Health Information - Schizophrenia FAQs

Schizophrenia is a brain illness that severely disrupts the ability to accurately interpret the world the around oneself. It is a disorder that profoundly affects thinking and judgment. Schizophrenia impairs a person's ability to logically reason, to organize and communicate thoughts, and to function in society.

Schizophrenia affects about 1% of the population worldwide. Symptoms typically manifest in early adulthood, often when a person is entering their most productive years.

It is important to understand that schizophrenia is not a "split personality" as depicted in the movie "The Three Faces of Eve," nor is it caused by bad parenting or personal weakness.

2. What causes schizophrenia?

Although a great deal is known about its biology, the causes of schizophrenia have not yet fully been elucidated. Through twin and adoption studies, we know that there is an inherited genetic component. We also know that environmental stress, particularly during the mother's second trimester of pregnancy, plays an important role in the development of schizophrenia in the offspring. Finally, we know that use of stimulant drugs, such as amphetamines, cocaine or PCP (angel dust), can trigger episodes of illness.

3. What are the symptoms of schizophrenia?

When untreated, people with schizophrenia develop bizarre, fixed ideas called delusions. For example, they may have the mistaken belief that they are being persecuted by unknown forces. People with schizophrenia also experience hallucinations, in which they may hear voices commanding them to act in certain ways. For example, a voice may tell them to kill themselves.

People with schizophrenia also evidence difficulty in organizing their thoughts and planning their ideas, and they frequently lose interest and motivation in life. This is slightly different from being depressed: It is a fundamental lack of interest as opposed to being too depressed to be interested.

Finally, people with schizophrenia may demonstrate memory deficits, attentional problems, and/or difficulties in expressing emotions and understanding them in others. These are referred to as the neurocognitive deficits of schizophrenia.

Unfortunately, one very serious symptom of schizophrenia is that most patients do not recognize that they are ill. They do not have insight into the fact that they have a mental problem and, therefore, often refuse treatment.

4. What happens to the brain in schizophrenia?

The schizophrenic brain is not normal. Many patients have enlarged cerebral ventricles, which are the fluid-filled spaces in the brain. Others may have structural abnormalities in the temporal lobes and metabolic abnormalities in the frontal and temporal lobes. All these features suggest that, in the schizophrenic brain, connections between brain parts are not normal and these dysfunctional connections lead to the symptoms of the disease.

5. What does it mean when a person with schizophrenia says they hear voices?

People with schizophrenia often experience auditory hallucinations in which they perceive voices that are quite distinct from their own thoughts. They may hear someone speaking to them, but no one is there. The content of these voices may vary, but it is typically pejorative or threatening.

Also, certain types of auditory hallucinations, (e.g., two or more voices commenting about the person's behavior or conversing with one another that the patient overhears) are characteristic of schizophrenia.

6. Are people with schizophrenia dangerous?

Generally, violent and criminal acts directly attributable to schizophrenia account for only a very small proportion of such acts in society. When they do occur, it may be because patients become so paranoid that they strike out at others in response to perceived threats, or they may have a command hallucination instructing them to hurt others. It is more common for hallucinations to instruct patients to hurt themselves, however, so instances of harming others are rare. Violence can also occur when schizophrenia is compounded by untreated drug use.

Therefore, while people with schizophrenia can hurt others, they are far more likely to hurt themselves. When they are violent, it is most often because they have not been adequately treated. It is far more likely for those with schizophrenia to be the objects of violence and crime than perpetrators.

7. What treatments are available?

The mainstay of successful treatment for schizophrenia is the class of drugs referred to as antipsychotics. Antipsychotic medication decreases most of the major symptoms of schizophrenia and prevents relapses.

Antipsychotic drugs have documented effectiveness, which is heightened when augmented by family-based psychoeducational programs and some types of personal psychotherapy. Personal psychotherapy, in particular, should be targeted at solving here-and-now, everyday problems rather than childhood or past events. A combination of psychoeducation, psychotherapy and antipsychotic medication can work together to dramatically decrease the rate of relapse and need for hospitalization in people with schizophrenia. This combination also improves the cognitive abilities, as well as social and occupational functioning.

Another important component of treatment is awareness of drug use and abuse. As many as 40% of patients with schizophrenia abuse drugs, which can prevent symptom remission and cause relapses. Therefore, it is important to identify and treat the problem of drug abuse when it compounds schizophrenia.

