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Schizophrenia is a serious mental illness characterised by hallucinations, delusions, and psychosis. It is one of the mental diseases in the schizophrenia spectrum, which contains similar illnesses such as Schizoaffective disorder, Schizotypal disorder, Schizoid personality disorder, and others.
People with schizophrenia have a strange or altered perception of reality. It's well known that schizophrenia is characterized by hallucinations and delusions, but also can impair thinking and attention, a breakdown in thought processes, and poor emotional response.
Schizophrenia usually manifests as auditory hallucinations, paranoid or bizarre delusions, and disorganized speech and thinking. It usually starts to manifest itself in young adulthood (often before the age of 19). It affects somewhere between 0.3-0.7% of people worldwide and is known in all cultures, both sexes, and all ethnic groups. Like most other mental illnesses, schizophrenia has to be dianosed using a differential diagnosis based both on observations of the patient and description of the patient's own experiences.
The cause of the disease is unknown, alhtough it is clear that genetic, early environment, neurobiology, psychological processes and social processes all contribute to risk factors for the disease. Both prescription and recreational drugs can often worsen the symptoms. Current research is focussed on neurobiological causes but to date, no single organic cause for the disease has been identified. Because each patient can have unique symptoms, there is also debate about whether schizophrenia is a distinct disease or a set of related disorders.
Although the etymology of the name is the Greek for "split mind", and the disease is often thought to be one of "split personalities", this does not accurately describe the disease.
Most schizophrenics are now treated with anti-psychotics, which help alleviate symptoms, but often have deleterious side effects. These medications suppress dopamine and serotonin receptors. In addition, psychotherapy, vocational and social rehabilitation are used as supplementary tools. Where the risk to the patient or others is extreme, involuntary hospitalization is necessary. However, hospital stays for schizophrenics continue to get shorter and less frequent.
Although the condition largely affects cognition, it also contributes to emotional and behavioral problems. Scizophrenics often have other major mental illnesses, such as clinical depression and anxiety disorders. Almost half of schizophrenics abuse drugs. Long term poverty, unemployment and homelessness are common. Their average life expectancy is 12–15 years shorter than others of the same sex and ethnicity, and their suicide rate is about 5% higher than the general population.
Although mental illnesses that resemble schizophrenia have been described in medical literature back to Egyptian times, the definition of a specific disease came slowly. Case reports describing persons who appear to meet the modern diagnostic criteria started appearing in the late 18th and early 19th century. The first of these was James Tilly Matthews in the 1790s. In 1853, French physician Benedict Morel described a condition that occurred in teenagers and young adults that would also meet the modern diagnostic criteria for schizophrenia, although for most of the rest of the 19th century, it was seen as a form of early dementia rather than as a psychosis. By the late 19th century, German psychiatrist Emil Kraepelin started to make a distinction between different types of dementia that were caused by pathologies of the brain and other conditions he called "mood disorders" that he did not believe had an organic cause.In 1908, Swiss psychiatrist Eugen Bleuler coined the word "schizophrenia" to describe what he felt was a fundamental disconnection between personality, thinking, memory and perception. His diagnostic criteria, which came to be called the "Four A's", included flat Affect, Autism, impaired Association of ideas and Ambivalence. However, he realized that his patients were clearly not suffering from a form of dementia as had been previously thought as, unlike dementia, schizophrenics occasionally improved and some regained full function of their faculties. However, the choice of terms was a poor one. Despite the improvement in diagnostic criteria and prognosis, even other medical professionals at the time did not see any "split" within the patient and, as such, the term tended to merely serve to mislead laypersons about the nature of the disease. By 1933, this misconception had entered popular literature and the term continued to be misused to mean "split personality".
In the beginning, the cause was seen as almost entirely genetic. The development of the now discredited pseudoscience of eugenics meant that many schizophrenics were sterilized in German, the United States and Scandinavia and during the Nazi period in Germany, many were summarily killed.
It was not until the 1960s that medical science finally started to develop the diagnostic criteria in use today. The event that spurred this was the misdiagnosis of persons with treatable or temporary conditions with schizophrenia. Another factor was that schizophrenia was a far more common diagnosis in the United States than in the United Kingdom. A 1972 article published in the journal Science argued that patients in the United States were judged solely on subjective and unreliable criteria. As such, in the 1970s, the diagnostic criteria were tightened to exclude questionable cases. These reforms also led to a revision of the entire Diagnostic and Statistical Manual of Mental Disorders which was published in 1980 and dropped several dozen questionable psychiatric disorders.
