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{{Infobox_Disease |
Name = Schizophrenia |
Image = |
Caption = |
DiseasesDB = 11890 |
ICD10 = {{ICD10|F|20||f|20}} |
ICD9 = {{ICD9|295}} |
ICDO = |
OMIM = 181500 |
MedlinePlus = |
eMedicineSubj = med |
eMedicineTopic = 2072 |
eMedicine_mult = {{eMedicine2|emerg|520}} |
MeshName = Schizophrenia |
MeshNumber = F03.700.750 |
}}
<!--Para1: Definition and characterization-->
'''Schizophrenia''' (from the ] word σχιζοφρένεια, "split mind") is a psychiatric ] that describes a ] characterized by impairments in the ] or expression of ] and by significant social or occupational dysfunction. A person experiencing schizophrenia is typically characterized as demonstrating disorganized ], and as experiencing ]s or auditory ]s.

Although the disorder is primarily thought to affect ], it can also contribute to chronic problems with ] and ]. Due to the many possible combinations of symptoms, heated debate is ongoing about whether the diagnosis necessarily or adequately describes a disorder, or alternatively whether it might represent a number of disorders. For this reason, ] deliberately called the disease "the schizophrenias" plural, when he coined the present name.

<!--Para2: Diagnosis and suspected causes-->
Diagnosis is based on the self-reported experiences of the patient, in combination with secondary signs observed by a ], ] or other competent clinician. No objective ] test for schizophrenia exists, though studies suggest that ], ] and social environment are important contributing factors. Current research into the development of the disorder often focuses on the role of neurobiology, although a reliable and identifiable organic cause has not been found. In the absence of objective laboratory tests to confirm the diagnosis, some question the ] of schizophrenia's status as a ]. Furthermore, some question the status of schizophrenia as a disease on the basis that they do not consider the condition to be an impairment.

<!--Para3: Tricky etymology and misconceptions-->
The term ''schizophrenia'' translates roughly as "shattered mind," and comes from the ] σχίζω (''schizo'', "to split" or "to divide") and φρήν (''phrēn'', "]"). Despite its etymology, schizophrenia is not synonymous with ], also known as multiple personality disorder or "split personality"; in ] the two are often confused. Although schizophrenia often leads to social or occupational ], a predisposition toward aggressive behavior is little associated with the illness.

<!--Para4: Comorbidity-->
Patients diagnosed with schizophrenia are highly likely to be diagnosed with other disorders. The lifetime ] of ] is typically around 40%. ] is also high with ], ], and social problems, and a generally decreased ] is also present. Patients diagnosed with schizophrenia typically live 10-12 years less than their healthy counterparts, owing to increased physical health problems and a high ] rate.

==Overview==
Schizophrenia is often described in terms of "positive" and "negative" symptoms. ''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, blunted or constricted ] and ], poverty of ] and lack of ]. Some models of schizophrenia include ] and planning difficulties in a third group, a "disorganization syndrome".

Additionally, ]s may be present. These may take the form of reduced or impaired psychological functions such as ], ], ], ] or ].

Onset of schizophrenia typically occurs in late adolescence or early adulthood, with males tending to show symptoms earlier than females.

In 1893 ] ] was the first to draw a distinction between what he termed ] ("premature dementia") and other psychotic illnesses. In 1908, ''"dementia praecox"'' was renamed "schizophrenia" by psychiatrist ], who discovered that the disorder is not a form of ].

The diagnostic category of schizophrenia has been widely criticised as lacking in scientific validity or reliability, consistent with evidence of poor levels of consistency in diagnostic practices and the use of criteria. One alternative suggests that the problems and issues making up the diagnosis of schizophrenia 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 and delusional beliefs amongst the general public.

Although no common cause of schizophrenia has been identified in all individuals diagnosed with the condition, currently most researchers and clinicians believe it results from a combination of both ] vulnerabilities (either inherited or acquired) and stressful life-events. This widely-adopted approach is known as the 'stress-vulnerability' model, and much scientific debate now focuses on how much each of these factors contributes to the development and maintenance of schizophrenia.

It is also thought that processes in early ] are important, particularly ] processes. In adult life, particular importance has been placed upon the function (or malfunction) of ] in the ] in the brain. This theory, known as the ] largely resulted from the accidental finding that a ] group which blocks dopamine function, known as the ]s, reduced psychotic symptoms. However, this theory is now thought to be overly simplistic as a complete explanation. These drugs have now been developed further and ] ] is commonly used as a first-line treatment. Although effective in many cases, these medications are not well tolerated by some patients due to significant ]. The positive symptoms are more responsive to medications; negative symptoms being less so.

Differences in brain structure have been found between people with schizophrenia and those without. However, these tend only to be reliable on the group level and, due to the significant variability between individuals, may not be reliably present in any particular individual.Significant brain atrophy and enlarged ventricles being the most conspicuous.

==History==
Accounts that may relate to symptoms of schizophrenia date back as far as 2000 BC in the ''Book of Hearts'', part of the ancient ]. However, a recent study<ref name="fn_1"> Searching for schizophrenia in ancient Greek and Roman literature: a ]. ''Acta Psychiatrica Scandanavica'', 107(5), 323&ndash;330.<br></ref> into the ] and ] literature showed that, while the general population probably had an awareness of psychotic disorders, there was no recorded condition that would meet the modern diagnostic criteria for schizophrenia in these societies.

