

• Social withdrawal,
• Extreme apathy (lack of interest or enthusiasm),
• Lack of drive or initiative,
• Emotional flatness,
• Loss of pleasure and lack of ability to experience pleasure,
• Decreased talking and neglect of personal hygiene, poor hygiene, and grooming habits or have a loss of interest in everyday activities,
• Speaking without inflection or monotone or not adding hand or head movements that normally provide the emotional emphasis in speech.

Tests and Diagnosis:

There is no single test for schizophrenia. The condition is usually diagnosed after assessment by a specialist in mental health.

A psychiatrist or other mental health professional should be involved in making a schizophrenia diagnosis. Some people with schizophrenia are afraid of their symptoms. They may be suspicious of others (paranoid). This can make it more difficult to confirm a schizophrenia diagnosis.

A schizophrenia diagnosis can be made when all of the following are true about a patient:

• Schizophrenia symptoms have been present for at least six months.
• The patient is significantly impaired by the symptoms. For example, has serious difficulty in working or with social relationships, compared to the period before symptoms began.
• Symptoms cannot be explained by another diagnosis, such as drug use or another mental illness.

If symptoms of schizophrenia are present or when psychiatrist suspects someone has schizophrenia, they typically ask for medical and psychiatric histories, conduct a physical exam, and run medical and psychological tests, including:

Tests and screenings: These may include complete blood count (CBC), other blood tests that may help rule out conditions with similar symptoms, and screening for alcohol and drugs. Other tests may include imaging studies, such as an MRI or CT scan.

Psychological evaluation: A psychiatrist or mental health provider will check the mental status by observing appearance, attitude and asking about thoughts, moods, delusions, hallucinations, substance abuse, and potential for violence or suicide.

For a psychiatrist to make a confident schizophrenia diagnosis, some of these symptoms must be present:

• Hallucinations.
• Delusions.
• Disorganized speech and behavior (talking and acting strangely).
• Lack of motivation and emotional expression.
• Lack of energy.
• Poor grooming habits.

Specific types of psychotic symptoms (called first-rank symptoms), when present, make a schizophrenia diagnosis more likely:

• Hearing own thoughts spoken aloud.
• Feeling that thoughts are being inserted into the mind, or removed from it, by an outside force.
• Feeling like other people can read minds.

A person with schizophrenia may describe these symptoms openly or a psychiatrist may deduce as they are likely to present, based on observations of a person’s speech and behavior.

Treatment of Schizophrenia:

It requires lifelong treatment, even when symptoms have subsided. Treatment with medications and psychosocial therapy can help to manage the condition. During crisis periods or times of severe symptoms, hospitalization may be necessary to ensure safety, proper nutrition, adequate sleep, and basic hygiene.

A psychiatrist experienced in treating schizophrenia usually guides treatment. The treatment team also may include a psychologist, social worker, psychiatric nurse, and possibly a case manager to coordinate care. The full-team approach may be available in clinics with expertise in schizophrenia treatment.

Medications:

Second-generation antipsychotics: These newer, second-generation medications are generally preferred because they pose a lower risk of serious side effects than do first-generation antipsychotics. Second-generation antipsychotics include:

• Aripiprazole (Abilify)
• Asenapine (Saphris)
• Brexpiprazole (Rexulti)
• Cariprazine (Vraylar)
• Clozapine (Clozaril)
• Iloperidone (Fanapt)
• Lurasidone (Latuda)
• Olanzapine (Zyprexa)
• Paliperidone (Invega)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)

First-generation antipsychotics: These first-generation antipsychotics have frequent and potentially significant neurological side effects, including the possibility of developing a movement disorder (tardive dyskinesia) that may or may not be reversible.

First-generation antipsychotics include:

• Chlorpromazine
• Fluphenazine
• Haloperidol
• Perphenazine

Psychosocial interventions: Once psychosis recedes, in addition to continuing on medication, psychological and social (psychosocial) interventions are important. These may include:

• Individual therapy: Psychotherapy may help to normalize thought patterns. Also, learning to cope with stress and identify early warning signs of relapse can help people with schizophrenia manage their illness.
• Social skills training: This focuses on improving communication and social interactions and improving the ability to participate in daily activities.
• Family therapy: This provides support and education to families dealing with schizophrenia.
• Vocational rehabilitation and supported employment: This focuses on helping people with schizophrenia prepare for, find and keep jobs.

Electroconvulsive therapy (ECT): This is a procedure in which a series of electric shocks are delivered to the brain. The shocks induce seizures, causing the release of neurotransmitters in the brain. This form of treatment is rarely used today in the treatment of schizophrenia. ECT may be useful when all medications fail or if severe depression or catatonia makes treating the illness difficult.

Complications:

Left untreated, schizophrenia can result in severe emotional, behavioral, and health problems, as well as legal and financial problems that affect every area of life. Complications that schizophrenia may cause or be associated with include:

• Suicide,
• Any type of self-injury,
• Anxiety and phobias,
• Depression,
• Abuse of alcohol, drugs, or prescription medications,
• Poverty,
• Homelessness,
• Family conflicts,
• Inability to work or attend school,
• Social isolation,
• Health problems, including those associated with antipsychotic medications, smoking, and poor lifestyle choices,
• Being a victim of aggressive behavior.

Aggressive behavior, although it is uncommon and typically related to lack of treatment, substance misuse, or a history of violence.

Prevention:

There is no sure way to prevent schizophrenia. However, early treatment may help get symptoms under control before serious complications develop and may help improve the long-term outlook.

Sticking with the treatment plan can help to prevent relapses or worsening of schizophrenia symptoms.

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