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{{Short description|Mental disorder with psychotic symptoms}} | |||
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{{Other uses}} | |||
{{Infobox_Disease | | |||
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Name = Schizophrenia | | |||
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Image = Bleuler.png | | |||
{{Use dmy dates|date=March 2023}} | |||
Caption = ] (1857–1939) coined the term "Schizophrenia" in 1908 | | |||
{{cs1 config|name-list-style=vanc|display-authors=6}} | |||
Width = 125 | | |||
{{Infobox medical condition | |||
DiseasesDB = 11890 | | |||
| name = Schizophrenia | |||
ICD10 = {{ICD10|F|20||f|20}} | | |||
| image = Cloth embroidered by a schizophrenia sufferer.jpg | |||
ICD9 = {{ICD9|295}} | | |||
| alt = Embroidery art with nonlinear text sewn into it with multiple colors of thread | |||
ICDO = | | |||
| caption = Cloth ] by a person diagnosed with schizophrenia | |||
OMIM = 181500 | | |||
| field = ]<ref>{{cite book | vauthors = Jones D | author-link = Daniel Jones (phonetician) | title = English Pronouncing Dictionary |veditors= Roach P, Hartmann J, Setter J |publisher=Cambridge University Press |orig-date=1917 |year=2003 | isbn = 978-3-12-539683-8}}</ref> | |||
MedlinePlus = 000928 | | |||
| symptoms = ]s, ]s, ], ]<ref name=WHO2022/><ref name=NIH2022>{{cite web |title=Schizophrenia |work= Health topics |url=https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml |publisher= US ] |date=April 2022|access-date=22 August 2022}}</ref> | |||
eMedicineSubj = med | | |||
| complications = Harm to self or others, social isolation, cognitive issues, ], ]s,<ref name=SBU2012>{{Cite web|url=http://www.sbu.se/en/publications/sbu-assesses/schizophrenia--pharmacological-treatments-patient-involvement-and-organization-of-care/|title=Medicinal treatment of psychosis/schizophrenia|date=21 November 2012 |publisher=] (SBU)|archive-url=https://web.archive.org/web/20170629092226/http://www.sbu.se/en/publications/sbu-assesses/schizophrenia--pharmacological-treatments-patient-involvement-and-organization-of-care/|archive-date=29 June 2017|url-status=live|access-date=26 June 2017}}</ref> ] and ] arising from ] medication<ref>{{cite web | vauthors = Proietto Sr J |title=Diabetes and Antipsychotic Drugs |url=https://www.medsafe.govt.nz/profs/puarticles/antipsychdiabetes.htm |publisher=] |date=November 2004}}</ref><ref>{{cite journal | vauthors = Holt RI | title = Association Between Antipsychotic Medication Use and Diabetes | journal = Current Diabetes Reports | volume = 19 | issue = 10 | pages = 96 | date = September 2019 | pmid = 31478094 | pmc = 6718373 | doi = 10.1007/s11892-019-1220-8 | publisher = ] |issn=1534-4827}}</ref> | |||
eMedicineTopic = 2072 | | |||
| onset = Ages 16 to 30<ref name=NIH2022/> | |||
eMedicine_mult = {{eMedicine2|emerg|520}} | | |||
| duration = Chronic<ref name=NIH2022/> | |||
MeshName = Schizophrenia | | |||
| causes = Environmental and genetic factors<ref name=Lancet2016/> | |||
MeshNumber = F03.700.750 | | |||
| risks = ], ] use in adolescence, ]- or ]-associated psychosis,<ref>{{cite journal |title=Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis|url=https://academic.oup.com/schizophreniabulletin/article/46/3/505/5588638 |journal=] |date=May 2020}}</ref> problems during pregnancy, ], being born or raised in a city<ref name=Lancet2016/><ref>{{cite journal | vauthors = Gruebner O, Rapp MA, Adli M, Kluge U, Galea S, Heinz A | title = Cities and Mental Health | journal = Deutsches Ärzteblatt International | volume = 114 | issue = 8 | pages = 121–127 | date = February 2017 | pmid = 28302261 | pmc = 5374256 | doi = 10.3238/arztebl.2017.0121 }}</ref> | |||
}} | |||
| diagnosis = Based on observed behavior, reported experiences, and reports of others familiar with the person<ref name=DSM5/> | |||
<!--Para1: Definition, symptoms and diagnosis--> | |||
| differential = ], ], ] (], ]), ],<ref name=Ferri2010>{{cite book|vauthors=Ferri FF |title=Ferri's differential diagnosis: a practical guide to the differential diagnosis of symptoms, signs, and clinical disorders |date=2010 |publisher=Elsevier/Mosby |location=Philadelphia |isbn=978-0-323-07699-9 |chapter=Chapter S |edition=2nd}}</ref> ],<ref name=Paris2018/> ], ], ], ], ], ], ], ] | |||
| prevention = | |||
| management = Counseling, ] training<ref name=WHO2022/><ref name=Lancet2016/> | |||
| medication = ]<ref name=Lancet2016/> | |||
| prognosis = 20–28 years shorter ]<ref name=Laursen2014/><ref name=NIHStat/> | |||
| frequency = ~0.32% (1 in 300) of the global population is affected.<ref name=WHO_FACT_SHEET>{{cite web |title=Schizophrenia Fact Sheet and Information |url=https://www.who.int/news-room/fact-sheets/detail/schizophrenia |publisher=]}}</ref> | |||
| deaths = ~17,000 (2015)<ref name=GBD2015/> | |||
}} | |||
<!-- Definition, symptoms, and diagnosis--> | |||
'''Schizophrenia''' is a ]<ref>{{cite web |title=ICD-11: 6A20 Schizophrenia |url=https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1683919430 |publisher=] |access-date= 23 August 2022 }}</ref><ref name= Lancet2016/> characterized variously by ]s (typically, ]), ]s, ] and behavior,<ref name=DSM5/> and ].<ref name= Lancet2016/> Symptoms ] and typically begin during young adulthood and are never resolved.<ref name=NIH2022/><ref name=DSM5/> There is no objective diagnostic test; diagnosis is based on observed behavior, a ] that includes the person's reported experiences, and reports of others familiar with the person.<ref name=DSM5/> For a diagnosis of schizophrenia, the described symptoms need to have been present for at least six months (according to the ]) or one month (according to the ]).<ref name=DSM5>{{cite book |title=Diagnostic and Statistical Manual of Mental Disorders: DSM-5 |edition=5th |date=2013 |publisher=American Psychiatric Association |location=Arlington, VA |isbn=978-0-89042-555-8 |pages=99–105}}</ref><ref name=Ferri2019/> Many people with schizophrenia have other mental disorders, especially ]s, ]s, and ].<ref name=DSM5/> | |||
<!-- Epidemiology and causes --> | |||
'''Schizophrenia''', from the ] ] ''schizein'' (σχίζειν, "to split") and ''phrēn'', ''phren-'' (φρήν, φρεν-, "]"), is a ] diagnosis that describes a mental illness characterized by impairments in the ] or expression of ], most commonly manifesting as auditory ]s, paranoid or bizarre ]s or ] in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood,<ref name="castle1991">{{cite journal |author=Castle E |coauthors=Wessely S, Der G, Murray RM |year=1991 |month= |title=The incidence of operationally defined schizophrenia in Camberwell 1965–84 |journal=] |volume=159 |pages=790-794 |pmid=1790446 |accessdate= 2008-02-24}}</ref> with approximately 0.4–0.6%<ref>{{cite journal |author=Bhugra, D| url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1140960 |year=2006 |title=The global prevalence of schizophrenia |journal=] |volume=2 | issue=5 |pages=372-373 |pmid=15916460 |accessdate= 2008-02-24}}</ref><ref name="fn_34">{{cite journal |author=Goldner EM |coauthors=Hsu L, Waraich P, Somers JM |year=2002 |title=Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature |journal=Canadian Journal of Psychiatry |volume=47 | issue=9 |pages=833-43 |pmid=12500753 |accessdate= 2008-02-24}}</ref> of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia exists.<ref name="DSM-IV-TR" /> | |||
About 0.3% to 0.7% of people are diagnosed with schizophrenia during their lifetime.<ref name=Javitt2014>{{cite journal |vauthors=Javitt DC |title=Balancing therapeutic safety and efficacy to improve clinical and economic outcomes in schizophrenia: a clinical overview |journal=The American Journal of Managed Care |volume=20 |issue=8 Suppl |pages=S160-165 |date=June 2014 |pmid=25180705}}</ref> In 2017, there were an estimated 1.1 million new cases and in 2022 a total of 24 million cases globally.<ref name=WHO2022/><ref name=GBD2018>{{cite journal |vauthors=James SL, Abate D |title=Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017 |journal=The Lancet |date=November 2018 |volume=392 |issue=10159 |pages=1789–1858 |doi=10.1016/S0140-6736(18)32279-7 |pmid=30496104 |pmc=6227754 }}</ref> Males are more often affected and on average have an earlier onset than females.<ref name=WHO2022>{{cite web |title=Schizophrenia Fact sheet | url = https://www.who.int/news-room/fact-sheets/detail/schizophrenia | publisher = ] | date = 10 January 2022 | access-date = 23 August 2022 }}</ref> The causes of schizophrenia may include ] and ] factors.<ref name=Lancet2016/> Genetic factors include a variety of common and rare ].<ref name=vandeLeemput2016>{{cite book|vauthors=van de Leemput J, Hess JL, Glatt SJ, Tsuang MT|date=2016|title=Genetics of Schizophrenia: Historical Insights and Prevailing Evidence |series=Advances in Genetics|volume=96|pages=99–141|doi=10.1016/bs.adgen.2016.08.001|pmid=27968732|isbn=978-0-12-809672-7 }}</ref> Possible environmental factors include ], childhood adversity, ] use during adolescence, infections, the ], and poor ].<ref name=Lancet2016/><ref name=Parakh2013/> | |||
<!-- Course and prognosis --> | |||
<!--Para2:lack of validity/controversies--> | |||
About half of those diagnosed with schizophrenia will have a significant improvement over the long term with no further relapses, and a small proportion of these will recover completely.<ref name=DSM5/><!-- Quote: "The course appears to be favorable in about 20% of those with schizophrenia, and a small number of individuals are reported to recover completely." --><ref name=Vita2018>{{cite journal | vauthors = Vita A, Barlati S | s2cid = 35299996 | title = Recovery from schizophrenia: is it possible? | journal = Current Opinion in Psychiatry | date = May 2018 |volume = 31 | issue = 3 | pages = 246–255 | doi = 10.1097/YCO.0000000000000407 | pmid = 29474266}}</ref> The other half will have a lifelong impairment.<ref name=Law2015>{{cite book | vauthors= Lawrence RE, First MB, Lieberman JA | chapter = Chapter 48: Schizophrenia and Other Psychoses | veditors= Tasman A, Kay J, Lieberman JA, First MB, Riba MB | title = Psychiatry | edition = fourth | date = 2015 | pages = 798, 816, 819 | doi = 10.1002/9781118753378.ch48 | publisher=John Wiley & Sons, Ltd. | isbn = 978-1-118-84547-9 }}</ref> In severe cases, people may be admitted to hospitals.<ref name=Vita2018/> Social problems such as ], poverty, ], exploitation, and victimization are commonly correlated with schizophrenia.<ref name=Killaspy2014/><ref name=Charleson2018>{{cite journal | vauthors = Charlson FJ, Ferrari AJ, Santomauro DF, Diminic S, Stockings E, Scott JG, McGrath JJ, Whiteford HA | title = Global Epidemiology and Burden of Schizophrenia: Findings From the Global Burden of Disease Study 2016 | journal = Schizophrenia Bulletin | volume = 44 | issue = 6 | pages = 1195–1203 | date = October 2018 | pmid = 29762765 | pmc = 6192504 | doi = 10.1093/schbul/sby058 }}</ref> Compared to the general population, people with schizophrenia have a higher suicide rate (about 5% overall) and more ],<ref name=Lancet2009>{{cite journal | vauthors = ], ] | s2cid = 208792724 | title = Schizophrenia | journal = Lancet | volume = 374 | issue = 9690 | pages = 635–645 | date = August 2009 | pmid = 19700006 | doi = 10.1016/S0140-6736(09)60995-8 | url = http://xa.yimg.com/kq/groups/19525360/611943554/name/Schizophrenia+-+The+Lancet.pdf | archive-url = https://web.archive.org/web/20130623065810/http://xa.yimg.com/kq/groups/19525360/611943554/name/Schizophrenia+-+The+Lancet.pdf | df = dmy-all | archive-date = 23 June 2013 | access-date = 23 December 2011 }}</ref><ref name=Jop2010>{{cite journal | vauthors = Hor K, Taylor M | title = Suicide and schizophrenia: a systematic review of rates and risk factors | journal = Journal of Psychopharmacology | volume = 24 | issue = 4 Suppl | pages = 81–90 | date = November 2010 | pmid = 20923923 | pmc = 2951591 | doi = 10.1177/1359786810385490 }}</ref> leading to an average decrease in ] by 20<ref name=Laursen2014>{{cite journal | vauthors = Laursen TM, Nordentoft M, Mortensen PB | title = Excess early mortality in schizophrenia| journal = Annual Review of Clinical Psychology | date = 2014 | volume = 10 | pages=425–448 | doi = 10.1146/annurev-clinpsy-032813-153657 | pmid = 24313570| doi-access = free }}</ref> to 28 years.<ref name=NIHStat/> In 2015, an estimated 17,000 deaths were linked to schizophrenia.<ref name=GBD2015>{{cite journal | vauthors = Wang H, Naghavi M, Allen C, etal | collaboration = GBD 2015 Mortality and Causes of Death Collaborators | title = Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015 | journal = Lancet | volume = 388 | issue = 10053 | pages = 1459–1544 | date = October 2016 | pmid = 27733281 | pmc = 5388903 | doi = 10.1016/S0140-6736(16)31012-1 }}</ref> | |||
Studies suggest that ], early environment, ] and ] and social processes are important contributory factors. Current psychiatric research is focused on the role of neurobiology, but a clear organic cause has not been found. Due to the many possible combinations of symptoms, there is debate about whether the diagnosis represents a single disorder or a number of discrete syndromes. For this reason, ] termed the disease ''the schizophrenias'' (plural) when he coined the name. Despite its ], schizophrenia is not synonymous with ], previously known as multiple personality disorder or split personality; in ] the two are often confused. | |||
<!-- Treatment --> | |||
<!--Para3: Dopamine hypothesis and treatment--> | |||
The mainstay of treatment is ] medication, including ] and ], along with ], job training, and ].<ref name=Lancet2016>{{cite journal | vauthors = Owen MJ, Sawa A, Mortensen PB | title = Schizophrenia | journal = The Lancet | volume = 388 | issue = 10039 | pages = 86–97 | date = July 2016 | pmid = 26777917 | pmc = 4940219 | doi = 10.1016/S0140-6736(15)01121-6 }}</ref> Up to a third of people do not respond to initial antipsychotics, in which case ] is offered.<ref name=Siskind2017>{{cite journal |vauthors=Siskind D, Siskind V, Kisely S |title=Clozapine Response Rates among People with Treatment-Resistant Schizophrenia: Data from a Systematic Review and Meta-Analysis |journal=Canadian Journal of Psychiatry |volume=62 |issue=11 |pages=772–777 |date=November 2017 |pmid=28655284|doi=10.1177/0706743717718167|pmc=5697625 }}</ref> In a network comparative meta-analysis of 15 antipsychotic drugs, clozapine was significantly more effective than all other drugs, although clozapine's heavily multimodal action may cause more significant side effects.<ref>{{cite journal | vauthors = Leucht S, Cipriani A, Spineli L, Mavridis D, Orey D, Richter F, Samara M, Barbui C, Engel RR, Geddes JR, Kissling W, Stapf MP, Lässig B, Salanti G, Davis JM | title = Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis | journal = Lancet | volume = 382 | issue = 9896 | pages = 951–962 | date = September 2013 | pmid = 23810019 | doi = 10.1016/S0140-6736(13)60733-3 | s2cid = 32085212 }}</ref> In situations where doctors judge that there is a risk of harm to self or others, they may impose short ].<ref name=BeckerKilian2006>{{cite journal | vauthors = Becker T, Kilian R | title = Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? | journal = Acta Psychiatrica Scandinavica. Supplementum | volume = 113 | issue = 429 | pages = 9–16 | year = 2006 | pmid = 16445476 | doi = 10.1111/j.1600-0447.2005.00711.x | s2cid = 34615961 }}</ref> Long-term hospitalization is used on a small number of people with severe schizophrenia.<ref name=Capdevielle2009>{{cite journal |vauthors=Capdevielle D, Boulenger JP, Villebrun D, Ritchie K |title=Durées d'hospitalisation des patients souffrant de schizophrénie: implication des systèmes de soin et conséquences médicoéconomiques |trans-title=Schizophrenic patients' length of stay: mental health care implication and medicoeconomic consequences |language=fr |journal=L'Encéphale |volume=35 |issue=4 |pages=394–399 |date=September 2009 |pmid=19748377 |doi=10.1016/j.encep.2008.11.005 }}</ref> In some countries where supportive services are limited or unavailable, long-term hospital stays are more common.<ref name=Narayan2012>{{cite journal | vauthors = Narayan KK, Kumar DS | title = Disability in a Group of Long-stay Patients with Schizophrenia: Experience from a Mental Hospital. | journal = Indian Journal of Psychological Medicine | date = January 2012 | volume = 34 | issue = 1 | pages = 70–75 | doi = 10.4103/0253-7176.96164 | pmid = 22661812| pmc = 3361848 | doi-access = free }}</ref> | |||
Increased ] in the ] of the brain is a consistent finding. The mainstay of treatment is pharmacotherapy with ] medications; these primarily work by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, though hospital stays are less frequent and for shorter periods than they were in previous years.<ref name="BeckerKilian2006">{{cite journal |author=Becker T |coauthors=Kilian R |year=2006 |title=Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? |journal=] Supplement |volume=429 |pages=9-16 |pmid=16445476 |accessdate=2008-02-24}}</ref> | |||
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<!--Para4: Impairment/chronicity and Comorbidity--> | |||
The disorder is primarily thought to affect ], but it also usually contributes to chronic problems with ] and ]. People diagnosed with schizophrenia are likely to be diagnosed with ] conditions, including ] and ]; the lifetime ] of ] is typically around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common and ] is decreased; the average life expectancy of people with the disorder is 10 to 12 years less than those without, owing to increased physical health problems and a high ] rate.<ref name="Brown_Barraclough_2000">{{cite journal |author=Brown S |coauthors=Inskip H, Barraclough B |year=2000 |title=Causes of the excess mortality of schizophrenia |journal=] |volume=177 |pages=212-7 |pmid=11040880 |accessdate= 2008-02-24}}</ref> | |||
==Signs and symptoms== | ==Signs and symptoms== | ||
], who had schizophrenia]] | |||
A person experiencing schizophrenia may demonstrate symptoms such as ], auditory ]s, and ]s. In severe cases, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are ]s of ]. The current classification of psychoses holds that symptoms need to have been present for at least one month in a period of at least six months of disturbed functioning. A schizophrenia-like psychosis of shorter duration is termed a ].<ref name="DSM-IV-TR">American Psychiatric Association (2004) Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). American Psychiatric Association. ISBN 0890420246. </ref> No one sign is diagnostic of schizophrenia, and all can occur in other medical and psychiatric conditions.<ref name="DSM-IV-TR" /> | |||
Schizophrenia is a ] characterized by significant alterations in ], thoughts, mood, and behavior.<ref name=NICE2014/> Symptoms are described in terms of ], negative, and ].<ref name=NIH2022/><ref>{{cite journal |vauthors=Stępnicki P, Kondej M, Kaczor AA |title=Current Concepts and Treatments of Schizophrenia |journal= Molecules|volume=23 |issue=8 |date=20 August 2018 |pmid=30127324|doi=10.3390/molecules23082087 |pmc=6222385 |page=2087|doi-access=free }}</ref> The positive symptoms of schizophrenia are the same for any ] and are sometimes referred to as psychotic symptoms. These may be present in any of the different psychoses and are often transient, making early diagnosis of schizophrenia problematic. Psychosis noted for the first time in a person who is later diagnosed with schizophrenia is referred to as a first-episode psychosis (FEP).<ref name=RAISE>{{cite web |title=RAISE Questions and Answers |url=https://www.nimh.nih.gov/health/topics/schizophrenia/raise/raise-questions-and-answers.shtml#4 |publisher= US ]|access-date=29 December 2019}}</ref><ref>{{cite journal | vauthors = Marshall M | title = Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review | journal = Archives of General Psychiatry | date = September 2005 | volume = 62 | issue = 9 | pages = 975–983 | doi = 10.1001/archpsyc.62.9.975 | pmid = 16143729| s2cid = 13504781 | doi-access = }}</ref> | |||
===Positive symptoms=== | |||
Social isolation commonly occurs and may be due to a number of factors. Impairment in ] is associated with schizophrenia, as are the active symptoms of paranoia from delusions and hallucinations, and the negative symptoms of apathy and ]. Many people diagnosed with schizophrenia avoid potentially stressful social situations that may exacerbate mental distress.<ref name="Freeman_BRT_2007">{{cite journal |author=Freeman D |coauthors=Garety PA, Kuipers E, Fowler D, Bebbington PE, Dunn G |year=2007 |title=Acting on persecutory delusions: the importance of safety seeking |journal=Behaviour Research and Therapy |volume=45 | issue=1 |pages=89-99 |pmid=16530161 |accessdate= 2008-02-24}}</ref> | |||
Positive symptoms are those symptoms that are not normally experienced, but are present in people during a psychotic episode in schizophrenia, including ]s, ]s, and disorganized thoughts, speech and behavior or inappropriate affect, typically regarded as manifestations of psychosis.<ref name=RAISE/> Hallucinations occur at some point in the lifetimes of 80% of those with schizophrenia<ref name=Montagnese2021>{{cite journal |vauthors=Montagnese M, Leptourgos P, Fernyhough C, et al |title=A Review of Multimodal Hallucinations: Categorization, Assessment, Theoretical Perspectives, and Clinical Recommendations |journal=Schizophr Bull |volume=47 |issue=1 |pages=237–248 |date=January 2021 |pmid=32772114 |pmc=7825001 |doi=10.1093/schbul/sbaa101 }}</ref> and most commonly involve the sense of ] (most often ]), but can sometimes involve any of the other ]s such as ], ], ], and ].<ref>{{cite journal |vauthors=Császár N, Kapócs G, Bókkon I |s2cid=52813070 |title=A possible key role of vision in the development of schizophrenia |journal=Reviews in the Neurosciences |volume=30 |issue=4 |pages=359–379 |date=27 May 2019 |pmid=30244235 |doi=10.1515/revneuro-2018-0022|doi-broken-date=3 December 2024 }}</ref> The frequency of hallucinations involving multiple senses is double the rate of those involving only one sense.<ref name=Montagnese2021/> They are also typically related to the content of the delusional theme.<ref name=DSMIV>{{cite book | author = American Psychiatric Association. Task Force on DSM-IV. | year = 2000 | title = Diagnostic and statistical manual of mental disorders: DSM-IV-TR. | publisher = American Psychiatric Pub. | isbn = 978-0-89042-025-6 | pages = 299–304 }}</ref> ]s are ] or ] in nature. ] such as feeling that ] or that ], sometimes termed passivity phenomena, are also common.<ref name=Heinz2016>{{cite journal | vauthors = Heinz A, Voss M, Lawrie SM, Mishara A, Bauer M, Gallinat J, Juckel G, Lang U, Rapp M, Falkai P, Strik W, Krystal J, Abi-Dargham A, Galderisi S | title = Shall we really say goodbye to first rank symptoms? | journal = European Psychiatry | volume = 37 | pages = 8–13 | date = September 2016 | pmid = 27429167 | doi = 10.1016/j.eurpsy.2016.04.010 | s2cid = 13761854 }}</ref><ref name=NIH2022/> Positive symptoms generally respond well to medication<ref name=Lancet2016/> and become reduced over the course of the illness, perhaps linked to the age-related decline in dopamine activity.<ref name=DSM5/> | |||
===Negative symptoms=== | |||
Late adolescence and early adulthood are peak years for the onset of schizophrenia. These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset. To minimize the effect of schizophrenia, much work has recently been done to identify and treat the ] phase of the illness, which has been detected up to 30 months before the onset of symptoms, but may be present longer.<ref name="Addington_et_al_2007">{{cite journal |author=Addington J |coauthors=Cadenhead KS, Cannon TD, Cornblatt B, McGlashan TH, Perkins DO, Seidman LJ, Tsuang M, Walker EF, Woods SW, Heinssen R |year=2007|title=North American prodrome longitudinal study: a collaborative multisite approach to prodromal schizophrenia research |journal=] |volume=33 | issue=3 |pages=665-72 |pmid=17255119 |accessdate= 2008-02-24}}</ref> Those who go on to develop schizophrenia may experience the non-specific symptoms of social withdrawal, irritability and ] in the prodromal period,<ref name="ParnasJorgensen1989">{{cite journal |author=Parnas J |coauthors=Jorgensen A |year=1989 |title=Pre-morbid psychopathology in schizophrenia spectrum |journal=] |volume=115 |pages=623-7 |pmid=2611591 |accessdate= 2008-02-24}}</ref> and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.<ref name="Amminger_et_al_2006">{{cite journal |author=Amminger GP |coauthors=Leicester S, Yung AR, Phillips LJ, Berger GE, Francey SM, Yuen HP, McGorry PD |year=2006 |title=Early-onset of symptoms predicts conversion to non-affective psychosis in ultra-high risk individuals |journal=] |volume=84 | issue=1 |pages=67-76 |pmid=16677803 |accessdate= 2008-02-24}}</ref> | |||
Negative symptoms are deficits of normal emotional responses, or of other thought processes. The five recognized domains of negative symptoms are: ] – showing flat expressions (monotone) or little emotion; ] – a poverty of speech; ] – an inability to feel pleasure; ] – the lack of desire to form relationships, and ] – a lack of motivation and ].<ref name=Adida2015>{{cite journal |vauthors=Adida M, Azorin JM, Belzeaux R, Fakra E |title= |journal=L'Encephale |volume=41 |issue=6 Suppl 1 |pages=6S15–17 |date=December 2015 |pmid=26776385 |doi=10.1016/S0013-7006(16)30004-5}}</ref><ref>{{cite journal |vauthors=Mach C, Dollfus S |title= |journal=L'Encephale |volume=42 |issue=2 |pages=165–171 |date=April 2016 |pmid=26923997 |doi=10.1016/j.encep.2015.12.020}}</ref> Avolition and anhedonia are seen as motivational deficits resulting from impaired reward processing.<ref>{{cite journal |vauthors=Waltz JA, Gold JM |title=Motivational Deficits in Schizophrenia and the Representation of Expected Value |journal=Current Topics in Behavioral Neurosciences |volume=27 |pages=375–410 |date=2016 |pmid=26370946 |doi=10.1007/7854_2015_385 |pmc=4792780 |isbn=978-3-319-26933-7 }}</ref><ref name=Husain2018>{{cite journal |vauthors=Husain M, Roiser JP |s2cid=49428707 |title=Neuroscience of apathy and anhedonia: a transdiagnostic approach. |journal=Nature Reviews. Neuroscience|volume=19 |issue=8 |pages=470–484 |date=August 2018 |pmid=29946157 |doi=10.1038/s41583-018-0029-9|url=https://ora.ox.ac.uk/objects/uuid:3e481f87-0ede-47dd-bdd8-2db78dfd3694 }}</ref> Reward is the main driver of motivation and this is mostly mediated by dopamine.<ref name=Husain2018/> It has been suggested that negative symptoms are multidimensional and they have been categorised into two subdomains of apathy or lack of motivation, and diminished expression.<ref name=Adida2015/><ref name=Galderisi2018>{{cite journal |vauthors=Galderisi S, Mucci A, Buchanan RW, Arango C |title=Negative symptoms of schizophrenia: new developments and unanswered research questions |journal=The Lancet. Psychiatry |volume=5 |issue=8 |pages=664–677 |date=August 2018 |pmid=29602739 |doi=10.1016/S2215-0366(18)30050-6 |s2cid=4483198 }}</ref> Apathy includes avolition, anhedonia, and social withdrawal; diminished expression includes blunt affect and alogia.<ref>{{cite journal |vauthors=Klaus F, Dorsaz O, Kaiser S |title= |journal=Revue médicale suisse |volume=14 |issue=619 |pages=1660–1664 |date=19 September 2018 |doi=10.53738/REVMED.2018.14.619.1660 |pmid=30230774|s2cid=246764656 }}</ref> Sometimes diminished expression is treated as both verbal and non-verbal.<ref>{{cite journal |vauthors=Batinic B |title=Cognitive Models of Positive and Negative Symptoms of Schizophrenia and Implications for Treatment. |journal=Psychiatria Danubina |volume=31 |issue=Suppl 2 |pages=181–184 |date=June 2019 |pmid=31158119}}</ref> | |||
Apathy accounts for around 50% of the most often found negative symptoms and affects functional outcome and subsequent quality of life. Apathy is related to disrupted cognitive processing affecting memory and planning including goal-directed behaviour.<ref>{{cite journal |vauthors=Bortolon C, Macgregor A, Capdevielle D, Raffard S |s2cid=13411386 |title=Apathy in schizophrenia: A review of neuropsychological and neuroanatomical studies. |journal=Neuropsychologia |volume=118 |issue=Pt B |pages=22–33 |date=September 2018 |pmid=28966139 |doi=10.1016/j.neuropsychologia.2017.09.033}}</ref> The two subdomains have suggested a need for separate treatment approaches.<ref name=Marder2014>{{cite journal |vauthors=Marder SR, Kirkpatrick B |s2cid=5172022 |title=Defining and measuring negative symptoms of schizophrenia in clinical trials |journal=European Neuropsychopharmacology|volume=24 |issue=5 |pages=737–743 |date=May 2014 |pmid=24275698 |doi=10.1016/j.euroneuro.2013.10.016}}</ref> A lack of distress is another noted negative symptom.<ref name=Tatsumi2020>{{cite journal |vauthors=Tatsumi K, Kirkpatrick B, Strauss GP, Opler M |s2cid=211141678 |title=The brief negative symptom scale in translation: A review of psychometric properties and beyond |journal=European Neuropsychopharmacology |date=April 2020 |volume=33 |pages=36–44 |doi=10.1016/j.euroneuro.2020.01.018 |pmid=32081498}}</ref> A distinction is often made between those negative symptoms that are inherent to schizophrenia, termed primary; and those that result from positive symptoms, from the side effects of antipsychotics, substance use disorder, and social deprivation – termed secondary negative symptoms.<ref>{{cite journal |vauthors=Klaus F, Kaiser S, Kirschner M |title=. |journal=Therapeutische Umschau |volume=75 |issue=1 |pages=51–56 |date=June 2018 |pmid=29909762 |doi=10.1024/0040-5930/a000966|s2cid=196502392 }}</ref> Negative symptoms are less responsive to medication and the most difficult to treat.<ref name=Marder2014/> However, if properly assessed, secondary negative symptoms are amenable to treatment.<ref name=Galderisi2018/> There is some evidence that the negative symptoms of schizophrenia are amenable to psychostimulant medication, although such drugs have varying degrees of risk for causing positive psychotic symptoms.<ref>{{Cite journal |last1=Lindenmayer |first1=Jean-Pierre |last2=Nasrallah |first2=Henry |last3=Pucci |first3=Michael |last4=James |first4=Steven |last5=Citrome |first5=Leslie |date=2013-07-01 |title=A systematic review of psychostimulant treatment of negative symptoms of schizophrenia: Challenges and therapeutic opportunities |url=https://www.sciencedirect.com/science/article/abs/pii/S0920996413001655 |journal=Schizophrenia Research |volume=147 |issue=2 |pages=241–252 |doi=10.1016/j.schres.2013.03.019 |pmid=23619055 |issn=0920-9964}}</ref> | |||
===Schneiderian classification=== | |||
The psychiatrist ] (1887–1967) listed the forms of psychotic symptoms that he thought distinguished schizophrenia from other psychotic disorders. These are called ''first-rank symptoms'' or ], and they include delusions of being controlled by an external force; the belief that thoughts are being inserted into or withdrawn from one's conscious STOMACH; the belief that one's thoughts are being broadcast to other people; and hearing hallucinatory voices that comment on one's thoughts or actions or that have a conversation with other hallucinated voices.<ref name="SchneiderClinicalPsychopathology">Schneider, K. (1959) ''Clinical Psychopathology''. New York: Grune and Stratton.</ref> The reliability of first-rank symptoms has been questioned,<ref name="fn_4">{{cite journal |author=Bertelsen, A |year=2002 |title=Schizophrenia and Related Disorders: Experience with Current Diagnostic Systems |journal=Psychopathology |volume=35 |pages=89-93 |pmid=12145490 |accessdate= 2008-02-24}}</ref> although they have contributed to the current diagnostic criteria. | |||
Scales for specifically assessing the presence of negative symptoms, and for measuring their severity, and their changes have been introduced since the earlier scales such as the ] that deals with all types of symptoms.<ref name=Marder2014/> These scales are the ''Clinical Assessment Interview for Negative Symptoms'' (CAINS), and the ''Brief Negative Symptom Scale'' (BNSS) also known as second-generation scales.<ref name=Marder2014/><ref name=Tatsumi2020/><ref>{{cite journal |vauthors=Wójciak P, Rybakowski J |title=Clinical picture, pathogenesis and psychometric assessment of negative symptoms of schizophrenia. |journal=Psychiatria Polska |volume=52 |issue=2 |pages=185–197 |date=30 April 2018 |pmid=29975360 |doi=10.12740/PP/70610|doi-access=free }}</ref> In 2020, ten years after its introduction, a cross-cultural study of the use of BNSS found valid and reliable ] evidence for its five-domain structure cross-culturally. The BNSS can assess both the presence and severity of negative symptoms of the five recognized domains and an additional item of reduced normal distress. It has been used to measure changes in negative symptoms in trials of psychosocial and pharmacological interventions.<ref name=Tatsumi2020/> | |||
===Positive and negative symptoms=== | |||
Schizophrenia is often described in terms of ''positive'' (or productive) and ''negative'' (or deficit) symptoms.<ref name="Sims_2002">Sims A (2002) Symptoms in the Mind: An Introduction to Descriptive Psychopathology (3rd edition). Edinburgh: Elsevier Science Ltd. ISBN 0-7020-2627-1</ref> Positive symptoms include ]s, ], and ], and are typically regarded as manifestations of ]. Negative symptoms are so-named because they are considered to be the loss or absence of normal traits or abilities, and include features such as flat or ] and ], poverty of ] (]), ], and lack of ] (]). Despite the appearance of blunted affect, recent studies indicate that there is often a normal or even heightened level of emotionality in Schizophrenia especially in response to stressful or negative events.<ref>{{cite journal |author=Cohen & Docherty |year=2004 |title=Affective reactivity of speech and emotional experience in patients with schizophrenia |journal=] |volume=69 | issue=1 |pages=7-14 |pmid=15145465 |accessdate= 2008-02-24}}</ref> A third symptom grouping, the ''disorganization syndrome'', is commonly described, and includes chaotic speech, thought, and behaviour. There is evidence for a number of other symptom classifications.<ref name="Peralta_Cuesta_2001">{{cite journal |author=Peralta V |coauthors=Cuesta MJ |year=2001 |title=How many and which are the psychopathological dimensions in schizophrenia? Issues influencing their ascertainment |journal=] |volume=49 | issue=3 |pages=269-85 |pmid=11356588 |accessdate= 2008-02-24}}</ref> | |||
===Cognitive symptoms=== | |||
==Diagnosis== | |||
{{See also |Visual processing abnormalities in schizophrenia}} | |||
Diagnosis is based on the self-reported experiences of the person as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a ], ], ] or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.<ref name="DSM-IV-TR" /> | |||
] throughout the human brain in a patient with schizophrenia. The most deficient areas are magenta, while the least deficient areas are blue.]] | |||
An estimated 70% of those with schizophrenia have cognitive deficits, and these are most pronounced in early-onset and late-onset illness.<ref name=Murante2017/><ref name=Kar2016>{{cite journal |vauthors=Kar SK, Jain M |title=Current understandings about cognition and the neurobiological correlates in schizophrenia |journal=Journal of Neurosciences in Rural Practice |volume=7 |issue=3 |pages=412–418 |date=July 2016 |pmid=27365960 |doi=10.4103/0976-3147.176185 |pmc=4898111 |doi-access=free }}</ref> These are often evident long before the onset of illness in the ], and may be present in childhood or early adolescence.<ref name=Bozikas2011/><ref>{{cite journal | vauthors = Shah JN, Qureshi SU, Jawaid A, Schulz PE | s2cid = 10970088 | title = Is there evidence for late cognitive decline in chronic schizophrenia? | journal = The Psychiatric Quarterly | volume = 83 | issue = 2 | pages = 127–144 | date = June 2012 | pmid = 21863346 | doi = 10.1007/s11126-011-9189-8 }}</ref> They are a core feature but not considered to be core symptoms, as are positive and negative symptoms.<ref name=Biedermann2016>{{cite journal |vauthors = Biedermann F, Fleischhacker WW | title = Psychotic disorders in DSM-5 and ICD-11 | journal = CNS Spectrums | date = August 2016 | volume = 21 | issue = 4 | pages = 349–354 | doi = 10.1017/S1092852916000316 | pmid = 27418328| s2cid = 24728447 }}</ref><ref name=Vidailhet2013/> However, their presence and degree of dysfunction is taken as a better indicator of functionality than the presentation of core symptoms.<ref name=Bozikas2011>{{cite journal | vauthors = Bozikas VP, Andreou C | s2cid = 26135485 | title = Longitudinal studies of cognition in first episode psychosis: a systematic review of the literature | journal = The Australian and New Zealand Journal of Psychiatry | volume = 45 | issue = 2 | pages = 93–108 | date = February 2011 | pmid = 21320033 | doi = 10.3109/00048674.2010.541418 }}</ref> Cognitive deficits become worse at first episode psychosis but then return to baseline, and remain fairly stable over the course of the illness.<ref name=Hashimoto2019/><ref name=Green2019/> | |||