This nonspecific concept of "]" has been around for many thousands of years, but schizophrenia was only classified as a distinct mental disorder by Kraepelin in 1893. He was the first to make a distinction in the psychotic disorders between what he called ''dementia praecox'' (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.<br></ref>, and particularly a form of ]. Kraepelin named the disorder 'dementia praecox' (early dementia) to distinguish it from other forms of dementia (such as ]) which typically occur late in life. He used this term because his studies focused on young adults with dementia.<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&ndash;74. ISBN 0-683-30417-8<br></ref>

The term ''schizophrenia'' is derived from the Greek words σχίζειν (split) and φρήν (mind) and was coined by ] in 1908 to refer to the lack of interaction between thought processes and ]. He was also the first to describe the symptoms as "positive" or "negative."<ref name="fn_2" /> Blueler described the main symptoms as 4 "A"'s: flattened Affect, Autism, impaired Association of ideas and Ambivalence. <ref name="fn_78"> Epistemological aspects of Eugen Bleuler's conception of schizophrenia in 1911. ''Medicine, Health Care, and Philosophy'', 3(2), 153-9.<br></ref> Bleuler suggested the name schizophrenia, as it was obvious that Kraepelin's name was misleading. The word "praecox" implied precocious or early onset, hence premature dementia, as opposed to ] from old age. Bleuler realized the illness was not a dementia as some of his patients improved rather than following a deteriorating course.

With the name 'schizophrenia' Bleuler intended to capture the separation of function between ], ], ], and ], however it is commonly misunderstood to mean that affected persons have a 'split personality' (something akin to the character in ] '']''). 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 perhaps arises in part due to the meaning of Bleuler's term 'schizophrenia' (literally 'split' or 'shattered mind'). Interestingly, the first known misuse of this word schizophrenia to mean 'split personality' (in the ] sense) was in an article by the poet ] in 1933.<ref name="fn_3">Turner, T. (1999) 'Schizophrenia'. In G.E. Berrios and R. Porter (eds) ''A History of Clinical Psychiatry''. London: Athlone Press. ISBN 0-485-24211-7<br></ref>

In the first half of the ] schizophrenia was considered by many to be a "hereditary defect", and individuals affected by schizophrenia became subject to ] in many countries. Hundreds of thousands were ], with or without consent, the majority in ], the ], and ] countries.<ref name="fn_76"> 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.<br></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<br></ref> Many people diagnosed with schizophrenia, together with other people labeled "mentally unfit", were murdered in the Nazi "]" program.

==Diagnosis==
===Criteria (signs and symptoms) ===
Like many mental illnesses, the diagnosis of schizophrenia is based upon the behavior of the person being assessed. 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.

The most commonly used criteria for diagnosing schizophrenia are from the ] ] (DSM) and the ] ] (ICD). The most recent versions are and .

Below is an abbreviated version of the diagnostic criteria from the DSM-IV-TR; the full version is available .

To be diagnosed as having schizophrenia, a person must display:

*A) 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)
** ]s
** ]s
** disorganized speech (e.g., frequent derailment or incoherence; speaking in abstracts). 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).

:Note: Only one Criterion A symptom 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.

*B) 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.

*C) 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) that meet Criterion A.

Additional criteria (D, E and F) are also given that exclude a diagnosis of schizophrenia if symptoms of ] or ] are present. Additionally a diagnosis of schizophrenia is excluded if the symptoms are the direct result of a substance (e.g., abuse of a drug, medication) or a general medical condition.

===Subtypes===
Historically, schizophrenia in the ] was classified into simple, ], ], and ]. The DSM now contains five sub-classifications of schizophrenia, the ICD-10 identifies 7:

* (295.2/F20.2) '''catatonic type''' (where marked absences or peculiarities of movement are present),
* (295.1/F20.1) ''']''' (where thought disorder and flat affect are present together),
* (295.3/F20.0) '''paranoid type''' (where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening is absent),
* (295.6/F20.5) '''residual type''' (where positive symptoms are present at a low intensity only) and
* (295.9/F20.3) '''undifferentiated type''' (psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types has not been met).

''NB:'' Brackets indicate codes for ] and ] diagnostic manuals, respectively. Some older classifications still use "Hebephrenic schizophrenia" instead of "Disorganized schizophrenia".

===Deficit Syndrome===
Currently, there is debate in the field about a new subtype known as the deficit syndrome. It is not currently included in the DSM-IV-TR, however it has been receiving a great deal of attention in the last 20 years. This subtype is more expansive than the other subtypes as a person can be diagnosed with both paranoid schizophrenia and the deficit syndrome. It is characterized by primary negative symptoms (which means that they cannot be caused by such things as the side-effects of medication or depression). People with the deficit syndrome tend to have extremely flat affect (do not appear to be very emotional), do not have good eye contact, do not enjoy normally pleasurable activities (see ]), and seem to be uninterested in social interaction. (There is, however, conflict in the research on this last point. While people who have been diagnosed with the deficit syndrome report being uninterested in social interaction, in the laboratory, they often report normal reactions to the situations.) Patients who have been diagnosed with the deficit syndrome tend to have a worse prognosis as these symptoms tend to be resistant to medication. This fact has brought much needed attention to negative symptoms (which have traditionally not been viewed as important as the positive symptoms).