Schizophrenia usually presents with:
- Hallucinations, usually auditory, but occasionally visual
- Delusions, usually something of a bizarre nature, or a feeling that they are being persecuted
- Disorganized thinking and speech, ranging from a loss of train of thought, through sentences that are only loosely connected, and finally confused and repetitious language.
- Social withdrawal leading to social isolation
- Sloppiness of dress and hygiene
- Loss of motivation and judgment
- Emotional difficulty, including lack of responsiveness
- Inability to comprehend social interactions and conventions
- In extreme cases, inability or unwillingness to speak, remaining motionless in uncomfortable or bizarre postures, meaningless agitation and catatonia
In some cases, a set of preliminary symptoms can be identified that can lead to early treatment. These include:
- Transient or self-limiting psychosis
- Social withdrawal
- Intense feelings of depression
To distinguish schizophrenia from other common psychiatric disorders, the psychiatrist Kurt Schnieder developed his "First-ranked symptoms". However, the usefulness of these symptoms in confirming a diagnosis are currently questioned, even though they appear in most authoritative texts.
- Delusions of being controlled by an external force
- The belief that thought are either being inserted into or withdrawn from the conscious mind
- The belief that one's thoughts are being broadcast to other people
- Hearing hallucinations that comment on the person's thoughts or actions, or hearing a conversation between different hallucinated voices
More recently, schizophrenia is characterized by a set of positive and negative symptoms. Positive symptoms are those that exist in schizophrenics, but are not experienced by most individuals. These include delusions, disordered thoughts and speech, and hallucinations of all five senses that result from psychosis. In most cases, the hallucinations relate to the content of the delusions. These symptoms generally respond well to medication. Negative symptoms are deficits of emotional response or thought processes and generally do not respond to medication. These include blunted affect and lack of emotional response, poor use of speech, anhedonia, lack of desire to form relationships, and lack of motivation. These negative symptoms all contribute to the poor quality of life experienced by most patients.
No exact cause of the disease is known, but it is believed that genetic and environmental factors both play a role. People with a family history of schizophrenia are more likely to be diagnosed with it. However, the variability of environmental factors makes it difficult to determine just how likely any given person with a family history will be to develop the disease. A person with a parent, child or sibling with the disease has a 6.5% chance of having it. A person who has an identical twin with the disease stands about a 40% chance of developing it. However, no specific gene has been identified as being associated with the disease, although the suspect group of genes overlaps those that play a role in bipolar disorder. Genetic science is also at a loss as to why such a disease would have developed given the workings of evolution as the disease is always maladaptive.
Some environmental factors have been identified as making schizophrenia more likely, including drug use, living environment and pre-natal stress such as viruses, toxins or malnutrition. However, there appears to be no link between parenting style and schizophrenia, although when the disease develops people in more supportive relationships tend to fare better. Persons born to older parents appear to be at higher risk. Living in an urban environment, even only as an adult, appears to roughly double the risk even after all other social factors have been accounted for. Social isolation, immigration, social adversity, racial discrimination, family dysfunction, unemployment and poor housing conditions also appear to play a role. Childhood abuse and trauma also appear to make schizophrenia more likely.
Marijuana, cocaine and amphetamines have all been linked to increased risk, and about half of schizophrenics abuse drugs or alcohol. However, of these only marijuana has been shown to have any causal link, and the others could be an attempt to self-medicate to cope with depression, anxiety, boredom and loneliness. However, even the link with marijuana appears largely dose dependent and it's exact effect remains controversial. In addition, mere abuse of cocaine, amphetamines and alcohol can lead to psychosis which mimics schizophrenia. It should be noted that schizophrenics are also more likely to use nicotine than the general population.
The pre-natal stressors that have been linked are hypoxia, infection and malnutrition. For some reason, a disproportionate number of schizophrenics are born in the first half of the year during winter and spring.
Like its causes, the mechanism that causes the mental status changes in schizophrenia patients is also poorly understood. The best accepted model is the dopamine hypothesis, which puts the symptoms down to the brain's misinterpretation of misfiring dopamine-accepting neurons. Another hypothesis is that the disease is the result both of poor neurodevelopment and later neurodegeneration. However, this latter theory does not explain many of the symptoms that are known to occur in schizophrenics.