8. What medications are used to treat schizophrenia?

Antipsychotic medication is the primary pharmacological treatment for schizophrenia. These medications decrease the symptoms of schizophrenia for most patients, but rarely ever cure the illness or return people to their premorbid levels of functioning. So, although some people with schizophrenia may appear normal, in reality, they almost never reclaim their full potential.

For many patients the addition of mood stabilizers, antidepressants and even antianxiety medications are valuable.

Approximately 50% of people with schizophrenia attempt suicide and 12% of those succeed. Suicide attempts those with schizophrenia is a major public health problem, but it is poorly recognized. As successful as antipsychotic medications have been in treating most of the symptoms of schizophrenia, they have failed to decrease the rate of suicide significantly. One exception to this is the drug clozapine (Clozaril), which has been shown to decrease the suicide rate in several studies.

9. How do antipsychotic medications work?

Currently all effective antipsychotic medications block the D2 dopamine receptor, a specialized protein to which chemicals, such as dopamine, attach in the brain. Blockade of the D2 receptor appears to be a necessary and sufficient condition for antipsychotic response. Blockade of another brain receptor, the serotonin 2 receptor, may also explain some of the action of antipsychotic drugs, as do alterations of other brain chemicals and receptors such as GABA, glutamate and neurotensin.

10. What are the side effects of these medications?

Some of the commonly noted side effects of antipsychotics are sedation, weight gain, dizziness, seizures, an inability to sit still, and hormone elevations that can cause sexual dysfunction and interfere with menstrual functioning. Blurred vision, constipation, dry mouth and rapid heartbeat also have been known to occur.

Conventional antipsychotics such as haloperidol (Haldol) can cause motor stiffness or twisting as well as tardive dyskinesia, a writhing and disfiguring movement disorder involving the face and head as well as other body parts. Its yearly incidence is about 1% for the severe type and 3% for milder types, and it can be irreversible.

The newer antipsychotics such as risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel) and clozapine (Clozaril) cause much less motor stiffness and twisting movements and, most likely, less tardive dyskinesia. These medications are superior in treating the apathy, disinterest and cognitive dysfunction associated with schizophrenia, but they can cause more weight gain and adversely affect cardiovascular and diabetes risk factors.

11. When can medications be stopped?

Continued antipsychotic medication treatment is strongly recommended, as the vast majority of patients with schizophrenia will have a dramatic recurrence of their psychotic symptoms if they discontinue their medication. There is accumulating evidence that for each relapse a patient experiences, it becomes increasingly difficult to treat their illness. In other words, every time a patient has an acute exacerbation, it becomes a little more difficult, and takes a little more time, to treat the next episode.

There may be some people with schizophrenia who do not need continued medication, but currently there is no way to accurately predict who they are. Medication discontinuation may be a consideration when the diagnosis is unclear or complicated by the use of stimulants such as amphetamines, cocaine or PCP. Almost all patients function better on antipsychotic medication. Additionally, there is accumulating evidence that early intervention (before they have full-blown psychotic symptoms) in those at high risk of developing schizophrenia may actually prevent a case from appearing.

12. How is schizophrenia diagnosed?

The diagnosis of schizophrenia is based on both a clinical interview assessing the patient's symptomatological profile and a careful psychiatric history assessing the course and development of the illness. These procedures allow the clinician to eliminate other possible psychiatric and medical illnesses.

A physical examination and laboratory testing are required to rule out disorders that might mimic the symptoms of schizophrenia. Such disorders include amphetamine or cocaine intoxication, encephalopathies, temporal lobe epilepsy, brain tumors, hyperthyroidism, Wilson's disease, and industrial toxicities.

Although there is no specific laboratory test for schizophrenia, magnetic resonance imaging (MRI), positron emission tomography (PET) and single-photon emission computed tomography (SPECT) scanning techniques can be enlightening, particularly at the first onset of symptoms.

The physical examination and laboratory tests can exclude most other disorders, with the clinical presentation and history ultimately confirming the diagnosis of schizophrenia.