===Presentation===
Symptoms may also be described as 'positive symptoms' (those additional to normal experience and behavior) and 'negative symptoms' (the lack or decline in normal experience or behavior). 'Positive symptoms' describe ] and typically include ], ] and ]. 'Negative symptoms' describe inappropriate or nonpresent emotion, ], and lack of motivation. In three-factor models of schizophrenia, a third symptom grouping, the so-called 'disorganization syndrome', is also given. This considers thought disorder and related disorganized behavior to be in a separate symptom cluster from delusions and hallucinations.

Some symptoms, such as social isolation, may be caused by a number of factors. One possible factor is impairment in ], which is associated with schizophrenia, but isolation may also result from an individual reacting to psychotic symptoms (such as paranoia) or avoiding potentially stressful social situations which may exacerbate mental distress in some people.

It is worth noting that many of the positive or psychotic symptoms may occur in a variety of disorders and not only in schizophrenia. The psychiatrist ] tried to list the particular forms of psychotic symptoms that he thought were particularly useful in distinguishing between schizophrenia and other disorders that could produce psychosis. These are called ''first rank symptoms'' or ''Schneiderian first rank symptoms'' and include delusions of being controlled by an external force, the belief that thoughts are being inserted into or withdrawn from your conscious mind, the belief that your thoughts are being broadcast to other people and hearing hallucinated voices which comment on your thoughts or actions, or may have a conversation with other hallucinated voices. As with other diagnostic methods, the reliability of 'first rank symptoms' has been questioned<ref name="fn_4"> Schizophrenia and Related Disorders: Experience with Current Diagnostic Systems. ''Psychopathology'', 35, 89&ndash;93.<br></ref>, although they remain in use as diagnostic criteria in many countries.

===Diagnostic issues and controversies===
It has been argued that the diagnostic approach to schizophrenia is flawed, as it relies on an assumption of a clear dividing line between what is considered to be ] (fulfilling the diagnostic criteria) and ] (not fulfilling the criteria). Recently it has been argued, notably by psychiatrist ] and psychologist ], that this makes little sense, as studies have shown that many people have psychotic experiences<ref name="fn_5"> Psychotic symptoms in non-clinical populations and the continuum of psychosis. ''Schizophrenia Research'', 54(1&ndash;2), 59&ndash;65.<br></ref> <ref name="fn_65"> The continuity of psychotic experiences in the general population. ''Clinical Psychology Review'', 21 (8),1125-41.<br></ref> and have delusion-like ideas<ref name="fn_67"> Measuring delusional ideation: the 21-item Peters et al. Delusions Inventory (PDI). ''Schizophrenia Bulletin'', 30, 1005-22.<br></ref> without becoming distressed, disabled or diagnosable by the categorical system (potentially because they interpret their experiences in more positive ways, or hold more pragmatic and commonly accepted beliefs).

Of particular concern is that the decision as to whether a symptom is present is a subjective decision by the person making the diagnosis or relies on an incoherent definition (for example, see the entries on ]s and ] for a discussion of this issue). 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 &mdash; a serious but nonspecific indicator".<ref name="fn_6"> Toward reformulating the diagnosis of schizophrenia. ''American Journal of Psychiatry'', 157(7), 1041&ndash;1050.<br></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. More recent studies have found agreement between any two psychiatrists when diagnosing schizophrenia tends to reach about 65% at best<ref name="fn_7"> Spurious precision: procedural validity of diagnostic assessment in psychotic disorders. ''American Journal of Psychiatry'', 152 (2), 220&ndash;3.<br></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 J. Read, L.R. Mosher, R.P. Bentall (eds) ''Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia''. ISBN 1-58391-906-6<br></ref>

In 2004 in Japan, the category of schizophrenia was abandoned and replaced with ].<ref name="Sato"> Renaming schizophrenia: a Japanese perspective. ''World Psychiatry'', 5(1), 53-5.</ref> In 2006, campaigners in the UK, under the banner of ], 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, (9 October 2006) </ref>

Alternatively, other proponents have argued for a new approach that would use the presence of specific ]s to make a diagnosis. These often accompany schizophrenia and 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.

The diagnostic approach to schizophrenia has also been opposed by the proponents of the ] movement, who argue that classifying specific thoughts and behaviors as an illness allows ] of people that society finds undesirable but who have committed no crime. They argue that this is a way of ] classifying a social problem as a medical one to allow the forcible detention and treatment of people displaying these behaviors, which is something which can be done under ] in most ].

An example of this can be seen in the ], where 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. In 2000 similar concerns about the abuse of psychiatry to unjustly silence and detain practitioners of the ] movement by the Chinese government led the ] ''Committee on the Abuse of Psychiatry and Psychiatrists'' to pass a resolution to urge the ] to investigate the situation in ].