The deficits in ] are seen to drive the negative psychosocial outcome in schizophrenia, and are claimed{{By whom|date=March 2024}} to equate to a possible reduction in IQ from the norm of 100 to 70–85.<ref>{{cite journal | vauthors=Javitt DC, Sweet RA |title=Auditory dysfunction in schizophrenia: integrating clinical and basic features. |journal=Nature Reviews. Neuroscience|volume=16 |issue=9 |pages=535–550 |date=September 2015|pmid=26289573|doi=10.1038/nrn4002|pmc=4692466 }}</ref><ref name=Megreya2016>{{cite journal |vauthors=Megreya AM |s2cid=26125559 |title=Face perception in schizophrenia: a specific deficit |journal=Cognitive Neuropsychiatry |volume=21 |issue=1 |pages=60–72 |date=2016 |pmid=26816133|doi=10.1080/13546805.2015.1133407}}</ref> Cognitive deficits may be of ] (nonsocial) or of ].<ref name=Murante2017>{{cite journal |vauthors=Murante T, Cohen CI |title=Cognitive Functioning in Older Adults With Schizophrenia |journal=Focus (American Psychiatric Publishing) |volume=15 |issue=1 |pages=26–34 |date=January 2017 |pmid=31975837 |doi=10.1176/appi.focus.20160032|pmc=6519630 }}</ref> Neurocognition is the ability to receive and remember information, and includes verbal fluency, ], ]ing, ], ], and ] and visual perception.<ref name=Green2019/> ] and attention are seen to be the most affected.<ref name=Megreya2016/><ref>{{cite journal |vauthors=Eack SM |title=Cognitive remediation: a new generation of psychosocial interventions for people with schizophrenia |journal=Social Work |volume=57 |issue=3 |pages=235–246 |date=July 2012 |pmid=23252315 |doi=10.1093/sw/sws008|pmc=3683242 }}</ref> Verbal memory impairment is associated with a decreased level of ] (relating meaning to words).<ref>{{cite journal | |||
An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizophrenia, tests are carried out to exclude medical illnesses which may rarely present with psychotic schizophrenia-like symptoms.<ref name="DSM-IV-TR" /> These include blood tests measuring ] to exclude ] or ], ] and serum ] to rule out a ], ] including ] to rule out a ] or chronic disease, and ] to exclude ] or ] infection; two commonly ordered investigations are ] to exclude ], and a ] of the head to exclude brain lesions. It is important to rule out a ] which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness and indicates an underlying medical illness. There are several psychiatric illnesses which may present with psychotic symptoms other than schizophrenia. These include ],<ref>{{cite journal |author=Pope HG |year=1983 |title=Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports |journal=Hospital and Community Psychiatry |volume=34 |pages=322-328 |url=http://psychservices.psychiatryonline.org/cgi/reprint/34/4/322.pdf |accessdate= 2008-02-24}}</ref> ],<ref>McGlashan TH (1987) Testing DSM-III symptom criteria for schizotypal and borderline personality disorders. Archives of General Psychiatry, 44: 15–22.</ref> drug intoxication, brief drug-induced psychosis, and ]. | |||
|vauthors=Pomarol-Clotet E, Oh M, Laws KR, McKenna PJ | title=Semantic priming in schizophrenia: systematic review and meta-analysis |journal=The British Journal of Psychiatry |volume=192 |issue=2 | pages=92–97 |date=February 2008 |pmid=18245021 |doi=10.1192/bjp.bp.106.032102 | hdl=2299/2735 |doi-access=free |hdl-access=free }}</ref> Another memory impairment is that of ].<ref>{{cite journal | vauthors = Goldberg TE, Keefe RS, Goldman RS, Robinson DG, Harvey PD | title = Circumstances under which practice does not make perfect: a review of the practice effect literature in schizophrenia and its relevance to clinical treatment studies | journal = Neuropsychopharmacology | volume = 35 | issue = 5 | pages = 1053–1062 | date = April 2010 | pmid = 20090669 | pmc = 3055399 | doi = 10.1038/npp.2009.211 | df = dmy-all }}</ref> An impairment in visual perception that is consistently found in schizophrenia is that of ].<ref name=Green2019/> ] impairments include an inability to perceive complex ]s.<ref>{{cite journal |vauthors=King DJ, Hodgekins J, Chouinard PA, Chouinard VA, Sperandio I |title=A review of abnormalities in the perception of visual illusions in schizophrenia. |journal=Psychonomic Bulletin and Review |volume=24 |issue=3 |pages=734–751 |date=June 2017 |pmid=27730532 |doi=10.3758/s13423-016-1168-5 |pmc = 5486866}}</ref> Social cognition is concerned with the mental operations needed to interpret, and understand the self and others in the social world.<ref name=Green2019>{{cite journal |vauthors=Green MF, Horan WP, Lee J |title=Nonsocial and social cognition in schizophrenia: current evidence and future directions |journal=World Psychiatry|volume=18 |issue=2 |pages=146–161 |date=June 2019 |pmid=31059632 |doi=10.1002/wps.20624|pmc=6502429 }}</ref><ref name=Murante2017/> This is also an associated impairment, and ] is often found to be difficult.<ref>{{cite journal | vauthors = Kohler CG, Walker JB, Martin EA, Healey KM, Moberg PJ | title = Facial emotion perception in schizophrenia: a meta-analytic review | journal = Schizophrenia Bulletin | volume = 36 | issue = 5 | pages = 1009–1019 | date = September 2010 | pmid = 19329561 | pmc = 2930336 | doi = 10.1093/schbul/sbn192 | df = dmy-all }}</ref><ref>{{cite journal | vauthors = Le Gall E, Iakimova G | title = | journal = L'Encéphale | volume = 44 | issue = 6 | pages = 523–537 | date = December 2018 | pmid = 30122298 | doi = 10.1016/j.encep.2018.03.004 | s2cid = 150099236 }}</ref> Facial perception is critical for ordinary social interaction.<ref>{{cite journal | vauthors = Grill-Spector K, Weiner KS, Kay K, Gomez J | title = The Functional Neuroanatomy of Human Face Perception | journal = Annual Review of Vision Science | volume = 3 | pages = 167–196 | date = September 2017 | pmid = 28715955 | pmc = 6345578 | doi = 10.1146/annurev-vision-102016-061214 }}</ref> Cognitive impairments do not usually respond to antipsychotics, and there are a number of ] that are used to try to improve them; ] is of particular help.<ref name=Vidailhet2013/> | |||
] of clumsiness and loss of fine motor movement are often found in schizophrenia, which may resolve with effective treatment of FEP.<ref name=Ferri2019/><ref>{{cite journal |vauthors=Fountoulakis KN, Panagiotidis P, Kimiskidis V, Nimatoudis I, Gonda X |s2cid=56476015 |title=Neurological soft signs in familial and sporadic schizophrenia |journal=Psychiatry Research |volume=272 |pages=222–229 |date=February 2019 |pmid=30590276 |doi=10.1016/j.psychres.2018.12.105 }}</ref> | |||
Investigations are not generally repeated for relapse unless there is a specific ''medical'' indication. These may include serum ] level (BSL) if ] has been prescribed previously, ] if ], or ] to exclude ]. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others. | |||
===Onset=== | |||
The most widely used criteria for diagnosing schizophrenia are from the ] ], the current version being DSM-IV-TR, and the ] ], currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian ] although, in practice, agreement between the two systems is high.<ref name="Jakobsen_et_al_2005">{{cite journal |author=Jakobsen KD |coauthors=Frederiksen JN, Hansen T, Jansson LB, Parnas J, Werge T |year=2005 |title=Reliability of clinical ICD-10 schizophrenia diagnoses |journal=Nordic Journal of Psychiatry |volume=59 | issue=3 |pages=209-12 |pmid=16195122 |accessdate= 2008-02-24}}</ref> The ] has developed the tool ''] (Schedules for Clinical Assessment in Neuropsychiatry)'' which can be used for diagnosing a number of psychiatric conditions, including schizophrenia. | |||
{{Further|Basic symptoms of schizophrenia}} | |||
{{See also|Childhood schizophrenia|Adolescence#Changes in the brain}} | |||
Onset typically occurs between the late teens and early 30s, with the peak incidence occurring in males in the early to mid-twenties, and in females in the late twenties.<ref name=NIH2022/><ref name=DSM5/><ref name=Ferri2019/> Onset before the age of 17 is known as early-onset,<ref>{{cite journal |vauthors=Bourgou Gaha S, Halayem Dhouib S, Amado I, Bouden A |title= |journal=L'Encephale |volume=41 |issue=3 |pages=209–214 |date=June 2015 |pmid=24854724 |doi=10.1016/j.encep.2014.01.005}}</ref> and before the age of 13, as can sometimes occur, is known as ] or very early-onset.<ref name=DSM5 /><ref name=DaFonseca2018>{{cite journal |vauthors=Da Fonseca D, Fourneret P |title= |journal=L'Encephale |volume=44 |issue=6S |pages=S8–S11 |date=December 2018 |pmid=30935493 |doi=10.1016/S0013-7006(19)30071-5|s2cid=150798223 }}</ref> Onset can occur between the ages of 40 and 60, known as late-onset schizophrenia.<ref name=Murante2017/> Onset over the age of 60, which may be difficult to differentiate as schizophrenia, is known as very-late-onset schizophrenia-like psychosis.<ref name=Murante2017/> Late onset has shown that a higher rate of females are affected; they have less severe symptoms and need lower doses of antipsychotics.<ref name=Murante2017/> The tendency for earlier onset in males is later seen to be balanced by a ] increase in the development in females. ] produced pre-menopause has a dampening effect on dopamine receptors but its protection can be overridden by a genetic overload.<ref>{{cite journal |vauthors=Häfner H |title=From Onset and Prodromal Stage to a Life-Long Course of Schizophrenia and Its Symptom Dimensions: How Sex, Age, and Other Risk Factors Influence Incidence and Course of Illness |journal=Psychiatry Journal |volume=2019 |page=9804836 |date=2019 |pmid=31139639 |doi=10.1155/2019/9804836 |pmc=6500669 |doi-access=free }}</ref> There has been a dramatic increase in the numbers of older adults with schizophrenia.<ref>{{cite journal | vauthors = Cohen CI, Freeman K, Ghoneim D, Vengassery A, Ghezelaiagh B, Reinhardt MM | title = Advances in the Conceptualization and Study of Schizophrenia in Later Life | journal = The Psychiatric Clinics of North America | volume = 41 | issue = 1 | pages = 39–53 | date = March 2018 | pmid = 29412847 | doi = 10.1016/j.psc.2017.10.004 }}</ref> | |||
Onset may happen suddenly or may occur after the slow and gradual development of a number of signs and symptoms, a period known as the ].<ref name=DSM5 /> Up to 75% of those with schizophrenia go through a prodromal stage.<ref name=George2017>{{cite journal |vauthors=George M, Maheshwari S, Chandran S, Manohar JS, Sathyanarayana Rao TS |title=Understanding the schizophrenia prodrome |journal=Indian Journal of Psychiatry |volume=59 |issue=4 |pages=505–509 |date=October 2017 |pmid=29497198 |doi=10.4103/psychiatry.IndianJPsychiatry_464_17|doi-broken-date=1 November 2024 |doi-access=free|pmc=5806335 }}</ref> The negative and cognitive symptoms in the prodrome stage can precede FEP (first episode psychosis) by many months and up to five years.<ref name=Hashimoto2019>{{cite journal |vauthors=Hashimoto K |s2cid=195814019 |title=Recent Advances in the Early Intervention in Schizophrenia: Future Direction from Preclinical Findings |journal=Current Psychiatry Reports |volume=21 |issue=8 |page=75 |date=5 July 2019 |pmid=31278495 |doi=10.1007/s11920-019-1063-7}}</ref><ref name=Conroy2018>{{cite journal |vauthors=Conroy S, Francis M, Hulvershorn LA |title=Identifying and treating the prodromal phases of bipolar disorder and schizophrenia |journal=Current Treatment Options in Psychiatry |volume=5 |issue=1 |pages=113–128 |date=March 2018 |pmid=30364516 |doi=10.1007/s40501-018-0138-0|pmc=6196741 }}</ref> The period from FEP and treatment is known as the duration of untreated psychosis (DUP) which is seen to be a factor in functional outcome. The prodromal stage is the high-risk stage for the development of psychosis.<ref name=Green2019/> Since the progression to first episode psychosis is not inevitable, an alternative term is often preferred of ].<ref name=Green2019/> Cognitive dysfunction at an early age impacts a young person's usual cognitive development.<ref>{{cite journal |vauthors=Lecardeur L, Meunier-Cussac S, Dollfus S |title= |journal=L'Encephale |volume=39 |pages=S64-71 |date=May 2013 |issue=Suppl 1 |pmid=23528322 |doi=10.1016/j.encep.2012.10.011}}</ref> Recognition and early intervention at the prodromal stage would minimize the associated disruption to educational and social development and has been the focus of many studies.<ref name=Hashimoto2019/><ref name=Conroy2018/> | |||
===DSM IV-TR Criteria=== | |||
To be diagnosed with schizophrenia, a person must display:<ref name="DSM-IV-TR" /> | |||
==Risk factors== | |||
*'''Characteristic symptoms''': Two or more of the following, each present for a significant portion of time during a one-month period (or less, if successfully treated) | |||
{{Main|Risk factors of schizophrenia}} | |||
** ]s | |||
Schizophrenia is described as a ] with no precise boundary, or single cause, and is thought to develop from ]s with involved vulnerability factors.<ref name=Lancet2016/><ref>{{cite journal | vauthors = Mullin AP, Gokhale A, Moreno-De-Luca A, Sanyal S, Waddington JL, Faundez V | title = Neurodevelopmental disorders: mechanisms and boundary definitions from genomes, interactomes and proteomes | journal = Translational Psychiatry | volume = 3 | issue = 12 | pages = e329 | date = December 2013 | pmid = 24301647 | pmc = 4030327 | doi = 10.1038/tp.2013.108 }}</ref><ref name= Davis2016/> The interactions of these ]s are complex, as numerous and diverse ] from conception to adulthood can be involved.<ref name=Davis2016>{{cite journal | vauthors = Davis J, Eyre H, Jacka FN, Dodd S, Dean O, McEwen S, Debnath M, McGrath J, Maes M, Amminger P, McGorry PD, Pantelis C, Berk M | title = A review of vulnerability and risks for schizophrenia: Beyond the two hit hypothesis | journal = Neuroscience and Biobehavioral Reviews | volume = 65 | pages = 185–194 | date = June 2016 | pmid = 27073049 | pmc = 4876729 | doi = 10.1016/j.neubiorev.2016.03.017 }}</ref> A genetic predisposition on its own, without interacting environmental factors, will not give rise to the development of schizophrenia.<ref name=Davis2016/><ref name=Perkovic2017>{{cite journal | vauthors = Perkovic MN, Erjavec GN, Strac DS, Uzun S, Kozumplik O, Pivac N | title = Theranostic Biomarkers for Schizophrenia | journal = International Journal of Molecular Sciences | volume = 18 | issue = 4 | page = 733 | date = March 2017 | pmid = 28358316 | pmc = 5412319 | doi = 10.3390/ijms18040733 | doi-access = free }}</ref> The genetic component means that ] brain development is disturbed, and environmental influence affects the postnatal development of the brain.<ref name= Suvisaari2010>{{cite journal | vauthors = Suvisaari J | title = | language = Finnish | journal = Duodecim; Laaketieteellinen Aikakauskirja | volume = 126 | issue = 8 | pages = 869–876 | date = 2010 | pmid = 20597333 }}</ref> Evidence suggests that genetically susceptible children are more likely to be vulnerable to the effects of environmental risk factors.<ref name= Suvisaari2010/> | |||
** ]s | |||
** disorganized speech (e.g., frequent derailment or incoherence; speaking in ]). See ]. | |||
** grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or ] behavior | |||
** negative symptoms, i.e., ] (lack or decline in emotional response), ] (lack or decline in speech), or ] (lack or decline in motivation). | |||
===Genetic=== | |||
:Note: Only one of these symptoms is required if delusions are bizarre or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other. | |||
Estimates of the ] of schizophrenia are between 70% and 80%, which implies that 70% to 80% of the individual differences in risk of schizophrenia are associated with genetics.<ref name=vandeLeemput2016/><ref name=Her2011/> These estimates vary because of the ] genetic and environmental influences, and their accuracy has been queried.<ref>{{cite journal | vauthors = O'Donovan MC, Williams NM, Owen MJ | title = Recent advances in the genetics of schizophrenia | journal = Human Molecular Genetics | volume = 12 Spec No 2 | pages = R125–133 | date = October 2003 | pmid = 12952866 | doi = 10.1093/hmg/ddg302 | doi-access = free }}</ref><ref name=Torrey2019>{{Cite journal |vauthors=Torrey EF, Yolken RH |s2cid=173991937 |date=August 2019 |title=Schizophrenia as a pseudogenetic disease: A call for more gene-environmental studies |journal=Psychiatry Research |volume=278 |pages=146–150 |doi=10.1016/j.psychres.2019.06.006|pmid=31200193 }}</ref> The greatest risk factor for developing schizophrenia is having a ] with the disease (risk is 6.5%); more than 40% of ] of those with schizophrenia are also affected.<ref name=BMJ07>{{cite journal | vauthors = Picchioni MM, Murray RM | title = Schizophrenia | journal = BMJ | volume = 335 | issue = 7610 | pages = 91–95 | date = July 2007 | pmid = 17626963 | pmc = 1914490 | doi = 10.1136/bmj.39227.616447.BE }}</ref> If one parent is affected the risk is about 13% and if both are affected the risk is nearly 50%.<ref name=Her2011>{{cite book|title=Adult psychopathology and diagnosis |year=2011 |publisher=John Wiley & Sons |isbn=978-1-118-13884-7 |chapter-url= https://books.google.com/books?id=iJtzm1KfU5oC&pg=PT282 |chapter= Chapter 8: Schizophrenia: Etiological considerations| veditors = Hersen M, Beidel DC |edition=6th| vauthors = Combs DR, Mueser KT, Gutierrez MM }}</ref> However, the ''DSM-5'' indicates that most people with schizophrenia have no family history of psychosis.<ref name=DSM5/> Results of ] studies of schizophrenia have generally failed to find consistent associations,<ref>{{cite journal | vauthors = Farrell MS, Werge T, Sklar P, Owen MJ, Ophoff RA, O'Donovan MC, Corvin A, Cichon S, Sullivan PF | title = Evaluating historical candidate genes for schizophrenia | journal = Molecular Psychiatry | volume = 20 | issue = 5 | pages = 555–562 | date = May 2015 | pmid = 25754081 | pmc = 4414705 | doi = 10.1038/mp.2015.16 }}</ref> and the ] identified by ] explain only a small fraction of the variation in the disease.<ref>{{Cite book |url= https://books.google.com/books?id=7ukmDAAAQBAJ |title=Schizophrenia and Psychotic Spectrum Disorders | vauthors = Schulz SC, Green MF, Nelson KJ |date=2016 |publisher=Oxford University Press |isbn=9780199378067 |pages=124–125 }}</ref> | |||
Many ] are known to be involved in schizophrenia, each with small effects and unknown ] and ].<ref name=vandeLeemput2016/><ref>{{cite journal | vauthors = Schork AJ, Wang Y, Thompson WK, Dale AM, Andreassen OA | title = New statistical approaches exploit the polygenic architecture of schizophrenia—implications for the underlying neurobiology | journal = Current Opinion in Neurobiology | volume = 36 | pages = 89–98 | date = February 2016 | pmid = 26555806 | pmc = 5380793 | doi = 10.1016/j.conb.2015.10.008 }}</ref><ref>{{cite journal|vauthors= Coelewij L, Curtis D|title=Mini-review: Update on the genetics of schizophrenia|journal=Annals of Human Genetics|volume=82|issue=5|year= 2018|pages=239–243|issn=0003-4800|doi=10.1111/ahg.12259|pmid= 29923609|s2cid=49311660|url=https://discovery.ucl.ac.uk/id/eprint/10064654/ |doi-access=free}}</ref> The summation of these effect sizes into a ] can explain at least 7% of the variability in liability for schizophrenia.<ref>{{cite journal | vauthors = Kendler KS | title = The Schizophrenia Polygenic Risk Score: To What Does It Predispose in Adolescence? | journal = JAMA Psychiatry | volume = 73 | issue = 3 | pages = 193–194 | date = March 2016 | pmid = 26817666 | doi = 10.1001/jamapsychiatry.2015.2964 }}</ref> Around 5% of cases of schizophrenia are understood to be at least partially attributable to rare ]s (CNVs); these ]s are associated with known genomic disorders involving ] at ] (]) and ] (]), duplications at ] (most frequently found) and deletions at ] (]).<ref name=Lowther2017p82>{{cite journal | vauthors = Lowther C, Costain G, Baribeau DA, Bassett AS | s2cid = 4776174 | title = Genomic Disorders in Psychiatry—What Does the Clinician Need to Know? | journal = Current Psychiatry Reports | volume = 19 | issue = 11 | page = 82 | date = September 2017 | doi = 10.1007/s11920-017-0831-5 | pmid = 28929285 }}</ref> Some of these CNVs increase the risk of developing schizophrenia by as much as 20-fold, and are frequently comorbid with autism and intellectual disabilities.<ref name=Lowther2017p82/> | |||
*'''Social/occupational dysfunction''': For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset. | |||
The genes ] and ] are associated with the severity of suicidal behavior. These genes code for stress response proteins needed in the control of the ], and their interaction can affect this axis. Response to stress can cause lasting changes in the ] possibly disrupting the negative feedback mechanism, ], and the regulation of emotion leading to altered behaviors.<ref name=Perkovic2017/> | |||
*'''Duration''': Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if successfully treated). | |||
The question of how schizophrenia could be primarily genetically influenced, given that people with schizophrenia have lower fertility rates, is a paradox. It is expected that ] that increase the risk of schizophrenia would be selected against, due to their negative effects on ]. A number of potential explanations have been proposed, including that ]s associated with schizophrenia risk confers a fitness advantage in unaffected individuals.<ref>{{Cite journal |vauthors= Bundy H, Stahl D, MacCabe JH |date=February 2011 |title=A systematic review and meta-analysis of the fertility of patients with schizophrenia and their unaffected relatives: Fertility in schizophrenia |journal=Acta Psychiatrica Scandinavica |volume=123 |issue=2 |pages=98–106 |doi= 10.1111/j.1600-0447.2010.01623.x|pmid=20958271 |s2cid=45179016 }}</ref><ref>{{Cite journal |vauthors= van Dongen J, Boomsma DI |date=March 2013 |title=The evolutionary paradox and the missing heritability of schizophrenia |journal=American Journal of Medical Genetics Part B: Neuropsychiatric Genetics |volume=162 |issue=2 |pages=122–136 |doi= 10.1002/ajmg.b.32135|pmid=23355297 |s2cid=9648115 }}</ref> While some evidence has not supported this idea,<ref name=Torrey2019/> others propose that a large number of alleles each contributing a small amount can persist.<ref>{{cite journal |vauthors= Owen MJ, Sawa A, Mortensen PB |title=Schizophrenia |journal=Lancet |date=2 July 2016 |volume=388 |issue=10039 |pages=86–97 |doi=10.1016/S0140-6736(15)01121-6 |pmid= 26777917|pmc=4940219}}</ref> | |||
Additional criteria are also given that exclude the diagnosis; thus schizophrenia cannot be diagnosed if symptoms of ] or ] are present, or the symptoms are the direct result of a substance (e.g., abuse of a drug/medication) or a general medical condition. | |||
A meta-analysis found that oxidative ] was significantly increased in schizophrenia.<ref name = Goh2021>{{cite journal |vauthors=Goh XX, Tang PY, Tee SF |title= 8-Hydroxy-2'-Deoxyguanosine and Reactive Oxygen Species as Biomarkers of Oxidative Stress in Mental Illnesses: A Meta-Analysis |journal= Psychiatry Investig |volume=18 |issue=7 |pages=603–618 |date=July 2021 |pmid=34340273 |pmc=8328836 |doi=10.30773/pi.2020.0417 |type= Meta-analysis}}</ref> | |||
===Subtypes=== | |||
Historically, schizophrenia in the ] was classified into simple, ], hebephrenic (now known as ]), and paranoid. The ] contains five sub-classifications of schizophrenia: | |||
===Environmental=== | |||
* ]: where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent (DSM code 295.3/ICD code F20.0) | |||
{{Further|Prenatal nutrition|Prenatal stress|Neuroplastic effects of pollution}} | |||
* ]: named 'hebephrenic schizophrenia' in the ICD. Where thought disorder and flat affect are present together (DSM code 295.1/ICD code F20.1) | |||
* ]: prominent psychomotor disturbances are evident. Symptoms can include catatonic stupor and ] (DSM code 295.2/ICD code F20.2) | |||
* '''undifferentiated type''': psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met (DSM code 295.9/ICD code F20.3) | |||
* '''residual type''': where positive symptoms are present at a low intensity only (DSM code 295.6/ICD code F20.5) | |||
Environmental factors, each associated with a slight risk of developing schizophrenia in later life include ], infection, ], and malnutrition in the mother during prenatal development.<ref name=Stilo2019>{{cite journal |vauthors=Stilo SA, Murray RM |title=Non-Genetic Factors in Schizophrenia |journal=Current Psychiatry Reports |volume=21 |issue=10 |page=100 |date=14 September 2019 |pmid=31522306 |doi=10.1007/s11920-019-1091-3 |pmc=6745031 }}</ref> A risk is associated with maternal obesity, in increasing ], and dysregulating the dopamine and serotonin pathways.<ref>{{cite journal |vauthors=Cirulli F, Musillo C, Berry A |s2cid=211029692 |title=Maternal Obesity as a Risk Factor for Brain Development and Mental Health in the Offspring |journal=Neuroscience|date= 5 February 2020 |volume=447 |pages=122–135 |pmid=32032668|doi= 10.1016/j.neuroscience.2020.01.023|hdl=11573/1387747 |hdl-access=free }}</ref> Both maternal stress and infection have been demonstrated to alter fetal ] through an increase of pro-inflammatory ]s.<ref name=Upthegrove2020>{{cite journal |vauthors=Upthegrove R, Khandaker GM |title=Cytokines, Oxidative Stress and Cellular Markers of Inflammation in Schizophrenia |journal=Current Topics in Behavioral Neurosciences |volume=44 |pages=49–66 |date=2020 |pmid=31115797 |doi= 10.1007/7854_2018_88|isbn=978-3-030-39140-9 |s2cid=162169817 |url= http://pure-oai.bham.ac.uk/ws/files/74984176/Upthegrove_Khandaker_Cytokines_oxidative_stress_and_cellular_markers_of_inflammation_in_schizophrenia_Current_Topics_in_Behavioral_Neurosciences_2019.pdf }}</ref> There is a slighter risk associated with being born in the winter or spring possibly due to ]<ref name=Chiang2016>{{cite journal |vauthors=Chiang M, Natarajan R, Fan X |s2cid= 206926835 |title=Vitamin D in schizophrenia: a clinical review |journal= Evidence-Based Mental Health |volume=19 |issue=1 |pages=6–9 |date= February 2016 |pmid=26767392 |doi=10.1136/eb-2015-102117 |pmc=10699337 }}</ref> or a prenatal ].<ref name=BMJ07/> Other infections during pregnancy or around the time of birth that have been linked to an increased risk include infections by '']'' and '']''.<ref>{{cite journal | vauthors = Arias I, Sorlozano A, Villegas E, de Dios Luna J, McKenney K, Cervilla J, Gutierrez B, Gutierrez J | title = Infectious agents associated with schizophrenia: a meta-analysis | journal = Schizophrenia Research | volume = 136 | issue = 1–3 | pages = 128–136 | date = April 2012 | pmid = 22104141 | doi = 10.1016/j.schres.2011.10.026 | hdl-access = free | s2cid = 2687441 | hdl = 10481/90076 }}</ref> The increased risk is about five to eight percent.<ref name=yolken>{{cite journal | vauthors = Yolken R | title = Viruses and schizophrenia: a focus on herpes simplex virus | journal = Herpes | volume = 11 | issue = Suppl 2 | pages = 83A–88A | date = June 2004 | pmid = 15319094 }}</ref> Viral infections of the brain during childhood are also linked to a risk of schizophrenia during adulthood.<ref>{{cite journal | vauthors = Khandaker GM | title = Childhood infection and adult schizophrenia: a meta-analysis of population-based studies. | journal = Schizophr. Res. | volume = 139 | issue = 1–3 | pages = 161–168 |date = August 2012 | pmid = 22704639 | pmc = 3485564 | doi = 10.1016/j.schres.2012.05.023}}</ref> ] is also associated with an increased risk of broadly defined schizophrenia-related disorders, with an ] of 2.4.<ref>{{cite journal | title = Cat Ownership and Schizophrenia-Related Disorders and Psychotic-Like Experiences: A Systematic Review and Meta-Analysis | journal = Schizophrenia Bulletin | volume = 50 | issue = 3 | pages = 489–495 | date = May 2024 | pmid = 38491934 | pmc = 11059805 | doi = 10.1093/schbul/sbad168 | vauthors = McGrath JJ, Lim CC, Saha S }}</ref> | |||
The ICD-10 recognises a further two subtypes: | |||
] (ACEs), severe forms of which are classed as ], range from being bullied or abused, to the death of a parent.<ref name=Pearce2019>{{cite journal |vauthors=Pearce J, Murray C, Larkin W |title=Childhood adversity and trauma:experiences of professionals trained to routinely enquire about childhood adversity |journal=Heliyon |volume=5 |issue=7 |page=e01900 |date=July 2019 |pmid=31372522 |doi=10.1016/j.heliyon.2019.e01900|doi-access=free |pmc=6658729 |bibcode=2019Heliy...501900P }}</ref> Many adverse childhood experiences can cause ] and increase the risk of psychosis.<ref name=Pearce2019/><ref>{{cite journal | vauthors = Dvir Y, Denietolis B, Frazier JA | title = Childhood trauma and psychosis | journal = Child and Adolescent Psychiatric Clinics of North America | volume = 22 | issue = 4 | pages = 629–641 | date = October 2013 | pmid = 24012077 | doi = 10.1016/j.chc.2013.04.006 | s2cid = 40053289 }}</ref><ref>{{cite journal | vauthors = Misiak B, Krefft M, Bielawski T, Moustafa AA, Sąsiadek MM, Frydecka D | s2cid = 21614845 | title = Toward a unified theory of childhood trauma and psychosis: A comprehensive review of epidemiological, clinical, neuropsychological and biological findings | journal = Neuroscience and Biobehavioral Reviews | volume = 75 | pages = 393–406 | date = April 2017 | pmid = 28216171 | doi = 10.1016/j.neubiorev.2017.02.015 }}</ref> Chronic trauma, including ACEs, can promote lasting inflammatory dysregulation throughout the nervous system.<ref name=Nettis2020>{{cite journal | vauthors = Nettis MA, Pariante CM, Mondelli V | title = Early-Life Adversity, Systemic Inflammation and Comorbid Physical and Psychiatric Illnesses of Adult Life | journal = Current Topics in Behavioral Neurosciences | volume = 44 | pages = 207–225 | date = 2020 | pmid = 30895531 | doi = 10.1007/7854_2019_89 | isbn = 978-3-030-39140-9 | s2cid = 84842249 | url = https://kclpure.kcl.ac.uk/portal/en/publications/earlylife-adversity-systemic-inflammation-and-comorbid-physical-and-psychiatric-illnesses-of-adult-life(d2cdfc38-19e7-4918-80f1-5525e6ff45bf).html}}</ref> It is suggested that early stress may contribute to the development of schizophrenia through these alterations in the immune system.<ref name= Nettis2020/> Schizophrenia was the last diagnosis to benefit from the link made between ACEs and adult mental health outcomes.<ref>{{cite journal |vauthors=Guloksuz S, van Os J |title=The slow death of the concept of schizophrenia and the painful birth of the psychosis spectrum |journal=Psychological Medicine |volume=48 |issue=2 |pages=229–244 |date=January 2018 |pmid=28689498 |doi=10.1017/S0033291717001775|doi-access=free }}</ref> | |||
* '''post-schizophrenic depression''': a depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present (ICD code F20.4) | |||
* '''simple schizophrenia''': insidious but progressive development of prominent negative symptoms with no history of psychotic episodes (ICD code F20.6) | |||
Living in an ] during childhood or as an adult has consistently been found to increase the risk of schizophrenia by a factor of two,<ref name= Lancet2009/><ref>{{cite journal |vauthors= Costa E, Silva JA, Steffen RE |title=Urban environment and psychiatric disorders: a review of the neuroscience and biology |journal=Metabolism: Clinical and Experimental |volume=100S |page=153940 |date=November 2019 |pmid=31610855|doi=10.1016/j.metabol.2019.07.004|s2cid=204704312 }}</ref> even after taking into account ], ], and size of ].<ref>{{cite journal | vauthors = van Os J | title = Does the urban environment cause psychosis? | journal = The British Journal of Psychiatry | volume = 184 | issue = 4 | pages = 287–8 | date = April 2004 | pmid = 15056569 | doi = 10.1192/bjp.184.4.287 | doi-access = free }}</ref> A possible link between the ] has been suggested to be the cause of the elevated risk of schizophrenia.<ref>{{cite journal |vauthors=Attademo L, Bernardini F, Garinella R, Compton MT |s2cid=25505446 |title= Environmental pollution and risk of psychotic disorders: A review of the science to date |journal=Schizophrenia Research |volume=181 |pages=55–59 |date=March 2017 |pmid=27720315 |doi=10.1016/j.schres.2016.10.003}}</ref> Other risk factors include ], immigration related to social adversity and racial discrimination, family dysfunction, unemployment, and poor housing conditions.<ref name=BMJ07/><ref>{{cite journal | vauthors = Selten JP, Cantor-Graae E, Kahn RS | s2cid = 21391349 | title = Migration and schizophrenia | journal = Current Opinion in Psychiatry | volume = 20 | issue = 2 | pages = 111–115 | date = March 2007 | pmid = 17278906 | doi = 10.1097/YCO.0b013e328017f68e }}</ref> Having a ], or parents younger than 20 years are also associated with schizophrenia.<ref name= Lancet2016 /><ref>{{cite journal | vauthors = Sharma R, Agarwal A, Rohra VK, Assidi M, Abu-Elmagd M, Turki RF | title = Effects of increased paternal age on sperm quality, reproductive outcome and associated epigenetic risks to offspring | journal = Reproductive Biology and Endocrinology | volume = 13 | pages = 35 | date = April 2015 | pmid = 25928123 | pmc = 4455614 | doi = 10.1186/s12958-015-0028-x | doi-access = free }}</ref> | |||
===Diagnostic issues and controversies=== | |||
Schizophrenia as a diagnostic entity has been criticised as lacking in scientific validity or reliability,<ref name="Bentall1992">Bentall RP (1992) ''Reconstructing Schizophrenia''. London: Routledge. ISBN 0415075246</ref><ref name="Boyle2002">Boyle M (2002) ''Schizophrenia: A Scientific Delusion?''. London: Routledge. ISBN 0415227186</ref> part of a larger ] of the validity of psychiatric diagnoses in general. One alternative suggests that the issues with the diagnosis would be better addressed as individual dimensions along which everyone varies, such that there is a spectrum or continuum rather than a cut-off between normal and ill. This approach appears consistent with research on ] and of a relatively high prevalence of psychotic experiences<ref name="fn_5">{{cite journal |author=Verdoux H |coauthors=van Os J |year=2002 |title=Psychotic symptoms in non-clinical populations and the continuum of psychosis |journal=] |volume=54 | issue=1-2 |pages=59-65 |pmid=11853979 |accessdate= 2008-02-24}}</ref><ref name="fn_65">{{cite journal |author=Johns LC |coauthors=van Os J |year=2001 |title=The continuity of psychotic experiences in the general population |journal=Clinical Psychology Review |volume=21 | issue=8 |pages=1125-41 |pmid=11702510 |accessdate= 2008-02-24}}</ref> and often non-distressing delusional beliefs<ref name="fn_67">{{cite journal |author=Peters ER |coauthors=Day S, McKenna J, Orbach G |year=2005 |title=Measuring delusional ideation: the 21-item Peters et al. Delusions Inventory (PDI) |journal=] |volume=30 |pages=1005-22 |pmid=15954204 |accessdate= 2008-02-24}}</ref> amongst the general public.<ref name="fn_65"/> | |||
====Substance use==== | |||
Another criticism is that the definitions used for criteria lack consistency;<ref name="David1999">{{cite journal |author=David AS |year=1999 |title=On the impossibility of defining delusions |journal=Philosophy, Psychiatry and Psychology |volume=6 | issue=1 |pages=17-20 |url=http://muse.jhu.edu/journals/philosophy_psychiatry_and_psychology/v006/6.1david.html |accessdate= 2008-02-24}}</ref> this is particularly relevant to the evaluation of ]s and ]. More recently, it has been argued that psychotic symptoms are not a good basis for making a diagnosis of schizophrenia as "psychosis is the 'fever' of mental illness — a serious but nonspecific indicator".<ref name="fn_6">{{cite journal |author=Tsuang MT |coauthors=Stone WS, Faraone SV |year=2000 |title=Toward reformulating the diagnosis of schizophrenia |journal=] |volume=157 | issue=7 |pages=1041-1050 |pmid=10873908 |accessdate= 2008-02-24}}</ref> | |||
{{Further|Risk factors of schizophrenia#Substance use|Substance-induced psychosis}} | |||
About half of those with schizophrenia use ] including ], tobacco, and ] excessively.<ref name=Gregg2007/><ref>{{cite journal | vauthors = Sagud M, Mihaljević-Peles A, Mück-Seler D, Pivac N, Vuksan-Cusa B, Brataljenović T, Jakovljević M | title = Smoking and schizophrenia | journal = Psychiatria Danubina | volume = 21 | issue = 3 | pages = 371–375 | date = September 2009 | pmid = 19794359 }}</ref> Use of ]s such as ] and ] can lead to a temporary ], which presents very similarly to schizophrenia. Rarely, alcohol use can also result in a similar ].<ref name= BMJ07/><ref name=alcohol>{{Cite journal |url= http://www.emedicine.com/med/topic3113.htm |title=Alcohol-Related Psychosis |access-date=27 September 2006 | vauthors = Larson M |date=30 March 2006 |journal=EMedicine |url-status=live |archive-url= https://web.archive.org/web/20081109011819/http://www.emedicine.com/MED/topic3113.htm |archive-date=9 November 2008}}</ref> Drugs may also be used as coping mechanisms by people who have schizophrenia, to deal with depression, ], boredom, and ].<ref name=Gregg2007>{{cite journal | vauthors = Gregg L, Barrowclough C, Haddock G | title = Reasons for increased substance use in psychosis | journal = Clinical Psychology Review | volume = 27 | issue = 4 | pages = 494–510 | date = May 2007 | pmid = 17240501 | doi = 10.1016/j.cpr.2006.09.004 }}</ref><ref name=Leweke08>{{cite journal | vauthors = Leweke FM, Koethe D | title = Cannabis and psychiatric disorders: it is not only addiction | journal = Addiction Biology | volume = 13 | issue = 2 | pages = 264–75 | date = June 2008 | pmid = 18482435 | doi = 10.1111/j.1369-1600.2008.00106.x | s2cid = 205400285 }}</ref> The use of cannabis and tobacco are not associated with the development of cognitive deficits, and sometimes a reverse relationship is found where their use improves these symptoms.<ref name=Vidailhet2013>{{cite journal | vauthors = Vidailhet P | title = . | journal = L'Encéphale | date = September 2013 | volume = 39 | issue = Suppl 2 | language= fr| pages = S83-92 | doi = 10.1016/S0013-7006(13)70101-5 | pmid=24084427}}</ref> However, ]s are associated with an increased risk of suicide, and a poor response to treatment.<ref name= Khokhar2018>{{cite book |vauthors=Khokhar JY, Henricks AM, Sullivan ED, Green AI |title=Apprentices to Genius: A tribute to Solomon H. Snyder |chapter=Unique Effects of Clozapine: A Pharmacological Perspective |series=Advances in Pharmacology |volume=82 |pages=137–162 |date=2018 |pmid=29413518|doi=10.1016/bs.apha.2017.09.009|pmc=7197512 |isbn=978-0128140871 }}</ref><ref>{{cite journal |vauthors=Bighelli I, Rodolico A, García-Mieres H, et al |title=Psychosocial and psychological interventions for relapse prevention in schizophrenia: a systematic review and network meta-analysis |journal=Lancet Psychiatry |volume=8 |issue=11 |pages=969–980 |date=November 2021 |pmid=34653393 |doi=10.1016/S2215-0366(21)00243-1 |s2cid=239003358 |doi-access=free |url=https://boris.unibe.ch/160225/8/Bighelli_LancetPsychiatry_2021.pdf }}</ref> | |||