13. How are schizophrenic patients cared for?

Antipsychotic medication, psychoeducational information and supportive psychotherapy are all effective treatments for schizophrenia. Additionally, assistance with vocational placement, rehabilitation services, legal and structured partial hospitalization, and outpatient and/or residential placement are also beneficial. Finally, it is often to the patients' advantage for physicians to address other medical conditions, as these patients often do not access medical care for other conditions. Lifestyle advice, such as on smoking, eating and exercise habits, also falls under the rubric of care.

14. What is going on in schizophrenia research?

Research on schizophrenia is progressing on many fronts. In the past 10 years, the antipsychotic medications used to treat schizophrenia have improved and are now more effective and cause fewer side effects. There is no cure for schizophrenia, however, so the search for more effective medicines continues.

New imaging techniques such as PET and functional magnetic resonance imaging (fMRI) are allowing us to more accurately understand brain and circuit dysfunctions and interconnection abnormalities through different brain parts. We are also now beginning to understand the role of genetics in the onset and symptoms of schizophrenia, and their role even in response to treatment. In addition, we are exploring techniques such as transcranial magnetic stimulation and postmortem studies, in which researchers study the tissues and cells of people with schizophrenia after they have died. Some of this work, for example, has shown that the illness actually begins while in the womb.

Exciting developments are occurring that combine knowledge from different disciplines. For example, studies combining brain imaging, genetics and pharmacology are being performed to understand why some patients respond to one medication but not another; why some patients have one side effect but not another; why some patients have an early onset and others a later one; and why some patients experience predominantly positive symptoms (e.g., hallucinations and delusions) while others have more of the negative symptoms such as apathy and disinterest.

15. Is schizophrenia hereditary?

People who have a relative with schizophrenia have a greater risk of developing the disorder than the general population. For example, if you have an identical twin with schizophrenia, your chance of having schizophrenia is 50% in contrast to the 1% chance for the public at large. Adoption studies have shown that biological relatives have an increased risk for schizophrenia whereas adoptive relatives have no increased risk. Such studies clearly point to the contribution of a genetic component in the development of schizophrenia. Nongenetic factors can also influence the development of schizophrenia, as evidenced by the fact that, even in people with identical genes (i.e., monozygotic twins), only in about 50% of the cases are both twins ill.

16. Can schizophrenia be caused by a virus?

The virus hypothesis of schizophrenia has been under consideration for more than 60 years. Its best evidence is that children born to mothers exposed to viruses during the second trimester of pregnancy, but not the first or third, have an increased risk for the development of schizophrenia. There is also the possibility that some viruses, such as the influenza or Borna virus, might mimic certain natural-occurring substances and, by doing so, cause some of the symptoms of illnesses like schizophrenia. This does not mean, however, that schizophrenia is caused by viruses. For example, it may be that the virus in the mother causes physiological stress, which in turn leads to development of the disease. Thus far, attempts to identify a specific virus contributing to the etiology of schizophrenia have failed, although this hypothesis continues to be actively explored.

17. What is the current policy regarding involuntary commitment?

Policies regarding involuntary commitment are different in every state. In California, for example, it is possible to put someone in the hospital involuntarily upon the recommendation of two physicians, a police officer, or others who are qualified to make this decision for a very specific reason. A person can be placed in a hospital against their will for up to 72 hours. That person can then ask for a hearing in which a judge rules whether to allow the involuntary commitment decision to stand.

One of the criteria for involuntary commitment is that the person have a mental illness and, as a result of this illness, be considered dangerous to themselves or others or greatly disabled. In this case, greatly disabled means that the person is unable to take care of basic needs such as the acquisition of food, clothing or shelter. Thus, a person has to be in a fairly severe state to be committed involuntarily.

18. Where can I get more information on schizophrenia?

There are many resources available to those who wish to learn more about schizophrenia. The following organizations can provide additional information:

The National Alliance for the Mentally Ill (NAMI) supplies general information and support and offers three brochures on schizophrenia, which in turn refer to books, Web sites, and other sources.
The National Institute of Mental Health (NIMH) also has brochures and other resources available at no charge.
The National Alliance for Research on Schizophrenia and Depression (NARSAD) publishes an informative brochure entitled "Understanding Schizophrenia."

Source: Answers provided by Steven Potkin, M.D., professor of psychiatry and director for psychiatric research at University of California, Irvine, Medical Center, in an interview with Claire Ginther. (2002)