Schizophrenia There are many misconceptions about schizophrenia. It is an illness that can be treated. One in a hundred people will experience schizophrenia during their lifetime 1 and the majority of people with schizophrenia will lead ordinary lives. Schizophrenia is a mental illness that affects the way someone thinks. It affects approximately 1 in every 100 people. It usually starts during early adulthood. It does not mean that someone has a split personality. The symptoms of schizophrenia can be split into two groups of positive and negative symptoms. Positive symptoms include hallucinations and delusions. These involve someone having experiences which are not based on reality. Negative symptoms include lack of motivation and becoming withdrawn. These kind of symptoms can be more long-lasting and persistent. It is likely that the cause of schizophrenia is due to a combination of both genetic and environmental factors, The common approach to treating schizophrenia involves antipsychotic medication and talking therapies. This factsheet covers - 1. What is schizophrenia? 2. What is borderline schizophrenia? 3. What are the symptoms of schizophrenia? 4. Subtypes of schizophrenia 5. How is schizophrenia diagnosed? 6. What causes schizophrenia? 7. How is schizophrenia treated? 8. Risks associated with schizophrenia
1. What is schizophrenia? Schizophrenia is a mental illness which occurs when the parts of the brain responsible for emotion and sensation stop working properly. The illness can develop slowly and a person may stop living their normal life, withdrawing from people, losing interest in things and possibly having angry outbursts. Schizophrenia often develops during late adolescence so such behaviour may seem like a normal phase. It is often only when other symptoms of schizophrenia, like psychosis (hallucinations and delusions) become apparent, that a mental illness might be recognised. The first acute episode can be a devastating experience, particularly as both the person experiencing the illness and those close to them will be unprepared. About one in a hundred people world-wide experience at least one such episode at some time during their lives, and it typically first starts in early adulthood, although it can affect someone of any age. Up to 30% of people with schizophrenia may have a lasting recovery, and 20% may show significant improvement. Around 50% of people diagnosed with schizophrenia will have a long-term illness, varying in severity, which may involve further episodes of becoming unwell, or may be more constant. 2 It is worth noting here that recovery may be interpreted differently. For some, it may mean a medical recovery, in the sense of remission. However, recovery is often used in another sense with regards to mental health. It can be defined as the concept of a process of building a meaningful life as defined by the person with a mental health problem themselves. There is a lot of information about this form of recovery on the Rethink Mental Illness website www.rethink.org. In schizophrenia the activity of chemicals (neurotransmitters) in the brain is unusual, and this may be a clue to the causes of the disorder. During what is referred to as "an acute episode", experience and thought processes become distorted. When severe, this can lead to intense panic, anger, depression, elation or over activity, possibly with periods of withdrawal between. It is not surprising that other people, particularly family and friends find the changes difficult to understand and may be devastated themselves. One common misconception is that schizophrenia is the result of 'split personality'. In fact, schizophrenia is not split personality, nor does it relate to multiple or any other personality disorder. The mistake comes from the fact that the name 'schizophrenia' was coined from two Greek words meaning 'split' and 'mind'. It was intended to represent the fact that processes of thought, feeling and intention which guide peoples actions no longer interact to form a coherent whole. 2. What is borderline schizophrenia? This refers to a condition which has some of the characteristics of schizophrenia, but not enough for a firm diagnosis, or perhaps some of the characteristics of schizophrenia and some of the characteristics of another condition. This term is also used in several different ways: as a separate 2