The dopamine hypothesis was formed after it was noted that when patients were given dopamine inhibitors, their psychotic symptoms improved. In addition, amphetamines, which increase dopamines, make schizophrenic symptoms worse. In the 1990s, the improvement of PET scans confirmed this. However, this model is now believed to be incomplete as newer medication for schizophrenics appears to be just as effective despite the fact that it has less affect on dopamine and has a greater effect suppressing serotonin.
It is also now believed that glutamate plays a role in the disease as autopsies of schizophrenic brains show very low levels of glutamate receptors. This hypothesis appears to be bolstered by the fact that drugs that block glutamates, like ketamine, often bring about schizophrenic like symptoms. In addition, low glutamate levels in normal adults are known to have an affect on the frontal lobe and hippocampus.
However, many of these results are in question as most schizophrenics who have been autopsied were being treated with medication for most of their life. This, in and of itself, could have caused the brain changes that were observed. In addition, PET scans of schizophrenics who have not been given drug treatment appear to have identical dopamine receptors to normal control brains. Moreover, in cases where schizophrenics are noted to have lower dopamine receptor levels, it may still not be clinically significant.
Studies of living brains have found notable differences in the frontal lobe, hippocampus and temporal lobes. Those who believe the condition is a neurodevelopmental disorder believe these parts of the brain do not fully develop in schizophrenics, explaining why symptoms arise in young adulthood when brain development is largely complete in most individuals. However, schizophrenics show a wide range of brain development issues and there is no one feature that distinguishes schizophrenics. Moreover, these abnormalities are common in other psychiatric disorders. However, in cases of early onset schizophrenia, there is an associated loss of grey matter in the brain which does indicate a neurodegenerative cause.
MRI studies also show that schizophrenics tend to have a smaller hippocampus and a smaller ventrical than normal controls. However, these volumetric differences appear at the range of MRI detection, so it is uncertain whether these parts of the brain don't develop fully or degenerate more quickly than those of average persons. However, MRIs also find abnormalities in the prefrontal cortex, temporal cortex and anterior cingulate cortex of schizophrenics even before symptoms occur. An fMRI shows that the positive symptoms of the disease appear to originate in the medial prefrontal cortex, amygdala and hippocampus. Negative symptoms appear to originate in the ventrolateral prefrontal cortex and ventral striatum. fMRIs also show that many of the cognitive difficulties experienced by schizophrenics develop in the very early steps of sensory processing.
PET scans show a lack of blood flow to the left parahippocampal region and a reduced ability to metabolize glucose in the thalamus and frontal cortex. However, there is increased blood flow where thought disorders originate in the frontal and temporal regions of the brain, while decreased blood flow is characteristic of hallucinations and delusions arising from the cingulate, left frontal and temporal regions. When patients were scanned during active auditory hallucinations, there was increased blood flow in the thalami, left hippocampus, right striatum, parahippocampus, orbitofrontal and cingulate areas.
A primary care physican who suspects schizophrenia will almost always make an immediate emergency referral to a psychiatrist. However, a family doctor may ask both patients and relations to write down symptoms and a recent medical and personal history rather than try to remember them at an appointment. They will also ensure that the patient lists all medication or drugs they may be using. The criteria for diagnosing schizophrenia are found in both the DSM-IV-TR and the ICD-10. A diagnosis is based on self-reported experiences of the patient, reports by others of the patient's behavior, and a full clinical work-up, including standard tests to rule out other organic conditions. Because most of the symptoms of schizophrenia are common (but very transient) in most of the population, the symptoms must meet a level of severity that in the subjective judgment of the physician is indicative of the disease and not another condition. A differential diagnosis must consider other mental illnesses bipolar disorder, borderline personality disorder, drug intoxication, drug-induced psychosis, delusional disorder, social anxiety disorder, avoidant personality disorder, and schizotypal personality disorder. It must also rule out organic disorders such as metabolic disturbance, systemic infection, syphillis, HIV, epilepsy and brain lesions. One difficulty posed by a diagnosis is that although Obsessive-Compulsive Disorder can be distinguished from schizophrenia, many patients have both conditions.