Western psychiatric medicine tends to favor a definition of symptoms that depends on form rather than content (an innovation first argued for by psychiatrists ] and ]). Therefore, a subject should be able to believe anything, however unusual or socially unacceptable, without being diagnosed delusional, unless their belief is held in a particular way. In principle, this would stop people being forcibly detained or treated simply for what they believe. However, the distinction between form and content is not easy, or always possible, to make in practice (see ]). This had led to accusations by ], ] and mental health system survivor groups that psychiatric abuses exist in the West as well.

==Causes==
===Genetic and environmental influences===
While the reliability of the schizophrenia diagnosis introduces difficulties in measuring the relative effect of genes and environment (for example, symptoms overlap to some extent with severe ] or major depression), evidence suggests that genetic vulnerability and environmental stressors can act in combination to result in diagnosis of schizophrenia<ref name="fn_12"> Genes for schizophrenia? Recent findings and their pathophysiological implications. '''', 361(9355), 417&ndash;9.<br></ref>.

The extent to which these factors influence the likelihood of being diagnosed with schizophrenia is debated widely, and currently, controversial. Schizophrenia is likely to be a diagnosis of complex inheritance (analogous to ] or ]). Thus, it is likely that several ] interact to generate risk for it<ref name="fn_75"> Schizophrenia: genes at last? ''Trends in Genetics'', 21(9), 518-25.<br></ref>. This, combined with disagreements over which research methods are best, or how data from genetic research should be interpreted, has led to differing estimates over genetic contribution.

====Genetic====
Substantial evidence suggests that the diagnosis of schizophrenia has a heritable component (some estimates are as high as 80%). Current research suggests that environmental factors play a significant role in the expression of any genetic disposition towards schizophrenia (i.e. if someone has the genes that increase risk, this will not automatically result in a diagnosis of schizophrenia later in life). A recent review of the genetic evidence has suggested a more than 28% chance of one identical twin obtaining the diagnosis if the other already has it<ref name="fn_9">], Bowler, A.E., Taylor, E.H. & Gottesman, I.I (1994) ''Schizophrenia and manic depressive disorder''. New York: Basic books. ISBN 0-465-07285-2<br></ref> (see ]), but such studies are not noted for pondering the likelihood of similarities of social class and/or other socio-psychological factors between the twins. The estimates of heritability of schizophrenia from twin studies varies a great deal, with some notable studies<ref name="fn_10"> Psychiatric hospitalization in twins. ''Acta Genet Med Gemellol (Roma)'', 33(2),321-32.<br></ref> <ref name="fn_11"> Schizophrenia in the NAS-NRC panel of 15,909 veteran twin pairs. ''Archives of General Psychiatry'', 1970 Nov; 23(5):469-77.<br></ref> showing rates as low as 11.0%&ndash;13.8% among monozygotic twins, and 1.8%&ndash;4.1% among dizygotic twins. However, ] and a vocal lobby of psychiatrists and scientists who are at present in the minority have taken to task the twin studies, and have argued that the genetic basis of schizophrenia is open to question.

There is currently a great deal of effort being put into ] studies of schizophrenia, which attempt to identify specific genes which may increase risk. Because of this, the genes that are thought to be most involved can change as new evidence is gathered. A 2003 review of ] studies listed seven genes as likely to increase risk for a later diagnosis of the disorder.<ref name="fn_12" /> Two more recent reviews<ref name="fn_75" /> <ref name="fn_79"> Molecular genetic studies of schizophrenia. ''Eur J Hum Genet'', 14 (6), 669-80.<br></ref> have suggested that the evidence is currently strongest for two genes known as ] (DTNBP1) and ] (NRG1), with a number of other genes (such as ], RGS4, PPP3CC, ZDHHC8, DISC1, and AKT1) showing some early promising results that have not yet been fully replicated.

====Environmental====
Considerable evidence indicates that stressful life events cause or trigger schizophrenia.<ref name="fn_15">. Stressful life events preceding the acute onset of schizophrenia: a cross-national study from the World Health Organization. ''Culture, Medicine and Psychiatry'', 11 (2), 123&ndash;205<br></ref> Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life.<ref name="fn_16"> Childhood Abuse and Lifetime Psychopathology in a Community Sample. ''American Journal of Psychiatry'',158, 1878-83.<br></ref> <ref name="fn_17"> Histories of childhood maltreatment in schizophrenia: Relationships with premorbid functioning, symptomatology, and cognitive deficits. ''Schizophrenia Research''<br></ref> <ref name="fn_18"> Childhood abuse as a risk factor for psychotic experiences. ''Acta Psychiatrica Scandinavica'', 109, 38-45.<br></ref>