diagnosis with its own group of symptoms, as a way of describing a mild form of schizophrenia, or as a diagnosis of personality abnormality. This fact that this diagnosis is somewhat vague gives it limited value. Often a person given a diagnosis of borderline schizophrenia will later be given a diagnosis of schizophrenia, mood disorder or personality disorder. 3. What are the symptoms of schizophrenia? The symptoms of schizophrenia can be divided into two groups: Positive symptoms These are symptoms of psychosis which are rarely experienced by general population. They refer to experiences which are additional to normal experience. They are not specific to schizophrenia as psychosis can occur in other mental illnesses as well. They are: Hallucinations Delusions Hallucinations are things that are experienced that are not based in reality (e.g. sounds or visions that appear out of nowhere). Although hallucinations can take any sensory form - auditory (sound), visual (sight), tactile (touch), gustatory (taste) and olfactory (smell) - hearing voices that other people do not hear is the most common type of hallucination in schizophrenia. Voices might describe activities taking place, take the form of a conversation, warn of dangers, or even order the person to do things. The thoughts can appear to be so loud that the person may believe that people nearby will also be able to hear them. The mind usually adjusts to this very quickly and rationalises that the voices are coming from somewhere real. The person will then find some explanation for where the voices are coming from. They may feel that someone else s thoughts have been put in their head, or that their own thoughts have been taken from them. It is possible, using medical imaging technology, to see changes in the speech area of the brain at the time when a person says that s/he is hearing the voices. This shows that this is a real experience, and the person really can hear something rather than just thinking it. Delusions are unshakeable beliefs based on the person s altered perception of reality, which may not correspond at all to the way others see the world. Delusions may take on different themes someone experiencing paranoid delusions may believe they are being chased, plotted against or poisoned. These people often believe that a member of their family or someone close to them is making this happen. Another theme could be a delusion of grandeur, in which a person believes he or she is a famous or important person. 3
Sometimes the delusions experienced by people with schizophrenia are quite bizarre; for instance, believing that people on television are directing special messages to them, or that their thoughts are being broadcast aloud to others. A person experiencing delusions may try to keep them secret, knowing that others would not understand. Others may be gradually overwhelmed and begin to act strangely due to their beliefs. Negative symptoms These are symptoms that involve loss of experience. In some cases, especially with hindsight, families may realise that their relative's behaviour has been changing over a period of time in subtle ways. They may for instance have become slower to think, talk and move, and may have become indifferent to social contact, their sleeping patterns may have changed so that they prefer to remain up all night and sleep all day. Body language may also be affected. These are the so-called 'negative symptoms' and they will affect the person in a different way from positive symptoms. The overall result is a reduction in motivation, and the extent of this can vary from minor to severe. Negative symptoms are much less dramatic those caused by psychosis, but they tend to be more persistent, and can remain after positive symptoms fade away. Recognising these changes can be particularly difficult if the illness develops during teenage years when behaviour like this may be expected. 4. Subtypes of schizophrenia 3 There are different subtypes of schizophrenia, which are simply descriptive and don t particularly make a difference to outcome or treatment. The subtypes are defined by behaviour at the time of assessment and may change over time. Paranoid prominent hallucinations or delusions of grandeur or persecution. The onset of this type tends to be later than for others. Disorganised or hebephrenic behaviour is disorganised and without purpose. Thought is disordered, speech may be incoherent, and there may be grimacing and mannerisms. Negative symptoms tend to appear early on. Catatonic this is very rare, with strange peculiarities of movement, such as staying fixed in one position with resistance to being moved, posturing, mutism or repeating words said by the examiner. Residual this is when an individual has had an episode of schizophrenia but there are now only negative symptoms. 5. How is schizophrenia diagnosed? At the moment, diagnosis relies on the opinion of the psychiatrist. There are no blood tests or scans that can establish the diagnosis, because that is not the nature of a mental illness. A doctor can usually be sure that a person is experiencing psychosis, and this is often part of schizophrenia or 4
