What is schizophrenia?

Causes and Symptoms

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 time. The disease does not always follow a downhill course. Bleuler’s views promised more hope for patients suffering from schizophrenia.

The word “schizophrenia” can roughly be translated to mean “split mind.” This does not mean, however, that individuals with schizophrenia have two personalities or two minds. Instead, it refers to how individuals with schizophrenia experience the world: The world can be one way in their mind and another way in what is going on around them.

The symptoms of schizophrenia are more well known than the cause. Diagnosis is based on a characteristic set of symptoms that must last for at least several months. The “psychotic symptoms” include a break with reality, hallucinations, delusions, or evidence of thought disorder. These symptoms are referred to as positive symptoms because they are so readily available. Negative symptoms, which are less readily observed, include withdrawal from society, the inability to show emotion or to feel pleasure or pain, total apathy, and lack of facial expression. A person with negative symptoms might be found simply sitting and staring blankly at the world, no matter what is happening. Schizophrenia can take many forms. Among the most frequent are those that display acute symptoms under the following labels. Melancholia includes depression and hypochondriacal delusions, with the patient claiming to be extremely physically ill but having no appropriate symptoms. Schizophrenia can also be catatonic, in which patients become immobile and seem fixed in one rigid position for long periods of time. Delusional states accompanied by hallucinations frequently involve hearing voices, which often scream and shout abusive and derogatory language at the patient or make outrageous demands.

Disconnected speech patterns, broken sentences, excessive body movement, and purposeless activity usually accompany the symptoms noted above. Victims of the disease also suffer through states of extreme anger and hostility. Cursing and outbursts of uncontrolled rage can result from relatively insignificant causes, such as someone looking at them “in the wrong way.” Many times, anniversaries of important life experiences, such as the death of a parent or the birthday of a parent or of the patient, can set off positive and negative symptoms. Hallucinations and mania can also follow traumatic events such as childbirth or combat experiences during war.

The paranoid form of schizophrenia is the only one that usually develops later in life, between the ages of thirty and thirty-five. It is a chronic form, meaning that patients suffering from it tend to become worse. Paranoid schizophrenia is characterized by a feeling of suspiciousness of everyone and everything, hallucinations, and delusions of persecution or grandiosity. This form becomes so bad that many victims commit suicide simply to escape their tormentors. Others turn on their alleged tormentors and kill them, or at least someone who seems to be responsible for their terrible condition.

Other chronic forms of the disease include hebephrenic schizophrenia. In this case, patients suffer disorders of thinking and frequent episodes of incoherent uttering of incomprehensible sounds or words. The victims move quickly from periods of great excitement to equally exhausting periods of desperate depression. They frequently have absurd, bizarre delusions such as perceived sex metamorphosis, identification with godlike creatures, or experiences of being born again and again literally and in a sense that is not tied to spiritual or religious practices.

Individuals suffering from “simple” schizophrenia exhibit constant feelings of dissatisfaction with everything in their lives or a complete feeling of indifference to anything that happens. They are usually isolated and estranged from their families or any other human beings. Patients with these symptoms tend to live as recluses with barely any interest in society, in work, or even in eating or in talking to anyone else.

The various types of schizophrenia start at different times in different people. Generally, however, except for the paranoid form, the disease develops during late adolescence. Men show signs of schizophrenia earlier than women, usually by age eighteen or nineteen. It is unusual for signs of the disorder to appear in males after age twenty. In women, symptoms may not appear until the early twenties and sometimes are not evident until age thirty. Sometimes, there are signs in childhood. People who later develop schizophrenia tended to be withdrawn and isolated as children and were often made fun of by others. Not all withdrawn children develop the disease, however, and there is no way to predict who will get it and who will not.

Schizophrenia is a genetic disease. Individuals with the disease are very likely to have close relatives—mothers, fathers, brothers, sisters, cousins, grandmothers, or grandfathers—with the disorder. According to the National Institute of Mental Health in 2015, schizophrenia occurs in roughly 1 percent of the general population, but it occurs in roughly 10 percent of individuals with a first-degree relative (parent, sibling) who has the disorder. The risk increases when one has an identical twin with schizophrenia; that individual then has a 40–65 percent chance of developing the disorder.