Evidence is also consistent that negative attitudes towards individuals with (or with a risk of developing) schizophrenia can have a significant adverse impact. In particular, critical comments, hostility, authoritarian and intrusive or controlling attitudes (termed 'high expressed emotion' by researchers) from family members have been found to correlate with a higher risk of relapse in schizophrenia across cultures.<ref name="fn_70"> The predictive utility of expressed emotion in schizophrenia: an aggregate analysis. ''Psychological Medicine'', 24, 707-718.<br></ref> It is not clear whether such attitudes play a causal role in the onset of schizophrenia, although those diagnosed in this way may claim it to be the primary causal factor. The research has focused on family members but also appears to relate to professional staff in regular contact with clients.<ref name="fn_71"> Expressed emotion of professionals towards mental health patients. ''Epidemiologia e Psychiatria Sociale'', 12(4), 232-235. ()<br></ref> While initial work addressed those diagnosed as schizophrenic, these attitudes have also been found to play a significant role in other mental health problems.<ref name="fn_66"> A review of expressed emotion research in health care. ''Clinical Psychology Review'', 20, 633-66.<br></ref> This approach does not blame 'bad parenting' or staffing, but addresses the attitudes, behaviors and interactions of all parties. Some go as far as to criticise the whole approach of seeking to localise 'mental illness' within one individual - the patient - rather than his/her group and its functionality, citing a ] effect.

Factors such as ] and ] also appear to be involved in increasing the risk of schizophrenia or schizophrenia relapse, perhaps due to the high levels of stress they engender, or faults in diagnostic procedure/assumptions. Racism in society, including in diagnostic practices, and/or the stress of living in a different culture, may explain why minority communities have shown higher rates of schizophrenia than members of the same ethnic groups resident in their home country. The "social drift hypothesis" suggests that the functional problems related to schizophrenia, or the stigma and prejudice attached to them, can result in more limited employment and financial opportunities, so that the causal pathway goes from mental health problems to poverty, rather than, or in addition to, the other direction. Some argue that ] and the long-term unemployed and homeless are simply being stigmatised.

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"> Does the urban environment cause psychosis? ''British Journal of Psychiatry'', 184 (4), 287&ndash;288.<br></ref> A recent study of 4.4 million men and women in ] found an alleged 68%&ndash;77% increased risk of diagnosed ] for people living in the most urbanized environments, a significant proportion of which is likely to be described as schizophrenia.<ref name="fn_20"> Urbanisation and incidence of psychosis and depression: Follow-up study of 4.4 million women and men in Sweden. ''British Journal of Psychiatry'', 184 (4), 293&ndash;298.<br></ref>

One curious finding is that people diagnosed with schizophrenia are more likely to have been born in ] or ]<ref name="fn_21"> A ] and meta-analysis of Northern Hemisphere season of birth studies in schizophrenia. ''Schizophrenia Bulletin'', 29 (3), 587&ndash;93.<br></ref> (at least in the ]). However, the effect is not large. Some researchers postulate that the correlation is due to viral infections during the third trimester (4-6 months) of pregnancy.

A study by Sweden's Karolinska Institute and Bristol University in the UK, looked at the medical records of over 700,000 people and calculated that 15.5% of cases of schizophrenia seen in the group may have been due to the patient having a father who was aged over 30 years at their birth, the researchers argue this is due to build up of mutations in the sperm of elder fathers.<ref name="fn_79" />

===Neurobiological influences===
====Early neurodevelopment====
It is also thought that processes in early ] are important, particularly during pregnancy. For example, women who were pregnant during the ], where many people were close to starvation, had a higher chance of having a child who would later develop schizophrenia.<ref name="fn_22"> Schizophrenia after prenatal famine. Further evidence. ''Archives of General Psychiatry'', 53(1), 25&ndash;31.<br></ref> Similarly, studies of ] mothers who were pregnant when they found out that their husbands had been killed during the ] of 1939&ndash;1940 have shown that their children were much more likely to develop schizophrenia when compared with mothers who found out about their husbands' death after pregnancy,<ref name="fn_23"> Prenatal loss of father and psychiatric disorders. ''Archives of General Psychiatry'', 35(4), 429&ndash;31.<br></ref> suggesting that even ] in the mother may have an effect. Furthermore, there is now significant evidence that ] exposure to infections increases the risk for developing schizophrenia later in life, providing additional evidence for a link between developmental pathology and risk of developing the condition.<ref name="fn_73"> Prenatal infection as a risk factor for schizophrenia. ''Schizophrenia Bulletin'', 32 (2), 200-2.<br></ref>

Some researchers have proposed that environmental influences during childhood also interact with neurobiological risk factors to influence the likelihood of developing schizophrenia later in life. The neurological development of children is considered sensitive to features of dysfunctional social settings, such as trauma, violence, lack of warmth in personal relationships and hostility. These have all been found to be risk factors for the later development of schizophrenia. Research has suggested that effects of the childhood environment, favorable or unfavorable, interact with genetics and the processes of neurodevelopment, with long-term consequences for brain function. Consequently, this is thought to influence the underlying vulnerability for psychosis later in life, particularly during the adult years.<ref name="fn_24"> The contribution of early traumatic events to schizophrenia in some patients: a traumagenic neurodevelopmental model. ''Psychiatry'', 64, 319-45. ()<br></ref>

] study<ref name="fn_25"> Reduced prefrontal activity predicts exaggerated striatal dopaminergic function in schizophrenia. ''Nature Neuroscience'', 5, 267-71.<br></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.]]