Perhaps because of these factors, studies examining the ] of schizophrenia have typically shown relatively low or inconsistent levels of diagnostic reliability. Most famously, ] 1972 study, published as '']'', demonstrated that the diagnosis of schizophrenia was (at least at the time) often subjective and unreliable.<ref>{{cite journal |author=Rosenhan D |url=http://www.stanford.edu/~kocabas/onbeingsane.pdf |year=1973 |title=On being sane in insane places |journal=] |volume=179 |pages=250-8 |pmid=4683124 |accessdate= 2008-02-24}}</ref> More recent studies have found agreement between any two psychiatrists when diagnosing schizophrenia tends to reach about 65% at best.<ref name="fn_7">{{cite journal |author=McGorry PD |coauthors=Mihalopoulos C, Henry L, Dakis J, Jackson HJ, Flaum M, Harrigan S, McKenzie D, Kulkarni J, Karoly R |year=1995 |title=Spurious precision: procedural validity of diagnostic assessment in psychotic disorders |journal=] |volume=152 | issue=2 |pages=220-3 |pmid=7840355 |accessdate= 2008-02-24}}</ref> This, and the results of earlier studies of diagnostic reliability (which typically reported even lower levels of agreement) have led some critics to argue that the diagnosis of schizophrenia should be abandoned.<ref name="fn_8">Read J (2004) Does 'schizophrenia' exist? Reliability and validity. In Read J, Mosher LR, Bentall RP (eds) ''Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia''. ISBN 1-58391-906-6</ref> | |||
] may be a contributory factor in the development of schizophrenia, potentially increasing the risk of the disease in those who are already at risk.<ref name= Patel2020>{{cite journal |vauthors=Patel S, Khan S, M S, Hamid P |title=The Association Between Cannabis Use and Schizophrenia: Causative or Curative? A Systematic Review |journal= ] |volume=12 |issue=7 |pages=e9309 |date=July 2020 |pmid=32839678 |pmc=7442038 |doi=10.7759/cureus.9309 |doi-access=free |url=}}</ref><ref name= Hasan2020>{{cite journal |vauthors=Hasan A, von Keller R, Friemel CM, Hall W, Schneider M, Koethe D, Leweke FM, Strube W, Hoch E |title=Cannabis use and psychosis: a review of reviews |journal=Eur Arch Psychiatry Clin Neurosci |volume=270 |issue=4 |pages= 403–412 |date=June 2020 |pmid=31563981 |doi=10.1007/s00406-019-01068-z |s2cid=203567900 |url=}}</ref><ref>{{cite web |title=Causes — Schizophrenia | url= https://www.nhs.uk/mental-health/conditions/schizophrenia/causes/ |publisher= UK ] |date=11 November 2019 |access-date= 8 December 2021}}</ref> The increased risk may require the presence of certain genes within an individual.<ref name= Parakh2013>{{cite journal | vauthors = Parakh P, Basu D | title = Cannabis and psychosis: have we found the missing links? | journal = ] | volume = 6 | issue = 4 | pages = 281–287 | date = August 2013 | pmid = 23810133 | doi = 10.1016/j.ajp.2013.03.012 | type = Review | quote = Cannabis acts as a component cause of psychosis, that is, it increases the risk of psychosis in people with certain genetic or environmental vulnerabilities, though by itself, it is neither a sufficient nor a necessary cause of psychosis. }}</ref> Its use is associated with doubling the rate.<ref>{{cite journal | vauthors = Ortiz-Medina MB, Perea M, Torales J, Ventriglio A, Vitrani G, Aguilar L, Roncero C | title = Cannabis consumption and psychosis or schizophrenia development | journal = The International Journal of Social Psychiatry | volume = 64 | issue = 7 | pages = 690–704 | date = November 2018 | pmid = 30442059 | doi = 10.1177/0020764018801690 | s2cid = 53563635 }}</ref> | |||
In 2004 in Japan, the Japanese term for schizophrenia was changed from ''Seishin-Bunretsu-Byo'' (mind-split-disease) to ''Tōgō-shitchō-shō'' (]).<ref name="Sato">{{cite journal |author=Sato M |year=2004 |title=Renaming schizophrenia: a Japanese perspective |journal=World Psychiatry |volume=5 | issue=1 |pages=53-5 |pmid=16757998 |accessdate= 2008-02-24}}</ref> In 2006, campaigners in the UK, under the banner of Campaign for Abolition of the Schizophrenia Label, argued for a similar rejection of the diagnosis of schizophrenia and a different approach to the treatment and understanding of the symptoms currently associated with it.<ref name="schizophrenia_invalid"> BBC News Online, (] ]). Retrieved on ]. </ref> | |||
==Causes== | |||
Alternatively, other proponents have put forward using the presence of specific ]s to make a diagnosis. These take the form of a reduction or impairment in basic psychological functions such as ], ], ] and ]. It is these sorts of difficulties, rather than the psychotic symptoms (which can in many cases be controlled by ] medication), which seem to be the cause of most ] in schizophrenia. However, this argument is relatively new and it is unlikely that the method of diagnosing schizophrenia will change radically in the near future.<ref name="GreenSchizophreniaBook">Green MF (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0393703347</ref> | |||
{{Main|Causes of schizophrenia}}{{See also|Aberrant salience}} | |||
The causes of schizophrenia are still unknown. Several models have been put forward to explain the link between altered brain function and schizophrenia.<ref name=Lancet2009/> The prevailing model of schizophrenia is that of a neurodevelopmental disorder, and the underlying changes that occur before symptoms become evident are seen as arising from the ].<ref>{{cite journal |vauthors=Hayes D, Kyriakopoulos M |title=Dilemmas in the treatment of early-onset first-episode psychosis |journal=Therapeutic Advances in Psychopharmacology |volume=8 |issue=8 |pages=231–239 |date=August 2018 |pmid=30065814 |doi=10.1177/2045125318765725|pmc=6058451 |doi-access= free }}</ref> Extensive studies support this model.<ref name=George2017/> Maternal infections, malnutrition and ] and ] are known risk factors for the development of schizophrenia, which usually emerges between the ages of 18 and 25, a period that overlaps with certain stages of neurodevelopment.<ref>{{cite journal |vauthors=Cannon TD |title=How Schizophrenia Develops: Cognitive and Brain Mechanisms Underlying Onset of Psychosis |journal=Trends Cogn Sci |volume=19 |issue=12 |pages=744–756 |date= December 2015 |pmid=26493362 |pmc=4673025 |doi=10.1016/j.tics.2015.09.009 }}</ref> Gene-environment interactions lead to deficits in the ]ry that affect sensory and cognitive functions.<ref name=George2017/> | |||
The common dopamine and glutamate models proposed are not mutually exclusive; each is seen to have a role in the neurobiology of schizophrenia.<ref>{{cite journal |vauthors=Correll CU, Schooler NR |title=Negative Symptoms in Schizophrenia: A Review and Clinical Guide for Recognition, Assessment, and Treatment |journal= Neuropsychiatric Disease and Treatment |volume=16 |pages=519–534 |date=2020 |pmid=32110026 |doi=10.2147/NDT.S225643 |pmc=7041437 |doi-access=free }}</ref> The most common model put forward was the ], which attributes psychosis to the mind's faulty interpretation of the misfiring of ].<ref>{{cite journal | vauthors = Howes OD | title = The Role of Genes, Stress, and Dopamine in the Development of Schizophrenia | journal = Biological Psychiatry | date = 1 January 2017 | volume = 81 | issue = 1 | pages = 9–20 | doi = 10.1016/j.biopsych.2016.07.014 | pmid = 27720198| pmc = 5675052 }}</ref> This has been directly related to the symptoms of delusions and hallucinations.<ref>{{cite journal|vauthors=Broyd A, Balzan RP, Woodward TS, Allen P|date=June 2017|title=Dopamine, cognitive biases and assessment of certainty: A neurocognitive model of delusions| url= https://kclpure.kcl.ac.uk/portal/en/publications/dopamine-cognitive-biases-and-assessment-of-certainty-a-neurocognitive-model-of-delusions(138513dd-3a44-4deb-bac1-be45767ef51b).html|journal=Clinical Psychology Review|volume=54|pages=96–106|doi= 10.1016/j.cpr.2017.04.006 |pmid= 28448827|s2cid=3729566 }}</ref><ref name=Lancet2014>{{cite journal | vauthors = Howes OD, Murray RM | title = Schizophrenia: an integrated sociodevelopmental-cognitive model | journal = Lancet | volume = 383 | issue = 9929 | pages = 1677–1687 | date = May 2014 | pmid = 24315522 | pmc = 4127444 | doi = 10.1016/S0140-6736(13)62036-X }}</ref><ref>{{cite journal | vauthors = Grace AA | title = Dysregulation of the dopamine system in the pathophysiology of schizophrenia and depression | journal = Nature Reviews. Neuroscience | volume = 17 | issue = 8 | pages = 524–532 | date = August 2016 | pmid = 27256556 | pmc = 5166560 | doi = 10.1038/nrn.2016.57 }}</ref> Abnormal dopamine signaling has been implicated in schizophrenia based on the usefulness of medications that affect the dopamine receptor and the observation that dopamine levels are increased during acute psychosis.<ref>{{cite journal | vauthors = Fusar-Poli P, Meyer-Lindenberg A | title = Striatal presynaptic dopamine in schizophrenia, part II: meta-analysis of -DOPA PET studies | journal = Schizophrenia Bulletin | volume = 39 | issue = 1 | pages = 33–42 | date = January 2013 | pmid = 22282454 | pmc = 3523905 | doi = 10.1093/schbul/sbr180 }}</ref><ref>{{cite journal | vauthors = Howes OD, Kambeitz J, Kim E, Stahl D, Slifstein M, Abi-Dargham A, Kapur S | title = The nature of dopamine dysfunction in schizophrenia and what this means for treatment | journal = Archives of General Psychiatry | volume = 69 | issue = 8 | pages = 776–786 | date = August 2012 | pmid = 22474070 | pmc = 3730746 | doi = 10.1001/archgenpsychiatry.2012.169 }}</ref> A decrease in ] in the ] may also be responsible for deficits in ].<ref>{{cite journal | vauthors = Arnsten AF, Girgis RR, Gray DL, Mailman RB | title = Novel Dopamine Therapeutics for Cognitive Deficits in Schizophrenia | journal = Biological Psychiatry | volume = 81 | issue = 1 | pages = 67–77 | date = January 2017 | pmid = 26946382 | pmc = 4949134 | doi = 10.1016/j.biopsych.2015.12.028 }}</ref><ref>{{cite journal | vauthors = Maia TV, Frank MJ | title = An Integrative Perspective on the Role of Dopamine in Schizophrenia | journal = Biological Psychiatry | volume = 81 | issue = 1 | pages = 52–66 | date = January 2017 | pmid = 27452791 | pmc = 5486232 | doi = 10.1016/j.biopsych.2016.05.021 }}</ref> | |||
The diagnosis of schizophrenia has been used for political rather than therapeutic purposes; in the ] an additional sub-classification of ] was created. Particularly in the ] (Russian Soviet Federated Socialist Republic), this diagnosis was used for the purpose of silencing political dissidents or forcing them to recant their ideas by the use of forcible confinement and treatment.<ref name="Wilkinson1986">{{cite journal |author=Wilkinson G |year=1986 |title=Political dissent and "sluggish" schizophrenia in the Soviet Union |journal=] |volume=293 | issue=6548 |pages=641-2 |pmid=3092963 |accessdate= 2008-02-24}}</ref> In 2000 there were similar concerns regarding ] of practitioners of the ] movement by the Chinese government. This led the ] ''Committee on the Abuse of Psychiatry and Psychiatrists'' to pass a resolution to urge the ] to investigate the situation in ].<ref name="Lyons2001">{{cite journal |author=Lyons D |year=2001 |title=Soviet-style psychiatry is alive and well in the People's Republic |journal=] |volume=178 |pages=380-381 |pmid=11282823 |accessdate= 2008-02-24}}</ref> | |||
The ] links alterations between ] and the ]s that affect ].<ref name=Pratt2017/> Studies have shown that a reduced expression of a ] – ], and glutamate blocking drugs such as ] and ] can mimic the symptoms and cognitive problems associated with schizophrenia.<ref name=Pratt2017>{{cite journal | vauthors = Pratt J, Dawson N, Morris BJ, Grent-'t-Jong T, Roux F, Uhlhaas PJ | title = Thalamo-cortical communication, glutamatergic neurotransmission and neural oscillations: A unique window into the origins of ScZ? | journal = Schizophrenia Research | volume = 180 | pages = 4–12 | date = February 2017 | pmid = 27317361 | doi = 10.1016/j.schres.2016.05.013 | s2cid = 205075178 | url = https://eprints.gla.ac.uk/132874/1/132874.pdf }}</ref><ref>{{cite journal | vauthors = Catts VS, Lai YL, Weickert CS, Weickert TW, Catts SV | title = A quantitative review of the post-mortem evidence for decreased cortical N-methyl-D-aspartate receptor expression levels in schizophrenia: How can we link molecular abnormalities to mismatch negativity deficits? | journal = Biological Psychology | volume = 116 | pages = 57–67 | date = April 2016 | pmid = 26549579 | doi = 10.1016/j.biopsycho.2015.10.013 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Michie PT, Malmierca MS, Harms L, Todd J | s2cid = 41179430 | title = The neurobiology of MMN and implications for schizophrenia | journal = Biological Psychology | volume = 116 | pages = 90–97 | date = April 2016 | pmid = 26826620 | doi = 10.1016/j.biopsycho.2016.01.011 }}</ref> Post-mortem studies consistently find that a subset of these neurons fail to express ] (]),<ref name = Marin2012>{{cite journal | vauthors = Marín O | s2cid = 205507186 | title = Interneuron dysfunction in psychiatric disorders | journal = Nature Reviews. Neuroscience | volume = 13 | issue = 2 | pages = 107–120 | date = January 2012 | pmid = 22251963 | doi = 10.1038/nrn3155 }}</ref> in addition to abnormalities in ]. The subsets of interneurons that are abnormal in schizophrenia are responsible for the synchronizing of neural ensembles needed during working memory tasks. These give the neural oscillations produced as ]s that have a frequency of between 30 and 80 ]. Both working memory tasks and gamma waves are impaired in schizophrenia, which may reflect abnormal interneuron functionality.<ref name = Marin2012 /><ref>{{cite journal | vauthors = Lewis DA, Hashimoto T, Volk DW | s2cid = 3335493 | title = Cortical inhibitory neurons and schizophrenia | journal = Nature Reviews. Neuroscience | volume = 6 | issue = 4 | pages = 312–324 | date = April 2005 | pmid = 15803162 | doi = 10.1038/nrn1648 }}</ref><ref>{{cite journal | vauthors = Senkowski D, Gallinat J | s2cid = 206104940 | title = Dysfunctional prefrontal gamma-band oscillations reflect working memory and other cognitive deficits in schizophrenia | journal = Biological Psychiatry | volume = 77 | issue = 12 | pages = 1010–1019 | date = June 2015 | pmid = 25847179 | doi = 10.1016/j.biopsych.2015.02.034 |quote=Several studies that investigated perceptual processes found impaired GBR in ScZ patients over sensory areas, such as the auditory and visual cortex. Moreover, studies examining steady-state auditory-evoked potentials showed deficits in the gen- eration of oscillations in the gamma band.}}</ref><ref>{{cite journal | vauthors = Reilly TJ, Nottage JF, Studerus E, Rutigliano G, Micheli AI, Fusar-Poli P, McGuire P | title = Gamma band oscillations in the early phase of psychosis: A systematic review | journal = Neuroscience and Biobehavioral Reviews | volume = 90 | pages = 381–399 | date = July 2018 | pmid = 29656029 | doi = 10.1016/j.neubiorev.2018.04.006 | quote = Decreased gamma power in response to a task was a relatively consistent finding, with 5 out of 6 studies reported reduced evoked or induced power. | s2cid = 4891072 | url = https://kclpure.kcl.ac.uk/portal/en/publications/e2f500b7-f358-433d-9f9c-7f6b9c52bb2f }}</ref> An important process that may be disrupted in neurodevelopment is astrogenesis – the formation of ]s. Astrocytes are crucial in contributing to the formation and maintenance of neural circuits and it is believed that disruption in this role can result in a number of neurodevelopmental disorders including schizophrenia.<ref name=Sloan2014>{{cite journal |vauthors=Sloan SA, Barres BA |title=Mechanisms of astrocyte development and their contributions to neurodevelopmental disorders |journal=Curr Opin Neurobiol |volume=27 |pages=75–81 |date=August 2014 |pmid=24694749 |pmc=4433289 |doi=10.1016/j.conb.2014.03.005 }}</ref> Evidence suggests that reduced numbers of astrocytes in deeper cortical layers are assocociated with a diminished expression of ], a ] in astrocytes; supporting the glutamate hypothesis.<ref name=Sloan2014/> | |||
==Epidemiology== | |||
Schizophrenia occurs equally in males and females although typically appears earlier in men with the peak ages of onset being 20–28 years for males and 26–32 years for females.<ref name="castle1991" /> Much rarer are instances of childhood-onset<ref name="Kumra_et_al_2001">{{cite journal |author=Kumra S |coauthors=Shaw M, Merka P, Nakayama E, Augustin R |year=2001 |title=Childhood-onset schizophrenia: research update |journal=Canadian Journal of Psychiatry |volume=46 | issue=10 |pages=923-30 |pmid=11816313 |accessdate= 2008-02-24}}</ref> and late- (middle age) or very-late-onset (old age) schizophrenia.<ref name="Howard_2005">Hassett A, Ames D, Chiu E (eds) (2005) Psychosis in the Elderly. London: Taylor and Francis. ISBN 18418439446</ref> The ] of schizophrenia, that is, the proportion of individuals expected to experience the disease at any time in their lives, is commonly given at 1%. A 2002 ] of many studies, however, found a lifetime prevalence of 0.55%.<ref name="fn_34" /> Despite the received wisdom that schizophrenia occurs at similar rates throughout the world, its prevalence varies across the world,<ref name="Jablensky_et_al_1992">{{cite journal |author=Jablensky A |coauthors=Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE, Day R, Bertelsen A |year=1992 |title=Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study |journal=Psychological Medicine Monograph Supplement |volume=20 |pages=1-97 |pmid=1565705 |accessdate= 2008-02-24}}</ref> within countries,<ref name="Kirkbride_et_al_2006">{{cite journal |author=Kirkbride JB |coauthors=Fearon P, Morgan C, Dazzan P, Morgan K, Tarrant J, Lloyd T, Holloway J, Hutchinson G, Leff JP, Mallett RM, Harrison GL, Murray RM, Jones PB |year=2006 |title=Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings From the 3-center ÆSOP study |journal=] |volume=63 | issue=3 |pages=250-258 |pmid=16520429 |accessdate= 2008-02-24}}</ref> and at the local and neighbourhood level.<ref name="Kirkbride_et_al_2007">{{cite journal |author=Kirkbride JB |coauthors=Fearon P, Morgan C, Dazzan P, Morgan K, Murray RM, Jones PB |year=2007 |title=Neighbourhood variation in the incidence of psychotic disorders in Southeast London |journal=Social Psychiatry and Psychiatric Epidemiology |volume=42 | issue=6 |pages=438-45 |pmid=17473901 |accessdate= 2008-02-24}}</ref> One particularly stable and replicable finding has been the association between living in an ] environment and schizophrenia diagnosis, even after factors such as ], ] and size of ] have been controlled for.<ref name="fn_19">{{cite journal |author=Van Os J |year=2004 |title=Does the urban environment cause psychosis? |journal=] |volume=184 | issue=4 |pages=287-288 |pmid=15056569 |accessdate= 2008-02-24}}</ref> Schizophrenia is known to be a major cause of ]. In a 1999 study of 14 countries, active ] was ranked the third-most-disabling condition, after ] and ] and before ] and ].<ref name="fn_35">{{cite journal |author=Ustun TB |coauthors=Rehm J, Chatterji S, Saxena S, Trotter R, Room R, Bickenbach J, and the ]/] Joint Project CAR Study Group |year=1999 |title=Multiple-informant ranking of the disabling effects of different health conditions in 14 countries |journal=] |volume=354 | issue=9173 |pages=111-115 |pmid=10408486 |accessdate= 2008-02-24}}</ref> | |||
Deficits in ]s, such as planning, inhibition, and working memory, are pervasive in schizophrenia. Although these functions are separable, their dysfunction in schizophrenia may reflect an underlying deficit in the ability to represent goal related information in working memory, and to use this to direct cognition and behavior.<ref>{{cite journal | vauthors = Lesh TA, Niendam TA, Minzenberg MJ, Carter CS | title = Cognitive control deficits in schizophrenia: mechanisms and meaning |journal=Neuropsychopharmacology | volume = 36 | issue = 1 | pages = 316–338 | date = January 2011 | pmid = 20844478 |pmc = 3052853 |doi =10.1038/npp.2010.156 }}</ref><ref>{{cite journal | vauthors = Barch DM, Ceaser A | title = Cognition in schizophrenia: core psychological and neural mechanisms | journal = Trends in Cognitive Sciences | volume = 16 | issue = 1 | pages = 27–34 | date = January 2012 | pmid = 22169777 | pmc = 3860986 | doi = 10.1016/j.tics.2011.11.015 }}</ref> These impairments have been linked to a number of neuroimaging and neuropathological abnormalities. For example, functional neuroimaging studies report evidence of reduced neural processing efficiency, whereby the dorsolateral prefrontal cortex is activated to a greater degree to achieve a certain level of performance relative to controls on working memory tasks. These abnormalities may be linked to the consistent post-mortem finding of reduced ], evidenced by increased ] density and reduced ] density. These cellular and functional abnormalities may also be reflected in structural neuroimaging studies that find reduced ] volume in association with deficits in working memory tasks.<ref>{{cite journal | vauthors = Eisenberg DP, Berman KF | title = Executive function, neural circuitry, and genetic mechanisms in schizophrenia | journal = Neuropsychopharmacology | volume = 35 |issue = 1 | pages = 258–277 | date = January 2010 | pmid = 19693005 | pmc = 2794926 | doi = 10.1038/npp.2009.111}}</ref> | |||
==Causes== | |||
{{main|Causes of schizophrenia}} | |||
] study<ref name="fn_25">{{cite journal |author=Meyer-Lindenberg A |coauthors=Miletich RS, Kohn PD, Esposito G, Carson RE, Quarantelli M, Weinberger DR, Berman KF |year=2002 |title=Reduced prefrontal activity predicts exaggerated striatal dopaminergic function in schizophrenia |journal=] |volume=5 |pages=267-71 |pmid=11865311 |accessdate= 2008-02-24}}</ref> suggests that the less the ]s are activated (<font color="red">red</font>) during a ] task, the greater the increase in abnormal ] activity in the ] (<font color="green">green</font>), thought to be related to the ]s in schizophrenia.]] | |||
While the reliability of the diagnosis introduces difficulties in measuring the relative effect of genes and environment (for example, symptoms overlap to some extent with severe ] or ]), evidence suggests that genetic and ]s can act in combination to result in schizophrenia.<ref name="fn_12">{{cite journal |author=Harrison PJ |coauthors=Owen MJ |year=2003 |title=Genes for schizophrenia? Recent findings and their pathophysiological implications |journal=] |volume=361 | issue=9355 |pages=417-9 |pmid=12573388 |accessdate= 2008-02-24}}</ref> Evidence suggests that the diagnosis of schizophrenia has a significant heritable component but that onset is significantly influenced by environmental factors or stressors.<ref name="fn_15">{{cite journal |author=Day R |coauthors=Nielsen JA, Korten A, Ernberg G, Dube KC, Gebhart J, Jablensky A, Leon C, Marsella A, Olatawura M, et al. |year=1987 |title=Stressful life events preceding the acute onset of schizophrenia: a cross-national study from the World Health Organization |journal=Culture, Medicine and Psychiatry |volume=11 | issue=2 |pages=123-205 |pmid=3595169 |accessdate= 2008-02-24}}</ref> The idea of an inherent vulnerability (or ''diathesis'') in some people, which can be unmasked by biological, psychological or environmental stressors, is known as the stress-diathesis model.<ref name="Corcoran_et_al_2003">{{cite journal |author=Corcoran C |coauthors=Walker E, Huot R, Mittal V, Tessner K, Kestler L, Malaspina D |year=2003 |title=The stress cascade and schizophrenia: etiology and onset |journal=] |volume=29 | issue=4 |pages=671-92 |pmid=14989406 |accessdate= 2008-02-24}}</ref> The idea that biological, psychological and social factors are all important is known as the "biopsychosocial" model. | |||
Positive symptoms have been linked to cortical thinning in the ].<ref>{{cite journal | vauthors = Walton E, Hibar DP, van Erp TG, Potkin SG, Roiz-Santiañez R, Crespo-Facorro B, Suarez-Pinilla P, Van Haren NE, de Zwarte SM, Kahn RS, Cahn W, Doan NT, Jørgensen KN, Gurholt TP, Agartz I, Andreassen OA, Westlye LT, Melle I, Berg AO, Mørch-Johnsen L, Faerden A, Flyckt L, Fatouros-Bergman H, Jönsson EG, Hashimoto R, Yamamori H, Fukunaga M, Preda A, De Rossi P, Piras F, Banaj N, Ciullo V, Spalletta G, Gur RE, Gur RC, Wolf DH, Satterthwaite TD, Beard LM, Sommer IE, Koops S, Gruber O, Richter A, Krämer B, Kelly S, Donohoe G, McDonald C, Cannon DM, Corvin A, Gill M, Di Giorgio A, Bertolino A, Lawrie S, Nickson T, Whalley HC, Neilson E, Calhoun VD, Thompson PM, Turner JA, Ehrlich S | title = Positive symptoms associate with cortical thinning in the superior temporal gyrus via the ENIGMA Schizophrenia consortium | journal = Acta Psychiatrica Scandinavica | volume = 135 | issue = 5 | pages = 439–447 | date = May 2017 | pmid = 28369804 | pmc = 5399182 | doi = 10.1111/acps.12718 }}</ref> The severity of negative symptoms has been linked to reduced thickness in the left medial ].<ref>{{cite journal | vauthors = Walton E, Hibar DP, van Erp TG, Potkin SG, Roiz-Santiañez R, Crespo-Facorro B, Suarez-Pinilla P, van Haren NE, de Zwarte SM, Kahn RS, Cahn W, Doan NT, Jørgensen KN, Gurholt TP, Agartz I, Andreassen OA, Westlye LT, Melle I, Berg AO, Morch-Johnsen L, Færden A, Flyckt L, Fatouros-Bergman H, Jönsson EG, Hashimoto R, Yamamori H, Fukunaga M, Jahanshad N, De Rossi P, Piras F, Banaj N, Spalletta G, Gur RE, Gur RC, Wolf DH, Satterthwaite TD, Beard LM, Sommer IE, Koops S, Gruber O, Richter A, Krämer B, Kelly S, Donohoe G, McDonald C, Cannon DM, Corvin A, Gill M, Di Giorgio A, Bertolino A, Lawrie S, Nickson T, Whalley HC, Neilson E, Calhoun VD, Thompson PM, Turner JA, Ehrlich S | title = Prefrontal cortical thinning links to negative symptoms in schizophrenia via the ENIGMA consortium | journal = Psychological Medicine | volume = 48 | issue = 1 | pages = 82–94 | date = January 2018 | pmid = 28545597 | pmc = 5826665 | doi = 10.1017/S0033291717001283 | collaboration = Karolinska Schizophrenia Project Consortium (KaSP) }}</ref> Anhedonia, traditionally defined as a reduced capacity to experience pleasure, is frequently reported in schizophrenia. However, a large body of evidence suggests that ] are intact in schizophrenia,<ref>{{cite journal | vauthors = Cohen AS, Minor KS | title = Emotional experience in patients with schizophrenia revisited: meta-analysis of laboratory studies | journal = Schizophrenia Bulletin | volume = 36 | issue = 1 | pages = 143–150 | date = January 2010 | pmid = 18562345 | pmc = 2800132 | doi = 10.1093/schbul/sbn061 }}</ref> and that what is reported to be anhedonia is a reflection of dysfunction in other processes related to reward.<ref>{{cite journal | vauthors = Strauss GP, Gold JM | title = A new perspective on anhedonia in schizophrenia | journal = The American Journal of Psychiatry | volume = 169 | issue = 4 | pages = 364–373 | date = April 2012 | pmid = 22407079 | pmc = 3732829 | doi = 10.1176/appi.ajp.2011.11030447 }}</ref> Overall, a failure of reward prediction is thought to lead to impairment in the generation of cognition and behavior required to obtain rewards, despite normal hedonic responses.<ref>{{cite book | vauthors = Young J, Anticevic A, Barch D | veditors = Charney D, Buxbaum J, Sklar P, Nestler E |title=Charney & Nestler's Neurobiology of Mental Illness |date=2018 |publisher=Oxford University Press. |location=New York |isbn=9780190681425 |pages=215, 217 |edition=5th |chapter=Cognitive and Motivational Neuroscience of Psychotic Disorders |quote=Several recent reviews (e.g., Cohen and Minor, 2010) have found that individuals with schizophrenia show relatively intact self-reported emotional responses to affect-eliciting stimuli as well as other indicators of intact response(215)...Taken together, the literature increasingly suggests that there may be a deficit in putatively DA-mediated reward learning and/ or reward prediction functions in schizophrenia. Such findings suggest that impairment in striatal reward prediction mechanisms may influence "wanting" in schizophrenia in a way that reduces the ability of individuals with schizophrenia to use anticipated rewards to drive motivated behavior.(217)}}</ref> | |||
=== Genetic === | |||
Estimates of the ] of schizophrenia tend to vary owing to the difficulty of separating the effects of genetics and the environment although ] have suggested a high level of heritability.<ref name="ODonovan_et_al_2003">{{cite journal |author=O'Donovan MC |coauthors=Williams NM, Owen MJ |year=2003 |title=Recent advances in the genetics of schizophrenia |journal=] |volume=12 Spec No 2 |pages=R125-33 |pmid=12952866 |accessdate= 2008-02-24}}</ref> It is likely that schizophrenia is a condition of complex inheritance, with several ] possibly interacting to generate risk for schizophrenia or the separate components that can co-occur leading to a diagnosis.<ref name="fn_75">{{cite journal |author=Owen MJ |coauthors=Craddock N, O'Donovan MC |year=2005 |title=Schizophrenia: genes at last? |journal=] |volume=21 | issue=9 |pages=518-25 |pmid=16009449 |accessdate= 2008-02-24}}</ref> Recent work has suggested that genes that raise the risk for developing schizophrenia are non-specific, and may also raise the risk of developing other psychotic disorders such as ].<ref name="Craddock_et_al_2006">{{cite journal |author=Craddock N |coauthors=O'Donovan MC, Owen MJ |year=2006 |title=Genes for schizophrenia and bipolar disorder? Implications for psychiatric nosology|journal=] |volume=32 | issue=1 |pages=9-16 |pmid=16319375 |accessdate= 2008-02-24}}</ref><ref name="Dalby_et_al_1986">{{cite journal |author=Dalby JT |coauthors=Morgan D, Lee M |year=1986 |title=Schizophrenia and mania in identical twin brothers |journal=] |volume=174 |pages=304-308 |pmid=3701318 |accessdate= 2008-02-24}}</ref> | |||
Another theory links abnormal ] to the development of ] which is significantly more common in those with schizophrenia.<ref name=Wilberg2019>{{cite journal | vauthors = Wiberg A, Ng M, Al Omran Y, Alfaro-Almagro F, McCarthy P, Marchini J, Bennett DL, Smith S, Douaud G, Furniss D | title = Handedness, language areas and neuropsychiatric diseases: insights from brain imaging and genetics | journal = Brain | volume = 142 | issue = 10 | pages = 2938–2947 | date = October 2019 | pmid = 31504236 | pmc = 6763735 | doi = 10.1093/brain/awz257 }}</ref> This abnormal development of hemispheric asymmetry is noted in schizophrenia.<ref>{{cite book |vauthors=Tzourio-Mazoyer N, Kennedy H, Van Essen DC, Christen Y |title=Micro-, Meso- and Macro-Connectomics of the Brain |chapter=Intra- and Inter-hemispheric Connectivity Supporting Hemispheric Specialization |series=Research and Perspectives in Neurosciences |date=2016 |pages=129–146 |doi=10.1007/978-3-319-27777-6_9 |pmid=28590670|isbn=978-3-319-27776-9 |s2cid=147813648 }}</ref> Studies have concluded that the link is a true and verifiable effect that may reflect a genetic link between lateralization and schizophrenia.<ref name=Wilberg2019/><ref>{{cite journal | vauthors = Ocklenburg S, Güntürkün O, Hugdahl K, Hirnstein M | title = Laterality and mental disorders in the postgenomic age—A closer look at schizophrenia and language lateralization | journal = Neuroscience and Biobehavioral Reviews | volume = 59 | pages = 100–110 | date = December 2015 | pmid = 26598216 | doi = 10.1016/j.neubiorev.2015.08.019 | s2cid = 15983622 }}</ref> | |||
=== Prenatal === | |||
It is thought that causal factors can initially come together in early ], including during pregnancy, to increase the risk of later developing schizophrenia. One curious finding is that people diagnosed with schizophrenia are more likely to have been born in winter or spring, (at least in the ]).<ref name="fn_21">{{cite journal |author=Davies G |coauthors=Welham J, Chant D, Torrey EF, McGrath J |year=2003 |title=A ] and ] of ] season of birth studies in schizophrenia |journal=] |volume=29 | issue=3|pages=587-93 |pmid=14609251 |accessdate= 2008-02-24}}</ref> There is now evidence that ] exposure to infections increases the risk for developing schizophrenia later in life, providing additional evidence for a link between in utero developmental pathology and risk of developing the condition.<ref name="fn_73">{{cite journal |author=Brown AS |year=2006 |title=Prenatal infection as a risk factor for schizophrenia |journal=] |volume=32 | issue=2 |pages=200-2 |pmid=16469941 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/content/full/32/2/200 |accessdate= 2008-02-24}}</ref> | |||
] have been used to link abnormalities in cellular functioning to symptoms.<ref>{{cite journal | vauthors = Friston KJ, Stephan KE, Montague R, Dolan RJ | title = Computational psychiatry: the brain as a phantastic organ | journal = The Lancet. Psychiatry | volume = 1 | issue = 2 | pages = 148–158 | date = July 2014 | pmid = 26360579 | doi = 10.1016/S2215-0366(14)70275-5 | s2cid = 15504512 }}</ref><ref>{{cite journal | vauthors = Griffin JD, Fletcher PC | title = Predictive Processing, Source Monitoring, and Psychosis | journal = Annual Review of Clinical Psychology | volume = 13 | pages = 265–289 | date = May 2017 | pmid = 28375719 | pmc = 5424073 | doi = 10.1146/annurev-clinpsy-032816-045145}}</ref> Both hallucinations and delusions have been suggested to reflect improper encoding of ], thereby causing expectation to excessively influence sensory perception and the formation of beliefs. In approved models of ] that mediate ], reduced NMDA receptor activation, could in theory result in the positive symptoms of delusions and hallucinations.<ref>{{cite journal | vauthors = Fletcher PC, Frith CD | s2cid = 6219485 | title = Perceiving is believing: a Bayesian approach to explaining the positive symptoms of schizophrenia | journal = Nature Reviews. Neuroscience | volume = 10 | issue = 1 | pages = 48–58 | date = January 2009 | pmid = 19050712 | doi = 10.1038/nrn2536 | url = https://pure.au.dk/ws/files/48560345/fletcher_frithNRN.pdf }}</ref><ref>{{cite journal | vauthors = Corlett PR, Taylor JR, Wang XJ, Fletcher PC, Krystal JH | title = Toward a neurobiology of delusions | journal = Progress in Neurobiology | volume = 92 | issue = 3 | pages = 345–369 | date = November 2010 | pmid = 20558235 | pmc = 3676875 | doi = 10.1016/j.pneurobio.2010.06.007 }}</ref><ref>{{cite journal | vauthors = Bastos AM, Usrey WM, Adams RA, Mangun GR, Fries P, Friston KJ | title = Canonical microcircuits for predictive coding | journal = Neuron | volume = 76 | issue = 4 | pages = 695–711 | date = November 2012 | pmid = 23177956 | pmc = 3777738 | doi = 10.1016/j.neuron.2012.10.038 }}</ref> | |||
=== Social === | |||
Living in an ] environment has been consistently found to be a risk factor for schizophrenia.<ref name="vanOs_et_al_2005">{{cite journal |author=van Os J |coauthors=Krabbendam L, Myin-Germeys I, Delespaul P |year= 2005 |title=The schizophrenia envirome |journal=Current Opinion in Psychiatry |volume=18 | issue=2 |pages=141-5 |pmid=16639166 |accessdate= 2008-02-24}}</ref><ref name="fn_19" /> Social disadvantage has been found to be a risk factor, including poverty<ref>{{cite journal |author=Mueser KT & McGurk SR |year=2004 |title=Schizophrenia |journal=] |volume=363 |issue=9426 |pages=2063-72 |pmid=15207959 |accessdate= 2008-02-24}}</ref> and migration related to social adversity, racial discrimination, family dysfunction, unemployment or poor housing conditions.<ref name="Selten_et_al_2007">{{cite journal |author= |coauthors=Cantor-Graae E, Kahn RS |year=2007 |title=Migration and schizophrenia |journal=] |volume=20 |issue=2 |pages=111-5 |pmid=17278906 |accessdate= 2008-02-24}}</ref> Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life.<ref name="Schenkel_et_al_2005">{{cite journal |author=Schenkel LS |coauthors=Spaulding WD, Dilillo D, Silverstein SM |year=2005 |title=Histories of childhood maltreatment in schizophrenia: Relationships with premorbid functioning, symptomatology, and cognitive deficits |journal=] |volume=76 |issue=2-3 |pages=273-286 |pmid=15949659 |accessdate= 2008-02-24}}</ref><ref name="Janssen_et_al_2004">{{cite journal |author=Janssen |coauthors=Krabbendam L, Bak M, Hanssen M, Vollebergh W, de Graaf R, van Os J |year=2004 |title=Childhood abuse as a risk factor for psychotic experiences |journal=] |volume=109 |pages=38-45 |pmid=14674957 |accessdate= 2008-02-24}}</ref> Parenting is not held responsible for schizophrenia but unsupportive dysfunctional relationships may contribute to an increased risk.<ref name="Bentall_et_al_2007"/><ref>{{cite journal |author=Subotnik, KL |coauthors=Goldstein, MJ, Nuechterlein, KH, Woo, SM and Mintz, J |year=2002 |title=Are Communication Deviance and Expressed Emotion Related to Family History of Psychiatric Disorders in Schizophrenia? |journal=] |volume=28 |issue=4 |pages=719-29 |pmid=12795501 |accessdate= 2008-02-24}}</ref> | |||
==Diagnosis== | |||
=== Substance use === | |||
{{Main|Diagnosis of schizophrenia}} | |||
{{Seealso|dual diagnosis}} | |||