another condition called bipolar disorder (previously known as manic depression). The only way to know which illness a person has is to look at details of how the illness started; whether they have had periods of depression or mania and to look for evidence of negative symptoms. Psychiatrists use diagnostic scales or schedules (ICD10 and DSM4) which enable them to recognise groups or clusters of symptoms as particular disorders. When diagnosis is very unclear and there appears to be a mixture of bipolar disorder and schizophrenia, the diagnosis may be schizoaffective disorder. If you feel strongly that you or some one you care for has been misdiagnosed, you may wish to seek advice regarding getting a second opinion. Regardless of the diagnosis, treatment should always be tailored to the symptoms a person is experiencing so a change in diagnosis might not matter too much in practice. Further information on second opinions is available in the Second Opinions factsheet, which is available to download for free from www.rethink.org/factsheets. A copy can also be obtained by contacting the Rethink Advice & Information Service (contact details in Further Information section). 6. What causes schizophrenia? A common theory in the past was that schizophrenia can be caused solely by poor upbringing is a myth. However, it seems that mental illnesses, such as schizophrenia, are caused by a combination of genetic and environmental factors. Genetic causes Schizophrenia tends to run in families in a similar way to conditions such as heart disease. Schizophrenia does cluster in certain families, but there is no one individual gene responsible for the illness and other risk factors are clearly involved. The lifetime risk for schizophrenia is approximately 1% 4. It has been found that having one parent affected by schizophrenia increases this to 13%. When both biological parents are affected, the lifetime risk goes up to 46%. The lifetime risk of identical twins is higher (48%) than that of nonidentical twins (approximately 10%). 5 This suggests that there is some genetic influence as identical twins share exactly the same genes. However, genetics cannot be the whole story. Otherwise, when one identical twin is affected by schizophrenia, it would be expected that the other twin would always be affected as well. But what exactly is inherited? The neurotransmitter system - the chemical messenger system of the brain - has received a great deal of attention as a possible cause of schizophrenia. Researchers have known for decades that there is a link between neurotransmitters and schizophrenia, because 5
drugs which alter these neurotransmitters also relieve the symptoms of schizophrenia. It is thought that overactivity of the neurotransmitter, dopamine, is involved in the psychotic symptoms of schizophrenia. Antipsychotic medication works partly by blocking dopamine. 6 Abnormal brain development Brain scans have shown that people with schizophrenia may have abnormalities of the brain. For example, research has shown that some people with schizophrenia have an enlargement of a part of the brain called the ventricles. It has also been found that the volume of certain parts of the brain are reduced in some people with schizophrenia. 7 It should be emphasized that these abnormalities are quite subtle and are not characteristic of all people with schizophrenia, and that they can occur in people who do not have a mental illness. No abnormalities specific to schizophrenia have been found. Our understanding of how brain development may be connected to schizophrenia is still not clear. It does seem that the wiring of the brain may be different. However, it is also not clear when this change may occur (e.g. during development in the womb or afterwards). Birth complications Research has found that complications during pregnancy and birth is associated more with people with schizophrenia than people without. Those that play a significant role in the development of schizophrenia include 8 : Low birth weight Developmental problems in the baby Bleeding during pregnancy Problems associated with lack of oxygen at the time of birth It has also been found that there are other factors which can affect an expectant mother, which could increase the risk of their child having schizophrenia. These include prenatal exposure to 9 : infections such as influenza rhesus incompatibility (an incompatibility between the mother and baby s blood) nutritional deficiency in the first three months of pregnancy major stress (e.g. disaster) However, the effect of such complications is small in comparison to other factors such as genetic heredity. Psychological triggers The main psychological triggers that can lead to the onset of symptoms of schizophrenia are stressful life events. These could include such events as a family bereavement, loss of a job, the birth of a child, or a house move. These kinds of experiences don t cause schizophrenia themselves 6