====Role of dopamine====
In adult life, particular importance has been placed upon the function (or malfunction) of dopamine in the ] in the brain. This theory, known as the ], largely resulted from the accidental finding that a drug group which blocks dopamine function, known as the ], reduced psychotic symptoms. These drugs have now been developed further and antipsychotic medication is commonly used as a first line treatment.

However, this theory is now thought to be overly simplistic as a complete explanation, partly because newer antipsychotic medication (called ] medication) is equally effective as older medication (called ] medication), but also affects ] function and may have slightly less of a ] blocking effect. Psychiatrist ] has also argued that ] have promoted certain oversimplified biological theories of mental illness to promote their own sales of biological treatments.<ref name="fn_26">Healy, D. (2002) ''The Creation of Psychopharmacology''. Cambridge, MA: Harvard University Press. ISBN 0-674-00619-4<br></ref>

====Role of glutamate and the NMDA receptor====
Interest has also focused on the neurotransmitter ] and the reduced function of the ] in the development of schizophrenia. This theory has largely been suggested by abnormally low levels of glutamate receptors found in postmortem brains of people previously diagnosed with schizophrenia<ref name="fn_27"> Molecular aspects of glutamate dysregulation: implications for schizophrenia and its treatment. ''Pharmacology and Therapeutics'', 97(2), 153-79.<br></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"> Effects of ketamine in normal and schizophrenic volunteers. ''Neuropsychopharmacology'', 25(4), 455-67.<br></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 the ] as an increasingly popular explanation.<ref name="fn_28"> Converging evidence of NMDA receptor hypofunction in the pathophysiology of schizophrenia. ''Annals of the New York Academy of Sciences'', 1003, 318-27.<br></ref> Further support of this theory has come from trials showing the efficacy of molecules, which are coagonists at the NMDA receptor complex, in reducing schizophrenic symptoms. The precursors D-serine, glycine, and D-cycloserine all enhance NMDA function through the glycine co-agonist site. Several placebo controlled trials have shown a reduction mainly in negative symptoms with high dose therapy.<ref name="fn_60"> Glutamatergic drugs for schizophrenia: a systematic review and meta-analysis. ''Schizophr Res'', 72:225-34.<br></ref> Currently type 1 glycine transporter inhibitors are in late-state preclinical for the treatment of schizophrenia. They increase glycine concentrations in the brain thus causing increased NMDA receptor activation and a reduction in symptoms.<ref name="fn_61"> The Glycine Transporter Type 1 Inhibitor. ''The Journal of Neuroscience'', 23 (20), 7586-7591.<br></ref>

====Anatomy and physiology of the brain====
Much recent research has focused on differences in structure or function in certain brain areas in people diagnosed with schizophrenia.

Early evidence for differences in the neural structure came from the discovery of ] enlargement in people diagnosed with schizophrenia, for whom negative symptoms were most prominent.<ref name="fn_29"> Cerebral ventricular size and cognitive impairment in chronic schizophrenia. ''Lancet'', 30;2 (7992), 924-6.<br></ref> However, this finding has not proved particularly reliable on the level of the individual person, with considerable variation between patients. A letter to the editor of the '']'' links ventricular enlargement with exposure to antipsychotic drugs.<ref>http://ajp.psychiatryonline.org/cgi/content/full/156/11/1843-b</ref>

More recent studies have shown a large number of differences in brain structure between people with and without diagnoses of schizophrenia.<ref name="fn_30"> Review of cognition and brain structure in schizophrenia: profiles, longitudinal course, and effects of treatment. ''Psychiatric Clinics of North America'', 27 (1), 1-18, vii.<br></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.

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, M.F. (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0-393-70334-7<br></ref> These differences are heavily linked to the ]s which often occur with schizophrenia, particularly in areas of ], ], ], ] and ].

] (EEG) recordings of persons with schizophrenia performing perception oriented tasks showed an absence of ] activity in the brain, indicating weak integration of critical neural networks in the brain.<ref name="fn_32"> Neural synchrony indexes disordered perception and cognition in schizophrenia. ''Proceedings of the National Academy of Sciences'', 101, 17288-93. ()<br></ref> Those who experienced intense hallucinations, delusions and disorganized thinking showed the lowest frequency synchronization. None of the drugs taken by the persons scanned had moved neural synchrony back into the gamma frequency range. Gamma band and working memory alterations may be related to alterations in ]s that produced the neurotransmitter ]. Alterations in a subclass of GABAergic interneurons which produce the calcium-binding protein ] have been shown to exist in the dorsolateral prefrontal cortex in schizophrenia.<ref name="fn_33"> Cortical inhibitory neurons and schizophrenia. ''Nature Reviews Neuroscience'', 6, 312-324.<br></ref>

==Incidence and prevalence==
In the western world, schizophrenia is typically diagnosed in late adolescence or early adulthood. In the western world, it is found approximately equally in men and women, though the onset tends to be later in women, who also tend to have a better course and outcome. Although rare, there are also instances of ] and ] that occurs in the elderly.