The relationship between schizophrenia and drug use is complex, meaning that a clear causal connection between drug use and schizophrenia has been difficult to distinguish. There is strong evidence that using certain drugs can trigger either the onset or relapse of schizophrenia in some people. It may also be the case, however, that people with schizophrenia use drugs to overcome negative feelings associated with both the commonly prescribed antipsychotic medication and the condition itself, where negative emotion, ] and ] are all considered to be core features.<ref name="Gregg_et_al_2007">{{cite journal |author=Gregg L |coauthors=Barrowclough C, Haddock G |year=2007 |title=Reasons for increased substance use in psychosis |journal=Clinical Psychology Review |volume=27 |issue=4 |pages=494-510 |pmid=17240501 |accessdate= 2008-02-24}}</ref> ]s trigger the release of dopamine and excessive dopamine function is believed to be responsible for many symptoms of schizophrenia (known as the ]), amphetamines may worsen schizophrenia symptoms.<ref name="Laruelle_et_al_1996">{{cite journal |author=Laruelle M |coauthors=Abi-Dargham A, van Dyck CH, Gil R, D'Souza CD, Erdos J, McCance E, Rosenblatt W, Fingado C, Zoghbi SS, Baldwin RM, Seibyl JP, Krystal JH, Charney DS, Innis RB |year=1996 |title=Single photon emission computerized tomography imaging of amphetamine-induced dopamine release in drug-free schizophrenic subjects |journal=Proceedings of the National Academy of Sciences of the USA |volume=93 |url=http://www.pnas.org/cgi/content/abstract/93/17/9235 |pages=9235-40 |pmid=8799184 |accessdate= 2008-02-24}}</ref> Schizophrenia can be triggered by heavy use of ] or stimulant drugs.<ref>{{cite journal |author=Mueser KT |coauthors=Yarnold PR, Levinson DF, Singh H, Bellack AS, Kee K, Morrison RL, Yadalam KG |year=1990 |title=Prevalence of substance abuse in schizophrenia: demographic and clinical correlates |journal=Schizophrenic Bulletin |volume=16 |issue=1 |pages=31-56 |pmid=2333480 |accessdate= 2008-02-24}}</ref> One study suggests that ] use can contribute to psychosis, though the researchers suspected cannabis use was only a small component in a broad range of factors that can cause psychosis.<ref name="fn_48">{{cite journal |author=Arseneault L |coauthors=Cannon M, Witton J, Murray RM |year=2004 |title=Causal association between cannabis and psychosis: examination of the evidence |journal=] |volume=184 |url=http://bjp.rcpsych.org/cgi/content/full/184/2/110 |pages=110-7 |pmid=14754822 |accessdate= 2008-02-24}}</ref> | |||
=== |
===Criteria=== | ||
Schizophrenia is diagnosed based on criteria in either the '']'' (DSM) published by the ] or the ] (ICD) published by the ] (WHO). These criteria use the self-reported experiences of the person and reported abnormalities in behavior, followed by a ]. The ] is an important part of the assessment.<ref>{{cite journal | vauthors = Soltan M, Girguis J | title = How to approach the mental state examination | url = https://www.bmj.com/content/357/sbmj.j1821 | journal = BMJ | volume = 357 | page = j1821 | access-date = 9 January 2020 | doi = 10.1136/sbmj.j1821 | pmid = 31055448 | date = 8 May 2017| s2cid = 145820368 }}</ref> An established tool for assessing the severity of positive and negative symptoms is the Positive and Negative Syndrome Scale (PANSS).<ref>{{cite journal | vauthors = Lindenmayer JP | title = Are Shorter Versions of the Positive and Negative Syndrome Scale (PANSS) Doable? A Critical Review. | journal = Innovations in Clinical Neuroscience | date = 1 December 2017 | volume = 14 | issue = 11–12 |pages=73–76 | pmid = 29410940| pmc = 5788254 }}</ref> This has been seen to have shortcomings relating to negative symptoms, and other scales – the ''Clinical Assessment Interview for Negative Symptoms'' (CAINS), and the ''Brief Negative Symptoms Scale'' (BNSS) have been introduced.<ref name=Marder2014/> The ], published in 2013, gives a ''Scale to Assess the Severity of Symptom Dimensions'' outlining eight dimensions of symptoms.<ref name=Biedermann2016/> | |||
A number of psychological mechanisms have been implicated in the development and maintenance of schizophrenia. ]es that have been identified in those with a diagnosis or those at risk, especially when under stress or in confusing situations, include excessive attention to potential threats, jumping to conclusions, making external ], impaired reasoning about social situations and ], difficulty distinguishing inner speech from speech from an external source, and difficulties with early visual processing and maintaining concentration.<ref>{{cite journal |author=Broome MR |coauthors=Woolley JB, Tabraham P, Johns LC, Bramon E, Murray GK, Pariante C, McGuire PK, Murray RM |year=2005 |title=What causes the onset of psychosis? |journal=] |volume=79 | issue=1 |pages=23-34 |pmid=16198238 |accessdate= 2008-02-26}}</ref><ref>{{cite journal |author= Lewis R|year=2004 |title=Should cognitive deficit be a diagnostic criterion for schizophrenia? |journal=] |volume=29 | issue=2 |pages=102-113 |pmid=15069464 |accessdate= 2008-02-26}}</ref><ref>{{cite journal |author=Brune M |coauthors=Abdel-Hamid M, Lehmkamper C, Sonntag C |year=2007 |title=Mental state attribution, neurocognitive functioning, and psychopathology: What predicts poor social competence in schizophrenia best? |journal=] |volume=92| issue=1-2 |pages=151-9 |pmid=17346931 |accessdate= 2008-02-26}}</ref><ref>{{cite journal |author=Sitskoorn MM |coauthors=Aleman A, Ebisch SJH, Appels MCM, Khan RS |year=2004 |title=Cognitive deficits in relatives of patients with schizophrenia: a meta-analysis |journal=] |volume=71 | issue=2 |pages=285-295 |pmid= 15474899 |accessdate= 2008-02-26}}</ref> Some cognitive features may reflect global ]s in ], ], ], ] or ], while others may be related to particular issues and experiences.<ref name="Kurtz_2005">{{cite journal |author=Kurtz MM |year=2005 |title=Neurocognitive impairment across the lifespan in schizophrenia: an update |journal=] |volume=74 | issue=1 |pages=15-26 |pmid=15694750 |accessdate= 2008-02-26}}</ref><ref name="Bentall_et_al_2007">{{cite journal |author=Bentall RP |coauthors=Fernyhough C, Morrison AP, Lewis S, Corcoran R |year=2007 |title=Prospects for a cognitive-developmental account of psychotic experiences |journal=Br J Clin Psychol |volume=46 | issue=Pt 2 |pages=155-73 |pmid=17524210 |accessdate= 2008-02-26}}</ref> Despite a common appearance of "blunted affect", recent findings indicate that many individuals diagnosed with schizophrenia are highly emotionally responsive, particularly to stressful or negative stimuli, and that such sensitivity may cause vulnerability to symptoms or to the disorder.<ref>{{cite journal |author=Cohen & Docherty |year=2004 |title=Affective reactivity of speech and emotional experience in patients with schizophrenia |journal=] |volume=69 | issue=1 |pages=7-14 |pmid=15145465 |accessdate= 2008-02-26}}</ref><ref>{{cite journal |author=Horan WP |coauthors=Blanchard JJ |year=2003 |title=Emotional responses to psychosocial stress in schizophrenia: the role of individual differences in affective traits and coping |journal=] |volume=60 | issue=2-3 |pages=271-83 |pmid=12591589 |accessdate= 2008-02-26}}</ref><ref>{{cite journal |author=Barrowclough C |coauthors=Tarrier N, Humphreys L, Ward J, Gregg L, Andrews B |year=2003 |title=Self-esteem in schizophrenia: relationships between self-evaluation, family attitudes, and symptomatology |journal=J Abnorm Psychol |volume=112 | issue=1 |pages=92-9 |pmid=12653417 |accessdate= 2008-02-26}}</ref> Some evidence suggests that the content of delusional beliefs and psychotic experiences can reflect emotional causes of the disorder, and that how a person interprets such experiences can influence symptomology.<ref>{{cite journal |author=Birchwood M |coauthors=Meaden A, Trower P, Gilbert P, Plaistow J |year=2000 |title=The power and omnipotence of voices: subordination and entrapment by voices and significant others |journal=Psychol Med |volume=30 | issue=2 |pages=337-44 |pmid=10824654 |accessdate= 2008-02-26}}</ref><ref>{{cite journal |author=Smith B |coauthors=Fowler DG, Freeman D, Bebbington P, Bashforth H, Garety P, Dunn G, Kuipers E |year=2006 |title=Emotion and psychosis: links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations |journal=] |volume=86 | issue=1-3 |pages=181-8 |pmid=16857346 |accessdate= 2008-02-26}}</ref><ref>{{cite journal |author=Beck, AT |year=2004 |title=A Cognitive Model of Schizophrenia |journal=Journal of Cognitive Psychotherapy |volume=18 | issue=3 |pages=281-88 |pmid= |accessdate= 2007-05-16}}</ref><ref>{{cite journal |author=Bell V |coauthors=Halligan PW, Ellis HD |year=2006 |title=Explaining delusions: a cognitive perspective |journal=] |volume=10 | issue=5 |pages=219-26 |pmid=16600666 |accessdate= 2008-02-26}}</ref> Further evidence for the role of psychological mechanisms comes from the effects of therapies on symptoms of schizophrenia.<ref>{{cite journal |author=Kuipers E |coauthors=Garety P, Fowler D, Freeman D, Dunn G, Bebbington P |year=2006 |title=Cognitive, emotional, and social processes in psychosis: refining cognitive behavioral therapy for persistent positive symptoms |journal=] |volume=32 | issue=Suppl 1 |pages=S24-31 |pmid=16885206 |accessdate= 2008-02-26}}</ref> | |||
DSM-5 states that to be diagnosed with schizophrenia, two diagnostic criteria have to be met over the period of one month, with a significant impact on social or occupational functioning for at least six months. One of the symptoms needs to be either delusions, hallucinations, or disorganized speech. A second symptom could be one of the negative symptoms, or severely disorganized or ].<ref name=DSM5/> A different diagnosis of ] can be made before the six months needed for the diagnosis of schizophrenia.<ref name=DSM5/> | |||
=== Neural === | |||
] and other ] technologies allow for the study of differences in brain activity among people diagnosed with schizophrenia.]] | |||
In Australia, the guideline for diagnosis is for six months or more with symptoms severe enough to affect ordinary functioning.<ref>{{cite web |title=Diagnosis of schizophrenia |url=https://www.healthdirect.gov.au/diagnosis-of-schizophrenia |publisher= Australian Department of Health |access-date=28 January 2020 |date=10 January 2019}}</ref> In the UK diagnosis is based on having the symptoms for most of the time for one month, with symptoms that significantly affect the ability to work, study, or carry on ordinary daily living, and with other similar conditions ruled out.<ref>{{cite web |title=Schizophrenia – Diagnosis |url=https://www.nhs.uk/conditions/schizophrenia/diagnosis/ |publisher= UK ] |access-date=28 January 2020 |date=23 October 2017}}</ref> | |||
Studies using ]s and ] technologies such as ] and ] to examine functional differences in brain activity have shown that differences seem to most commonly occur in the ]s, ], and ]s.<ref name="fn_31">Green MF (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0-393-70334-7</ref> These differences have been linked to the ]s often associated with schizophrenia.<ref name="Green2006">{{cite journal |author=Green MF |year=2006 |title=Cognitive impairment and functional outcome in schizophrenia and bipolar disorder |journal=] |volume=67 | issue=Suppl 9 |pages=3-8 |pmid=16965182 |accessdate= 2008-02-26}}</ref> The role of antipsychotic medication, which nearly all those studied had taken, in causing such abnormalities is also unclear.<ref>{{cite journal |author=Dean CE |url=http://ajp.psychiatryonline.org/cgi/content/full/156/11/1843-b |year=2006 |title=Typical neuroleptics and increased subcortical volumes |journal=] |volume=156 |issue=11 |pages=1843-4 |pmid=10553769 |accessdate= 2008-02-26}}</ref> | |||
The ICD criteria are typically used in European countries; the DSM criteria are used predominantly in the United States and Canada, and are prevailing in research studies. In practice, agreement between the two systems is high.<ref>{{cite journal | vauthors = Jakobsen KD, Frederiksen JN, Hansen T, Jansson LB, Parnas J, Werge T | title = Reliability of clinical ICD-10 schizophrenia diagnoses | journal = Nordic Journal of Psychiatry | volume = 59 | issue = 3 | pages = 209–212 | year = 2005 | pmid = 16195122 | doi = 10.1080/08039480510027698 | s2cid = 24590483 }}</ref> The current proposal for the ] criteria for schizophrenia recommends adding self-disorder as a symptom.<ref name=Heinz2016/> | |||
Particular focus has been placed upon the function of dopamine in the ] of the brain. This focus largely resulted from the accidental finding that a drug group which blocks dopamine function, known as the ], could reduce psychotic symptoms. An influential theory, known as the ], proposed that a malfunction involving dopamine pathways was the cause of (the positive symptoms of) schizophrenia. This theory is now thought to be overly simplistic as a complete explanation, partly because newer antipsychotic medication (called ] medication) can be equally effective as older medication (called ] medication), but also affects ] function and may have slightly less of a ] blocking effect.<ref name="JonesPilowsky2002">{{cite journal |author=Jones HM |coauthors=Pilowsky LS |year=2002 |title=Dopamine and antipsychotic drug action revisited |journal=] |volume=181 |pages=271-275 |pmid=12356650 |accessdate= 2008-02-26}}</ref> | |||
A major unresolved difference between the two diagnostic systems is that of the requirement in DSM of an impaired functional outcome. WHO for ICD argues that not all people with schizophrenia have functional deficits and so these are not specific for the diagnosis.<ref name=Biedermann2016/> | |||
Interest has also focused on the neurotransmitter ] and the reduced function of the ] in schizophrenia. This has largely been suggested by abnormally low levels of ]s found in postmortem brains of people previously diagnosed with schizophrenia<ref name="fn_27">{{cite journal |author=Konradi C |coauthors=Heckers S |year=2003 |title=Molecular aspects of glutamate dysregulation: implications for schizophrenia and its treatment |journal=] |volume=97 |issue=2 |pages=153-79 |pmid=12559388 |accessdate= 2008-02-26}}</ref> and the discovery that the glutamate blocking drugs such as ] and ] can mimic the symptoms and cognitive problems associated with the condition.<ref name="fn_59">{{cite journal |author=Lahti AC |coauthors=Weiler MA, Tamara Michaelidis BA, Parwani A, Tamminga CA |year=2001 |title=Effects of ketamine in normal and schizophrenic volunteers |journal=] |volume=25 |issue=4 |pages=455-67 |pmid=11557159 |accessdate= 2008-02-26}}</ref> The fact that reduced glutamate function is linked to poor performance on tests requiring ] and ] function and that glutamate can affect ] function, all of which have been implicated in schizophrenia, have suggested an important mediating (and possibly causal) role of glutamate pathways in schizophrenia.<ref name="fn_28">{{cite journal |author=Coyle JT |coauthors=Tsai G, Goff D |year=2003 |title=Converging evidence of NMDA receptor hypofunction in the pathophysiology of schizophrenia |journal=Annals of the ] |volume=1003 |pages=318-27 |pmid=14684455 |accessdate= 2008-02-26}}</ref> Further support of this theory has come from preliminary trials suggesting the efficacy of coagonists at the NMDA receptor complex in reducing some of the positive symptoms of schizophrenia.<ref name="fn_60">{{cite journal |author=Tuominen HJ |coauthors=Tiihonen J, Wahlbeck K |year=2005 |title=Glutamatergic drugs for schizophrenia: a systematic review and meta-analysis |journal=] |volume=72 |pages=225-34 |pmid=15560967 |accessdate= 2008-02-26}}</ref> | |||
=== Neuroimaging techniques === | |||
There have also been findings of differences in the size and structure of certain brain areas in schizophrenia, starting with the discovery of ] enlargement in those for whom negative symptoms were most prominent.<ref name="fn_29">{{cite journal |author=Johnstone EC |coauthors=Crow TJ, Frith CD, Husband J, Kreel L |year=1976 |title=Cerebral ventricular size and cognitive impairment in chronic schizophrenia |journal=] |volume=2 |issue=7992 |pages=924-6 |pmid=62160 |accessdate= 2008-02-26}}</ref> However, this has not proven particularly reliable on the level of the individual person, with considerable variation between patients. More recent studies have shown various differences in brain structure between people with and without diagnoses of schizophrenia.<ref name="fn_30">{{cite journal |author=Flashman LA |coauthors=Green MF |year=2004 |title=Review of cognition and brain structure in schizophrenia: profiles, longitudinal course, and effects of treatment |journal=Psychiatric Clinics of North America |volume=27 |issue=1 |pages=1-18, vii |pmid=15062627 |accessdate= 2008-02-26}}</ref> While brain structure changes have been found in people diagnosed with schizophrenia who have never been treated with antipsychotic drugs<ref name="Cahn_et_al_2002">Cahn W, Hulshoff Pol HE, Bongers M, Schnack HG, Mandl RC, Van Haren NE, Durston S, Koning H, Van Der Linden JA, Kahn RS. (2002) Brain morphology in antipsychotic-naïve schizophrenia: a study of multiple brain structures. ''Br J Psychiatry Suppl'', 43, s66-72. PMID 12271803</ref> there is evidence that the medication itself might cause additional changes in the brain's structure.<ref name="Molina_et_al_2005">Molina V, Reig S, Sanz J, Palomo T, Benito C, Sánchez J, Sarramea F, Pascau J, Desco M. (2005) Increase in gray matter and decrease in white matter volumes in the cortex during treatment with atypical neuroleptics in schizophrenia. ''Schizophr Res'', 80(1), 61-71. 16150576</ref> However, as with earlier studies, many of these differences are only reliably detected when comparing groups of people, and are unlikely to predict any differences in brain structure of an individual person with schizophrenia. | |||
] has become a tool in understanding brain activity and connectivity differences in individuals with schizophrenia. Through resting-state fMRI, researchers have observed altered connectivity patterns within several key brain networks, such as the default mode network (DMN),<ref>{{Cite journal |last1=Whitfield-Gabrieli |first1=Susan |last2=Ford |first2=Judith M. |date=2012-04-27 |title=Default Mode Network Activity and Connectivity in Psychopathology |url=https://www.annualreviews.org/doi/10.1146/annurev-clinpsy-032511-143049 |journal=Annual Review of Clinical Psychology |language=en |volume=8 |issue=1 |pages=49–76 |doi=10.1146/annurev-clinpsy-032511-143049 |pmid=22224834 |issn=1548-5943}}</ref> salience network (SN),<ref>{{Cite journal |last=Menon |first=Vinod |date=October 2011 |title=Large-scale brain networks and psychopathology: a unifying triple network model |url=https://linkinghub.elsevier.com/retrieve/pii/S1364661311001719 |journal=Trends in Cognitive Sciences |language=en |volume=15 |issue=10 |pages=483–506 |doi=10.1016/j.tics.2011.08.003|pmid=21908230 }}</ref> and central executive network (CEN).<ref>{{Cite journal |last1=Baker |first1=Justin T. |last2=Holmes |first2=Avram J. |last3=Masters |first3=Grace A. |last4=Yeo |first4=B. T. Thomas |last5=Krienen |first5=Fenna |last6=Buckner |first6=Randy L. |last7=Öngür |first7=Dost |date=2014-02-01 |title=Disruption of Cortical Association Networks in Schizophrenia and Psychotic Bipolar Disorder |journal=JAMA Psychiatry |language=en |volume=71 |issue=2 |pages=109–118 |doi=10.1001/jamapsychiatry.2013.3469 |issn=2168-622X |pmc=4435541 |pmid=24306091}}</ref> Alterations may underlie cognitive and emotional symptoms in schizophrenia, such as disorganized thinking, impaired attention, and emotional dysregulation. | |||
===Comorbidities=== | |||
==Treatment and services== | |||
] showing overlapping ]s in genes associated with ] of ] (ASD), ], ] and schizophrenia: | |||
{{main|Treatment of schizophrenia}} | |||
{{legend|#007fff|Genes associated with epilepsy}} | |||
], which revolutionized treatment of schizophrenia in the 1950s.]] | |||
{{legend|#007f7f|Genes associated with schizophrenia}} | |||
The concept of a cure as such remains controversial, as there is no consensus on the definition, although some criteria for the remission of symptoms have recently been suggested.<ref name="fn_63">van Os J, Burns T, Cavallaro R, ''et al'' (2006). Standardized remission criteria in schizophrenia. ''Acta Psychiatrica Scandinavica'', 113(2), 91–5. PMID 16423159</ref> <!-- and they are...?--> The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the most common being the ] (PANSS).<ref name="fn_68">Kay SR, Fiszbein A, Opler LA (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. '']'', 13(2), 261–76. PMID 3616518</ref> | |||
{{legend|#d4aaff|Genes associated with autism spectrum disorder}} | |||
Management of symptoms and improving function is thought to be more achievable than a cure. Treatment was revolutionized in the mid 1950s with the development and introduction of ].<ref name="Turner2007">{{cite journal | author=Turner T. | title=Unlocking psychosis | journal=Brit J Med | year=2007 | volume=334 | issue=suppl | pages=s7 }}</ref> A ] is increasingly adopted, emphasizing hope, empowerment and social inclusion.<ref name="Bellack06">Bellack AS. (2006) Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. ''].'' Jul;32(3):432-42. PMID 16461575</ref> | |||
{{legend|#ff0000|Genes associated with dystonia}}]] | |||
Many people with schizophrenia may have one or more ], such as ], ], or substance use disorder. These are separate disorders that require treatment.<ref name=DSM5/> When comorbid with schizophrenia, substance use disorder and ] both increase the risk for violence.<ref name=Richard-Devantoy2009/> Comorbid substance use disorder also increases the risk of suicide.<ref name=Khokhar2018/> | |||
]s often co-occur with schizophrenia, and may be an early sign of relapse.<ref name=Staedt2010/> Sleep disorders are linked with positive symptoms such as ] and can adversely affect ] and cognition.<ref name=Staedt2010>{{cite journal |vauthors=Staedt J, Hauser M, Gudlowski Y, Stoppe G |title=Sleep disorders in schizophrenia |journal=Fortschritte der Neurologie-Psychiatrie |volume=78 |issue=2 |pages=70–80 |date=February 2010 |pmid=20066610 |doi=10.1055/s-0028-1109967|s2cid=260137215 }}</ref> The consolidation of memories is disrupted in sleep disorders.<ref name=Pocivavsek2018/> They are associated with severity of illness, a poor prognosis, and poor quality of life.<ref name=Monti2013/><ref>{{cite journal |vauthors=Faulkner SM, Bee PE, Meyer N, Dijk DJ, Drake RJ |title=Light therapies to improve sleep in intrinsic circadian rhythm sleep disorders and neuro-psychiatric illness: A systematic review and meta-analysis |journal=Sleep Medicine Reviews |volume=46 |pages=108–123 |date=August 2019 |pmid=31108433|doi=10.1016/j.smrv.2019.04.012|doi-access=free }}</ref> Sleep onset and maintenance insomnia is a common symptom, regardless of whether treatment has been received or not.<ref name=Monti2013>{{cite journal | vauthors = Monti JM, BaHammam AS, Pandi-Perumal SR, Bromundt V, Spence DW, Cardinali DP, Brown GM | title = Sleep and circadian rhythm dysregulation in schizophrenia | journal = Progress in Neuro-Psychopharmacology & Biological Psychiatry | volume = 43 | pages = 209–216 | date = June 2013 | pmid = 23318689 | doi = 10.1016/j.pnpbp.2012.12.021 | hdl-access = free | s2cid = 19626589 | hdl = 11336/3858 }}</ref> Genetic variations have been found associated with these conditions involving the ], dopamine and ], and signal transduction.<ref>{{cite journal | vauthors = Assimakopoulos K, Karaivazoglou K, Skokou M, Kalogeropoulou M, Kolios P, Gourzis P, Patrinos GP, Tsermpini EE | title = Genetic Variations Associated with Sleep Disorders in Patients with Schizophrenia: A Systematic Review | journal = Medicines | volume = 5 | issue = 2 | page = 27 | date = March 2018 | pmid = 29587340 | pmc = 6023503 | doi = 10.3390/medicines5020027 | doi-access = free }}</ref> | |||
Hospitalization may occur with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or ]). Long-term inpatient stays are now less common due to ], although can still occur.<ref name="BeckerKilian2006" /> Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or ] team, supported employment<ref>McGurk, SR, Mueser KT, Feldman K, Wolfe R, Pascaris A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. ''Am J Psychiatry.'' Mar;164(3):437–41. PMID 17329468</ref> and patient-led support groups. | |||
Schizophrenia is also associated with a number of somatic comorbidities including ], ]s, and ]s. The association of these with schizophrenia may be partially due to medications (e.g. ] from antipsychotics), environmental factors (e.g. complications from an increased rate of cigarette smoking), or associated with the disorder itself (e.g. diabetes mellitus type 2 and some cardiovascular diseases are thought to be genetically linked). These somatic comorbidities contribute to reduced life expectancy among persons with the disorder.<ref>{{cite journal |vauthors=Dieset I, Andreassen O, Haukvik U|title=Somatic Comorbidity in Schizophrenia: Some Possible Biological Mechanisms Across the Life Span |journal= Schizophrenia Bulletin|volume=42 |issue=6 |date=2016 |pages=1316–1319 | pmid=27033328|doi=10.1093/schbul/sbw028 |pmc=5049521 |doi-access=free }}</ref> | |||
In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. The outcome for people diagnosed with schizophrenia in non-Western countries may actually be better than for people in the West.<ref name="fn_41">Kulhara P (1994). Outcome of schizophrenia: some transcultural observations with particular reference to developing countries. ''European Archives of Psychiatry and Clinical Neuroscience'', 244(5), 227–35. PMID 7893767</ref> The reasons for this effect are not clear, although ] are being conducted. | |||
===Differential diagnosis=== | |||
{{see also|Dual diagnosis|Comparison of bipolar disorder and schizophrenia}} | |||
To make a diagnosis of schizophrenia ].<ref>{{cite journal |vauthors=Schrimpf LA, Aggarwal A, Lauriello J |title=Psychosis |journal=Continuum (Minneap Minn) |volume=24 |issue=3 |pages=845–860 |date=June 2018 |pmid=29851881 |doi=10.1212/CON.0000000000000602|s2cid=243933980 }}</ref>{{Rp|page=858|quote=Psychosis as a primary mental health disorder is a diagnosis of exclusion. Many different manifestations of psychotic symptoms are directly related to an underlying medical or neurologic disorder. Delirium and dementia are the two most important disorders to rule out and can present in a very subtle fashion.}} Psychotic symptoms lasting less than a month may be diagnosed as ], or as schizophreniform disorder. Psychosis is noted in ''Other specified schizophrenia spectrum and other psychotic disorders'' as a DSM-5 category. ] is diagnosed if symptoms of ] are substantially present alongside psychotic symptoms. Psychosis that results from a general medical condition or substance is termed secondary psychosis.<ref name=DSM5/><!-- cites previous four sentences --> | |||
Psychotic symptoms may be present in several other conditions, including ],<ref name=Ferri2010/> ],<ref name=Paris2018>{{cite journal | vauthors = Paris J | title = Differential Diagnosis of Borderline Personality Disorder | journal = The Psychiatric Clinics of North America | date = December 2018 | volume = 41 | issue = 4 | pages=575–582 | doi = 10.1016/j.psc.2018.07.001 | pmid = 30447725| s2cid = 53951650 }}</ref> ], ], and a number of ]s. Non-bizarre delusions are also present in ], and social withdrawal in ], ] and ]. Schizotypal personality disorder has symptoms that are similar but less severe than those of schizophrenia.<ref name=DSM5/> Schizophrenia occurs along with obsessive–compulsive disorder (OCD) considerably more often than could be explained by chance, although it can be difficult to distinguish obsessions that occur in OCD from the delusions of schizophrenia.<ref>{{cite journal | vauthors = Bottas A |title=Comorbidity: Schizophrenia With Obsessive-Compulsive Disorder |journal=Psychiatric Times |volume=26 |issue=4 |date=15 April 2009 |url=http://www.psychiatrictimes.com/display/article/10168/1402540 |url-status=live |archive-url=https://web.archive.org/web/20130403064649/http://www.psychiatrictimes.com/display/article/10168/1402540 |archive-date=3 April 2013}}</ref> There can be considerable overlap with the symptoms of ].<ref>{{cite journal |vauthors=OConghaile A, DeLisi LE |title=Distinguishing schizophrenia from posttraumatic stress disorder with psychosis |journal=Curr Opin Psychiatry |volume=28 |issue=3 |pages=249–255 |date=May 2015 |pmid=25785709 |doi=10.1097/YCO.0000000000000158 |s2cid=12523516 }}</ref> | |||
A more general medical and neurological examination may be needed to rule out medical illnesses which may rarely produce psychotic schizophrenia-like symptoms, such as ], ], ], ], ], ], and brain lesions. Stroke, ], ], ], and ]s such as ], ], ], and the ]s may also be associated with schizophrenia-like psychotic symptoms.<ref>{{cite book|title=Bradley's neurology in clinical practice|year=2012|publisher=Elsevier/Saunders|location=Philadelphia, PA|isbn=978-1-4377-0434-1| vauthors= Murray ED, Buttner N, Price BH | volume = 1 | edition=6th|pages=92–111| veditors = Bradley WG, Daroff RB, Fenichel GM, Jankovic J |chapter=Depression and Psychosis in Neurological Practice}}</ref> It may be necessary to rule out a ], which can be distinguished by visual hallucinations, acute onset and fluctuating ], and indicates an underlying medical illness. Investigations are not generally repeated for relapse unless there is a specific ''medical'' indication or possible ] from ].<ref>{{cite journal |vauthors=Leucht S, Bauer S, Siafis S, Hamza T, Wu H, Schneider-Thoma J, Salanti G, Davis JM |title=Examination of Dosing of Antipsychotic Drugs for Relapse Prevention in Patients With Stable Schizophrenia: A Meta-analysis |journal=JAMA Psychiatry |volume=78 |issue=11 |pages=1238–1248 |date=November 2021 |pmid=34406325 |pmc=8374744 |doi=10.1001/jamapsychiatry.2021.2130}}</ref> In children hallucinations must be separated from typical childhood fantasies.<ref name=DSM5/> It is difficult to distinguish childhood schizophrenia from autism.<ref name=DaFonseca2018/> | |||
==Prevention== | |||
] of schizophrenia is difficult as there are no reliable markers for the later development of the disorder.<ref>{{cite journal | vauthors = Cannon TD, Cornblatt B, McGorry P | title = The empirical status of the ultra high-risk (prodromal) research paradigm | journal = Schizophrenia Bulletin | volume = 33 | issue = 3 | pages = 661–664 | date = May 2007 | pmid = 17470445 | pmc = 2526144 | doi = 10.1093/schbul/sbm031 }}</ref> | |||
] diagnose and treat patients in the prodromal phase of the illness. There is some evidence that these programs reduce symptoms. Patients tend to prefer early treatment programs to ordinary treatment and are less likely to disengage from them. As of 2020, it is unclear whether the benefits of early treatment persist once the treatment is terminated.<ref>{{cite journal |vauthors=Puntis S, Minichino A, De Crescenzo F, Cipriani A, Lennox B, Harrison R |title=Specialised early intervention teams for recent-onset psychosis |journal=Cochrane Database Syst Rev |volume=11 |issue=11 |pages=CD013288 |date=November 2020 |pmid=33135811 |doi=10.1002/14651858.CD013288.pub2 |pmc=8092671 | quote=p. 22: There is low-certainty evidence for the use of SEl services in comparison to TAU for a small reduction in psychiatric hospitalisation, and moderate-certainty evidence of a large effect of reduction in disengagement from mental health services. There is moderate-certainty evidence that SEI results in a small reduction of positive (hallucinations, delusions and disordered thinking) and negative symptoms (social withdrawal, flat or blunted affect, and poverty of speech) and low-certainty evidence that it greatly increases satisfaction in care, while there is low-certainty evidence that it improves general functioning and the likelihood of recovery. These effects were only observed during treatment and there was no evidence that outcomes are improved after the treatment has finished, although these were based on only one trial.}}</ref> | |||
] may reduce the risk of psychosis in those at high risk after a year<ref>{{cite journal | vauthors = Stafford MR, Jackson H, Mayo-Wilson E, Morrison AP, Kendall T | title = Early interventions to prevent psychosis: systematic review and meta-analysis | journal = BMJ | volume = 346 | page = f185 | date = January 2013 | pmid = 23335473 | pmc = 3548617 | doi = 10.1136/bmj.f185 }}</ref> and is recommended in this group, by the ] (NICE).<ref name="NICE2014">{{cite web|title=Psychosis and schizophrenia in adults: treatment and management |url=http://www.nice.org.uk/nicemedia/live/14382/66534/66534.pdf |publisher = ] (NICE) |access-date=19 April 2014 |pages=4–34|date=March 2014 |archive-url=https://web.archive.org/web/20140420070946/http://www.nice.org.uk/nicemedia/live/14382/66534/66534.pdf |archive-date=20 April 2014 }}</ref> Another preventive measure is to avoid drugs that have been associated with development of the disorder, including ], cocaine, and ].<ref name="BMJ07" /> | |||
Antipsychotics are prescribed following a first-episode psychosis, and following remission, a preventive maintenance use is continued to avoid relapse. However, it is recognized that some people do recover following a single episode and that long-term use of antipsychotics will not be needed but there is no way of identifying this group.<ref name=Taylor2019>{{cite journal |vauthors=Taylor M, Jauhar S |title=Are we getting any better at staying better? The long view on relapse and recovery in first episode nonaffective psychosis and schizophrenia |journal=Therapeutic Advances in Psychopharmacology |volume=9 |date=September 2019|page=204512531987003 |pmid=31523418|doi=10.1177/2045125319870033 |pmc=6732843 }}</ref> | |||
==Management== | |||
{{Main|Management of schizophrenia}} | |||
The primary treatment of schizophrenia is the use of ], often in combination with ] and ]s.<ref name=Lancet2009/><ref>{{cite journal | vauthors = Weiden PJ |title=Beyond Psychopharmacology: Emerging Psychosocial Interventions for Core Symptoms of Schizophrenia. |journal=Focus (American Psychiatric Publishing) |volume=14 |issue=3 |pages=315–327 |date=July 2016 |pmid=31975812|doi=10.1176/appi.focus.20160014|pmc=6526802 }}</ref> Community support services including drop-in centers, visits by members of a ], ],<ref>{{cite journal | vauthors = McGurk SR, Mueser KT, Feldman K, Wolfe R, Pascaris A | title = Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial | journal = The American Journal of Psychiatry | volume = 164 | issue = 3 | pages = 437–441 | date = March 2007 | pmid = 17329468 | doi = 10.1176/appi.ajp.164.3.437 }}</ref> and support groups are common. The time between the onset of psychotic symptoms to being given treatment – the duration of untreated psychosis (DUP) – is associated with a poorer outcome in both the short term and the long term.<ref>{{cite journal | vauthors = Souaiby L, Gaillard R, Krebs MO |title= |journal=Encephale |volume=42 |issue=4 |pages=361–366 |date=August 2016|pmid=27161262 |doi=10.1016/j.encep.2015.09.007 }}</ref> | |||
] or ] admission to hospital may be imposed by doctors and courts who deem a person to be having a severe episode. In the UK, large mental hospitals termed asylums began to be closed down in the 1950s with the advent of antipsychotics, and with an awareness of the negative impact of long-term hospital stays on recovery.<ref name=Killaspy2014>{{cite journal |vauthors=Killaspy H|title= Contemporary mental health rehabilitation|journal=East Asian Archives of Psychiatry|volume=24 | issue=3|pages=89–94|date=September 2014|pmid = 25316799}}</ref> This process was known as ], and community and supportive services were developed to support this change. Many other countries followed suit with the US starting in the 60s.<ref>{{cite journal | vauthors = Fuller Torrey E | title = Deinstitutionalization and the rise of violence. | journal = CNS Spectrums | date = June 2015 | volume = 20 | issue = 3 | pages = 207–214 | doi = 10.1017/S1092852914000753 | pmid = 25683467| s2cid = 22210482 }}</ref> There still remain a smaller group of people who do not improve enough to be discharged.<ref name=Killaspy2014/><ref name=Capdevielle2009/> In some countries that lack the necessary supportive and social services, long-term hospital stays are more usual.<ref name=Narayan2012/> | |||
===Medication=== | ===Medication=== | ||
] (trade name Risperdal) is a common ] medication.]] | |||
The mainstay of psychiatric treatment for schizophrenia is an ] medication.<ref name="fn_72">The Royal College of Psychiatrists & The British Psychological Society (2003). (PDF). London: Gaskell and the British Psychological Society. Retrieved on ].</ref> These can reduce the "positive" symptoms of psychosis. Most antipsychotics take around 7–14 days to have their main effect. | |||
] (trade name '''Risperdal''') is a common ] medication.]] | |||
Though expensive, the newer ] drugs are usually preferred for ] over the older ]s; they are often better tolerated and associated with lower rates of ], although they are more likely to induce weight gain and ]-related diseases.<ref name="fn_62">Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK, Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. '']'', 353 (12), 1209–23. PMID 16172203</ref> Prolactin elevations have been reported in women with schizophrenia taking atypical antipsychotics.<ref name="Dickson_et_al_1995">Dickson RA, Dalby JT, Williams R, Edwards AL. (1995) Risperidone induced prolactin elevations in premenopausal women with schizophrenia. ''American Journal of Psychiatry'',152,1102-1103. PMID 7540803</ref>It remains unclear whether the newer antipsychotics reduce the chances of developing ], a rare but serious and potentially fatal neurological disorder most often caused by an adverse reaction to ] or antipsychotic drugs.<ref name="Ananth_et_al_2004">Ananth J, Parameswaran S, Gunatilake S, Burgoyne K, Sidhom T. (2004) Neuroleptic malignant syndrome and atypical antipsychotic drugs. ''Journal of Clinical Psychiatry'', 65 (4), 464-70. PMID 15119907</ref> | |||