The patient must show at least two of these symptoms for most of the time during a one month period:
- Disorganized speech that severely impairs the ability to communicate with others
- Grossly disorganized behavior (such as dressing inappropriately or crying frequently), or catatonia
- Blunted affect, decline in or lack of speech, decline in or lack of motivation
In the alternative, the patient must suffer from just one of these very severe symptoms:
- Bizarre delusions
- Auditory hallucinations that form a running commentary on the patient's actions
- Hearing two or more voices
In addition, the patient must also meet these two criteria
- Social or occupational dysfunction, such as ability to work, personal relationships or self-care.
- Signs that these disturbances have lasted at least six months.
If all these criteria are not met, alternative diagnoses can be schizophreniform disorder or brief psychotic disorder. Schizophrenia is also excluded if the patient has mood disorders or pervasive developmental disorder.
Once diagnosed, the patient is usually classified into one of five subtypes of schizophrenia
- Paranoid type, characterized by delusions and auditory hallucinations in the absence of thought disorders, disorganized behavior and flat affect. Delusions are generally either persecutory or grandiose and may include jealousy or extreme religious belief.
- Disorganized type, characterized by the presence of both thought disorders and flat affect
- Catatonic type, where the patient is immobile or only engages in agitated but purposeless movement.
- Undifferentiated type, where the patient shows psychosis, but not paranoia, disorganization, or catatonia
- Residual type, where the positive symptoms are of low intensity
Prevention and ManagementEdit
Although it is hoped that early intervention will avoid the worst symptoms of schizophrenia, there is currently no conclusive proof that early treatment has any effect on the course of the disease. It is accepted that early intervention can help in the short term, particularly with psychosis, but over a period of five years, no difference can be seen. As such, treatment for the condition before symptoms appear (based on precursor symptoms) is not recommended. It is believed that persons at risk should avoid marijuana and other cannabis products. It is hoped that once the disease is better understood, intervention can be targeted at those with genetic and environmental risk factors. It is also hoped that, in future, schizophrenia can be treated as a public health issue and persons at risk because of socioeconomic factors could be screened more frequently. However, at present, there is no guarantee that resources used in such an effort might not be better used elsewhere.
Because of the nature of the disease, most sufferers don't realize that they are sufferering from a mental illness and rarely seek medical attention of their own accord. In the majority of cases, patients are brought for medical attention by family members. In some cases, family may need the assistance of law enforcement or emergency medical personnel.
Schizophrenia is difficult to manage as no one treatment will work for all patients. At present, medication is the preferred approach. There is no cure for the disease so all treatment focusses on management of symptoms and improving brain function.
Anti-psychotics have been the preferred approach since they were first developed in the 1950s. However, these drugs have severe side effects such as sedation, repetitive and uncontrollable body movements, neuroleptic malignant syndrome, obesity and diabetes mellitus. However, the range of anti-psychotics currently available often have more manageable side effects and older drugs used to treat schizophrenia are used less often. These drugs usually take 7–14 days to have their full effect on the patient. However, some patients fail to respond to even a combination of anti-psychotics given for a period of over six weeks. For thse patients, clozapine is used despite it's severe side effects that can include myocarditis and lowering the white blood cell count. In addition, the effectiveness of these drugs in preventing psychotic episodes is under review as many schizophrenics who use the drugs still have such episodes while schizophrenics who avoid the drugs are actually less likely to have such episodes.
The cost of treatment must also be considered. Newer atypical anti-psychotics tend to have better results and lesser side effects, but are also significantly more expensive than older anti-psychotics.
Severe schizophrenics usually require hospitalization, although hospital stays are getting shorter and less frequent as treatment methods improve. Many hospitals have drop-in clinics to treat schizophrenics on an out-patient basis.
Behavioral therapies are also used with schizophrenics, again with mixed success. Psychotherapy has been effective, but is rarely used due to its cost and the lack of proper training. Cognitive behavioral therapy has also been effective. However, one of the most effective forms of therapy is whole family therapy, including the patient's parents, siblings and partners in the process.
One of the common problems in treating schizophrenics is that many of them will reject the idea that they will require treatment for the rest of their lives. They will often stop taking their medication as their symptoms subside, believing the medication has cured them, only to suffer a relapse and once again believe they do not need medical treatment.
