Schizophrenia

Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. The term schizophrenia comes from two Greek words that mean "split mind." It was coined around 1908, by a Swiss doctor named Eugen Bleuler, to describe the splitting apart of mental functions that he regarded as the central characteristic of schizophrenia. (Note that the splitting apart of mental functions in schizophrenia differs from the "split personality" of people with multiple personality disorder.) Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs.

Although schizophrenia was described by doctors as far back as Hippocrates (500 B.C.), it is a difficult disease to classify. Many scientists prefer the plural terms schizophrenias or schizophrenic disorders to the singular schizophrenia because of the lack of agreement in classification, as well as the possibility that different subtypes may eventually be shown to have different causes.

The schizophrenic disorders are a major social tragedy because of the large number of persons affected and because of the severity of their impairment. It is estimated that people who suffer from schizophrenia fill 50% of the hospital beds in psychiatric units and 25% of all hospital beds. A number of studies indicate that about 1% of the world's population is affected by schizophrenia, without regard to race, social class, level of education, or cultural influences. (However, outcome may vary from culture to culture, depending on the familial support of the patient.) Most patients are diagnosed in their late teens or early twenties, but the symptoms of schizophrenia can emerge at any point in the life cycle. The male/female ratio in adults is about 1.2:1. Male patients typically have their first acute episode in their early twenties, while female patients are usually closer to 30 when they are diagnosed.

Schizophrenia is rarely diagnosed in preadolescent children, although patients as young as five or six have been reported. Childhood schizophrenia is at the upper end of the spectrum of severity and shows a greater gender disparity. It affects one or two children in every 10,000; the male/female ratio is 2:1.

The course of schizophrenia in adults can be divided into three phases or stages. In the acute phase, the patient has an overt loss of contact with reality (psychotic episode) that requires intervention and treatment. In the second or stabilization phase, the initial psychotic symptoms have been brought under control, but the patient is at risk for relapse if treatment is interrupted. In the third or maintenance phase, the patient is relatively stable and can be kept indefinitely on antipsychotic medications. Even in the maintenance phase, however, relapses are not unusual and patients do not always return to full functional ability.

Recently, some psychiatrists have begun to use a classification of schizophrenia based on two main types. People with Type I, or positive schizophrenia, have a rapid (acute) onset of symptoms and tend to respond well to drugs. They also tend to suffer more from the "positive" symptoms, such as delusions and hallucinations. People with Type II, or negative schizophrenia, are usually described as poorly adjusted before their schizophrenia slowly overtakes them. They have predominantly "negative" symptoms, such as withdrawal from others and a slowing of mental and physical reactions (psychomotor retardation).

It is still customary to divide schizophrenia into a number of subtypes, as specified in the fourth (1994) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (as well as the fourth edition update, [DSM-IVTR]) specifies five subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual.

Disorganized schizophrenia (formerly called hebephrenic schizophrenia) is marked by disorganized speech, thinking, and behavior on the patient's part, coupled with flat or inappropriate emotional responses to a situation (affect). Most patients in this category have weak personality structures prior to their initial acute psychotic episode.

Catatonic schizophrenia is characterized by disturbances of movement that may include rigidity, stupor, agitation, bizarre posturing, and repetitive imitations of the movements or speech of other people. These patients are at risk for malnutrition, exhaustion, or self-injury. For unknown reasons, this type is presently uncommon in developed countries. Catatonia as a symptom is most commonly associated with mood disorders.

Patients in this category have the characteristic positive and negative symptoms of schizophrenia but do not meet the specific criteria for the paranoid, disorganized, or catatonic subtypes.

This category is used for patients who have had at least one acute schizophrenic episode, but do not presently have strong positive psychotic symptoms, such as delusions and hallucinations. They may have negative symptoms, such as withdrawal from others, or mild forms of positive symptoms, which indicate that the disorder has not completely resolved.

The DSM-IV and DSM-IV-TR definition of schizophrenia includes three so-called negative symptoms. They are termed negative because they represent the lack or absence of behaviors. The negative symptoms that are considered diagnostic of schizophrenia are a lack of emotional response (affective flattening), poverty of speech, and absence of volition or will. In general, the negative symptoms are more difficult for doctors to evaluate than the positive symptoms.

The treatment of schizophrenia depends in part on the patient's stage or phase. Patients in the acute phase are hospitalized in most cases, to prevent harm to the patient or others and to begin treatment with antipsychotic medications. The best results are usually obtained when drugs are combined with social treatments. A patient having a first psychotic episode should be given a CT or MRI (magnetic resonance imaging) scan to rule out structural brain disease.

Most schizophrenics can benefit from psychotherapy once their acute symptoms have been brought under control by antipsychotic medication. Psychoanalytic approaches are not recommended. Behavior therapy, however, is often helpful in assisting patients to acquire skills for daily living and social interaction. It can be combined with occupational therapy to prepare the patient for eventual employment.