The first-line treatment for schizophrenia is an antipsychotic. The first-generation antipsychotics, now called ], like ], are ]s that block D<sub>2</sub> receptors, and affect the ] of ]. Those brought out later, the second-generation antipsychotics known as ], including ] and ], can also have an effect on another neurotransmitter, ]. Antipsychotics can reduce the symptoms of anxiety within hours of their use, but, for other symptoms, they may take several days or weeks to reach their full effect.<ref name=RAISE/><ref name=nhsTreatment/> They have little effect on negative and cognitive symptoms, which may be helped by additional psychotherapies and medications.<ref>{{cite journal | vauthors = Ortiz-Orendain J, Covarrubias-Castillo SA, Vazquez-Alvarez AO, Castiello-de Obeso S, Arias Quiñones GE, Seegers M, Colunga-Lozano LE | title = Modafinil for people with schizophrenia or related disorders | journal = The Cochrane Database of Systematic Reviews | volume = 12 | page = CD008661 | date = December 2019 | issue = 12 | pmid = 31828767 | pmc = 6906203 | doi = 10.1002/14651858.CD008661.pub2 }}</ref> There is no single antipsychotic suitable for first-line treatment for everyone, as responses and tolerances vary between people.<ref>{{cite journal | vauthors = Lally J, MacCabe JH | title = Antipsychotic medication in schizophrenia: a review | journal = British Medical Bulletin | volume = 114 | issue = 1 | pages = 169–179 | date = June 2015 | pmid = 25957394 | doi = 10.1093/bmb/ldv017 | doi-access = }}</ref> Stopping medication may be considered after a single psychotic episode where there has been a full recovery with no symptoms for twelve months. Repeated relapses worsen the long-term outlook and the risk of relapse following a second episode is high, and long-term treatment is usually recommended.<ref>{{cite journal | vauthors = Keks N, Schwartz D, Hope J | title = Stopping and switching antipsychotic drugs | journal = Australian Prescriber | volume = 42 | issue = 5 | pages = 152–157 | date = October 2019 | pmid = 31631928 | pmc = 6787301 | doi = 10.18773/austprescr.2019.052 }}</ref><ref name=Harrow2013>{{cite journal | vauthors = Harrow M, Jobe TH | title = Does long-term treatment of schizophrenia with antipsychotic medications facilitate recovery? | journal = Schizophrenia Bulletin | volume = 39 | issue = 5 | pages = 962–5 | date = September 2013 | pmid = 23512950 | pmc = 3756791 | doi = 10.1093/schbul/sbt034 }}</ref> | |||
The two classes of antipsychotics are generally thought equally effective for the treatment of the positive symptoms. Some researchers have suggested that the atypicals offer additional benefit for the negative symptoms and cognitive deficits associated with schizophrenia, although the clinical significance of these effects has yet to be established. Recent reviews have refuted the claim that atypical antipsychotics have fewer extrapyramidal side effects than typical antipsychotics, especially when the latter are used in low doses or when low potency antipsychotics are chosen.<ref name="fn_36">Leucht S, Wahlbeck K, Hamann J, Kissling W (2003). New generation antipsychotics versus low-potency conventional antipsychotics: a ] and meta-analysis. '']'', 361(9369), 1581–9. PMID 12747876</ref> | |||
About half of those with schizophrenia will respond favourably to antipsychotics, and have a good return of functioning.<ref>{{cite journal |vauthors=Elkis H, Buckley PF |title=Treatment-Resistant Schizophrenia |journal=The Psychiatric Clinics of North America |volume=39 |issue=2 |pages=239–65 |date=June 2016 |pmid=27216902|doi=10.1016/j.psc.2016.01.006}}</ref> However, positive symptoms persist in up to a third of people. Following two trials of different antipsychotics over six weeks, that also prove ineffective, they will be classed as having treatment-resistant schizophrenia (TRS), and ] will be offered.<ref>{{cite journal |vauthors=Gillespie AL, Samanaite R, Mill J, Egerton A, MacCabe JH |title=Is treatment-resistant schizophrenia categorically distinct from treatment-responsive schizophrenia? a systematic review |journal=BMC Psychiatry |volume=17 |issue=1 |page=12 |date=13 January 2017 |pmid=28086761 |doi=10.1186/s12888-016-1177-y|pmc=5237235 |doi-access=free }}</ref><ref name=Siskind2017/> Clozapine is of benefit to around half of this group although it has the potentially serious side effect of ] (lowered ] count) in less than 4% of people.<ref name=Lancet2009/><ref name=BMJ07/><ref>{{cite journal | vauthors = Essali A, Al-Haj Haasan N, Li C, Rathbone J | title = Clozapine versus typical neuroleptic medication for schizophrenia | journal = The Cochrane Database of Systematic Reviews | issue = 1 | page = CD000059 | date = January 2009 | volume = 2009 | pmid = 19160174 | doi = 10.1002/14651858.CD000059.pub2 | pmc = 7065592 }}</ref> | |||
Response of symptoms to medication is variable; "Treatment-resistant schizophrenia" is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics.<ref>{{cite journal | author = Meltzer HY | title = Treatment-resistant schizophrenia--the role of clozapine | journal = Current Medical Research and Opinion | volume = 14 | issue = 1 | pages = 1–20 | date = 1997 | pmid=9524789 }}</ref> Patients in this category may be prescribed ],<ref>{{cite journal | author = Wahlbeck K, Cheine MV, Essali A | title = Clozapine versus typical neuroleptic medication for schizophrenia | journal = The Cochrane Database of Systematic Reviews | volume = | issue = 2 | pages = | publisher = John Wiley and Sons, Ltd. | date = 2007 | pmid=10796289 | doi = 10.1002/14651858.CD000059 | id = ISSN 1464-780X}}</ref> a medication of superior effectiveness but several potentially lethal side effects including ] and ].<ref>{{cite journal | author = Haas SJ, Hill R, Krum H | title = Clozapine-associated myocarditis: a review of 116 cases of suspected myocarditis associated with the use of clozapine in Australia during 1993–2003 | journal = Drug Safety | volume = 30 | pages = 47–57 | date = 2007 | pmid=17194170 }}</ref> Clozapine may have the additional benefit of reducing propensity for substance abuse in schizophrenic patients. <ref>{{cite journal |author = Lee M, Dickson RA, Campbell M, Oliphant J, Gretton H, Dalby JT. |title = Clozapine and substance abuse in patients with schizophrenia |journal = Canadian Journal of Psychiatry |volume = 43 |pages = 855-856 |date = 1998 }}</ref> For other patients who are unwilling or unable to take medication regularly, long-acting ] preparations of antipsychotics may be given every two weeks to achieve control. The United States of America and Australia are two countries with ] allowing the forced administration of this type of medication on those who refuse but are otherwise stable and living in the community. Some findings have found that in the longer-term some individuals may do better not taking antipsychotics.<ref>Harrow M, Jobe TH. (2007) Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. ''J Nerv Ment Dis.'' May;195(5):406-14. PMID 17502806</ref> Despite the promising results of early pilot trials,<ref name="pmid11356585">{{cite journal |author=Peet M, Brind J, Ramchand CN, Shah S, Vankar GK |title=Two double-blind placebo-controlled pilot studies of eicosapentaenoic acid in the treatment of schizophrenia |journal=Schizophr. Res. |volume=49 |issue=3 |pages=243–51 |year=2001 |pmid=11356585 |doi=}}</ref> ] failed to improve schizophrenic symptoms, according to the most recent ].<ref name="pmid17194275">{{cite journal |author=Freeman MP, Hibbeln JR, Wisner KL, Davis JM, Mischoulon D, Peet M, Keck PE, Marangell LB, Richardson AJ, Lake J, Stoll AL |title=Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry |journal=The Journal of clinical psychiatry |volume=67 |issue=12 |pages=1954–67 |year=2006 |pmid=17194275 |doi=}}</ref> | |||
About 30 to 50 percent of people with schizophrenia do not accept that they have an illness or comply with their recommended treatment.<ref>{{cite journal | vauthors = Baier M | title = Insight in schizophrenia: a review | journal = Current Psychiatry Reports | volume = 12 | issue = 4 | pages = 356–361 | date = August 2010 | pmid = 20526897 | doi = 10.1007/s11920-010-0125-7 | s2cid = 29323212 }}</ref> For those who are unwilling or unable to take medication regularly, ] of antipsychotics may be used,<ref>{{cite journal | vauthors = Peters L, Krogmann A, von Hardenberg L, Bödeker K, Nöhles VB, Correll CU | title = Long-Acting Injections in Schizophrenia: a 3-Year Update on Randomized Controlled Trials Published January 2016 – March 2019 | journal = Current Psychiatry Reports | volume = 21 | issue = 12 | pages = 124 | date = November 2019 | pmid = 31745659 | doi = 10.1007/s11920-019-1114-0 | s2cid = 208144438 }}</ref> which reduce the risk of relapse to a greater degree than oral medications.<ref>{{cite journal | vauthors = Leucht S, Tardy M, Komossa K, Heres S, Kissling W, Salanti G, Davis JM | title = Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis | journal = Lancet | volume = 379 | issue = 9831 | pages = 2063–2071 | date = June 2012 | pmid = 22560607 | doi = 10.1016/S0140-6736(12)60239-6 | s2cid = 2018124 }}</ref> When used in combination with psychosocial interventions, they may improve long-term ] to treatment.<ref name=Depo06>{{cite journal | vauthors = McEvoy JP | title = Risks versus benefits of different types of long-acting injectable antipsychotics | journal = The Journal of Clinical Psychiatry | volume = 67 | issue = Suppl 5 | pages = 15–18 | year = 2006 | pmid = 16822092 }}</ref> | |||
===Psychological and social interventions=== | |||
] is also widely recommended and used in the treatment of schizophrenia, although services may often be confined to pharmacotherapy because of reimbursement problems or lack of training.<ref>Moran, M (2005). ''Psychiatr News'' ] ], Volume 40, Number 22, page 24. Retrieved on ].</ref> | |||
The ] medication ] (Cobenfy) was approved for medical use in the United States in September 2024.<ref name="FDA PR 20240926">{{cite press release | title=FDA Approves Drug with New Mechanism of Action for Treatment of Schizophrenia | website=U.S. ] (FDA) | date=26 September 2024 | url=https://www.fda.gov/news-events/press-announcements/fda-approves-drug-new-mechanism-action-treatment-schizophrenia | access-date=27 September 2024 | archive-date=27 September 2024 | archive-url=https://web.archive.org/web/20240927004824/https://www.fda.gov/news-events/press-announcements/fda-approves-drug-new-mechanism-action-treatment-schizophrenia | url-status=live }} {{PD-notice}}</ref><ref>{{cite press release | title=U.S. Food and Drug Administration Approves Bristol Myers Squibb's Cobenfy (xanomeline and trospium chloride), a First-In-Class Muscarinic Agonist for the Treatment of Schizophrenia in Adults | publisher=Bristol Myers Squibb | via=Business Wire | date=27 September 2024 | url=https://www.businesswire.com/news/home/20240925382351/en/U.S.-Food-and-Drug-Administration-Approves-Bristol-Myers-Squibb%E2%80%99s-COBENFY%E2%84%A2-xanomeline-and-trospium-chloride-a-First-In-Class-Muscarinic-Agonist-for-the-Treatment-of-Schizophrenia-in-Adults | access-date=27 September 2024}}</ref> It is the first ] approved by the US ] (FDA) to treat schizophrenia.<ref name="FDA PR 20240926" /> | |||
] (CBT) is used to reduce symptoms and improve related issues such as ], social functioning, and insight. Although the results of early trials were inconclusive,<ref name="fn_38">Cormac I, Jones C, Campbell C (2002). Cognitive behaviour therapy for schizophrenia. ''Cochrane Database of ]s'', (1), CD000524. PMID 11869579</ref> more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia.<ref name="fn_39">Zimmermann G, Favrod J, Trieu VH, Pomini V (2005). The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. ''Schizophrenia Research'', 77, 1–9. PMID 16005380</ref> Another approach is cognitive remediation therapy, a technique aimed at remediating the ]s sometimes present in schizophrenia. Based on techniques of ], early evidence has shown it to be cognitively effective, with some improvements related to measurable changes in brain activation as measured by ].<ref name="fn_40">Wykes T, Brammer M, Mellers J, ''et al'' (2002). Effects on the brain of a psychological treatment: cognitive remediation therapy: functional magnetic resonance imaging in schizophrenia. ''British Journal of Psychiatry'', 181, 144–52. PMID 12151286</ref> A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy.<ref>Hogarty GE, Flesher S, Ulrich R, Carter M, ''et al'' (2004). Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior. ''Arch Gen Psychiatry.'' Sep;61(9):866–76.PMID 15351765</ref> | |||
Negative and cognitive symptoms are an unmet clinical need in antipsychotic-based treatment approaches. Psychostimulant drugs have been found effective in the treatment of negative symptoms, but are rarely prescribed due to concerns about the excacerbation of positive symptoms.<ref>{{Cite journal |last1=Lindenmayer |first1=Jean-Pierre |last2=Nasrallah |first2=Henry |last3=Pucci |first3=Michael |last4=James |first4=Steven |last5=Citrome |first5=Leslie |date=2013-07-01 |title=A systematic review of psychostimulant treatment of negative symptoms of schizophrenia: Challenges and therapeutic opportunities |url=https://www.sciencedirect.com/science/article/abs/pii/S0920996413001655 |journal=Schizophrenia Research |volume=147 |issue=2 |pages=241–252 |doi=10.1016/j.schres.2013.03.019 |issn=0920-9964}}</ref> It is possible that low-dose psychedelic therapies could be of benefit in schizophrenia through their prosocial and procognitive effects, although there is a serious risk that high dose psychedelic therapies could lead to worsening of positive symptoms.<ref>{{Cite journal |last1=Sapienza |first1=Jacopo |last2=Martini |first2=Francesca |last3=Comai |first3=Stefano |last4=Cavallaro |first4=Roberto |last5=Spangaro |first5=Marco |last6=De Gregorio |first6=Danilo |last7=Bosia |first7=Marta |date=2024-09-18 |title=Psychedelics and schizophrenia: a double-edged sword |url=https://www.nature.com/articles/s41380-024-02743-x |journal=Molecular Psychiatry |language=en |pages=1–14 |doi=10.1038/s41380-024-02743-x |pmid=39294303 |issn=1476-5578}}</ref> | |||
] or Education, which addresses the whole family system of an individual with a diagnosis of schizophrenia, has been consistently found to be beneficial, at least if the duration of intervention is longer-term.<ref>McFarlane WR, Dixon L, Lukens E, Lucksted A (2003). Family psychoeducation and schizophrenia: a review of the literature. ''J Marital Fam Ther.'' Apr;29(2):223–45. PMID 12728780 </ref><ref>Glynn SM, Cohen AN, Niv N (2007). New challenges in family interventions for schizophrenia. '' Expert Rev Neurother.'' Jan;7(1):33–43. PMID 17187495</ref><ref>Pharoah F, Mari J, Rathbone J, Wong W. (2006) Cochrane Database of Systematic Reviews, Issue 4</ref> Aside from therapy, the impact of schizophrenia on families and the burden on carers has been recognized, with the increasing availability of self-help books on the subject.<ref>{{cite book | author = Jones, S., Hayward, P. | title = Coping with Schizophrenia: A Guide for Patients, Families and Caregivers | publisher = Oneworld Pub. | date = 2004 | location = Oxford, England | id = ISBN 1-85168-344-5}}</ref><ref>{{cite book | last = Torrey | first = EF | authorlink = E. Fuller Torrey | title = Surviving Schizophrenia: A Manual for Families, Consumers, and Providers (5th Edition) | publisher = HarperCollins | date = 2006 | id = ISBN 0-06-084259-8}}</ref> There is also some evidence for benefits from social skills training, although there have also been significant negative findings.<ref>Kopelowicz A, Liberman RP, Zarate R (2006). Recent advances in social skills training for schizophrenia. ''].'' 2006 Oct;32 Suppl 1:S12–23. PMID 16885207 </ref><ref>American Psychiatric Association (2004) Practice Guideline for the Treatment of Patients With Schizophrenia. Second Edition.</ref> Some studies have explored the possible benefits of music therapy and other creative therapies.<ref>Talwar N, Crawford MJ, Maratos A, Nur U, McDermott O, Procter S (2006). Music therapy for in-patients with schizophrenia: Exploratory randomised controlled trial. ''The British Journal of Psychiatry.'' Nov;189:405–9. PMID 17077429 </ref><ref>Ruddy R, Milnes D. (2005) Cochrane Database of Systematic Reviews, Issue 4</ref><ref>Ruddy RA, Dent-Brown K. (2007) Cochrane Database of Systematic Reviews, Issue 1.</ref> | |||
====Adverse effects==== | |||
The ] model is alternative to inpatient hospital treatment using a minimal medication approach. It is described as a ]-therapeutic ] method, characterized by its founder as "the 24 hour a day application of interpersonal phenomenologic interventions by a nonprofessional staff, usually without neuroleptic drug treatment, in the context of a small, homelike, quiet, supportive, protective, and tolerant social environment."<ref name="mosh99">Mosher LR (1999) Soteria and Other Alternatives to Acute Psychiatric Hospitalization: A Personal and Professional Review. ''Journal of Nervous and Mental Disease'', 187, 142–149. PMID 10086470</ref> Although research evidence is limited, a 2008 systematic review found the programme equally as efffective as treatment with medication in people diagnosed with first and second episode schizophrenia.<ref name="Calton_et_al_2008">Calton T, Ferriter M, Huband N, Spandler H. A systematic review of the Soteria paradigm for the treatment of people diagnosed with schizophrenia. '']'', 34 (1), 181-92. PMID 17573357</ref> | |||
{{Further information|Antipsychotic#Adverse effects}} | |||
], including ], are associated with all commercially available ] to varying degrees.<ref name=Chow2020>{{cite journal |vauthors=Chow CL, Kadouh NK, Bostwick JR, VandenBerg AM |date=June 2020 |title=Akathisia and Newer Second-Generation Antipsychotic Drugs: A Review of Current Evidence |url= |journal=Pharmacotherapy |volume=40 |issue=6 |pages=565–574 |doi=10.1002/phar.2404 |pmid=32342999|hdl=2027.42/155998 |s2cid=216596357 |hdl-access=free }}</ref>{{Rp|page=566|quote=However, EPS, particularly akathisia, occurs, to some degree, with all commercially available SGAs.}} There is little evidence that second generation antipsychotics have reduced levels of extrapyramidical symptoms compared to typical antipsychotics.<ref name=Chow2020/>{{Rp|page=566|quote=Furthermore, previous meta-analyses and systematic reviews comparing the safety and tolerability of FGAs and SGAs have found little evidence to support the notion that as a class, SGAs pose a reduced risk for EPS com- pared with FGAs. However, high-potency FGAs do tend to pose the greatest risk for EPS.}} ] can occur due to long-term use of antipsychotics, developing after months or years of use.<ref>{{cite journal |vauthors=Carbon M, Kane JM, Leucht S, Correll CU |date=October 2018 |title=Tardive dyskinesia risk with first- and second-generation antipsychotics in comparative randomized controlled trials: a meta-analysis |journal=World Psychiatry |volume=17 |issue=3 |pages=330–340 |doi=10.1002/wps.20579 |pmc=6127753 |pmid=30192088}}</ref> The antipsychotic ] is also associated with ] (including ]), ], and ]. | |||
===Psychosocial interventions=== | |||
{{Further|Management of schizophrenia#Psychosocial}} | |||
A number of psychosocial interventions that include several types of ] may be useful in the treatment of schizophrenia such as: ],<ref name=Pharoah2010>{{cite journal | vauthors = Pharoah F, Mari J, Rathbone J, Wong W | title = Family intervention for schizophrenia | journal = The Cochrane Database of Systematic Reviews | volume = 12 | issue = 12 | pages = CD000088 | date = December 2010 | pmid = 21154340 | pmc = 4204509 | doi = 10.1002/14651858.CD000088.pub2 | veditors = Pharoah F }}</ref> ], cognitive remediation therapy (CRT),<ref>{{cite journal | vauthors = Bellani M, Ricciardi C, Rossetti MG, Zovetti N, Perlini C, Brambilla P | title = Cognitive remediation in schizophrenia: the earlier the better? | journal = Epidemiology and Psychiatric Sciences | volume = 29 | issue = | pages = e57 | date = September 2019 | pmid = 31556864 | pmc = 8061237 | doi = 10.1017/S2045796019000532 }}</ref> cognitive behavioral therapy (CBT), and ].<ref>{{cite journal | vauthors = Philipp R, Kriston L, Lanio J, Kühne F, Härter M, Moritz S, Meister R | title = Effectiveness of metacognitive interventions for mental disorders in adults-A systematic review and meta-analysis (METACOG) | journal = Clinical Psychology & Psychotherapy | volume = 26 | issue = 2 | pages = 227–240 | date = March 2019 | pmid = 30456821 | doi = 10.1002/cpp.2345 | s2cid = 53872643 }}</ref><ref>{{cite journal | vauthors = Rouy M, Saliou P, Nalborczyk L, Pereira M, Roux P, Faivre N | title = Systematic review and meta-analysis of metacognitive abilities in individuals with schizophrenia spectrum disorders | journal = Neuroscience and Biobehavioral Reviews | volume = 126 | issue = | pages = 329–337 | date = July 2021 | pmid = 33757817 | doi = 10.1016/j.neubiorev.2021.03.017 | s2cid = 232288918 | url = https://hal.archives-ouvertes.fr/hal-03178486/file/2020.12.03.20243113v1.full.pdf }}</ref> Skills training, help with substance use, and weight management – often needed as a side effect of an antipsychotic – are also offered.<ref>{{cite journal | vauthors = Dixon LB, Dickerson F, Bellack AS, Bennett M, Dickinson D, Goldberg RW, Lehman A, Tenhula WN, Calmes C, Pasillas RM, Peer J, Kreyenbuhl J | title = The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements | journal = Schizophrenia Bulletin | volume = 36 | issue = 1 | pages = 48–70 | date = January 2010 | pmid = 19955389 | pmc = 2800143 | doi = 10.1093/schbul/sbp115 }}</ref> In the US, interventions for first episode psychosis have been brought together in an overall approach known as ] (CSC) and also includes support for education.<ref name=RAISE/> In the UK ''care across all phases'' is a similar approach that covers many of the treatment guidelines recommended.<ref name=NICE2014/> The aim is to reduce the number of relapses and stays in the hospital.<ref name=Pharoah2010/> | |||
Other support services for education, employment, and housing are usually offered. For people with severe schizophrenia, who are discharged from a stay in the hospital, these services are often brought together in an integrated approach to offer support in the community away from the hospital setting. In addition to medicine management, housing, and finances, assistance is given for more routine matters such as help with shopping and using public transport. This approach is known as ] (ACT) and has been shown to achieve positive results in symptoms, social functioning and quality of life.<ref>{{cite journal | vauthors = Bond GR, Drake RE | title = The critical ingredients of assertive community treatment. | journal = World Psychiatry | date = June 2015 | volume = 14 | issue = 2 | pages = 240–242 | doi = 10.1002/wps.20234 | pmid = 26043344| pmc = 4471983 }}</ref><ref>{{cite journal | vauthors = Smeerdijk M | title = . | journal = Tijdschrift voor Psychiatrie | date = 2017 | volume = 59 | issue = 8 | pages = 466–473 | pmid = 28880347}}</ref> Another more intense approach is known as ''intensive care management'' (ICM). ICM is a stage further than ACT and emphasises support of high intensity in smaller caseloads, (less than twenty). This approach is to provide long-term care in the community. Studies show that ICM improves many of the relevant outcomes including social functioning.<ref>{{cite journal | vauthors = Dieterich M | title = Intensive case management for severe mental illness | journal=The Cochrane Database of Systematic Reviews | date = 6 January 2017 | volume = 1 | issue = 1 | page = CD007906 | doi = 10.1002/14651858.CD007906.pub3 | pmid = 28067944| pmc = 6472672 }}</ref> | |||
Some studies have shown little evidence for the effectiveness of CBT in either reducing symptoms or preventing relapse.<ref>{{cite journal | vauthors = Jauhar S, McKenna PJ, Radua J, Fung E, Salvador R, Laws KR | title = Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias | journal = The British Journal of Psychiatry | volume = 204 | issue = 1 | pages = 20–29 | date = January 2014 | pmid = 24385461 | doi = 10.1192/bjp.bp.112.116285 | type = Review | doi-access = free }}</ref><ref name=Jones2018>{{cite journal | vauthors = Jones C, Hacker D, Meaden A, Cormac I, Irving CB, Xia J, Zhao S, Shi C, Chen J | title = Cognitive behavioural therapy plus standard care versus standard care plus other psychosocial treatments for people with schizophrenia | journal = The Cochrane Database of Systematic Reviews | volume = 11 | issue = 11 | pages = CD008712 | date = November 2018 | pmid = 30480760 | pmc = 6516879 | doi = 10.1002/14651858.CD008712.pub3 }}</ref> However, other studies have found that CBT does improve overall psychotic symptoms (when in use with medication) and it has been recommended in Canada, but has been seen to have no effect on social function, relapse, or quality of life.<ref>{{cite journal | title = Cognitive Behavioural Therapy for Psychosis: A Health Technology Assessment| journal = Ontario Health Technology Assessment Series | date = 2018 |volume = 18 | issue = 5 |pages = 1–141 | pmid = 30443277 | pmc = 6235075 | author = Health Quality Ontario }}</ref> In the UK it is recommended as an add-on therapy in the treatment of schizophrenia.<ref name=nhsTreatment/><ref name=Jones2018/> ] are seen to improve negative symptoms in some people, and are recommended by NICE in the UK.<ref name=nhsTreatment>{{cite web | title = Schizophrenia – Treatment | url = https://www.nhs.uk/conditions/schizophrenia/treatment/ | publisher= UK ] | access-date = 8 January 2020 | date = 23 October 2017}}</ref> This approach is criticised as having not been well-researched,<ref>{{cite journal | vauthors = Ruddy R, Milnes D | title = Art therapy for schizophrenia or schizophrenia-like illnesses | journal = The Cochrane Database of Systematic Reviews | issue = 4 | page = CD003728 | date = October 2005 | pmid = 16235338 | doi = 10.1002/14651858.CD003728.pub2 | url = http://www.cochrane.org/reviews/en/ab003728.html | archive-url = https://web.archive.org/web/20111027132811/http://www2.cochrane.org/reviews/en/ab003728.html | df = dmy-all | url-status=live | archive-date = 27 October 2011 }}</ref><ref>{{cite journal | vauthors = Ruddy RA, Dent-Brown K | title = Drama therapy for schizophrenia or schizophrenia-like illnesses | journal = The Cochrane Database of Systematic Reviews | issue = 1 | page = CD005378 | date = January 2007 | pmid = 17253555 | doi = 10.1002/14651858.CD005378.pub2 | url = http://www.cochrane.org/reviews/en/ab005378.html | archive-url = https://web.archive.org/web/20110825024045/http://www2.cochrane.org/reviews/en/ab005378.html | df = dmy-all | url-status=live | archive-date = 25 August 2011 }}</ref> and arts therapies are not recommended in Australian guidelines for example.<ref>{{cite journal |vauthors=Galletly C, Castle D, Dark F, et al |title=Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders |journal=Aust N Z J Psychiatry |volume=50 |issue=5 |pages=410–472 |date=May 2016 |pmid=27106681 |doi=10.1177/0004867416641195 |s2cid=6536743 |url=|doi-access=free }}</ref> ], in which people with ] of schizophrenia, provide help to each other, is of unclear benefit.<ref>{{cite journal |vauthors= Chien WT, Clifton AV, Zhao S, Lui S |title=Peer support for people with schizophrenia or other serious mental illness. |journal=The Cochrane Database of Systematic Reviews |date=4 April 2019 |volume=4 |issue=6 |page=CD010880 |doi=10.1002/14651858.CD010880.pub2 |pmid=30946482|pmc=6448529 }}</ref> | |||
===Other=== | ===Other=== | ||
Exercise including aerobic exercise has been shown to improve positive and negative symptoms, cognition, working memory, and improve quality of life.<ref name=Girdler2019>{{cite journal | vauthors =Girdler SJ, Confino JE, Woesner ME | title = Exercise as a Treatment for Schizophrenia: A Review. |journal= Psychopharmacology Bulletin | date = 15 February 2019 | volume = 49 | issue = 1 | pages=56–69 | pmid=30858639| pmc = 6386427 }}</ref><ref name=Firth2017>{{cite journal | vauthors = Firth J | title = Aerobic Exercise Improves Cognitive Functioning in People With Schizophrenia: A Systematic Review and Meta-Analysis | journal = Schizophrenia Bulletin | date = 1 May 2017 | volume = 43 | issue = 3 | pages = 546–556 | doi = 10.1093/schbul/sbw115 | pmid = 27521348| pmc = 5464163 }}</ref> Exercise has also been shown to increase the volume of the ] in those with schizophrenia. A decrease in hippocampal volume is one of the factors linked to the development of the disease.<ref name=Girdler2019/> However, there still remains the problem of increasing motivation for, and maintaining participation in physical activity.<ref>{{cite journal | vauthors = Tréhout M, Dollfus S |title = . | journal = L'Encéphale | date = December 2018 | volume = 44 | issue = 6 | pages = 538–547 | doi=10.1016/j.encep.2018.05.005 | pmid = 29983176|s2cid = 150334210 }}</ref> Supervised sessions are recommended.<ref name=Firth2017/> In the UK healthy eating advice is offered alongside exercise programs.<ref>{{cite web |title=Quality statement 7: Promoting healthy eating, physical activity and smoking cessation {{!}} Psychosis and schizophrenia in adults |date=12 February 2015 |url=https://www.nice.org.uk/guidance/qs80/chapter/Quality-statement-7-Promoting-healthy-eating-physical-activity-and-smoking-cessation |publisher= UK ]}}</ref> | |||
] is not considered a ] but may be prescribed in cases where other treatments have failed. It is more effective where symptoms of catatonia are present,<ref>{{cite journal |author=Greenhalgh J, Knight C, Hind D, Beverley C, Walters S |year=2005 |month=March |title= Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies.|journal= Health Technol Assess.|volume= 9|issue=9 |pages=1-156 |url=http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15774232 (abstract) |accessdate= 2007-06-17}}</ref> and is recommended for use under ] guidelines in the UK for catatonia if previously effective, though there is no recommendation for use for schizophrenia otherwise.<ref>{{cite web |url=http://www.nice.org.uk/page.aspx?o=TA059 |title= The clinical effectiveness and cost effectiveness of electroconvulsive Therapy (ECT) for depressive illness, schizophrenia, catatonia and mania.|accessdate=2007-06-17 |author= National Institute for Health and Clinical Excellence|year= 2003|month=April |publisher= National Institute for Health and Clinical Excellence|language= English}}</ref> ] has now become a rare procedure and is not a recommended treatment for schizophrenia.<ref name="Mashour_et_al_2005">Mashour GA, Walker EE, Martuza RL. (2005) Psychosurgery: past, present, and future. ''Brain Research: Brain Research Reviews'', 48 (3), 409-19. PMID 15914249</ref> | |||
An inadequate diet is often found in schizophrenia, and associated vitamin deficiencies including those of ], and ] are linked to the risk factors for the development of schizophrenia and for early death including heart disease.<ref name=Firth2018>{{cite journal | vauthors = Firth J, Carney R, Stubbs B, Teasdale SB, Vancampfort D, Ward PB, Berk M, Sarris J | title = Nutritional Deficiencies and Clinical Correlates in First-Episode Psychosis: A Systematic Review and Meta-analysis | journal = Schizophrenia Bulletin | volume = 44 | issue = 6 | pages = 1275–1292 | date = October 2018 | pmid = 29206972 | pmc = 6192507 | doi = 10.1093/schbul/sbx162 }}</ref><ref name=Rastogi2020>{{cite journal | vauthors = Rastogi A, Viani-Walsh D, Akbari S, Gall N, Gaughran F, Lally J | title = Pathogenesis and management of Brugada syndrome in schizophrenia: A scoping review | journal = General Hospital Psychiatry | volume = 67 | pages = 83–91 | date = October 2020 | pmid = 33065406 | pmc = 7537626 | doi = 10.1016/j.genhosppsych.2020.09.003 }}</ref> Those with schizophrenia possibly have the worst diet of all the mental disorders. Lower levels of folate and vitamin D have been noted as significantly lower in first episode psychosis.<ref name=Firth2018/> The use of supplemental folate is recommended.<ref>{{cite journal | vauthors = Martone G | title = Enhancement of recovery from mental illness with l-methylfolate supplementation | journal = Perspectives in Psychiatric Care | volume = 54 | issue = 2 | pages = 331–334 | date = April 2018 | pmid = 28597528 | doi = 10.1111/ppc.12227 | doi-access = free }}</ref> A ] has also been noted.<ref name=Firth2019>{{cite journal | vauthors = Firth J, Teasdale SB, Allott K, Siskind D, Marx W, Cotter J, Veronese N, Schuch F, Smith L, Solmi M, Carvalho AF, Vancampfort D, Berk M, Stubbs B, Sarris J | title = The efficacy and safety of nutrient supplements in the treatment of mental disorders: a meta-review of meta-analyses of randomized controlled trials | journal = World Psychiatry | volume = 18 | issue = 3 | pages = 308–324 | date = October 2019 | pmid = 31496103 | pmc = 6732706 | doi = 10.1002/wps.20672 }}</ref> ] is also often deficient and this is linked to worse symptoms. Supplementation with B vitamins has been shown to significantly improve symptoms, and to put in reverse some of the cognitive deficits.<ref name=Firth2018/> It is also suggested that the noted dysfunction in gut microbiota might benefit from the use of ].<ref name=Firth2019/> | |||
Service-user led movements have become integral to the recovery process in ] and ]; groups such as the ] and the ] have developed a self-help approach that aims to provide support and assistance outside the traditional medical model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of criteria for ] or ], they aim to destigmatize the experience and encourage individual responsibility and a positive self-image. Partnerships between hospitals and consumer-run groups are becoming more common, with services working toward remediating social withdrawal, building social skills and reducing rehospitalization.<ref name="Goering_et_al_2006">Goering P, Durbin J, Sheldon CT, Ochocka J, Nelson G, Krupa T. Who uses consumer-run self-help organizations? ''American Journal of Orthopsychiatry'', 76 (3), 367-73. PMID 16981815</ref> | |||
==Prognosis== | ==Prognosis== | ||
{{Main|Prognosis of schizophrenia}}{{See also|Physical health in schizophrenia}} | |||
Numerous international studies have demonstrated favorable long-term outcomes for around half of those diagnosed with schizophrenia, with substantial variation between individuals and regions.<Ref>Harrison G, Hopper K, Craig T, Laska E, Siegel C, Wanderling J, Dube KC, Ganev K, Giel R, an der Heiden W, Holmberg SK, Janca A, Lee PW, León CA, Malhotra S, Marsella AJ, Nakane Y, Sartorius N, Shen Y, Skoda C, Thara R, Tsirkin SJ, Varma VK, Walsh D, Wiersma D. (2001) Recovery from psychotic illness: a 15- and 25-year international follow-up study. ''Br J Psychiatry.'' Jun;178:506-17. PMID 11388966</ref> One retrospective study found that about a third of people made a full recovery, about a third showed improvement but not a full recovery, and a third remained ill.<ref name="fn_42">Harding CM, Brooks GW, Ashikaga T, Strauss JS, Breier A (1987). The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. ''American Journal of Psychiatry'', 144(6), 727–35. PMID 3591992</ref> A clinical study using strict recovery criteria (concurrent remission of positive and negative symptoms and adequate social and vocational functioning continuously for two years) found a recovery rate of 14% within the first five years.<ref name="fn_43">Robinson DG, Woerner MG, McMeniman M, Mendelowitz A, Bilder RM (2004). Symptomatic and functional recovery from a first episode of schizophrenia or ]. ''American Journal of Psychiatry'', 161, 473–479. PMID 14992973</ref> A 5-year community study found that 62% showed overall improvement on a composite measure of symptomatic, clinical and functional outcomes.<ref>Harvey, C.A., Jeffreys, S.E., McNaught, A.S., Blizard, R.A., King, M.B.(2007) ''International Journal of Social Psychiatry,'' Vol. 53, No. 4, 340-356</ref> Rates are not always comparable across studies because an exact definition of what constitutes recovery has not been widely accepted, although standardized criteria have been suggested.<ref name="fn_63" /> | |||
]s lost due to schizophrenia per 100,000 inhabitants in 2004 | |||
{{Col-begin}} | |||
{{Col-break}} | |||
{{legend|#b3b3b3|no data}} | |||
{{legend|#ffff65|≤ 185}} | |||
{{legend|#fff200|185–197}} | |||
{{legend|#ffdc00|197–207}} | |||
{{legend|#ffc600|207–218}} | |||
{{legend|#ffb000|218–229}} | |||
{{legend|#ff9a00|229–240}} | |||
{{Col-break}} | |||
{{legend|#ff8400|240–251}} | |||
{{legend|#ff6e00|251–262}} | |||
{{legend|#ff5800|262–273}} | |||
{{legend|#ff4200|273–284}} | |||
{{legend|#ff2c00|284–295}} | |||
{{legend|#cb0000|≥ 295}} | |||
{{col-end}}]] | |||
<!-- Life expectancy --> | |||