PrognosisEditSchizophrenia is a chronic condition and sufferers will require lifetime treatment. Schizophrenics have a lifespan of 12–15 years shorter than average persons of the same sex and ethnic background, with that gap growing over time. The main contributing factors are obesity, a sedentary lifestyle, and smoking. Well over 80% of schizophrenics are smokers and tend to smoke heavily.
The ability of a schizophrenic to function normally or take care of themselves does tend to decline over time.
The psychosis related to schizophrenia is the third most severe type of disability, rating better than quadriplegia and dementia, but worse than paraplegia or blindness. About 75% of schizophrenics suffer psychosis to the point of disability at some point. However, the majority of schizophrenics live independently, and some have been known to make a full recovery. After a first episode, about half of patients have a good outcome, a third an intermediate outcome, and about a quarter have a poor outcome.
Although schizophrenics are at a higher risk of suicide, it is far less common than first believed, and best estimates now put the risk at less than 5% worse than the population as a whole, and in almost all cases it occurs during the first period of hospitalization. As such, suicide risk does not have a major impact on lifespan. It must be noted, however, that suicide attempts are far more common.
Other complications of the disease are self-destructive behavior, self-injury, clinical depression, drug abuse, poverty, homelessness, family breakdown, inability to work or attend school, side effects of medication, being a victim of or perpetrator of crime and heart disease.
Schizophrenia affects about 3-7 persons per 1,000 population at some point in their lives. It is about 40% more common in men, who also tend to develop symptoms earlier. The peak years for the onset of symptoms is 20-28 in males and 26-32 in females. Onset in childhood and in persons of middle age or older is very rare. Variation between populations is quite high, both at a region to region level and even at a neighborhood to neighborhood level.
Schizophrenia is poorly understood by the public and a diagnosis carries a significant stigma. Suggestions have been made to change it's name in order to more properly describe the nature of the disease. This has already been done in Japanese, where it went from "mind split disease" to "integration disorder". Media coverage of schizophrenia tends to be focussed on rare violent crimes committed by schizophrenics than directing it's attention to more typical cases of the disease.
Lay persons are also fearful of violence perpetrated by schizophrenics. However, in almost all cases where schizophrenics are violent, other drugs are involved. For example, drug abuse in a region is a much better predictor of homicide than the rate of schizophrenia in the region. Conversely, schizophrenics are far more likely than a person in the general population to be a victim of a violent crime.
Schizophrenia also carries significant social costs. The direct and indirect costs of the disease are estimated to be $62.0 billion per year in the United States alone.
On the seriesEdit
Schizophrenia has been a focus of several episodes and plays a large part in the series as a whole.
James and DannyEdit
Schizophrenia marks an important point of character development for James Wilson. In the Season 1 episode Histories, we learn that Wilson's sympathy for homeless patients arises from the fact that his brother Danny Wilson is homeless and Wilson hasn't seen him in years. Even Gregory House was surprised that Wilson was able to hide this from him given that House knows Wilson's family.
However, it is not until Season 5 episode The Social Contract that we learn the whole story. Danny's homelessness was the result of schizophrenia. Moreover, Wilson blamed himself for Danny's condition because when Danny was at Princeton University while James was at medical school at Columbia University, Danny's paranoia would usually manifest itself by him having call James and rant about how his professors were conspiring against him. One night, James lost his patience and hung up on him. The next day, Danny left school without his medication and was never seen again.
House, rightly or wrongly, puts Wilson's personality characteristic of always backing down and trying to molify everyone to this incident. In addition, it is further revealed that Wilson's agreement to come and work at Princeton-Plainsboro Teaching Hospital was driven largely by his wish to have more time to look for Danny, who was thought to still be in the Princeton area. This was confirmed when James once saw Danny through the window of a diner, but could not catch up with him. It can rightly be said that Danny's schizophrenia provides a good portion of Wilson's backstory in the series and explains a great deal of his personality and motivation and why he puts up with House.
The MisdiagnosisEditMany critics saw The Socratic Method as an early turning point in the series. It shows House not just as a doctor who is only interested in puzzles, but as a doctor who has a great disdain for doctors who jump to the obvious conclusions when there is plenty of evidence that's easy to find.