The lifetime ] of schizophrenia is commonly given at 1%; however, a recent review of studies from around the world estimated it to be 0.55%.<ref name="fn_34"> Prevalence and incidence studies of schizophrenic disorders: a ] of the literature. ''Canadian Journal of Psychiatry'', 47(9), 833&ndash;43.<br></ref> The same study also found that prevalence may vary greatly from country to country, despite the received wisdom that schizophrenia occurs at the same rate throughout the world. It is worth noting however, that this may be in part due to differences in the way schizophrenia is diagnosed. The ] of schizophrenia was given as a range of between 7.5 and 16.3 cases per year per 100,000 population.

Schizophrenia is also a major cause of ]. In a recent 14-country study,<ref name="fn_35">. Multiple-informant ranking of the disabling effects of different health conditions in 14 countries. '''', 354(9173), 111&ndash;115.<br></ref> active ] was ranked the third most disabling condition after ] and ] and before ] and ].

==Treatment==
===Medication and hospitalization===
Currently schizophrenia has not been cured although many psychiatrists and psychologists believe that it can be managed. The first line pharmacological therapy for schizophrenia is usually the use of ] medication <ref name="fn_72"> ''Schizophrenia. Full national clinical guideline on core interventions in primary and secondary care''. London: Gaskell and the British Psychological Society.<br></ref>. The concept of 'curing' schizophrenia is controversial as there are no clear criteria for what might constitute a ], although some criteria for the remission of symptoms have recently been suggested<ref name="fn_63"> Standardized remission criteria in schizophrenia. ''Acta Psychiatrica Scandinavica'', 113(2), 91-5.<br></ref>. Therefore, antipsychotic drugs are only thought to provide symptomatic relief from the positive symptoms of psychosis. The newer ] medications (such as ], ], ], ], ], ], and ]) are usually preferred over older ] medications (such as ] and ]) due to their favorable side-effect profile. Compared to the typical antipsychotics, the atypicals are associated with a lower incident rate of ] side effects (EPS) and ] (TD) although they are more likely to induce weight gain and so increase risk for ]-related diseases<ref name="fn_62"> Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. ''The New England Journal of Medicine'', 353 (12), 1209-23.<br></ref>. It is still unclear whether newer drugs reduce the chances of developing the rare but potentially life-threatening ] (NMS). While the atypical antipsychotics are associated with less EPS and TD than the conventional antipsychotics, some of the agents in this class (especially olanzapine and clozapine) appear to be associated with metabolic side effects such as ], ] and ] that must be considered when choosing appropriate pharmacotherapy.

Atypical and typical antipsychotics are generally thought to be equivalent for the treatment of the positive symptoms of schizophrenia. It has been suggested by some researchers that the atypicals have some beneficial effects on negative symptoms and cognitive deficits associated with schizophrenia, although the clinical significance of these effects has yet to be established. However, recent reviews have suggested that typical antipsychotics, when dosed conservatively, may have similar effects to atypicals.<ref name="fn_36"> New generation antipsychotics versus low-potency conventional antipsychotics: a ] and meta-analysis. ''Lancet'', 361(9369), 1581-9.<br></ref> The atypical antipsychotics are much more costly as they are still within patent, whereas the older drugs are available in inexpensive generic forms. ] is a drug from a new class of antipsychotic drugs (variously named 'dopamine system stabilizers' or 'partial dopamine agonists'<ref name="fn_37"> Aripiprazole, an Antipsychotic With a Novel Mechanism of Action, and Risperidone vs Placebo in Patients With Schizophrenia and Schizoaffective Disorder. ''Archives of General Psychiatry'', 60(7), 681&ndash;90.<br></ref>) that have recently been developed and is now widely licensed to treat schizophrenia.

The efficacy of schizophrenia treatment is often assessed by using standardized assessment methods, one of the most common being the positive and negative syndrome scale (]).<ref name="fn_68"> The positive and negative syndrome scale (PANSS) for schizophrenia. ''Schizophrenia Bulletin'', 13(2), 261-76.<br></ref>

Hospitalization may occur with severe episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or ]). Mental health legislation may also allow people to be treated against their will. However, in many countries such legislation does not exist, or does not have the power to enforce involuntary hospitalization or treatment.

===Therapy and community support===
] or other forms of talk therapy may be offered, with cognitive behavioral therapy being the most frequently used. This may focus on the direct reduction of the symptoms, or on related aspects, such as issues of ], social functioning, and insight. Although the results of early trials with ] (CBT) were inconclusive<ref name="fn_38"> Cognitive behaviour therapy for schizophrenia. ''Cochrane Database of ]s'', (1), CD000524.<br></ref>, more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia<ref name="fn_39"> The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. ''Schizophrenia Research'', 77, 1-9.<br></ref>.

A relatively new approach has been the use of 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"> Effects on the brain of a psychological treatment: cognitive remediation therapy: functional magnetic resonance imaging in schizophrenia. ''British Journal of Psychiatry'', 181, 144-52.<br></ref>

] (also known as ECT or 'electroshock therapy') may be used in countries where it is legal. It is not considered a ] but may be prescribed in cases where other treatments have failed. ] has now become a rare procedure and is not a recommended treatment for schizophrenia.

Other support services may also be available, such as drop-in centers, visits from members of a 'community mental health team' or ] team, and patient-led support groups. In recent years the importance of service-user led recovery based movements has grown substantially throughout ] and ]. Groups such as the ] and more recently, the ], have developed a self-help approach that aims to provide support and assistance outside of 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.