Schizophrenia has great human and economic costs.<ref name=Lancet2016/> It decreases life expectancy by between 10<ref name=Laursen2014/><!-- Laursen2014 shows a range of 10-25 in the article text--> and 28 years.<ref name=NIHStat/> This is primarily because of its association with heart disease,<ref name=Kritharides2017>{{cite journal |vauthors=Kritharides L, Chow V, Lambert TJ |date=6 February 2017 |title=Cardiovascular disease in patients with schizophrenia |journal=The Medical Journal of Australia |volume=206 |issue=2 |pages=91–95 |doi=10.5694/mja16.00650 |pmid=28152356 |s2cid=5388097}}</ref> diabetes,<ref name=NIHStat/> ], poor diet, a ], and smoking, with an increased rate of suicide playing a lesser role.<ref name=Laursen2014/><ref>{{cite journal | vauthors = Erlangsen A, Eaton WW, Mortensen PB, Conwell Y | title = Schizophrenia—a predictor of suicide during the second half of life? | journal = Schizophrenia Research | volume = 134 | issue = 2–3 | pages = 111–117 | date = February 2012 | pmid = 22018943 | pmc = 3266451 | doi = 10.1016/j.schres.2011.09.032 }}</ref> Side effects of antipsychotics may also increase the risk.<ref name=Laursen2014/> | |||
Almost 40% of those with schizophrenia die from complications of cardiovascular disease which is seen to be increasingly associated.<ref name=Rastogi2020/> An underlying factor of sudden cardiac death may be ] (BrS) – BrS mutations that overlap with those linked with schizophrenia are the ] mutations.<ref name=Rastogi2020/> BrS may also be drug-induced from certain antipsychotics and antidepressants.<ref name=Rastogi2020/> ], or excessive fluid intake, is relatively common in people with chronic schizophrenia.<ref>{{cite book| vauthors = Goroll AH, Mulley AG |title=Primary Care Medicine: Office Evaluation and Management of The Adult Patient |edition=Sixth|date=2011|publisher=Lippincott Williams & Wilkins|isbn=978-1-4511-2159-9|page=Chapter 101|url=https://books.google.com/books?id=fXpKo1afC2YC&pg=PT1766}}</ref><ref name=Rizvi2019>{{cite journal | vauthors = Rizvi S, Gold J, Khan AM | title = Role of Naltrexone in Improving Compulsive Drinking in Psychogenic Polydipsia. | journal = Cureus | date = 5 August 2019 | volume = 11 | issue = 8 | page =e5320 | doi = 10.7759/cureus.5320 | doi-access = free | pmid = 31598428| pmc = 6777931 }}</ref> This may lead to ] which can be life-threatening. Antipsychotics can lead to a ], but there are several other factors that may contribute to the disorder; it may reduce life expectancy by 13 percent.<ref name=Rizvi2019/> Barriers to improving the mortality rate in schizophrenia are poverty, overlooking the symptoms of other illnesses, stress, stigma, and medication side effects.<ref>{{cite journal |vauthors=Seeman MV |s2cid=170078453 |title=Schizophrenia Mortality: Barriers to Progress |journal=The Psychiatric Quarterly |volume=90 |issue=3 |pages=553–563 |date=September 2019 |pmid=31147816 |doi=10.1007/s11126-019-09645-0}}</ref> | |||
The ] conducted two long-term follow-up studies involving more than 2,000 people suffering from schizophrenia in different countries. These studies found patients have much better long-term outcomes in developing countries (], ] and ]) than in developed countries (], ], ], ], ], ], ], and ]),<ref name="fn_44">Hopper K, Wanderling J (2000). Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. '']'', 26 (4), 835–46. PMID 11087016</ref> despite the fact antipsychotic drugs are typically not widely available in poorer countries, raising questions about the effectiveness of such drug-based treatments. | |||
<!-- Disability --> | |||
Several factors are associated with a better prognosis: Being female, acute (vs. insidious) onset of symptoms, older age of first episode, predominantly positive (rather than negative) symptoms, presence of mood symptoms and good premorbid functioning.<ref name="Davidson_Glashan_1997">Davidson L, McGlashan TH. (1997) The varied outcomes of schizophrenia. ''Canadian Journal of Psychiatry'', 42 (1), 34–43. PMID 9040921</ref><ref name="Lieberman_et_al_1996">Lieberman JA, Koreen AR, Chakos M, Sheitman B, Woerner M, Alvir JM, Bilder R. (1996) Factors influencing treatment response and outcome of first-episode schizophrenia: implications for understanding the pathophysiology of schizophrenia. ''Journal of Clinical Psychiatry'', 57 Suppl 9, 5–9. PMID 8823344</ref> Most studies done on this subject, however, are correlational in nature, and a clear cause-and-effect relationship is difficult to establish. Evidence is also consistent that negative attitudes towards individuals with schizophrenia can have a significant adverse impact. In particular, critical comments, hostility, authoritarian and intrusive or controlling attitudes (termed high ']' or 'EE' by researchers) from family members have been found to correlate with a higher risk of relapse in schizophrenia across cultures.<ref name="fn_70">Bebbington PE, Kuipers E (1994). The predictive utility of expressed emotion in schizophrenia: an aggregate analysis. ''Psychological Medicine'', 24, 707–718. PMID 7991753</ref> | |||
Schizophrenia is a major cause of ]. In 2016, it was classed as the 12th most disabling condition.<ref>{{cite journal | vauthors = Charlson FJ, Ferrari AJ, Santomauro DF, Diminic S, Stockings E, Scott JG, McGrath JJ, Whiteford HA | title = Global Epidemiology and Burden of Schizophrenia: Findings From the Global Burden of Disease Study 2016 | journal = Schizophrenia Bulletin | volume = 44 | issue = 6 | pages = 1195–1203 | date = October 2018 | pmid = 29762765 | pmc = 6192504 | doi = 10.1093/schbul/sby058 }}</ref> Approximately 75% of people with schizophrenia have ongoing disability with relapses.<ref>{{cite journal | vauthors = Smith T, Weston C, Lieberman J | title = Schizophrenia (maintenance treatment) | journal = American Family Physician | volume = 82 | issue = 4 | pages = 338–339 | date = August 2010 | pmid = 20704164}}</ref> Some people do recover completely and others function well in society.<ref>{{cite journal | vauthors = Warner R | s2cid = 26666000 | title = Recovery from schizophrenia and the recovery model | journal = Current Opinion in Psychiatry | volume = 22 | issue = 4 | pages = 374–380 | date = July 2009 | pmid = 19417668 | doi = 10.1097/YCO.0b013e32832c920b }}</ref> Most people with schizophrenia live independently with community support.<ref name=Lancet2009/> About 85% are unemployed.<ref name=Lancet2016/> In people with a first episode of psychosis in schizophrenia a good long-term outcome occurs in 31%, an intermediate outcome in 42% and a poor outcome in 31%.<ref>{{cite journal | vauthors = Menezes NM, Arenovich T, Zipursky RB | s2cid = 23475454 | title = A systematic review of longitudinal outcome studies of first-episode psychosis | journal = Psychological Medicine | volume = 36 | issue = 10 | pages = 1349–62 | date = October 2006 | pmid = 16756689 | doi = 10.1017/S0033291706007951 | url = https://pdfs.semanticscholar.org/8539/923c1b4f6bacb128d478b9ec7f6e95559210.pdf | archive-url = https://web.archive.org/web/20200922015257/https://pdfs.semanticscholar.org/8539/923c1b4f6bacb128d478b9ec7f6e95559210.pdf | archive-date = 22 September 2020}}</ref> Males are affected more often than females, and have a worse outcome.<ref>{{cite book |vauthors=Coyle JT |title=Neurodegenerative Diseases |chapter=Schizophrenia: Basic and Clinical |series=Advances in Neurobiology |volume=15 |pages=255–280 |date=2017 |pmid=28674984 |doi=10.1007/978-3-319-57193-5_9|isbn=978-3-319-57191-1 }}</ref> Studies showing that outcomes for schizophrenia appear better in the ] than the ]<ref name=Isa07>{{cite journal | vauthors = Isaac M, Chand P, Murthy P | title = Schizophrenia outcome measures in the wider international community | journal = The British Journal of Psychiatry. Supplement | volume = 50 | pages = s71–77 | date = August 2007 | pmid = 18019048 | doi = 10.1192/bjp.191.50.s71 | doi-access = free }}</ref> have been questioned.<ref>{{cite journal | vauthors = Cohen A, Patel V, Thara R, Gureje O | title = Questioning an axiom: better prognosis for schizophrenia in the developing world? | journal = Schizophrenia Bulletin | volume = 34 | issue = 2 | pages = 229–244 | date = March 2008 | pmid = 17905787 | pmc = 2632419 | doi = 10.1093/schbul/sbm105 }}</ref> Social problems, such as long-term unemployment, poverty, homelessness, exploitation, ] and victimization are common consequences, and lead to ].<ref name=Killaspy2014/><ref name=Charleson2018/> | |||
<!-- Suicide --> | |||
===Mortality=== | |||
There is a higher than average ] associated with schizophrenia estimated at 5% to 6%, most often occurring in the period following onset or first hospital admission.<ref name=Ferri2019>{{cite book |title=Ferri's clinical advisor 2019: 5 books in 1 |pages=1225–1226|date=2019 |isbn=9780323530422 | vauthors = Ferri FF |publisher=Elsevier }}</ref><ref name=Jop2010/> Several times more (20 to 40%) attempt suicide at least once.<ref name=DSM5/><ref name=Chiang2016/> There are a variety of risk factors, including male sex, depression, a high ],<ref>{{cite journal | vauthors = Carlborg A, Winnerbäck K, Jönsson EG, Jokinen J, Nordström P | s2cid = 204385719 | title = Suicide in schizophrenia | journal = Expert Review of Neurotherapeutics | volume = 10 | issue = 7 | pages = 1153–1164 | date = July 2010 | pmid = 20586695 | doi = 10.1586/ern.10.82 | doi-access = free }}</ref> heavy smoking,<ref>{{cite journal |vauthors=Tsoi DT, Porwal M, Webster AC |title=Interventions for smoking cessation and reduction in individuals with schizophrenia |journal=The Cochrane Database of Systematic Reviews |issue=2 |page=CD007253 |date=28 February 2013 |volume=2013 |pmid=23450574|doi=10.1002/14651858.CD007253.pub3|pmc=6486303 }}</ref> and substance use.<ref name=Khokhar2018/> Repeated relapse is linked to an increased risk of suicidal behavior.<ref name=Taylor2019/> The use of clozapine can reduce the risk of suicide, and of aggression.<ref>{{cite journal |vauthors=Sriretnakumar V, Huang E, Müller DJ |date=2015 |title=Pharmacogenetics of clozapine treatment response and side-effects in schizophrenia: an update |journal=Expert Opinion on Drug Metabolism & Toxicology |volume=11 |issue=11 |pages=1709–1731 |doi=10.1517/17425255.2015.1075003 |pmid=26364648 |s2cid=207492339}}</ref> | |||
In a study of over 168,000 Swedish citizens undergoing psychiatric treatment, schizophrenia was associated with an average life expectancy of approximately 80–85% of that of the general population. Women with a diagnosis of schizophrenia were found to have a slightly better life expectancy than that of men, and as a whole, a diagnosis of schizophrenia was associated with a better life expectancy than ], ], ] and ].<ref name="fn_45">Hannerz H, Borga P, Borritz M (2001). Life expectancies for individuals with psychiatric diagnoses. ''Public Health'', 115 (5), 328–37. PMID 11593442</ref> There is a high ] rate associated with schizophrenia; a recent study showed that 30% of patients diagnosed with this condition had attempted suicide at least once during their lifetime.<ref name="fn_46">Radomsky ED, Haas GL, Mann JJ, Sweeney JA (1999). Suicidal behavior in patients with schizophrenia and other psychotic disorders. ''American Journal of Psychiatry'', 156(10), 1590–5. PMID 10518171</ref> <ref name="fn_128">Williams R, Dalby JT. Eds. (1989). Depression in Schizophrenics. New York: Plenum Publishing.</ref>Another study suggested that 10% of persons with schizophrenia die by suicide.<ref name="fn_47">Caldwell CB, Gottesman II. (1990). Schizophrenics kill themselves too: a review of risk factors for suicide. '']'', 16(4), 571–89. PMID 2077636</ref> Other identified factors include smoking, poor diet, little exercise and the negative health effects of psychiatric drugs.<ref name="Brown_Barraclough_2000" /> | |||
<!-- Drug use --> | |||
A strong association between ] has been shown in worldwide studies.<ref>{{cite journal | vauthors = de Leon J, Diaz FJ | s2cid = 32975940 | title = A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors | journal = Schizophrenia Research | volume = 76 | issue = 2–3 | pages = 135–157 | date = July 2005 | pmid = 15949648 | doi = 10.1016/j.schres.2005.02.010 }}</ref><ref name=Keltner2006>{{cite journal | vauthors = Keltner NL, Grant JS | title = Smoke, smoke, smoke that cigarette | journal = Perspectives in Psychiatric Care | volume = 42 | issue = 4 | pages = 256–261 | date = November 2006 | pmid = 17107571 | doi = 10.1111/j.1744-6163.2006.00085.x }}</ref> ] is especially high in those diagnosed with schizophrenia, with estimates ranging from 80 to 90% being regular smokers, as compared to 20% of the general population.<ref name=Keltner2006/> Those who smoke tend to smoke heavily, and additionally smoke cigarettes with high nicotine content.<ref name=DSMIV/> Some propose that this is in an effort to improve symptoms.<ref>{{cite journal | vauthors = Kumari V, Postma P | s2cid = 15581894 | title = Nicotine use in schizophrenia: the self medication hypotheses | journal = Neuroscience and Biobehavioral Reviews | volume = 29 | issue = 6 | pages = 1021–1034 | date = January 2005 | pmid = 15964073 | doi = 10.1016/j.neubiorev.2005.02.006 }}</ref> Among people with schizophrenia use of cannabis is also common.<ref name=Khokhar2018/> | |||
Schizophrenia leads to an increased risk of dementia.<ref>{{cite journal |vauthors=Cai L, Huang J |title=Schizophrenia and risk of dementia: a meta-analysis study |journal=Neuropsychiatr Dis Treat |volume=14 |issue= |pages=2047–2055 |date=2018 |pmid=30147318 |pmc=6095111 |doi=10.2147/NDT.S172933 |doi-access=free }}</ref> | |||
===Violence=== | ===Violence=== | ||
Most people with schizophrenia are not aggressive, and are more likely to be victims of violence rather than perpetrators.<ref name=DSM5/> People with schizophrenia are commonly exploited and victimized by violent crime as part of a broader dynamic of social exclusion.<ref name=Killaspy2014/><ref name=Charleson2018/> People diagnosed with schizophrenia are also subject to forced drug injections, seclusion, and restraint at high rates.<ref name=BeckerKilian2006/><ref name=Capdevielle2009/> | |||
The relationship between violent acts and schizophrenia is a contentious topic. Current research indicates that the percentage of people with schizophrenia who commit violent acts is higher than the percentage of people without any disorder, but lower than is found for disorders such as alcoholism, and the difference is reduced or not found in same-neighbourhood comparisons when related factors are taken into account, notably sociodemographic variables and substance misuse.<ref name="Walsh02">Walsh E, Buchanan A, Fahy T (2002). Violence and schizophrenia: examining the evidence. ''British Journal of Psychiatry.'' 2002 Jun;180:490–5. PMID 12042226</ref><ref name="Stuart 03">Stuart, H (2003). Violence and mental illness: an overview. ''World Psychiatry.'' June; 2(2): 121–124. PMID 16946914 Retrieved on ].</ref><ref>Steadman HJ, Mulvey EP, Monahan J, ''et al'' (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. ''Archives of General Psychiatry.'' May;55(5):393–401. PMID 9596041</ref><ref>Swanson JW, Swartz MS, Van Dorn RA, Elbogen EB, ''et al'' (2006). A national study of violent behavior in persons with schizophrenia. ''Archives of General Psychiatry.'' May;63(5):490–9. PMID 16651506</ref><ref>Swanson JW, Holzer CE, Ganju VK, Jono RT. (1990) Violence and Psychiatric Disorder in the Community: Evidence From the Epidemiologic Catchment Area Surveys ''Hosp Community Psychiatry'' 41:761-770, July 1990 PMID 2142118</ref> Studies have indicated that 5% to 10% of those charged with murder in Western countries have a schizophrenia spectrum disorder.<ref name="Mullen 06">Mullen PE (2006). Schizophrenia and violence: from correlations to preventive strategies. ''Advances in Psychiatric Treatment'' 12: 239–248. Retrieved on ].</ref><ref name="fn_52">Simpson AI, McKenna B, Moskowitz A, Skipworth J, Barry-Walsh J (2004). Homicide and mental illness in New Zealand, 1970–2000. ''British Journal of Psychiatry'', 185, 394–8. PMID 15516547</ref><ref name="fn_53">Fazel S, Grann M (2004). Psychiatric morbidity among homicide offenders: a Swedish population study. ''American Journal of Psychiatry'', 161(11), 2129–31. PMID 15514419</ref> | |||
The risk of violence by people with schizophrenia is small. There are minor subgroups where the risk is high.<ref name=Richard-Devantoy2009>{{cite journal |vauthors=Richard-Devantoy S, Olie JP, Gourevitch R |title= |journal=L'Encephale |volume=35 |issue=6 |pages=521–530 |date=December 2009 |pmid=20004282 |doi=10.1016/j.encep.2008.10.009}}</ref> This risk is usually associated with a comorbid disorder such as a substance use disorder – in particular alcohol, or with antisocial personality disorder.<ref name=Richard-Devantoy2009/> Substance use disorder is strongly linked, and other risk factors are linked to deficits in cognition and social cognition including facial perception and insight that are in part included in ] impairments.<ref>{{cite journal |vauthors=Ng R, Fish S, Granholm E |title=Insight and theory of mind in schizophrenia. |journal=Psychiatry Research |volume=225 |issue=1–2 |pages=169–174 |date=30 January 2015 |pmid=25467703 |doi=10.1016/j.psychres.2014.11.010|pmc=4269286 }}</ref><ref>{{cite journal |vauthors=Bora E |title=Relationship between insight and theory of mind in schizophrenia: A meta-analysis |journal=Schizophrenia Research |volume=190 |pages=11–17 |date=December 2017 |pmid=28302393 |doi=10.1016/j.schres.2017.03.029|s2cid=36263370 }}</ref> Poor cognitive functioning, decision-making, and facial perception may contribute to making a wrong judgement of a situation that could result in an inappropriate response such as violence.<ref>{{cite journal |vauthors=Darmedru C, Demily C, Franck N |title= |journal=L'Encephale |volume=44 |issue=2 |pages=158–167 |date=April 2018 |pmid=28641817 |doi=10.1016/j.encep.2017.05.001}}</ref> These associated risk factors are also present in antisocial personality disorder which when present as a comorbid disorder greatly increases the risk of violence.<ref>{{cite journal | vauthors = Richard-Devantoy S, Bouyer-Richard AI, Jollant F, Mondoloni A, Voyer M, Senon JL | title = | journal = Revue d'Épidemiologie et de Santé Publique | volume = 61 | issue = 4 | pages = 339–350 | date = August 2013 | pmid = 23816066 | doi = 10.1016/j.respe.2013.01.096 }}</ref><ref>{{cite journal | vauthors = Sedgwick O, Young S, Baumeister D, Greer B, Das M, Kumari V | title = Neuropsychology and emotion processing in violent individuals with antisocial personality disorder or schizophrenia: The same or different? A systematic review and meta-analysis | journal = The Australian and New Zealand Journal of Psychiatry | volume = 51 | issue = 12 | pages = 1178–1197 | date = December 2017 | pmid = 28992741 | doi = 10.1177/0004867417731525 | s2cid = 206401875 | doi-access = free }}</ref> | |||
The occurrence of ] in schizophrenia has sometimes been linked to a higher risk of violent acts. Findings on the specific role of delusions or hallucinations have been inconsistent, but have focused on delusional jealousy, perception of threat and command hallucinations. It has been proposed that a certain type of individual with schizophrenia may be most likely to offend, characterized by a history of educational difficulties, low IQ, conduct disorder, early-onset substance misuse and offending prior to diagnosis.<ref name= "Mullen 06"/> | |||
==Epidemiology== | |||
A consistent finding is that individuals with a diagnosis of schizophrenia are often the victims of violent crime—at least 14 times more often than they are perpetrators.<ref>Brekke JS, Prindle C, Bae SW, Long JD (2001). Risks for individuals with schizophrenia who are living in the community. ''Psychiatric Services.'' Oct;52(10):1358–66. PMID 11585953</ref><ref name="fn_55">Fitzgerald PB, de Castella AR, Filia KM, Filia SL, Benitez J, Kulkarni J (2005). Victimization of patients with schizophrenia and related disorders. ''Australia and New Zealand Journal of Psychiatry'', 39(3), 169-74. (1), 187–9. PMID 15701066</ref> Another consistent finding is a link to substance misuse, particularly alcohol,<ref name="fn_51">Walsh E, Gilvarry C, Samele C, ''et al'' (2004). Predicting violence in schizophrenia: a prospective study. ''Schizophrenia Research'', 67(2–3), 247-52. PMID 14984884</ref> among the minority who commit violent acts. Violence by or against individuals with schizophrenia typically occurs in the context of complex social interactions within a family setting,<ref> Solomon PL, Cavanaugh MM, Gelles RJ (2005). Family Violence among Adults with Severe Mental Illness. ''Trauma, Violence, & Abuse'', Vol. 6, No. 1, 40–54. PMID 15574672</ref> and is also an issue in clinical services<ref>Chou KR, Lu RB, Chang M (2001). Assaultive behavior by psychiatric in-patients and its related factors. ''Journal of Nursing Research.'' Dec;9(5):139–51. PMID 11779087</ref> and in the wider community.<ref>Logdberg B, Nilsson LL, Levander MT, Levander S (2004). Schizophrenia, neighbourhood, and crime. ''Acta Psychiatrica Scandinavica,'' 110(2) Page 92. PMID 15233709 Retrieved on ]</ref> | |||
{{Main|Epidemiology of schizophrenia}} | |||
[[File:Schizophrenia world map-Deaths per million persons-WHO2012.svg|thumb|upright=1.3|Deaths per million persons due to schizophrenia in 2012 | |||
{{Div col|small=yes|colwidth=10em}} | |||
{{legend|#ffff20|0–0}}{{legend|#ffc020|1–1}}{{legend|#ff9a20|2–2}}{{legend|#f08015|3–3}}{{legend|#d85010|4–6}}{{legend|#d02010|7–20}}{{div col end}}]] | |||
In 2017,{{update after|2022|8|22}} the ] estimated there were 1.1 million new cases;<ref name=GBD2018/> in 2022 the World Health Organization (WHO) reported a total of 24 million cases globally.<ref name=WHO2022/> Schizophrenia affects around 0.3–0.7% of people at some point in their life.<ref name=Javitt2014/><ref name=NIHStat>{{cite web|title=Schizophrenia |url= http://www.nimh.nih.gov/health/statistics/prevalence/schizophrenia.shtml |date= 22 April 2022 |access-date= 23 August 2022 |publisher= US ] (NIMH)|work= Statistics}}</ref> In areas of conflict this figure can rise to between 4.0 and 6.5%.<ref>{{cite journal | vauthors = Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford H, Saxena S | title = New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis | journal = Lancet | volume = 394 | issue = 10194 | pages = 240–248 | date = July 2019 | pmid = 31200992 | pmc = 6657025 | doi = 10.1016/S0140-6736(19)30934-1 }}</ref> It occurs 1.4 times more frequently in males than females and typically appears earlier in men.<ref name=BMJ07/> | |||
Worldwide, schizophrenia is the most common ].<ref name=Kar2016/> The frequency of schizophrenia varies across the world,<ref name=DSM5/> within countries,<ref>{{cite journal | vauthors = Kirkbride JB, Fearon P, Morgan C, Dazzan P, Morgan K, Tarrant J, Lloyd T, Holloway J, Hutchinson G, Leff JP, Mallett RM, Harrison GL, Murray RM, Jones PB | title = Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AeSOP study | journal = Archives of General Psychiatry | volume = 63 | issue = 3 | pages = 250–258 | date = March 2006 | pmid = 16520429 | doi = 10.1001/archpsyc.63.3.250 | doi-access = free }}</ref> and at the local and neighborhood level;<ref>{{cite journal | vauthors = Kirkbride JB, Fearon P, Morgan C, Dazzan P, Morgan K, Murray RM, Jones PB | title = Neighbourhood variation in the incidence of psychotic disorders in Southeast London | journal = Social Psychiatry and Psychiatric Epidemiology | volume = 42 | issue = 6 | pages = 438–445 | date = June 2007 | pmid = 17473901 | doi = 10.1007/s00127-007-0193-0 | s2cid = 19655724 }}</ref> this variation in ] between studies over time, across geographical locations, and by gender is as high as fivefold.<ref name=Lancet2016/> | |||
==Screening and prevention== | |||
There are no reliable markers for the later development of schizophrenia although research is being conducted into how well a combination of genetic risk plus non-disabling psychosis-like experience predicts later diagnosis.<ref name="Cannon_et_al_2007">Cannon TD, Cornblatt B, McGorry P. (2007) Editor's Introduction: The Empirical Status of the Ultra High-Risk (Prodromal) Research Paradigm. '']'', 33 (3), 661–4. PMID 17470445</ref> People who fulfil the 'ultra high-risk mental state' criteria, that include a family history of schizophrenia plus the presence of transient or self-limiting psychotic experiences, have a 20–40% chance of being diagnosed with the condition after one year.<ref name="Drake_Lewis_2005">Drake RJ, Lewis SW. (2005) Early detection of schizophrenia. ''Current Opinion in Psychiatry'', 18 (2), 147–50. PMID 16639167</ref> The use of psychological treatments and medication has been found effective in reducing the chances of people who fulfill the 'high-risk' criteria from developing full-blown schizophrenia.<ref name="vanOs_Delespaul_2005">Van Os J, Delespaul P. (2005) Toward a world consensus on prevention of schizophrenia. ''Dialogues in Clinical Neuroscience'', 7 (1), 53–67.</ref> However, the treatment of people who may never develop schizophrenia is controversial, in light of the side-effects of antipsychotic medication; particularly with respect to the potentially disfiguring ] and the rare but potentially lethal ].<ref name="Haroun_et_al_2006">Haroun N, Dunn L, Haroun A, Cadenhead KS. (2006) Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research. '']'', 32 (1), 166–78. PMID 16207892. </ref> The most widely used form of preventative health care for schizophrenia takes the form of public education campaigns that provide information on risk factors, early detection and treatment options.<ref name="Hafner_et_al_2004">Hafner H, Maurer K, Ruhrmann S, ''et al''. (2004) "Early detection and secondary prevention of psychosis: facts and visions". ''European Archives of Psychiatry and Clinical Neuroscience'', 254 (2), 117–28. PMID 15146341</ref> | |||
Schizophrenia causes approximately one percent of worldwide ]{{update after|2022|8|24}}<ref name=BMJ07/> and resulted in 17,000 deaths in 2015.<ref name=GBD2015/> | |||
== Popular views and misconceptions == | |||
] has been identified as a major obstacle in the recovery of patients with schizophrenia.<ref>McGorry, Patrick (2003). "The Influence of Stigma on Preventive Efforts in Psychotic Disorders," in ''Schizophrenia (WPA Series in Evidence & Experience in Psychiatry)'', p. 292.</ref> 12.8% of a large, representative sample of Americans in a 1999 study believed that individuals with schizophrenia were "very likely" to do something violent against others, and 48.1% said that they were "somewhat likely" to. Over 74% said that people with schizophrenia were either "not very able" or "not able at all" to make decisions concerning their treatment, and 70.2% said the same of money management decisions.<ref>Pescosolido BA, Monahan J, Link BG, Stueve A, Kikuzawa S (1999). "The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems," ''],'' 89(9):1339–45. PMID 10474550</ref> The perception of individuals with psychosis as violent has more than doubled in prevalence since the 1950s, according to one meta-analysis.<ref>Phelan, Jo C., Link, Bruce G., Stueve, Ann, Pescosolido, Bernice A. (1997). "Public Conceptions of Mental Illness in 1950 and 1996: What Is Mental Illness and Is It to be Feared?," ''Journal of Health and Social Behavior'', 41(2):188-207</ref> | |||
In 2000,{{update after|2022|8|22}} WHO found the percentage of people affected and the number of new cases that develop each year is roughly similar around the world, with age-standardized prevalence per 100,000 ranging from 343 in Africa to 544 in Japan and Oceania for men, and from 378 in Africa to 527 in Southeastern Europe for women.<ref>{{update after|2022|8|22}} {{cite web|title=Global burden of schizophrenia in the year 2000|date= 15 August 2006| url=https://www.who.int/healthinfo/statistics/bod_schizophrenia.pdf|publisher=] | vauthors = Ayuso-Mateos JL |access-date=27 February 2013|url-status=live|archive-url=https://web.archive.org/web/20160304075113/http://www.who.int/healthinfo/statistics/bod_schizophrenia.pdf|archive-date=4 March 2016}}</ref> | |||
As public understanding of mental illness as a ] is yet developing, patients may be discouraged by friends or family members from taking prescribed medication.<ref Name="PsychNews00">American Psychiatric Association. Americans Still Cling to Myths About Mental Illness, Survey Finds. ''Psychiatric News.'' December 7, 2001 Volume 36 Number 23 </ref> Consumers' views on treatment and recovery may differ from those of mental health professionals.<ref name="Bellack06"/> | |||
==History== | |||
==Alternative approaches== | |||
{{Main|History of schizophrenia}} | |||
An approach broadly known as the ] movement, most active in the 1960s, opposes the orthodox medical view of schizophrenia as an illness.<ref name="Cooper1969">Cooper D (1969) ''The Dialectics of Liberation''. London: Penguin Books Ltd. ISBN 0140210296</ref> Psychiatrist ] argued that psychiatric patients are not ill, but rather individuals with unconventional thoughts and behavior that make society uncomfortable.<ref name="Szasz1984">Szasz T (1984) ''The Myth of Mental Illness: Foundations of a Theory of Personal Contact (revised edition''. New York: Harper and Row. ISBN 0060911514</ref> He argues that society unjustly seeks to control them by classifying their behavior as an illness and forcibly treating them as a method of ]. According to this view, "schizophrenia" does not actually exist but is merely a form of ], created by society's concept of what constitutes normality and abnormality. Szasz has never considered himself to be "anti-psychiatry" in the sense of being against psychiatric treatment, but simply believes that treatment should be conducted between consenting adults, rather than imposed upon anyone against his or her will. Similarly, psychiatrists ], ], ] and ]<ref> {{cite book | last = Colin | first = Ross | title = Schizophrenia: Innovations in Diagnosis and Treatment | publisher = Haworth Press | date = 2004 | isbn = 0789022699}} </ref> have argued that the symptoms of what is called mental illness are comprehensible reactions to impossible demands that society and particularly family life places on some sensitive individuals. Laing, Arieti, Lidz and Ross were notable in valuing the ''content'' of ] experience as worthy of interpretation, rather than considering it simply as a secondary but essentially meaningless marker of underlying psychological or neurological distress. Laing described eleven case studies of people diagnosed with schizophrenia and argued that the content of their actions and statements was meaningful and logical in the context of their family and life situations.<ref>R.D. Laing's and Aaron Esterson. ''Sanity, Madness and the Family'' (1964)</ref> In 1956, ], ] and his colleagues ], ], and ]<ref>Bateson, G., Jackson, D. D., Haley, J. & Weakland, J., 1956, Toward a theory of schizophrenia. (in: 'Behavioral Science', vol.1, 251-264)</ref> articulated a theory of schizophrenia, related to Laing's work, as stemming from ] situations where a person receives different or contradictory messages. Madness was therefore an expression of this distress and should be valued as a ] and trans-formative experience. In the books ''Schizophrenia and the Family'' and ''The Origin and Treatment of Schizophrenic Disorders'' Lidz and his colleagues explain their belief that parental behaviour can result in mental illness in children. Arieti's '']'' won the 1975 scientific ] in the United States. | |||
===Conceptual development=== | |||
The concept of schizophrenia as a result of civilization has been developed further by psychologist ] in his 1976 book '']''; he proposed that until the beginning of historic times, schizophrenia or a similar condition was the normal state of human consciousness.<ref name="Jaynes1976">Jaynes J (1976) ''The Origin of Consciousness in the Breakdown of the Bicameral Mind''. Houghton Mifflin. ISBN 0395207290</ref> This would take the form of a "]" where a normal state of low affect, suitable for routine activities, would be interrupted in moments of crisis by "mysterious voices" giving instructions, which early people characterized as interventions from the gods. Researchers into ]ism have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman;<ref name="fn_57">Polimeni J, Reiss JP (2002). How shamanism and group selection may reveal the origins of schizophrenia. ''Medical Hypothesis'', 58(3), 244–8. PMID 12018978</ref> the experience of having access to multiple realities is not uncommon in schizophrenia, and is a core experience in many shamanic traditions. Equally, the shaman may have the skill to bring on and direct some of the ] psychiatrists label as illness. ], on the other hand, accept the psychiatric diagnoses. However, unlike the current ] they argue that ] causes the shaman's schizoid personalities.<ref>], "The seven stages of historical personality" in ''The Emotional Life of Nations'' (Karnac, 2002). Available at Retrieved on ].</ref> Speculation regarding primary and important religious figures as having schizophrenia abound. Commentators such as ] and others have endorsed the idea that major religious figures experienced psychosis, heard voices and displayed delusions of grandeur.<ref>] (1986). ''The Transcendental Temptation: A Critique of Religion and the Paranormal'' (]) ISBN 0-87975-645-4</ref> | |||
{{Main|History of schizophrenia#Conceptual development}} | |||
{{Further|Dementia praecox}} | |||
].]] | |||
Accounts of a schizophrenia-like ] are rare in records before the 19th century; the earliest case reports were in 1797 and 1809.<ref>{{cite journal | vauthors = Heinrichs RW | title = Historical origins of schizophrenia: two early madmen and their illness | journal = Journal of the History of the Behavioral Sciences | volume = 39 | issue = 4 | pages = 349–363 | year = 2003 | pmid = 14601041 | doi = 10.1002/jhbs.10152 | doi-access = free }}</ref> The term '']'' ("premature dementia") was used by German psychiatrist Heinrich Schüle in 1886 and then in 1891 by ] in a case report of ]. In 1893 ] used the term in making a distinction, known as the ], between the two psychoses: dementia praecox and ] (now called ]).<ref name=Laursen2014/> When it became evident that the disorder was not a degenerative dementia, it was renamed ''schizophrenia'' by ] in 1908.<ref name=Kuhn2004>{{cite journal | vauthors = Kuhn R, Cahn CH | title = Eugen Bleuler's concepts of psychopathology | journal = History of Psychiatry | volume = 15 | issue = 59 Pt 3 | pages = 361–366 | date = September 2004 | pmid = 15386868 | doi = 10.1177/0957154X04044603 | s2cid = 5317716 }}</ref> | |||
The word ''schizophrenia'' ("splitting of the mind") is ], derived from the ] ''schizein'' ({{Langx|grc|σχίζειν|lit=to split}}) and ''phrēn'' ({{langx|grc|φρήν|lit=mind}}).<ref>{{cite web |title=Schizophrenia {{!}} Definition of Schizophrenia by Lexico |url=https://www.lexico.com/en/definition/schizophrenia |archive-url=https://web.archive.org/web/20200310144713/https://www.lexico.com/en/definition/schizophrenia |archive-date=10 March 2020 |publisher=Lexico Dictionaries {{!}} English }}</ref> Its use was intended to describe the separation of function between ], ], memory, and perception.<ref name=Kuhn2004/> | |||
Psychiatrist ] has argued that schizophrenia may be the evolutionary price we pay for a left brain hemisphere specialization for ].<ref name="fn_56">Crow TJ (1997). Schizophrenia as failure of hemispheric dominance for language. ''Trends in Neurosciences'', 20(8), 339–343. PMID 9246721</ref> Since psychosis is associated with greater levels of right brain hemisphere activation and a reduction in the usual left brain hemisphere dominance, our language abilities may have evolved at the cost of causing schizophrenia when this system breaks down. | |||
In the early 20th century, the psychiatrist ] categorized the psychotic symptoms of schizophrenia into two groups: hallucinations and delusions. The hallucinations were listed as specific to auditory and the delusions included thought disorders. These were seen as important symptoms, termed ]. The most common first-rank symptom was found to belong to thought disorders.{{page needed|date=August 2022}}<ref>{{page needed|date=August 2022}} {{cite book| vauthors = Schneider K |author-link1=Kurt Schneider |title=Clinical Psychopathology |edition=5th |year=1959 |publisher=Grune & Stratton |location=New York }}</ref>{{page needed|date=August 2022}}<ref>{{page needed|date=August 2022}} {{cite book | vauthors = Moore D |title=Textbook of Clinical Neuropsychiatry |edition=Second |publisher=CRC Press |date=25 April 2008|isbn=9781444109740 }}</ref> In 2013 the first-rank symptoms were excluded from the DSM-5 criteria;<ref>{{cite journal | vauthors = Tandon R, Gaebel W, Barch DM, Bustillo J, Gur RE, Heckers S, Malaspina D, Owen MJ, Schultz S, Tsuang M, Van Os J, Carpenter W | title = Definition and description of schizophrenia in the DSM-5 | journal = Schizophrenia Research | volume = 150 | issue = 1 | pages = 3–10 | date = October 2013 | pmid = 23800613 | doi = 10.1016/j.schres.2013.05.028 | s2cid = 17314600 }}</ref> while they may not be useful in diagnosing schizophrenia, they can assist in ].<ref>{{cite journal | vauthors = Picardi A | title = The Two Faces of First-Rank Symptoms | journal = Psychopathology | volume = 52 | issue = 4 | pages = 221–231 | date = 2019 | pmid = 31610542 | doi = 10.1159/000503152 | s2cid = 204702486 | doi-access = free }}</ref> | |||
===Alternative medical treatments=== | |||