but can trigger its development in someone who is already vulnerable to it. 10 Substance misuse Drugs do not directly cause schizophrenia. However, there is evidence consistent with the view that certain drugs such as cannabis can trigger psychosis 11. This risk is increased when cannabis is used during adolescence 12. This is a particular risk for those that may already be vulnerable to mental health problems, like those who have a history of mental illness in the family. The Rethink Advice & Information Service has produced a factsheet Dual Diagnosis, which has more information on substance misuse and mental illness. A copy can be obtained by contacting the Rethink Advice & Information Service (contact details in Further Information section) or a copy can be downloaded for free at www.rethink.org/factsheets 7. How is schizophrenia treated? It is recommended that schizophrenia is treated using a combination of medication and talking therapies 13. When you are first diagnosed with schizophrenia one of your first priorities may be finding the right treatment. It is likely that you will need to consider medication with your doctor. The most common medications used to control the symptoms of schizophrenia are antipsychotics. Newer antipsychotics (often referred to as atypical or second generation antipsychotics) may also help with negative symptoms, which the older (also known as typical or first generation antipsychotics) have little effect on. 14 The symptoms of schizophrenia can also be treated with talking therapies. Cognitive behaviour therapy has helped many people deal with experiencing psychosis. 'Only the Best' is an in depth Rethink Mental Illness guide to choosing and getting the most out of antipsychotic and mood stabilising medication. The Rethink Advice & Information Service has also produced the factsheets Antipsychotics and Talking treatments and psychological therapies. You can get a hard copy of any of these by contacting the Rethink Advice & Information Service on (contact details in Further Information section). You can also download copies for free from www.rethink.org/factsheets 8. Risks associated with schizophrenia People with schizophrenia die, on average, ten years younger than people without the condition. 15 Research has found that people with severe mental illness, such as schizophrenia, are at higher risk of being overweight, experiencing coronary heart disease and having diabetes, among other health issues. This may be due to genetic factors, lifestyle choices (such as smoking and diet) or side effects from medication. 16 7
The Rethink Advice & Information Service has produced a factsheet Physical health and Nutrition. A copy of this can be obtained by contacting the service (contact details in Further Information section) or a copy can be downloaded for free from www.rethink.org/factsheets Approximately 20-40% of people with schizophrenia attempt suicide sometime during their life 17, and about 1 in 10 actually succeed 18. A review of research has found that the risk of suicide in people in schizophrenia is not so much associated with the psychotic symptoms of the condition. Instead, it has been associated more with mood symptoms, feelings of agitation and restlessness, and an awareness of how the condition is affecting mental functioning. 19 1 National Institute of Health and Clinical Excellence. Core interventions in care (update). Clinical Guidance 82, http://www.nice.org.uk. 2009. 2 Reveley, A., 2006. Your guide to schizophrenia. London: Hodder Arnold 3 Reveley, A., 2006. Your guide to schizophrenia. London: Hodder Arnold 4 Royal College of Psychiatrists, 2010. Schizophrenia [Online] Available at: http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/schizophrenia/schizoph renia.aspx [Accessed January 2011] 5 Stefan, M., Travis, M. and Murray, R.M. (Eds.) (2002) An atlas of schizophrenia. London: Parthenon Publishing. 6 Reveley, A., 2006. Your guide to schizophrenia. London: Hodder Arnold 7 Fragnou, S. & Murray, R.M., 2000. Schizophrenia. London: Martin Dunitz 8 Reveley, A., 2006. Your guide to schizophrenia. London: Hodder Arnold 9 Reveley, A., 2006. Your guide to schizophrenia. London: Hodder Arnold 10 Reveley, A., 2006. Your guide to schizophrenia. London: Hodder Arnold 11 Moore, T, H, M. et al,, 2007. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. The Lancet. 370 (9584), pp.319-328 12 Arseneault L, Cannon M, Poulton R, Murray R, Caspi A, Moffitt TE., 2002. Cannabis use in adolescence and risk for adult psychosis: longitudinal prospective study. British Medical Journal. 23;325(7374):1183-4. 13 National Institute of Health and Clinical Excellence. Core interventions in the treatment and management of schizophrenia in primary and secondary care (update). Clinical Guidance 82, http://www.nice.org.uk. 2009. 14 Royal College of Psychiatrists, 2010. Antipsychotic medication [Online] Available at: http://www.rcpsych.ac.uk/mentalhealthinfo/treatments/antipsychoticmedication.as px [Accessed February 2011] 15 Reveley, A., 2006. Your guide to schizophrenia. London: Hodder Arnold 16 Disability Rights Commission (2006) Equal Treatment: Closing the Gap, London, Disability Rights Commission 17 Pompili, M. et al. Suicide risk in schizophrenia: learning from the past to change the future. Annals of General Psychiatry 2007: 6:10 18 Allebeck, P. Schizophrenia: a life shortening disease. Schizophrenia Bulletin 1989; 15: 81-89 19 Hawton, K., Sutton, L., Haw, C., Sinclair, J. and Deeks, J.D. (2005) Schizophrenia and suicide: systematic review of risk factors. British Journal of Psychiatry, 187, 9-20 8
The content of this product is available in Large Print (16 point). Please call 0300 5000 927. RET0113 Rethink Mental Illness 2011 Last updated January 2011 Next update January 2013 Last updated 01/10/2010