House is sitting in the emergency room waiting room when Luke Palmeiro gets into an argument with Dr. Wells about the treatment of Luke's mother, Lucy Palmeiro. Wells has written off Lucy as an alcoholic who developed a deep-vein thrombosis due to what are undoubtedly lengthy periods of unconsciousness. As Luke argues the point, House chimes in and sarcastically points out to Luke that Wells is a professional who obviously did some simple confirmation of his diagnosis of alcoholism. When Wells' reaction shows that he did no such thing, House agrees to take on the case.
At first, House's team is astounded, but House insists Lucy, a woman in her mid-thirties, is obviously too young to have developed a thrombosis. His team is even more astounded when House agrees to meet the woman. He spends hours at her side, just listening to her ramble. Wilson realizes House is more intrigued with the patient's schizophrenia than her other medical conditions. House denies it, but his response shows that he is deeply concerned about the way schizophrenics have been treated.
As the case progresses, House is right at every turn. Her thrombosis was the result of Vitamin K deficiency, and he also discovers she has liver cancer. However, when Luke is taken away by child services and House realizes that Lucy must have called them, he starts taking another look at her diagnosis of schizophrenia. He realizes that Lucy didn't show symptoms until her thirties - very late for schizophrenia. He redoubles his efforts, working all night to realize that her diagnosis was based on her choice of specialists - in this case a referral to a psychiatrist. When he starts pushing a new differential diagnosis, Allison Cameron suggests Wilson's disease and House realizes that one of the doctors Lucy didn't get to see was an opthamologist, who was most likely looking for Kaiser-Fleischer rings to confirm it. The team finds the rings and Lucy improves quickly on treatment, restoring her sanity and reuniting herself with her son.
However, once the patient is cured, House loses interest in her. Wilson realizes he was right about it being about the schizophrenia.
When would a man wish he has schizophrenia? In House's case, it's at the end of Season 5 when he starts to see the Amber hallucination. Instead of jumping to the obvious "horse" of Vicodin, he develops a list of seven possible diagnoses. As he whittles them down one by one, he is left with only Vicodin and schizophrenia as possibilities. As Amber taunts him (schizophrenia means losing his medical license, giving up Vicodin means living in pain), House still grabs for the zebra and despite his age and absence of other symptoms, gives himself insulin shock therapy in order to treat the schizophrenia. When Amber disappears after he regains consciousness, he seems triumphant until he goes to celebrate that evening and sees Amber taunting with "It's Later Than You Think".
Margaret McPherson was a high functioning schizophrenic in a stable relationship with her husband Billy. She was managing her condition with risperidone and frequent trips to an out-patient clinic. However, because of the stigma involved, she hid her condition from her husband.
However, the side effects of her medication caught up with her and she started vomitting in front of her husband, who insisted she go to the hospital. She maintained the charade perplexing the emergency room staff. Her stomach pain with no cause confused the ER staff. She was eventually referred to doctor house
However, the only thing wrong with Margaret was that she was starting to suffer withdrawal symptoms from her medication. After the nausea, she soon developed tachycardia and fever, also seemingly for no reason. Her answers throughout her stay were all clearly lies and the lies just kept getting bigger.
As the medication cleared from her body, her schizophrenia started to reassert itself, bringing out psychosis and hallucinations. When new hire Dr. Kelly Benedict suggested that Margaret had started to develop bipolar disorder, Dr. House realized that it was the final symptoms that were the real problem and the earlier ones were the side effects. He started treatment for schizophrenia and Margaret once again became lucid. She had to reveal to her husband that she was schizophrenic. House had realized that Margaret's lies were made in the hope that she would soon be released and would be able to seek out treatment from her primary care physician without Billy's knowledge.
Billy was shocked and wondered how he could deal with Margaret. House chastized him telling him that, no matter what he originally thought, this was the woman he married and that marriage was always hard. Billy returned to Margaret's side and her prognosis looked good.
- Schizophrenia at NIH
- Schizophrenia at Wikipedia
- Schizophrenia at Mayo Clinic Links to the different forms of schizophrenia can also be found at this page.
- Schizophrenia risk factors
- Five Ridiculous Myths You Probably Believe About Schizophrenia at Cracked.com
- New research shows schizophrenia may be 8 distinct disorders at IFL Science
|January 2012||February 2012||March 2012|
|Jeffrey Sparkman||Schizophrenia||Three Stories|
This article was the featured article for February 2012. It was the first disease to be featured.