Subtypes of schizophrenia—classified as paranoid, disorganized, ], undifferentiated, and residual—were difficult to distinguish and are no longer recognized as separate conditions by DSM-5 (2013) or ICD-11.<ref name=Reed2019>{{cite journal | vauthors = Reed GM, First MB, Kogan CS, Hyman SE, Gureje O, Gaebel W, Maj M, Stein DJ, Maercker A, Tyrer P, Claudino A, Garralda E, Salvador-Carulla L, Ray R, Saunders JB, Dua T, Poznyak V, Medina-Mora ME, Pike KM, Ayuso-Mateos JL, Kanba S, Keeley JW, Khoury B, Krasnov VN, Kulygina M, Lovell AM, de Jesus Mari J, Maruta T, Matsumoto C, Rebello TJ, Roberts MC, Robles R, Sharan P, Zhao M, Jablensky A, Udomratn P, Rahimi-Movaghar A, Rydelius PA, Bährer-Kohler S, Watts AD, Saxena S | title = Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders | journal = World Psychiatry | volume = 18 | issue = 1 | pages = 3–19 | date = February 2019 | pmid = 30600616 | pmc = 6313247 | doi = 10.1002/wps.20611 }}</ref><ref>{{Cite web |title=Updates to DSM-5 Criteria & Text |url=https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5/updates-to-dsm-5-criteria-text |access-date=21 February 2019 |publisher=www.psychiatry.org}}</ref><ref>{{cite journal | vauthors = Tandon R | title = Schizophrenia and Other Psychotic Disorders in Diagnostic and Statistical Manual of Mental Disorders (DSM)-5: Clinical Implications of Revisions from DSM-IV | journal = Indian Journal of Psychological Medicine | volume = 36 | issue = 3 | pages = 223–225 | date = July 2014 | pmid = 25035542 | pmc = 4100404 | doi = 10.4103/0253-7176.135365 | doi-access = free }}</ref> | |||
A branch of ] that deals with schizophrenia is known as ]. Orthomolecular psychiatry considers the schizophrenias to be a group of disorders; management entails performing the appropriate diagnostic tests and then providing the appropriate therapy.<ref name = Pfeiffer>{{cite book |author=Pfeiffer, Carl C. |title=Nutrition and Mental Illness: An Orthomolecular Approach to Balancing Body Chemistry |publisher=Healing Art Press |location= |year= |pages= |isbn=0-89281-226-5}}</ref> Vitamin B-3 (]) has been proposed as an effective treatment in some cases.<ref>Hoffer and Walker, ''Orthomolecular Nutrition''. Keats Publishing, 1978</ref> The body's adverse reactions to ] are ]; proponents of orthomolecular psychiatric thought claim that an adverse reaction to gluten is involved in the etiology of some cases. This theory—discussed by one author in three British journals in the 1970s<ref> Dohan FC (1970). Coeliac disease and schizophrenia. ''Lancet'', 1970 April 25;1(7652):897–8. PMID 4191543<br />*Dohan FC (1973). Coeliac disease and schizophrenia. ''British Medical Journal'', 3(5870): 51–52. PMID 4740433<br />* Dohan FC (1979). Celiac-type diets in schizophrenia. '' Am J Psychiatry'', 1979 May;136(5):732–3. PMID 434265</ref>—is unproven. A 2006 literature review suggests that gluten may be a factor for patients with celiac disease and for a subset of patients afflicted with schizophrenia, but that further study is needed to conclusively confirm such a link.<ref name="Kalaydjian_AE"> Kalaydjian AE, Eaton W, Cascella N, Fasano A (2006). The gluten connection: the association between schizophrenia and celiac disease. ''Acta Psychiatr Scand.'' 2006 Feb;113(2):82–90. PMID 16423158</ref> Some researchers suggest that dietary and nutritional treatments may hold promise in the treatment of schizophrenia.<ref name="pmid18208598">{{cite journal |author=Lakhan SE, Vieira KF |title=Nutritional therapies for mental disorders |journal=Nutr J |volume=7 |issue= |pages=2 |year=2008 |pmid=18208598 |doi=10.1186/1475-2891-7-2}}</ref> | |||
=== Breadth of diagnosis === | |||
==History== | |||
Before the 1960s, nonviolent ]s and women were sometimes diagnosed with schizophrenia, categorizing the latter as ill for not performing their duties as wives and mothers.<ref name= Lane2010/> In the mid- to late 1960s, black men were categorized as "hostile and aggressive" and diagnosed as schizophrenic at much higher rates, their ] and ] activism labeled as delusions.<ref name=Lane2010>{{Cite web |vauthors= Lane C |date= 5 May 2010|title=How Schizophrenia Became a Black Disease: An Interview With Jonathan Metzl|url=http://www.psychologytoday.com/blog/side-effects/201005/how-schizophrenia-became-black-disease-interview-jonathan-metzl|access-date=5 April 2021|work=]}}</ref><ref>{{page needed|date=August 2022}} {{Cite book|vauthors=Metz J|title=]|year=2010|isbn=978-0-8070-8592-9| publisher = Beacon Press}}</ref> | |||
Descriptions of schizophrenia-like symptoms date back to ''circa'' 2000 BC in the ''Book of Hearts''—part of the ] ]. However, study of the ] and ] literature shows that although the general population probably had an awareness of psychotic disorders, there was no recorded condition that would meet the modern criteria for schizophrenia.<ref name="fn_1>Evans K, McGrath J, Milns R. (2003). Searching for schizophrenia in ancient Greek and Roman literature: a ]. ''Acta Psychiatrica Scandanavica'', 107(5), 323–330. PMID 12752027</ref> Symptoms resembling schizophrenia were, however, reported in ] and ] during the ]. In '']'', for example, ] described a condition somewhat resembling schizophrenia which he called ''Junun Mufrit'' (severe madness), which he distinguished from other forms of madness (''Junun'') such as ], ] and ] ].<ref name=Dening-57>Hanafy A. Youssef, Fatma A. Youssef and T. R. Dening (1996), "Evidence for the existence of schizophrenia in medieval Islamic society", ''History of Psychiatry'' '''7''': 55-62 .</ref> | |||
In the early 1970s in the United States, the diagnostic model for schizophrenia was broad and clinically based using ]. Schizophrenia was diagnosed far more in the United States than in Europe, where the ] criteria were followed. The US model was criticised for failing to demarcate clearly those people with a mental illness. In 1980 DSM III was published and showed a shift in focus from the clinically based ] to a reason-based medical model.{{what|date=December 2024}}<ref>{{cite journal |vauthors=Wilson M |date=March 1993 |title=DSM-III and the transformation of American psychiatry: a history |journal=The American Journal of Psychiatry |volume=150 |issue=3 |pages=399–410 |doi=10.1176/ajp.150.3.399 |pmid=8434655}}</ref> DSM IV brought an increased focus on an evidence-based medical model.<ref>{{cite journal |vauthors=Fischer BA |date=December 2012 |title=A review of American psychiatry through its diagnoses: the history and development of the Diagnostic and Statistical Manual of Mental Disorders. |journal=The Journal of Nervous and Mental Disease |volume=200 |issue=12 |pages=1022–1030 |doi=10.1097/NMD.0b013e318275cf19 |pmid=23197117 |s2cid=41939669}}</ref> | |||
=== Historical treatment === | |||
{{Main|History of schizophrenia#Development of treatments in the 20th century}} | |||
], the first antipsychotic developed in the 1950s]] | |||
In the 1930s a number of shock procedures which induced seizures (convulsions) or comas were used to treat schizophrenia.<ref name=Jones2000>{{cite journal |vauthors=Jones K |date=March 2000 |title=Insulin coma therapy in schizophrenia |journal=Journal of the Royal Society of Medicine |volume=93 |issue=3 |pages=147–149 |doi=10.1177/014107680009300313 |pmc=1297956 |pmid=10741319}}</ref> ] involved injecting large doses of ] to induce comas, which in turn produced ] and convulsions.<ref name=Jones2000/><ref>{{cite journal |vauthors=Jobes DA, Chalker SA |date=26 September 2019 |title=One Size Does Not Fit All: A Comprehensive Clinical Approach to Reducing Suicidal Ideation, Attempts, and Deaths. |journal=International Journal of Environmental Research and Public Health |volume=16 |issue=19 |page=3606 |doi=10.3390/ijerph16193606 |pmc=6801408 |pmid=31561488 |doi-access=free}}</ref> The use of electricity to induce seizures was in use as ] (ECT) by 1938.<ref>{{cite journal |vauthors=Ali SA, Mathur N, Malhotra AK, Braga RJ |date=April 2019 |title=Electroconvulsive Therapy and Schizophrenia: A Systematic Review |journal=Molecular Neuropsychiatry |volume=5 |issue=2 |pages=75–83 |doi=10.1159/000497376 |pmc=6528094 |pmid=31192220}}</ref> | |||
Carried out from the 1930s until the 1970s in the United States and until the 1980s in France, ], including such modalities as the ], is recognized as a ].<ref>{{cite journal |vauthors=Mashour GA, Walker EE, Martuza RL |date=June 2005 |title=Psychosurgery: past, present, and future |journal=Brain Research. Brain Research Reviews |volume=48 |issue=3 |pages=409–419 |doi=10.1016/j.brainresrev.2004.09.002 |pmid=15914249 |s2cid=10303872}}</ref><ref>{{Cite web |vauthors=Mendez J |date=1 February 2013|title=Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment |url= https://www.ohchr.org/sites/default/files/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf |access-date= 22 August 2022 |publisher=Office of the High Commissioner for Human Rights}}</ref> In the mid-1950s, ], the first ], was introduced,<ref>{{cite journal |vauthors=Turner T |date=January 2007 |title=Chlorpromazine: unlocking psychosis |journal=BMJ |volume=334 Suppl 1 |issue=suppl |page=s7 |doi=10.1136/bmj.39034.609074.94 |pmid=17204765 |s2cid=33739419}}</ref> followed in the 1970s by clozapine, the first ].<ref>{{cite journal |vauthors=Aringhieri S |date=December 2018 |title=Molecular targets of atypical antipsychotics: From mechanism of action to clinical differences. |journal=Pharmacology & Therapeutics |volume=192 |pages=20–41 |doi=10.1016/j.pharmthera.2018.06.012 |pmid=29953902 |s2cid=49602956}}</ref> | |||
=== Political abuse === | |||
{{Further information|Political abuse of psychiatry}} | |||
From the 1960s until 1989, psychiatrists in the ] and ] diagnosed thousands of people with ],<ref>{{Cite journal|vauthors=Park YS, Sang M, Jun JY, Kim SJ|date=2014|title=Psychiatry in former socialist countries: implications for north korean psychiatry|journal=Psychiatry Investigation|volume=11|issue=4|pages=363–370|doi=10.4306/pi.2014.11.4.363|issn=1738-3684|pmc=4225199|pmid=25395966}}</ref><ref>{{page needed|date=August 2022}} {{Cite book|vauthors=Gosden R|title=Punishing the patient: how psychiatrists misunderstand and mistreat schizophrenia|date=2001|publisher=Scribe Publications|isbn=0-908011-52-0|location=Melbourne|oclc=47177633}}</ref> without signs of psychosis, based on "the assumption that symptoms would later appear".<ref>{{cite journal | vauthors = Sfera A | title = Can Psychiatry be Misused Again? | journal = Frontiers in Psychiatry | volume = 4 | pages = 101 | date = September 2013 | pmid = 24058348 | pmc = 3766833 | doi = 10.3389/fpsyt.2013.00101 | doi-access = free }}</ref> Now discredited, the diagnosis provided a convenient way to confine political dissidents.<ref name=Merskey1988>{{Cite journal| vauthors = Merskey H |date=15 October 1988|title=IPPNW: Forum for Soviet anti-American propaganda?|journal=CMAJ: Canadian Medical Association Journal|volume=139|issue=8|pages=699–700|issn=0820-3946|pmc=1268271}}</ref> | |||
==Society and culture== | |||
{{See also|List of people with schizophrenia|Religion and schizophrenia|}}In the United States, the annual cost of schizophrenia – including direct costs (outpatient, inpatient, drugs, and long-term care) and non-healthcare costs (law enforcement, reduced workplace productivity, and unemployment) – was estimated at $62.7 billion for the year 2002.<ref>{{cite journal | vauthors = Wu EQ, Birnbaum HG, Shi L, Ball DE, Kessler RC, Moulis M, Aggarwal J | title = The economic burden of schizophrenia in the United States in 2002 | journal = The Journal of Clinical Psychiatry | volume = 66 | issue = 9 | pages = 1122–1129 | date = September 2005 | pmid = 16187769 | doi = 10.4088/jcp.v66n0906 }}</ref>{{efn|A 2007 review stated that the 2002 estimate was still the best available,<ref>{{cite journal | vauthors = McEvoy JP | title = The costs of schizophrenia | journal = The Journal of Clinical Psychiatry | volume = 68 | issue = Suppl 14 | pages = 4–7 | date = 2007 | pmid = 18284271 | doi = }}</ref> and a 2018 review cited the same $62.7 billion.<ref> | |||
{{cite journal |vauthors=Zhang W, Amos TB, Gutkin SW, et al |title=A systematic literature review of the clinical and health economic burden of schizophrenia in privately insured patients in the United States |journal=Clinicoecon Outcomes Res |volume=10 |issue= |pages=309–320 |date=2018 |pmid=29922078 |pmc=5997131 |doi=10.2147/CEOR.S156308 |doi-access=free }}</ref>}} In the UK the cost in 2016 was put at £11.8 billion per year with a third of that figure directly attributable to the cost of hospital, social care and treatment.<ref name="Lancet2016" /> | |||
=== Stigma === | |||
] (1856–1926) refined the concept of ].]] | |||
], an American mathematician and joint recipient of the 1994 ], had schizophrenia. His life was the subject of the 1998 book, '']'', by ].]] | |||
Although a broad concept of ] has existed for thousands of years, schizophrenia was only classified as a distinct mental disorder by ] in 1893. He was the first to make a distinction in the psychotic disorders between what he called '']'' (early dementia—a term first used by psychiatrist ] ) and ]. Kraepelin believed that ''dementia praecox'' was primarily a disease of the brain,<ref name="fn_2">Kraepelin E. (1907) ''Text book of psychiatry (7th ed)'' (trans. A.R. Diefendorf). London: Macmillan.</ref> and particularly a form of ], distinguished from other forms of dementia, such as ], which typically occur later in life.<ref name="fn_49">"''Conditions in Occupational Therapy: effect on occupational performance.''" ed. Ruth A. Hansen and Ben Atchison (Baltimore: Lippincott, Williams & Williams, 2000), 54–74. ISBN 0-683-30417-8</ref> | |||
In 2002, the term for schizophrenia in Japan was changed from {{nihongo||精神分裂病|seishin-bunretsu-byō|lit. 'mind-split disease'}} to {{nihongo||統合失調症|tōgō-shitchō-shō|lit. 'integration–dysregulation syndrome'}} to reduce ].<ref>{{cite journal | vauthors = Yamaguchi S, Mizuno M, Ojio Y, Sawada U, Matsunaga A, Ando S, Koike S | title = Associations between renaming schizophrenia and stigma-related outcomes: A systematic review | journal = Psychiatry and Clinical Neurosciences | volume = 71 | issue = 6 | pages = 347–362 | date = June 2017 | pmid = 28177184 | doi = 10.1111/pcn.12510 | doi-access = free }}</ref> The new name, also interpreted as "integration disorder", was inspired by the biopsychosocial model.<ref>{{cite journal | vauthors = Sato M | title = Renaming schizophrenia: a Japanese perspective | journal = World Psychiatry | volume = 5 | issue = 1 | pages = 53–55 | date = February 2006 | pmid = 16757998 | pmc = 1472254 }}</ref> A similar change was made in South Korea in 2012 to attunement disorder.<ref>{{cite journal | vauthors = Park SC, Park YC | title = Korea in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition | journal = Journal of Korean Medical Science | volume = 35 | issue = 2 | pages = e6 | date = January 2020 | pmid = 31920014 | pmc = 6955430 | doi = 10.3346/jkms.2020.35.e6 | edition = Fifth }}</ref> | |||
The word ''schizophrenia''—which translates roughly as "splitting of the mind" and comes from the ] roots ''schizein'' (σχίζειν, "to split") and ''phrēn'', ''phren-'' (φρήν, φρεν-, "]")<ref>{{cite journal |author=Kuhn R; tr. Cahn CH |title=Eugen Bleuler's concepts of psychopathology |journal=Hist Psychiatry |volume=15 |issue=3 |date=2004 |pages=361–6 |doi=10.1177/0957154X04044603 |pmid=15386868}}</ref>—was coined by ] in 1908 and was intended to describe the separation of function between ], ], ], and ]. Bleuler described the main symptoms as 4 ''A'''s: flattened ''Affect'', ''Autism'', impaired ''Association'' of ideas and ''Ambivalence''.<ref name="fn_78"> Stotz-Ingenlath G. (2000). Epistemological aspects of Eugen Bleuler's conception of schizophrenia in 1911. ''Medicine, Health Care, and Philosophy'', 3(2), 153–9. PMID 11079343</ref> Bleuler realized that the illness was not a ] as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead. | |||
=== Cultural depictions === | |||
The term ''schizophrenia'' is commonly misunderstood to mean that affected persons have a "split personality". Although some people diagnosed with schizophrenia may hear voices and may experience the voices as distinct personalities, schizophrenia does not involve a person changing among distinct multiple personalities. The confusion arises in part due to the meaning of Bleuler's term ''schizophrenia'' (literally "split" or "shattered mind"). The first known misuse of the term to mean "split personality" was in an article by the poet ] in 1933.<ref name="fn_3">Turner T. (1999) 'Schizophrenia'. In ] and ] (eds) ''A History of Clinical Psychiatry''. London: Athlone Press. ISBN 0-485-24211-7</ref> | |||
Media coverage, especially movies, reinforce the public perception of an association between schizophrenia and violence.<ref>{{cite journal | vauthors = Fazel S, Gulati G, Linsell L, Geddes JR, Grann M | title = Schizophrenia and violence: systematic review and meta-analysis | journal = PLOS Medicine | volume = 6 | issue = 8 | pages = e1000120 | date = August 2009 | pmid = 19668362 | pmc = 2718581 | doi = 10.1371/journal.pmed.1000120 | doi-access = free }}</ref> A majority of movies have historically depicted characters with schizophrenia as criminal, dangerous, violent, unpredictable and homicidal, and depicted delusions and hallucinations as the main symptoms of schizophrenic characters, ignoring other common symptoms,<ref name= Owen2012>{{cite journal |vauthors=Owen PR |title=Portrayals of schizophrenia by entertainment media: a content analysis of contemporary movies |journal=Psychiatr Serv |volume=63 |issue=7 |pages=655–9 |date=July 2012 |pmid=22555313 |doi=10.1176/appi.ps.201100371}}</ref> furthering stereotypes of schizophrenia including the idea of a split personality.<ref>{{cite journal |vauthors=Katschnig H |title=Psychiatry's contribution to the public stereotype of schizophrenia: Historical considerations |journal=J Eval Clin Pract |volume=24 |issue=5 |pages=1093–1100 |date=October 2018 |pmid=30112785 |pmc=6174929 |doi=10.1111/jep.13011 }}</ref> | |||
The book '']'' chronicled the life of ] who had been diagnosed with schizophrenia and won the ]. The book was made into a ]; an earlier documentary film was '']''. | |||
In the first half of the twentieth century schizophrenia was considered to be a hereditary defect, and sufferers were subject to ] in many countries. Hundreds of thousands were ], with or without consent—the majority in ], the ], and ]n countries.<ref name="fn_76">Allen GE. (1997). The social and economic origins of genetic determinism: a case history of the American Eugenics Movement, 1900–1940 and its lessons for today. ''Genetica'', 99, 77–88. PMID 9463076</ref><ref name="fn_77">Read J, Masson J. (2004) Genetics, eugenics and mass murder. In J. Read, L.R. Mosher, R.P. Bentall (eds) ''Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia''. ISBN 1-58391-906-6</ref> Along with other people labeled "mentally unfit", many diagnosed with schizophrenia were murdered in the Nazi "]" program.<ref name="Lifton_2000">Lifton RJ. (2000) ''The Nazi Doctors: Medical Killing and the Psychology of Genocide''. Basic Books. ISBN 0465049052</ref> | |||
In the UK, guidelines for reporting conditions and award campaigns have shown a reduction in negative reporting since 2013.<ref>{{cite journal |vauthors=Chen M, Lawrie S |title=Newspaper depictions of mental and physical health. |journal=BJPsych Bulletin |volume=41 |issue=6 |pages=308–313 |date=December 2017 |pmid=29234506 |doi=10.1192/pb.bp.116.054775|pmc=5709678 }}</ref> | |||
The diagnostic description of schizophrenia has changed over time. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe.<ref name="Wing1971">Wing JK (1971) International comparisons in the study of the functional psychoses. ''British Medical Bulletin'', 27 (1), 77–81. PMID 4926366</ref> This was partly due to looser diagnostic criteria in the US, which used the ] manual, contrasting with Europe and its ]. This was one of the factors in leading to the revision not only of the diagnosis of schizophrenia, but the revision of the whole DSM manual, resulting in the publication of the ].<ref name="Wilson1993">Wilson M. (1993) DSM-III and the transformation of American psychiatry: a history. ''American Journal of Psychiatry'', 150 (3), 399–410. PMID 8434655</ref> | |||
In 1964 a ] of three males diagnosed with schizophrenia who each had the delusional belief that they were ] was published as '']''; a film with the title '']'' was released in 2020.<ref>{{cite journal | vauthors = Dyga K, Stupak R | title = Ways of understanding of religious delusions associated with a change of identity on the example of identification with Jesus Christ. | journal=Psychiatria Polska | date = 28 February 2018 | volume = 52 | issue = 1 | pages = 69–80 | doi=10.12740/PP/64378 | pmid=29704415| doi-access = free }}</ref><ref>{{cite journal | vauthors = Dein S, Littlewood R | title = Religion and psychosis: a common evolutionary trajectory? | journal = Transcultural Psychiatry | date = July 2011 | volume = 48 | issue = 3 | pages =318–335 | doi = 10.1177/1363461511402723 | pmid = 21742955| s2cid = 12991391 }}</ref> | |||
===Cultural references=== | |||
The book and film '']'' chronicled the life of ], a ]-winning mathematician who was diagnosed with schizophrenia. The ] film ''Devrai'' (Featuring ]) is a presentation of a patient with schizophrenia. The film, set in the ] region of ] in Western ], shows the behavior, mentality, and struggle of the patient as well as his loved-ones. It also portrays the treatment of this mental illness using medication, dedication and plenty of patience by the close relatives of the patient. Other factual books have been written by relatives on family members; Australian journalist ] told the story of her son's battle with schizophrenia in ''Tell me I'm Here'',<ref>{{cite book | last = Deveson | first = Anne | authorlink = Anne Deveson | title = Tell Me I'm Here | publisher = Penguin | date = 1991 | pages = | id = ISBN 0-14-027257-7}}</ref> later made into a movie. | |||
==Research directions== | |||
In ] '']'' the poet Ivan Bezdomnyj is institutionalized and diagnosed with schizophrenia after witnessing the devil (Woland) predict Berlioz's death. The book '']'' by ] recounts his struggle into schizophrenia and his journey back to sanity. | |||
{{See also|Animal models of schizophrenia}} | |||
A 2015 Cochrane review found unclear evidence of benefit from brain stimulation techniques to treat the positive symptoms of schizophrenia, in particular auditory verbal hallucinations (AVHs).<ref>{{cite journal |vauthors =Dougall N, Maayan N, Soares-Weiser K, McDermott LM, McIntosh A |title=Transcranial magnetic stimulation (TMS) for schizophrenia. |journal=The Cochrane Database of Systematic Reviews |volume=2015 |date=20 August 2015 |issue=8 |pages=CD006081 |doi=10.1002/14651858.CD006081.pub2 |pmid=26289586|pmc=9395125 |hdl=1893/22520 |hdl-access=free }}</ref> Most studies focus on ] (tDCM), and ] (rTMS).<ref name=Nathou2019>{{cite journal |vauthors=Nathou C, Etard O, Dollfus S |date=2019 |title=Auditory verbal hallucinations in schizophrenia: current perspectives in brain stimulation treatments. |journal=Neuropsychiatric Disease and Treatment|volume=15 |pages=2105–2117 |pmid=31413576 |pmc=6662171 |doi=10.2147/NDT.S168801 |doi-access=free }}</ref> Techniques based on focused ultrasound for ] could provide insight for the treatment of AVHs.<ref name=Nathou2019/> | |||
The study of potential ] that would help in diagnosis and treatment of schizophrenia is an active area of research as of 2020. Possible biomarkers include markers of inflammation,<ref name=Upthegrove2020/> ],<ref>{{cite journal |vauthors=Kraguljac NV, McDonald WM, Widge AS, Rodriguez CI, Tohen M, Nemeroff CB |title=Neuroimaging Biomarkers in Schizophrenia |journal=Am J Psychiatry |pages=509–521 |date=January 2021 |volume=178 |issue=6 |pmid=33397140 |doi=10.1176/appi.ajp.2020.20030340|pmc=8222104 }}</ref> ] (BDNF),<ref>{{cite journal |vauthors=Khavari B, Cairns MJ |title=Epigenomic Dysregulation in Schizophrenia: In Search of Disease Etiology and Biomarkers |journal=Cells |volume=9 |issue=8 |date=August 2020 |page=1837 |pmid=32764320 |doi=10.3390/cells9081837|pmc=7463953 |doi-access=free }}</ref> and speech analysis. Some markers such as ] are useful in detecting levels of inflammation implicated in some psychiatric disorders but they are not disorder-specific. Other inflammatory cytokines are found to be elevated in first episode psychosis and acute relapse that are normalized after treatment with antipsychotics, and these may be considered as state markers.<ref>{{cite journal |vauthors=Goldsmith DR, Crooks CL, Walker EF, Cotes RO |title=An Update on Promising Biomarkers in Schizophrenia |journal=Focus (American Psychiatric Publishing)|volume=16 |issue=2 |pages=153–163 |date=April 2018 |doi=10.1176/appi.focus.20170046 |pmid=31975910|pmc=6526854 }}</ref> Deficits in ]s in schizophrenia may serve as a marker of an impaired thalamocortical circuit, and a mechanism for memory impairment.<ref name=Pocivavsek2018>{{cite journal |vauthors=Pocivavsek A, Rowland LM |title=Basic Neuroscience Illuminates Causal Relationship Between Sleep and Memory: Translating to Schizophrenia |journal=Schizophrenia Bulletin |volume=44 |issue=1 |pages=7–14 |date=13 January 2018 |pmid=29136236|doi=10.1093/schbul/sbx151|pmc=5768044 |doi-access=free }}</ref> ]s are highly influential in early neuronal development, and their disruption is implicated in several ] disorders; ]s (cimiRNAs) are found in ]s such as blood and cerebrospinal fluid, and changes in their levels are seen to relate to changes in microRNA levels in specific regions of brain tissue. These studies suggest that cimiRNAs have the potential to be early and accurate biomarkers in a number of disorders including schizophrenia.<ref>{{cite journal |vauthors=Kumar S, Reddy PH |title=Are circulating microRNAs peripheral biomarkers for Alzheimer's disease? |journal=Biochim Biophys Acta |volume=1862 |issue=9 |pages=1617–1627 |date=September 2016 |pmid=27264337 |pmc=5343750 |doi=10.1016/j.bbadis.2016.06.001 |url=}}</ref><ref>{{cite journal |vauthors=van den Berg MM, Krauskopf J, Ramaekers JG, et al. |title=Circulating microRNAs as potential biomarkers for psychiatric and neurodegenerative disorders |journal=Prog Neurobiol |volume=185 |pages=101732 |date=February 2020 |pmid=31816349 |doi=10.1016/j.pneurobio.2019.101732 |s2cid=208790466|doi-access=free }}</ref> | |||
==References== | |||
{{reflist|2}} | |||
] aims to identify biomarkers within these brain networks,<ref>{{Cite journal |last1=Palaniyappan |first1=Lena |last2=Liddle |first2=Peter F. |date=2013-04-24 |title=Diagnostic Discontinuity in Psychosis: A Combined Study of Cortical Gyrification and Functional Connectivity |url=https://academic.oup.com/schizophreniabulletin/article-abstract/40/3/675/1903745?redirectedFrom=fulltext |journal=Schizophrenia Bulletin |volume=40 |issue=3 |pages=675–684 |doi=10.1093/schbul/sbt050 |issn=1745-1701 |pmc=3984507 |pmid=23615812}}</ref> potentially aiding in earlier diagnosis and better tracking of treatment responses in schizophrenia. | |||
==Further reading== | |||
<!-- Please only include material which addresses schizophrenia in general, rather than specific aspects, or related topics --> | |||
<div class="references-small"> | |||
* ] (2003) ''Madness explained: Psychosis and Human Nature''. London: Penguin Books Ltd. ISBN 0-7139-9249-2 | |||
* ] (1997) ''Mental Disease in History: A selection of translated readings''. New York: Peter Lang Publishing. ISBN 0-8204-3056-0 | |||
* ] et al. (2003) The Neuroanatomy of Schizophrenia: Circuitry and Neurotransmitter Systems. ''Clinical Neuroscience Research'' 3:77–107. Available at | |||
* Green, M.F. (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0-393-70334-7 | |||
* Keen, T. M. (1999) Schizophrenia: orthodoxy and heresies. A review of alternative possibilities. ''Journal of Psychiatric and Mental Health Nursing'', 1999, 6, 415–424. PMID 10818864 | |||
*] (1999) ''The Divided Self: An Existential Study in Sanity and Madness''. London: Penguin Books Ltd. ISBN 0-140-13537-5 | |||
*], ] & Alice Cornelison, ''Schizophrenia and the Family''. International Universities Press, 1965. ISBN 978-0823660018 | |||
* Noll, Richard (2007) ''The Encyclopedia of Schizophrenia and Other Psychotic Disorders, Third Edition'' ISBN 0-8160-6405-9 | |||
* | |||
* Read, J., Mosher, L.R., Bentall, R. (2004) ''Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia''. ISBN 1-58391-906-6. A critical approach to biological and genetic theories, and a review of social influences on schizophrenia. | |||
* | |||
* Shaner, A., Miller, G. F., & Mintz, J. (2004). Schizophrenia as one extreme of a sexually selected fitness indicator. ''Schizophrenia Research'', 70(1), 101–109. PMID 15246469 Retrieved on ]. | |||
* ] (1976) ''Schizophrenia: The Sacred Symbol of Psychiatry''. New York: Basic Books. ISBN 0-465-07222-4 | |||
* ] : "Sexuality, War, and Schizophrenia: Collected ] Papers", Publisher: Transaction Publishers 1991, ISBN 0-88738-365-3 (On the Origin of the 'Influencing Machine' in Schizophrenia.) | |||
* Wiencke, Markus (2006) ''Schizophrenie als Ergebnis von Wechselwirkungen: Georg Simmels Individualitätskonzept in der Klinischen Psychologie''. In David Kim (ed.), ''Georg Simmel in Translation: Interdisciplinary Border-Crossings in Culture and Modernity'' (pp. 123–155). Cambridge Scholars Press, Cambridge, ISBN 1-84718-060-5 | |||
</div> | |||
== Explanatory notes == | |||
==External links== | |||
{{Notelist}} | |||
*{{dmoz|Health/Mental_Health/Disorders/Schizophrenia/}} | |||
* Bibliography of scholarly histories on schizophrenia and dementia praecox, (2000-mid 2007). | |||
== References == | |||
;News, information and further description | |||
{{Reflist}} | |||
* | |||
* | |||
* Film made in 1940 showing some of the symptoms of Schizophrenia. | |||
* | |||
* - 'Information for families caring for people with mental illness' | |||
;Critical approaches to schizophrenia | |||
* Leo, Jonathan Ph.D., & Jay Joseph, Psy. D. | |||
== External links == | |||
{{featured article}} | |||
{{Medical condition classification and resources | |||
{{Mental and behavioural disorders}} | |||
| DiseasesDB = 11890 | |||
| ICD11 = {{ICD11|6A20}} | |||
| ICD10 = {{ICD10|F|20||f|20}} | |||
| ICD9 = {{ICD9|295}} | |||
| ICDO = | |||
| OMIM = 181500 | |||
| MedlinePlus = 000928 | |||
| eMedicineSubj = med | |||
| eMedicineTopic = 2072 | |||
| eMedicine_mult = {{eMedicine2|emerg|520}} | |||
| MeshName = Schizophrenia | |||
| MeshNumber = F03.700.750 | |||
| Scholia = Q41112 | |||
}} | |||
{{Schizophrenia}} | |||
{{Mental and behavioural disorders|selected = schizophrenia}} | |||
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Latest revision as of 21:08, 22 December 2024
Mental disorder with psychotic symptoms For other uses, see Schizophrenia (disambiguation).Medical condition
Schizophrenia is a mental disorder characterized variously by hallucinations (typically, hearing voices), delusions, disorganized thinking and behavior, and flat or inappropriate affect. Symptoms develop gradually and typically begin during young adulthood and are never resolved. There is no objective diagnostic test; diagnosis is based on observed behavior, a psychiatric history that includes the person's reported experiences, and reports of others familiar with the person. For a diagnosis of schizophrenia, the described symptoms need to have been present for at least six months (according to the DSM-5) or one month (according to the ICD-11). Many people with schizophrenia have other mental disorders, especially mood disorders, anxiety disorders, and obsessive–compulsive disorder.
About 0.3% to 0.7% of people are diagnosed with schizophrenia during their lifetime. In 2017, there were an estimated 1.1 million new cases and in 2022 a total of 24 million cases globally. Males are more often affected and on average have an earlier onset than females. The causes of schizophrenia may include genetic and environmental factors. Genetic factors include a variety of common and rare genetic variants. Possible environmental factors include being raised in a city, childhood adversity, cannabis use during adolescence, infections, the age of a person's mother or father, and poor nutrition during pregnancy.
About half of those diagnosed with schizophrenia will have a significant improvement over the long term with no further relapses, and a small proportion of these will recover completely. The other half will have a lifelong impairment. In severe cases, people may be admitted to hospitals. Social problems such as long-term unemployment, poverty, homelessness, exploitation, and victimization are commonly correlated with schizophrenia. Compared to the general population, people with schizophrenia have a higher suicide rate (about 5% overall) and more physical health problems, leading to an average decrease in life expectancy by 20 to 28 years. In 2015, an estimated 17,000 deaths were linked to schizophrenia.
The mainstay of treatment is antipsychotic medication, including olanzapine and risperidone, along with counseling, job training, and social rehabilitation. Up to a third of people do not respond to initial antipsychotics, in which case clozapine is offered. In a network comparative meta-analysis of 15 antipsychotic drugs, clozapine was significantly more effective than all other drugs, although clozapine's heavily multimodal action may cause more significant side effects. In situations where doctors judge that there is a risk of harm to self or others, they may impose short involuntary hospitalization. Long-term hospitalization is used on a small number of people with severe schizophrenia. In some countries where supportive services are limited or unavailable, long-term hospital stays are more common.
Signs and symptoms
Schizophrenia is a mental disorder characterized by significant alterations in perception, thoughts, mood, and behavior. Symptoms are described in terms of positive, negative, and cognitive symptoms. The positive symptoms of schizophrenia are the same for any psychosis and are sometimes referred to as psychotic symptoms. These may be present in any of the different psychoses and are often transient, making early diagnosis of schizophrenia problematic. Psychosis noted for the first time in a person who is later diagnosed with schizophrenia is referred to as a first-episode psychosis (FEP).
Positive symptoms
Positive symptoms are those symptoms that are not normally experienced, but are present in people during a psychotic episode in schizophrenia, including delusions, hallucinations, and disorganized thoughts, speech and behavior or inappropriate affect, typically regarded as manifestations of psychosis. Hallucinations occur at some point in the lifetimes of 80% of those with schizophrenia and most commonly involve the sense of hearing (most often hearing voices), but can sometimes involve any of the other senses such as taste, sight, smell, and touch. The frequency of hallucinations involving multiple senses is double the rate of those involving only one sense. They are also typically related to the content of the delusional theme. Delusions are bizarre or persecutory in nature. Distortions of self-experience such as feeling that others can hear one's thoughts or that thoughts are being inserted into one's mind, sometimes termed passivity phenomena, are also common. Positive symptoms generally respond well to medication and become reduced over the course of the illness, perhaps linked to the age-related decline in dopamine activity.
Negative symptoms
Negative symptoms are deficits of normal emotional responses, or of other thought processes. The five recognized domains of negative symptoms are: blunted affect – showing flat expressions (monotone) or little emotion; alogia – a poverty of speech; anhedonia – an inability to feel pleasure; asociality – the lack of desire to form relationships, and avolition – a lack of motivation and apathy. Avolition and anhedonia are seen as motivational deficits resulting from impaired reward processing. Reward is the main driver of motivation and this is mostly mediated by dopamine. It has been suggested that negative symptoms are multidimensional and they have been categorised into two subdomains of apathy or lack of motivation, and diminished expression. Apathy includes avolition, anhedonia, and social withdrawal; diminished expression includes blunt affect and alogia. Sometimes diminished expression is treated as both verbal and non-verbal.
Apathy accounts for around 50% of the most often found negative symptoms and affects functional outcome and subsequent quality of life. Apathy is related to disrupted cognitive processing affecting memory and planning including goal-directed behaviour. The two subdomains have suggested a need for separate treatment approaches. A lack of distress is another noted negative symptom. A distinction is often made between those negative symptoms that are inherent to schizophrenia, termed primary; and those that result from positive symptoms, from the side effects of antipsychotics, substance use disorder, and social deprivation – termed secondary negative symptoms. Negative symptoms are less responsive to medication and the most difficult to treat. However, if properly assessed, secondary negative symptoms are amenable to treatment. There is some evidence that the negative symptoms of schizophrenia are amenable to psychostimulant medication, although such drugs have varying degrees of risk for causing positive psychotic symptoms.