As to why the disease develops later in life rather than at birth, investigators provide the following information. First, the brain develops more slowly than other organs and does not stop developing until late adolescence. Many genetic diseases remain dormant until later in life, such as Huntington’s chorea and multiple sclerosis.

Schizophrenia operates by disrupting the way in which brain cells communicate with each other. The neurotransmitters that carry signals from one brain cell to another might be abnormal. Malfunction in one of the transmitters, dopamine, seems to be a source of the problem. This seems likely because the major medicines that are successful in the treatment of schizophrenia limit the production or carrying power of dopamine. Another likely suspect is serotonin, a transmitter whose presence or absence has important influences on behavior.

In 2003, researchers announced that they had discovered clues that pointed to a specific gene as the possible cause of schizophrenia. The gene is known as dysbindin, and it is involved in the operation of the synapses, the points where one neuron wires itself to another. The team found that genetic variations in the dysbindin gene were more common among schizophrenic patients. Medical research is increasingly pinpointing regions, or loci, within chromosomes that contain genetic mutations, a task that has proven difficult in years past. Since the human genome sequence has become available, however, research groups have started to focus on the same handful of loci, suggesting that they could be seeing a true signal for the disease. The gene dysbindin has been located in these limited chromosomal regions. Moreover, Icelandic researchers have discovered a gene called neuregulin-1 that also tends to cluster in specific loci. Mutations in this gene are highly correlated with schizophrenia in about 15 percent of Icelandic patients. Other disregulated genes have since been linked to schizophrenia. Scientists believe that no one single gene causes the schizophrenia; however, there are multiple "susceptibility" genes that may make a person more vulnerable to the disorder.

Treatment and Therapy

Since the 1950s, 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), which emerges only after many years of use and 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.

Dystonia is another side effect. Symptoms include the abrupt stiffening of muscles, such as in the arms, neck, and face. Most of these effects can be controlled or reversed with antihistamines. Some patients receiving medication are afflicted with effects similar to those movements associated with Parkinson’s disease. They suffer from the slowing of movements in their arms and legs, tremors, and muscle spasms. Their faces seem frozen into a sad, masklike expression. These effects can be treated with medication. Another problem is akathisia, a feeling developed by many patients that they cannot sit still. Their jumpiness can be treated with benzodiazepines such as Valium or Xanax. Benzodiazepines are addictive substances, so their use must be monitored by health professionals and care givers. Many side effects are so severe that patients cite them as the major reason that they do not take their medicine. Some patients treated with Clozapine may experience agranulocytosis, or the loss of white blood cells; therefore, people using this medication should have their white blood cell counts checked frequently.

Many patients report great value in family or rehabilitation therapy. These therapies are not intended to cure the disease or to “fix” the family dynamic. Instead, they are aimed at helping families learn how to live with and emotionally support mentally ill family members. Family support is important for those suffering from schizophrenia because many are unable to live on their own. Therapy can also help family members understand and deal with their own frustration that accompanies having a severely mentally ill family member. Rehabilitation therapy attempts to teach patients the social, coping, and vocational skills that they need to become more independent within society.

The results of treatment are not always positive, even with medication and therapy. According to the Substance Abuse and Mental Health Services Administration, suicide is the leading cause of premature death among schizophrenics.

Perspective and Prospects

Hopes for improving the treatment of schizophrenia rest mainly on the continuing development of new drugs and genetic research. Several studies suggest that psychotherapy directed at improving social skills and reducing stress helps many people with the disease to 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 can 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.

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.

In 2015, researchers at the University of Cambridge began experimenting with a method outside of pharmaceuticals for treating the cognitive impairments associated with schizophrenia. Because drugs to treat such symptoms had not yet been developed, researchers used technology to create an app for the iPad that could potentially improve the memory of schizophrenics. The game, titled Wizard, was intended to support the patient's episodic memory through a motivating, interesting, and approachable concept. This idea represents the ongoing efforts to help schizophrenics live fuller lives on a daily basis.

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