Scales for specifically assessing the presence of negative symptoms, and for measuring their severity, and their changes have been introduced since the earlier scales such as the PANNS that deals with all types of symptoms. These scales are the Clinical Assessment Interview for Negative Symptoms (CAINS), and the Brief Negative Symptom Scale (BNSS) also known as second-generation scales. In 2020, ten years after its introduction, a cross-cultural study of the use of BNSS found valid and reliable psychometric evidence for its five-domain structure cross-culturally. The BNSS can assess both the presence and severity of negative symptoms of the five recognized domains and an additional item of reduced normal distress. It has been used to measure changes in negative symptoms in trials of psychosocial and pharmacological interventions.
Cognitive symptoms
See also: Visual processing abnormalities in schizophreniaAn estimated 70% of those with schizophrenia have cognitive deficits, and these are most pronounced in early-onset and late-onset illness. These are often evident long before the onset of illness in the prodromal stage, and may be present in childhood or early adolescence. They are a core feature but not considered to be core symptoms, as are positive and negative symptoms. However, their presence and degree of dysfunction is taken as a better indicator of functionality than the presentation of core symptoms. Cognitive deficits become worse at first episode psychosis but then return to baseline, and remain fairly stable over the course of the illness.
The deficits in cognition are seen to drive the negative psychosocial outcome in schizophrenia, and are claimed to equate to a possible reduction in IQ from the norm of 100 to 70–85. Cognitive deficits may be of neurocognition (nonsocial) or of social cognition. Neurocognition is the ability to receive and remember information, and includes verbal fluency, memory, reasoning, problem solving, speed of processing, and auditory and visual perception. Verbal memory and attention are seen to be the most affected. Verbal memory impairment is associated with a decreased level of semantic processing (relating meaning to words). Another memory impairment is that of episodic memory. An impairment in visual perception that is consistently found in schizophrenia is that of visual backward masking. Visual processing impairments include an inability to perceive complex visual illusions. Social cognition is concerned with the mental operations needed to interpret, and understand the self and others in the social world. This is also an associated impairment, and facial emotion perception is often found to be difficult. Facial perception is critical for ordinary social interaction. Cognitive impairments do not usually respond to antipsychotics, and there are a number of interventions that are used to try to improve them; cognitive remediation therapy is of particular help.
Neurological soft signs of clumsiness and loss of fine motor movement are often found in schizophrenia, which may resolve with effective treatment of FEP.
Onset
Further information: Basic symptoms of schizophrenia See also: Childhood schizophrenia and Adolescence § Changes in the brainOnset typically occurs between the late teens and early 30s, with the peak incidence occurring in males in the early to mid-twenties, and in females in the late twenties. Onset before the age of 17 is known as early-onset, and before the age of 13, as can sometimes occur, is known as childhood schizophrenia or very early-onset. Onset can occur between the ages of 40 and 60, known as late-onset schizophrenia. Onset over the age of 60, which may be difficult to differentiate as schizophrenia, is known as very-late-onset schizophrenia-like psychosis. Late onset has shown that a higher rate of females are affected; they have less severe symptoms and need lower doses of antipsychotics. The tendency for earlier onset in males is later seen to be balanced by a post-menopausal increase in the development in females. Estrogen produced pre-menopause has a dampening effect on dopamine receptors but its protection can be overridden by a genetic overload. There has been a dramatic increase in the numbers of older adults with schizophrenia.
Onset may happen suddenly or may occur after the slow and gradual development of a number of signs and symptoms, a period known as the prodromal stage. Up to 75% of those with schizophrenia go through a prodromal stage. The negative and cognitive symptoms in the prodrome stage can precede FEP (first episode psychosis) by many months and up to five years. The period from FEP and treatment is known as the duration of untreated psychosis (DUP) which is seen to be a factor in functional outcome. The prodromal stage is the high-risk stage for the development of psychosis. Since the progression to first episode psychosis is not inevitable, an alternative term is often preferred of at risk mental state. Cognitive dysfunction at an early age impacts a young person's usual cognitive development. Recognition and early intervention at the prodromal stage would minimize the associated disruption to educational and social development and has been the focus of many studies.
Risk factors
Main article: Risk factors of schizophreniaSchizophrenia is described as a neurodevelopmental disorder with no precise boundary, or single cause, and is thought to develop from gene–environment interactions with involved vulnerability factors. The interactions of these risk factors are complex, as numerous and diverse insults from conception to adulthood can be involved. A genetic predisposition on its own, without interacting environmental factors, will not give rise to the development of schizophrenia. The genetic component means that prenatal brain development is disturbed, and environmental influence affects the postnatal development of the brain. Evidence suggests that genetically susceptible children are more likely to be vulnerable to the effects of environmental risk factors.
Genetic
Estimates of the heritability of schizophrenia are between 70% and 80%, which implies that 70% to 80% of the individual differences in risk of schizophrenia are associated with genetics. These estimates vary because of the difficulty in separating genetic and environmental influences, and their accuracy has been queried. The greatest risk factor for developing schizophrenia is having a first-degree relative with the disease (risk is 6.5%); more than 40% of identical twins of those with schizophrenia are also affected. If one parent is affected the risk is about 13% and if both are affected the risk is nearly 50%. However, the DSM-5 indicates that most people with schizophrenia have no family history of psychosis. Results of candidate gene studies of schizophrenia have generally failed to find consistent associations, and the genetic loci identified by genome-wide association studies explain only a small fraction of the variation in the disease.
Many genes are known to be involved in schizophrenia, each with small effects and unknown transmission and expression. The summation of these effect sizes into a polygenic risk score can explain at least 7% of the variability in liability for schizophrenia. Around 5% of cases of schizophrenia are understood to be at least partially attributable to rare copy number variations (CNVs); these structural variations are associated with known genomic disorders involving deletions at 22q11.2 (DiGeorge syndrome) and 17q12 (17q12 microdeletion syndrome), duplications at 16p11.2 (most frequently found) and deletions at 15q11.2 (Burnside–Butler syndrome). Some of these CNVs increase the risk of developing schizophrenia by as much as 20-fold, and are frequently comorbid with autism and intellectual disabilities.
The genes CRHR1 and CRHBP are associated with the severity of suicidal behavior. These genes code for stress response proteins needed in the control of the HPA axis, and their interaction can affect this axis. Response to stress can cause lasting changes in the function of the HPA axis possibly disrupting the negative feedback mechanism, homeostasis, and the regulation of emotion leading to altered behaviors.
The question of how schizophrenia could be primarily genetically influenced, given that people with schizophrenia have lower fertility rates, is a paradox. It is expected that genetic variants that increase the risk of schizophrenia would be selected against, due to their negative effects on reproductive fitness. A number of potential explanations have been proposed, including that alleles associated with schizophrenia risk confers a fitness advantage in unaffected individuals. While some evidence has not supported this idea, others propose that a large number of alleles each contributing a small amount can persist.
A meta-analysis found that oxidative DNA damage was significantly increased in schizophrenia.
Environmental
Further information: Prenatal nutrition, Prenatal stress, and Neuroplastic effects of pollutionEnvironmental factors, each associated with a slight risk of developing schizophrenia in later life include oxygen deprivation, infection, prenatal maternal stress, and malnutrition in the mother during prenatal development. A risk is associated with maternal obesity, in increasing oxidative stress, and dysregulating the dopamine and serotonin pathways. Both maternal stress and infection have been demonstrated to alter fetal neurodevelopment through an increase of pro-inflammatory cytokines. There is a slighter risk associated with being born in the winter or spring possibly due to vitamin D deficiency or a prenatal viral infection. Other infections during pregnancy or around the time of birth that have been linked to an increased risk include infections by Toxoplasma gondii and Chlamydia. The increased risk is about five to eight percent. Viral infections of the brain during childhood are also linked to a risk of schizophrenia during adulthood. Cat exposure is also associated with an increased risk of broadly defined schizophrenia-related disorders, with an odds ratio of 2.4.
Adverse childhood experiences (ACEs), severe forms of which are classed as childhood trauma, range from being bullied or abused, to the death of a parent. Many adverse childhood experiences can cause toxic stress and increase the risk of psychosis. Chronic trauma, including ACEs, can promote lasting inflammatory dysregulation throughout the nervous system. It is suggested that early stress may contribute to the development of schizophrenia through these alterations in the immune system. Schizophrenia was the last diagnosis to benefit from the link made between ACEs and adult mental health outcomes.
Living in an urban environment during childhood or as an adult has consistently been found to increase the risk of schizophrenia by a factor of two, even after taking into account drug use, ethnic group, and size of social group. A possible link between the urban environment and pollution has been suggested to be the cause of the elevated risk of schizophrenia. Other risk factors include social isolation, immigration related to social adversity and racial discrimination, family dysfunction, unemployment, and poor housing conditions. Having a father older than 40 years, or parents younger than 20 years are also associated with schizophrenia.
Substance use
Further information: Risk factors of schizophrenia § Substance use, and Substance-induced psychosisAbout half of those with schizophrenia use recreational drugs including alcohol, tobacco, and cannabis excessively. Use of stimulants such as amphetamine and cocaine can lead to a temporary stimulant psychosis, which presents very similarly to schizophrenia. Rarely, alcohol use can also result in a similar alcohol-related psychosis. Drugs may also be used as coping mechanisms by people who have schizophrenia, to deal with depression, anxiety, boredom, and loneliness. The use of cannabis and tobacco are not associated with the development of cognitive deficits, and sometimes a reverse relationship is found where their use improves these symptoms. However, substance use disorders are associated with an increased risk of suicide, and a poor response to treatment.
Cannabis use may be a contributory factor in the development of schizophrenia, potentially increasing the risk of the disease in those who are already at risk. The increased risk may require the presence of certain genes within an individual. Its use is associated with doubling the rate.
Causes
Main article: Causes of schizophreniaSee also: Aberrant salienceThe causes of schizophrenia are still unknown. Several models have been put forward to explain the link between altered brain function and schizophrenia. The prevailing model of schizophrenia is that of a neurodevelopmental disorder, and the underlying changes that occur before symptoms become evident are seen as arising from the interaction between genes and the environment. Extensive studies support this model. Maternal infections, malnutrition and complications during pregnancy and childbirth are known risk factors for the development of schizophrenia, which usually emerges between the ages of 18 and 25, a period that overlaps with certain stages of neurodevelopment. Gene-environment interactions lead to deficits in the neural circuitry that affect sensory and cognitive functions.
The common dopamine and glutamate models proposed are not mutually exclusive; each is seen to have a role in the neurobiology of schizophrenia. The most common model put forward was the dopamine hypothesis of schizophrenia, which attributes psychosis to the mind's faulty interpretation of the misfiring of dopaminergic neurons. This has been directly related to the symptoms of delusions and hallucinations. Abnormal dopamine signaling has been implicated in schizophrenia based on the usefulness of medications that affect the dopamine receptor and the observation that dopamine levels are increased during acute psychosis. A decrease in D1 receptors in the dorsolateral prefrontal cortex may also be responsible for deficits in working memory.
The glutamate hypothesis of schizophrenia links alterations between glutamatergic neurotransmission and the neural oscillations that affect connections between the thalamus and the cortex. Studies have shown that a reduced expression of a glutamate receptor – NMDA receptor, and glutamate blocking drugs such as phencyclidine and ketamine can mimic the symptoms and cognitive problems associated with schizophrenia. Post-mortem studies consistently find that a subset of these neurons fail to express GAD67 (GAD1), in addition to abnormalities in brain morphometry. The subsets of interneurons that are abnormal in schizophrenia are responsible for the synchronizing of neural ensembles needed during working memory tasks. These give the neural oscillations produced as gamma waves that have a frequency of between 30 and 80 hertz. Both working memory tasks and gamma waves are impaired in schizophrenia, which may reflect abnormal interneuron functionality. An important process that may be disrupted in neurodevelopment is astrogenesis – the formation of astrocytes. Astrocytes are crucial in contributing to the formation and maintenance of neural circuits and it is believed that disruption in this role can result in a number of neurodevelopmental disorders including schizophrenia. Evidence suggests that reduced numbers of astrocytes in deeper cortical layers are assocociated with a diminished expression of EAAT2, a glutamate transporter in astrocytes; supporting the glutamate hypothesis.
Deficits in executive functions, such as planning, inhibition, and working memory, are pervasive in schizophrenia. Although these functions are separable, their dysfunction in schizophrenia may reflect an underlying deficit in the ability to represent goal related information in working memory, and to use this to direct cognition and behavior. These impairments have been linked to a number of neuroimaging and neuropathological abnormalities. For example, functional neuroimaging studies report evidence of reduced neural processing efficiency, whereby the dorsolateral prefrontal cortex is activated to a greater degree to achieve a certain level of performance relative to controls on working memory tasks. These abnormalities may be linked to the consistent post-mortem finding of reduced neuropil, evidenced by increased pyramidal cell density and reduced dendritic spine density. These cellular and functional abnormalities may also be reflected in structural neuroimaging studies that find reduced grey matter volume in association with deficits in working memory tasks.
Positive symptoms have been linked to cortical thinning in the superior temporal gyrus. The severity of negative symptoms has been linked to reduced thickness in the left medial orbitofrontal cortex. Anhedonia, traditionally defined as a reduced capacity to experience pleasure, is frequently reported in schizophrenia. However, a large body of evidence suggests that hedonic responses are intact in schizophrenia, and that what is reported to be anhedonia is a reflection of dysfunction in other processes related to reward. Overall, a failure of reward prediction is thought to lead to impairment in the generation of cognition and behavior required to obtain rewards, despite normal hedonic responses.
Another theory links abnormal brain lateralization to the development of being left-handed which is significantly more common in those with schizophrenia. This abnormal development of hemispheric asymmetry is noted in schizophrenia. Studies have concluded that the link is a true and verifiable effect that may reflect a genetic link between lateralization and schizophrenia.
Bayesian models of brain functioning have been used to link abnormalities in cellular functioning to symptoms. Both hallucinations and delusions have been suggested to reflect improper encoding of prior expectations, thereby causing expectation to excessively influence sensory perception and the formation of beliefs. In approved models of circuits that mediate predictive coding, reduced NMDA receptor activation, could in theory result in the positive symptoms of delusions and hallucinations.
Diagnosis
Main article: Diagnosis of schizophreniaCriteria
Schizophrenia is diagnosed based on criteria in either the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association or the International Statistical Classification of Diseases and Related Health Problems (ICD) published by the World Health Organization (WHO). These criteria use the self-reported experiences of the person and reported abnormalities in behavior, followed by a psychiatric assessment. The mental status examination is an important part of the assessment. An established tool for assessing the severity of positive and negative symptoms is the Positive and Negative Syndrome Scale (PANSS). This has been seen to have shortcomings relating to negative symptoms, and other scales – the Clinical Assessment Interview for Negative Symptoms (CAINS), and the Brief Negative Symptoms Scale (BNSS) have been introduced. The DSM-5, published in 2013, gives a Scale to Assess the Severity of Symptom Dimensions outlining eight dimensions of symptoms.
DSM-5 states that to be diagnosed with schizophrenia, two diagnostic criteria have to be met over the period of one month, with a significant impact on social or occupational functioning for at least six months. One of the symptoms needs to be either delusions, hallucinations, or disorganized speech. A second symptom could be one of the negative symptoms, or severely disorganized or catatonic behaviour. A different diagnosis of schizophreniform disorder can be made before the six months needed for the diagnosis of schizophrenia.
In Australia, the guideline for diagnosis is for six months or more with symptoms severe enough to affect ordinary functioning. In the UK diagnosis is based on having the symptoms for most of the time for one month, with symptoms that significantly affect the ability to work, study, or carry on ordinary daily living, and with other similar conditions ruled out.
The ICD criteria are typically used in European countries; the DSM criteria are used predominantly in the United States and Canada, and are prevailing in research studies. In practice, agreement between the two systems is high. The current proposal for the ICD-11 criteria for schizophrenia recommends adding self-disorder as a symptom.
A major unresolved difference between the two diagnostic systems is that of the requirement in DSM of an impaired functional outcome. WHO for ICD argues that not all people with schizophrenia have functional deficits and so these are not specific for the diagnosis.
Neuroimaging techniques
Functional magnetic resonance imaging (fMRI) has become a tool in understanding brain activity and connectivity differences in individuals with schizophrenia. Through resting-state fMRI, researchers have observed altered connectivity patterns within several key brain networks, such as the default mode network (DMN), salience network (SN), and central executive network (CEN). Alterations may underlie cognitive and emotional symptoms in schizophrenia, such as disorganized thinking, impaired attention, and emotional dysregulation.
Comorbidities
Many people with schizophrenia may have one or more other mental disorders, such as anxiety disorders, obsessive–compulsive disorder, or substance use disorder. These are separate disorders that require treatment. When comorbid with schizophrenia, substance use disorder and antisocial personality disorder both increase the risk for violence. Comorbid substance use disorder also increases the risk of suicide.
Sleep disorders often co-occur with schizophrenia, and may be an early sign of relapse. Sleep disorders are linked with positive symptoms such as disorganized thinking and can adversely affect cortical plasticity and cognition. The consolidation of memories is disrupted in sleep disorders. They are associated with severity of illness, a poor prognosis, and poor quality of life. Sleep onset and maintenance insomnia is a common symptom, regardless of whether treatment has been received or not. Genetic variations have been found associated with these conditions involving the circadian rhythm, dopamine and histamine metabolism, and signal transduction.
Schizophrenia is also associated with a number of somatic comorbidities including diabetes mellitus type 2, autoimmune diseases, and cardiovascular diseases. The association of these with schizophrenia may be partially due to medications (e.g. dyslipidemia from antipsychotics), environmental factors (e.g. complications from an increased rate of cigarette smoking), or associated with the disorder itself (e.g. diabetes mellitus type 2 and some cardiovascular diseases are thought to be genetically linked). These somatic comorbidities contribute to reduced life expectancy among persons with the disorder.
Differential diagnosis
See also: Dual diagnosis and Comparison of bipolar disorder and schizophreniaTo make a diagnosis of schizophrenia other possible causes of psychosis need to be excluded. Psychotic symptoms lasting less than a month may be diagnosed as brief psychotic disorder, or as schizophreniform disorder. Psychosis is noted in Other specified schizophrenia spectrum and other psychotic disorders as a DSM-5 category. Schizoaffective disorder is diagnosed if symptoms of mood disorder are substantially present alongside psychotic symptoms. Psychosis that results from a general medical condition or substance is termed secondary psychosis.
Psychotic symptoms may be present in several other conditions, including bipolar disorder, borderline personality disorder, substance intoxication, substance-induced psychosis, and a number of drug withdrawal syndromes. Non-bizarre delusions are also present in delusional disorder, and social withdrawal in social anxiety disorder, avoidant personality disorder and schizotypal personality disorder. Schizotypal personality disorder has symptoms that are similar but less severe than those of schizophrenia. Schizophrenia occurs along with obsessive–compulsive disorder (OCD) considerably more often than could be explained by chance, although it can be difficult to distinguish obsessions that occur in OCD from the delusions of schizophrenia. There can be considerable overlap with the symptoms of post-traumatic stress disorder.
A more general medical and neurological examination may be needed to rule out medical illnesses which may rarely produce psychotic schizophrenia-like symptoms, such as metabolic disturbance, systemic infection, syphilis, HIV-associated neurocognitive disorder, epilepsy, limbic encephalitis, and brain lesions. Stroke, multiple sclerosis, hyperthyroidism, hypothyroidism, and dementias such as Alzheimer's disease, Huntington's disease, frontotemporal dementia, and the Lewy body dementias may also be associated with schizophrenia-like psychotic symptoms. It may be necessary to rule out a delirium, which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness, and indicates an underlying medical illness. Investigations are not generally repeated for relapse unless there is a specific medical indication or possible adverse effects from antipsychotic medication. In children hallucinations must be separated from typical childhood fantasies. It is difficult to distinguish childhood schizophrenia from autism.
Prevention
Prevention of schizophrenia is difficult as there are no reliable markers for the later development of the disorder.
Early intervention programs diagnose and treat patients in the prodromal phase of the illness. There is some evidence that these programs reduce symptoms. Patients tend to prefer early treatment programs to ordinary treatment and are less likely to disengage from them. As of 2020, it is unclear whether the benefits of early treatment persist once the treatment is terminated.
Cognitive behavioral therapy may reduce the risk of psychosis in those at high risk after a year and is recommended in this group, by the National Institute for Health and Care Excellence (NICE). Another preventive measure is to avoid drugs that have been associated with development of the disorder, including cannabis, cocaine, and amphetamines.
Antipsychotics are prescribed following a first-episode psychosis, and following remission, a preventive maintenance use is continued to avoid relapse. However, it is recognized that some people do recover following a single episode and that long-term use of antipsychotics will not be needed but there is no way of identifying this group.
Management
Main article: Management of schizophreniaThe primary treatment of schizophrenia is the use of antipsychotic medications, often in combination with psychosocial interventions and social supports. Community support services including drop-in centers, visits by members of a community mental health team, supported employment, and support groups are common. The time between the onset of psychotic symptoms to being given treatment – the duration of untreated psychosis (DUP) – is associated with a poorer outcome in both the short term and the long term.
Voluntary or involuntary admission to hospital may be imposed by doctors and courts who deem a person to be having a severe episode. In the UK, large mental hospitals termed asylums began to be closed down in the 1950s with the advent of antipsychotics, and with an awareness of the negative impact of long-term hospital stays on recovery. This process was known as deinstitutionalization, and community and supportive services were developed to support this change. Many other countries followed suit with the US starting in the 60s. There still remain a smaller group of people who do not improve enough to be discharged. In some countries that lack the necessary supportive and social services, long-term hospital stays are more usual.
Medication
The first-line treatment for schizophrenia is an antipsychotic. The first-generation antipsychotics, now called typical antipsychotics, like haloperidol, are dopamine antagonists that block D2 receptors, and affect the neurotransmission of dopamine. Those brought out later, the second-generation antipsychotics known as atypical antipsychotics, including olanzapine and risperidone, can also have an effect on another neurotransmitter, serotonin. Antipsychotics can reduce the symptoms of anxiety within hours of their use, but, for other symptoms, they may take several days or weeks to reach their full effect. They have little effect on negative and cognitive symptoms, which may be helped by additional psychotherapies and medications. There is no single antipsychotic suitable for first-line treatment for everyone, as responses and tolerances vary between people. Stopping medication may be considered after a single psychotic episode where there has been a full recovery with no symptoms for twelve months. Repeated relapses worsen the long-term outlook and the risk of relapse following a second episode is high, and long-term treatment is usually recommended.
About half of those with schizophrenia will respond favourably to antipsychotics, and have a good return of functioning. However, positive symptoms persist in up to a third of people. Following two trials of different antipsychotics over six weeks, that also prove ineffective, they will be classed as having treatment-resistant schizophrenia (TRS), and clozapine will be offered. Clozapine is of benefit to around half of this group although it has the potentially serious side effect of agranulocytosis (lowered white blood cell count) in less than 4% of people.
About 30 to 50 percent of people with schizophrenia do not accept that they have an illness or comply with their recommended treatment. For those who are unwilling or unable to take medication regularly, long-acting injections of antipsychotics may be used, which reduce the risk of relapse to a greater degree than oral medications. When used in combination with psychosocial interventions, they may improve long-term adherence to treatment.
The fixed-dose combination medication xanomeline/trospium chloride (Cobenfy) was approved for medical use in the United States in September 2024. It is the first cholinergic agonist approved by the US Food and Drug Administration (FDA) to treat schizophrenia.
Negative and cognitive symptoms are an unmet clinical need in antipsychotic-based treatment approaches. Psychostimulant drugs have been found effective in the treatment of negative symptoms, but are rarely prescribed due to concerns about the excacerbation of positive symptoms. It is possible that low-dose psychedelic therapies could be of benefit in schizophrenia through their prosocial and procognitive effects, although there is a serious risk that high dose psychedelic therapies could lead to worsening of positive symptoms.
Adverse effects
Further information: Antipsychotic § Adverse effectsExtrapyramidal symptoms, including akathisia, are associated with all commercially available antipsychotic to varying degrees. There is little evidence that second generation antipsychotics have reduced levels of extrapyramidical symptoms compared to typical antipsychotics. Tardive dyskinesia can occur due to long-term use of antipsychotics, developing after months or years of use. The antipsychotic clozapine is also associated with thromboembolism (including pulmonary embolism), myocarditis, and cardiomyopathy.
Psychosocial interventions
Further information: Management of schizophrenia § PsychosocialA number of psychosocial interventions that include several types of psychotherapy may be useful in the treatment of schizophrenia such as: family therapy, group therapy, cognitive remediation therapy (CRT), cognitive behavioral therapy (CBT), and metacognitive training. Skills training, help with substance use, and weight management – often needed as a side effect of an antipsychotic – are also offered. In the US, interventions for first episode psychosis have been brought together in an overall approach known as coordinated speciality care (CSC) and also includes support for education. In the UK care across all phases is a similar approach that covers many of the treatment guidelines recommended. The aim is to reduce the number of relapses and stays in the hospital.
Other support services for education, employment, and housing are usually offered. For people with severe schizophrenia, who are discharged from a stay in the hospital, these services are often brought together in an integrated approach to offer support in the community away from the hospital setting. In addition to medicine management, housing, and finances, assistance is given for more routine matters such as help with shopping and using public transport. This approach is known as assertive community treatment (ACT) and has been shown to achieve positive results in symptoms, social functioning and quality of life. Another more intense approach is known as intensive care management (ICM). ICM is a stage further than ACT and emphasises support of high intensity in smaller caseloads, (less than twenty). This approach is to provide long-term care in the community. Studies show that ICM improves many of the relevant outcomes including social functioning.
Some studies have shown little evidence for the effectiveness of CBT in either reducing symptoms or preventing relapse. However, other studies have found that CBT does improve overall psychotic symptoms (when in use with medication) and it has been recommended in Canada, but has been seen to have no effect on social function, relapse, or quality of life. In the UK it is recommended as an add-on therapy in the treatment of schizophrenia. Arts therapies are seen to improve negative symptoms in some people, and are recommended by NICE in the UK. This approach is criticised as having not been well-researched, and arts therapies are not recommended in Australian guidelines for example. Peer support, in which people with personal experience of schizophrenia, provide help to each other, is of unclear benefit.
Other
Exercise including aerobic exercise has been shown to improve positive and negative symptoms, cognition, working memory, and improve quality of life. Exercise has also been shown to increase the volume of the hippocampus in those with schizophrenia. A decrease in hippocampal volume is one of the factors linked to the development of the disease. However, there still remains the problem of increasing motivation for, and maintaining participation in physical activity. Supervised sessions are recommended. In the UK healthy eating advice is offered alongside exercise programs.
An inadequate diet is often found in schizophrenia, and associated vitamin deficiencies including those of folate, and vitamin D are linked to the risk factors for the development of schizophrenia and for early death including heart disease. Those with schizophrenia possibly have the worst diet of all the mental disorders. Lower levels of folate and vitamin D have been noted as significantly lower in first episode psychosis. The use of supplemental folate is recommended. A zinc deficiency has also been noted. Vitamin B12 is also often deficient and this is linked to worse symptoms. Supplementation with B vitamins has been shown to significantly improve symptoms, and to put in reverse some of the cognitive deficits. It is also suggested that the noted dysfunction in gut microbiota might benefit from the use of probiotics.
Prognosis
Main article: Prognosis of schizophreniaSee also: Physical health in schizophreniano data ≤ 185 185–197 197–207 207–218 218–229 229–240 | 240–251 251–262 262–273 273–284 284–295 ≥ 295 |
Schizophrenia has great human and economic costs. It decreases life expectancy by between 10 and 28 years. This is primarily because of its association with heart disease, diabetes, obesity, poor diet, a sedentary lifestyle, and smoking, with an increased rate of suicide playing a lesser role. Side effects of antipsychotics may also increase the risk.
Almost 40% of those with schizophrenia die from complications of cardiovascular disease which is seen to be increasingly associated. An underlying factor of sudden cardiac death may be Brugada syndrome (BrS) – BrS mutations that overlap with those linked with schizophrenia are the calcium channel mutations. BrS may also be drug-induced from certain antipsychotics and antidepressants. Primary polydipsia, or excessive fluid intake, is relatively common in people with chronic schizophrenia. This may lead to hyponatremia which can be life-threatening. Antipsychotics can lead to a dry mouth, but there are several other factors that may contribute to the disorder; it may reduce life expectancy by 13 percent. Barriers to improving the mortality rate in schizophrenia are poverty, overlooking the symptoms of other illnesses, stress, stigma, and medication side effects.
Schizophrenia is a major cause of disability. In 2016, it was classed as the 12th most disabling condition. Approximately 75% of people with schizophrenia have ongoing disability with relapses. Some people do recover completely and others function well in society. Most people with schizophrenia live independently with community support. About 85% are unemployed. In people with a first episode of psychosis in schizophrenia a good long-term outcome occurs in 31%, an intermediate outcome in 42% and a poor outcome in 31%. Males are affected more often than females, and have a worse outcome. Studies showing that outcomes for schizophrenia appear better in the developing than the developed world have been questioned. Social problems, such as long-term unemployment, poverty, homelessness, exploitation, stigmatization and victimization are common consequences, and lead to social exclusion.
There is a higher than average suicide rate associated with schizophrenia estimated at 5% to 6%, most often occurring in the period following onset or first hospital admission. Several times more (20 to 40%) attempt suicide at least once. There are a variety of risk factors, including male sex, depression, a high IQ, heavy smoking, and substance use. Repeated relapse is linked to an increased risk of suicidal behavior. The use of clozapine can reduce the risk of suicide, and of aggression.
A strong association between schizophrenia and tobacco smoking has been shown in worldwide studies. Smoking is especially high in those diagnosed with schizophrenia, with estimates ranging from 80 to 90% being regular smokers, as compared to 20% of the general population. Those who smoke tend to smoke heavily, and additionally smoke cigarettes with high nicotine content. Some propose that this is in an effort to improve symptoms. Among people with schizophrenia use of cannabis is also common.
Schizophrenia leads to an increased risk of dementia.
Violence
Most people with schizophrenia are not aggressive, and are more likely to be victims of violence rather than perpetrators. People with schizophrenia are commonly exploited and victimized by violent crime as part of a broader dynamic of social exclusion. People diagnosed with schizophrenia are also subject to forced drug injections, seclusion, and restraint at high rates.
The risk of violence by people with schizophrenia is small. There are minor subgroups where the risk is high. This risk is usually associated with a comorbid disorder such as a substance use disorder – in particular alcohol, or with antisocial personality disorder. Substance use disorder is strongly linked, and other risk factors are linked to deficits in cognition and social cognition including facial perception and insight that are in part included in theory of mind impairments. Poor cognitive functioning, decision-making, and facial perception may contribute to making a wrong judgement of a situation that could result in an inappropriate response such as violence. These associated risk factors are also present in antisocial personality disorder which when present as a comorbid disorder greatly increases the risk of violence.
Epidemiology
Main article: Epidemiology of schizophreniaIn 2017, the Global Burden of Disease Study estimated there were 1.1 million new cases; in 2022 the World Health Organization (WHO) reported a total of 24 million cases globally. Schizophrenia affects around 0.3–0.7% of people at some point in their life. In areas of conflict this figure can rise to between 4.0 and 6.5%. It occurs 1.4 times more frequently in males than females and typically appears earlier in men.
Worldwide, schizophrenia is the most common psychotic disorder. The frequency of schizophrenia varies across the world, within countries, and at the local and neighborhood level; this variation in prevalence between studies over time, across geographical locations, and by gender is as high as fivefold.
Schizophrenia causes approximately one percent of worldwide disability adjusted life years and resulted in 17,000 deaths in 2015.
In 2000, WHO found the percentage of people affected and the number of new cases that develop each year is roughly similar around the world, with age-standardized prevalence per 100,000 ranging from 343 in Africa to 544 in Japan and Oceania for men, and from 378 in Africa to 527 in Southeastern Europe for women.
History
Main article: History of schizophreniaConceptual development
Main article: History of schizophrenia § Conceptual development Further information: Dementia praecoxAccounts of a schizophrenia-like syndrome are rare in records before the 19th century; the earliest case reports were in 1797 and 1809. The term dementia praecox ("premature dementia") was used by German psychiatrist Heinrich Schüle in 1886 and then in 1891 by Arnold Pick in a case report of hebephrenia. In 1893 Emil Kraepelin used the term in making a distinction, known as the Kraepelinian dichotomy, between the two psychoses: dementia praecox and manic depression (now called bipolar disorder). When it became evident that the disorder was not a degenerative dementia, it was renamed schizophrenia by Eugen Bleuler in 1908.
The word schizophrenia ("splitting of the mind") is Modern Latin, derived from the Greek schizein (Ancient Greek: σχίζειν, lit. 'to split') and phrēn (Ancient Greek: φρήν, lit. 'mind'). Its use was intended to describe the separation of function between personality, thinking, memory, and perception.
In the early 20th century, the psychiatrist Kurt Schneider categorized the psychotic symptoms of schizophrenia into two groups: hallucinations and delusions. The hallucinations were listed as specific to auditory and the delusions included thought disorders. These were seen as important symptoms, termed first-rank. The most common first-rank symptom was found to belong to thought disorders. In 2013 the first-rank symptoms were excluded from the DSM-5 criteria; while they may not be useful in diagnosing schizophrenia, they can assist in differential diagnosis.
Subtypes of schizophrenia—classified as paranoid, disorganized, catatonic, undifferentiated, and residual—were difficult to distinguish and are no longer recognized as separate conditions by DSM-5 (2013) or ICD-11.
Breadth of diagnosis
Before the 1960s, nonviolent petty criminals and women were sometimes diagnosed with schizophrenia, categorizing the latter as ill for not performing their duties as wives and mothers. In the mid- to late 1960s, black men were categorized as "hostile and aggressive" and diagnosed as schizophrenic at much higher rates, their civil rights and Black Power activism labeled as delusions.
In the early 1970s in the United States, the diagnostic model for schizophrenia was broad and clinically based using DSM II. Schizophrenia was diagnosed far more in the United States than in Europe, where the ICD-9 criteria were followed. The US model was criticised for failing to demarcate clearly those people with a mental illness. In 1980 DSM III was published and showed a shift in focus from the clinically based biopsychosocial model to a reason-based medical model. DSM IV brought an increased focus on an evidence-based medical model.
Historical treatment
Main article: History of schizophrenia § Development of treatments in the 20th centuryIn the 1930s a number of shock procedures which induced seizures (convulsions) or comas were used to treat schizophrenia. Insulin shock involved injecting large doses of insulin to induce comas, which in turn produced hypoglycemia and convulsions. The use of electricity to induce seizures was in use as electroconvulsive therapy (ECT) by 1938.
Carried out from the 1930s until the 1970s in the United States and until the 1980s in France, psychosurgery, including such modalities as the lobotomy, is recognized as a human rights abuse. In the mid-1950s, chlorpromazine, the first typical antipsychotic, was introduced, followed in the 1970s by clozapine, the first atypical antipsychotic.
Political abuse
Further information: Political abuse of psychiatryFrom the 1960s until 1989, psychiatrists in the USSR and Eastern Bloc diagnosed thousands of people with sluggish schizophrenia, without signs of psychosis, based on "the assumption that symptoms would later appear". Now discredited, the diagnosis provided a convenient way to confine political dissidents.
Society and culture
See also: List of people with schizophrenia and Religion and schizophreniaIn the United States, the annual cost of schizophrenia – including direct costs (outpatient, inpatient, drugs, and long-term care) and non-healthcare costs (law enforcement, reduced workplace productivity, and unemployment) – was estimated at $62.7 billion for the year 2002. In the UK the cost in 2016 was put at £11.8 billion per year with a third of that figure directly attributable to the cost of hospital, social care and treatment.
Stigma
In 2002, the term for schizophrenia in Japan was changed from seishin-bunretsu-byō (精神分裂病, lit. 'mind-split disease') to tōgō-shitchō-shō (統合失調症, lit. 'integration–dysregulation syndrome') to reduce stigma. The new name, also interpreted as "integration disorder", was inspired by the biopsychosocial model. A similar change was made in South Korea in 2012 to attunement disorder.
Cultural depictions
Media coverage, especially movies, reinforce the public perception of an association between schizophrenia and violence. A majority of movies have historically depicted characters with schizophrenia as criminal, dangerous, violent, unpredictable and homicidal, and depicted delusions and hallucinations as the main symptoms of schizophrenic characters, ignoring other common symptoms, furthering stereotypes of schizophrenia including the idea of a split personality.
The book A Beautiful Mind chronicled the life of John Forbes Nash who had been diagnosed with schizophrenia and won the Nobel Memorial Prize in Economic Sciences. The book was made into a film with the same name; an earlier documentary film was A Brilliant Madness.
In the UK, guidelines for reporting conditions and award campaigns have shown a reduction in negative reporting since 2013.
In 1964 a case study of three males diagnosed with schizophrenia who each had the delusional belief that they were Jesus Christ was published as The Three Christs of Ypsilanti; a film with the title Three Christs was released in 2020.
Research directions
See also: Animal models of schizophreniaA 2015 Cochrane review found unclear evidence of benefit from brain stimulation techniques to treat the positive symptoms of schizophrenia, in particular auditory verbal hallucinations (AVHs). Most studies focus on transcranial direct-current stimulation (tDCM), and repetitive transcranial magnetic stimulation (rTMS). Techniques based on focused ultrasound for deep brain stimulation could provide insight for the treatment of AVHs.
The study of potential biomarkers that would help in diagnosis and treatment of schizophrenia is an active area of research as of 2020. Possible biomarkers include markers of inflammation, neuroimaging, brain-derived neurotrophic factor (BDNF), and speech analysis. Some markers such as C-reactive protein are useful in detecting levels of inflammation implicated in some psychiatric disorders but they are not disorder-specific. Other inflammatory cytokines are found to be elevated in first episode psychosis and acute relapse that are normalized after treatment with antipsychotics, and these may be considered as state markers. Deficits in sleep spindles in schizophrenia may serve as a marker of an impaired thalamocortical circuit, and a mechanism for memory impairment. MicroRNAs are highly influential in early neuronal development, and their disruption is implicated in several CNS disorders; circulating microRNAs (cimiRNAs) are found in body fluids such as blood and cerebrospinal fluid, and changes in their levels are seen to relate to changes in microRNA levels in specific regions of brain tissue. These studies suggest that cimiRNAs have the potential to be early and accurate biomarkers in a number of disorders including schizophrenia.
Ongoing fMRI research aims to identify biomarkers within these brain networks, potentially aiding in earlier diagnosis and better tracking of treatment responses in schizophrenia.
Explanatory notes
- A 2007 review stated that the 2002 estimate was still the best available, and a 2018 review cited the same $62.7 billion.
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