In many non-Western societies, schizophrenia may be treated with more informal, community-led methods. A particularly sobering thought for Western psychiatry is that the outcome for people diagnosed with schizophrenia in non-Western countries may actually be much better<ref name="fn_41"> Outcome of schizophrenia: some transcultural observations with particular reference to developing countries. ''European Archives of Psychiatry and Clinical Neuroscience'', 244(5), 227&ndash;35.<br></ref> than for people in the West. The reasons for this recently discovered fact are still far from clear, although cross-cultural studies are being conducted to find out why.

A recent randomised controlled trial found that music therapy significantly improved symptom scores in a group of patients diagnosed with schizophrenia.<ref>
{{cite journal| quotes = Music therapy may provide a means of improving mental health among people with schizophrenia, but its effects in acute psychoses have not been explored | last = Crawford | first = Mike J. | authorlink = | coauthors = Talwar, Nakul, et al. | year = 2006 | month = November | title = Music therapy for in-patients with schizophrenia: Exploratory randomised controlled trial | journal = The British Journal of Psychiatry (2006) | volume = 189 | pages = 405-409 | url = http://bjp.rcpsych.org/cgi/content/abstract/189/5/405}}</ref> A notable early mention of the beneficial effect of music on mental illness was in 1621 by Robert Burton in ].<ref>Burton, R. . Cf. especially subsection 3, on and after line 3480, "Music a Remedy".</ref>

===Dietary supplements===
] (found naturally in foods such as oily fish, flax seeds, hemp seeds, walnuts and canola oil) have recently been studied as a treatment for schizophrenia. Although the number of research trials has been limited, the majority of randomized controlled trials have found omega-3 supplements to be effective when used as a dietary supplement.<ref name="fn_64"> Omega-3 fatty acids in the treatment of psychiatric disorders. ''Drugs'', 65(8), 1051-9.<br></ref>

==Prognosis==
] for any particular individual affected by schizophrenia is particularly hard to judge as treatment and access to treatment is continually changing, as new methods become available and medical recommendations change.

One retrospective study has shown that about a third of people make a full recovery, about a third show improvement but not a full recovery, and a third remain ill.<ref name="fn_42"> 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&ndash;35.<br></ref> A more recent study using stricter recovery criteria (i.e. concurrent remission of positive and negative symptoms and specific instances of adequate social / vocational functioning) reported a recovery rate of 13.7%.<ref name="fn_43"> Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder. ''American Journal of Psychiatry'', 161, 473-479.<br></ref>

The exact definition of what constitutes a recovery has not been widely defined, however, although criteria have recently been suggested to define a remission in symptoms.<ref name="fn_63" /> Therefore, this makes it difficult to give an exact estimate as recovery and remission rates are not always comparable across studies.

The ] conducted two long-term follow-up studies involving more than 2,000 people suffering from schizophrenia in different countries. These studies findings were that these patients have much better long-term outcomes in poor countries (], ] and ]) than in rich countries (], ], ], ], ], ], ], and ]),<ref name="fn_44"> 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. ''Schizophrenia Bulletin'', 26 (4), 835-46.<br></ref> despite the fact antipsychotic drugs are typically not widely available in poorer countries, thus raising questions about the effectiveness such drug-based treatments.

Prognosis also depends on some other factors. Females tend to show recovery rates higher than males, and acute and sudden onset of schizophrenia is associated with higher rates of recovery, while gradual onset is associated with lower rates. Most studies done on this subject, however, are correlational in nature, and a clear cause-and-effect relationship is difficult to establish. Pre-morbid functioning and positive prognosis also seem to be correlated.

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"> Life expectancies for individuals with psychiatric diagnoses. ''Public Health'', 115 (5), 328-37.<br></ref>

There is an extremely 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"> Suicidal behavior in patients with schizophrenia and other psychotic disorders. ''American Journal of Psychiatry'', 156(10), 1590&ndash;5.<br></ref> Another study suggested that 10% of persons with schizophrenia die by suicide.<ref name="fn_47"> Schizophrenics kill themselves too: a review of risk factors for suicide. ''Schizophrenia Bulletin'', 16(4), 571&ndash;89.<br></ref>

== Recovery and Rehabilitation ==

Just as the diagnosis itself is mired in controversy and counter-accusation, it is difficult to establish a clear picture of recovery and rehabilitation. Both long ago and in the recent past, patients in developed countries were told that chances of recovery were limited, with statistics being quoted to support this negative prognosis. Today, with the advent of a vocal ] in mental health, statistics are quoted in a conflicting fashion, and attention is drawn to cultural and local factors in impeding or accelerating recovery. Rehabilitation provision is uneven and strongly dependent on local political culture and/or resources.

==Schizophrenia and drug use==
The relationship between schizophrenia and drug use is complex, meaning that a clear causal connection between drug use and schizophrenia has been difficult to tease apart. 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.

The rate of substance use is known to be particularly high in this group. In a recent study, 60% of people with schizophrenia were found to use substances and 37% would be diagnosable with a substance use disorder.<ref name="fn_74"> Substance use in persons with schizophrenia: baseline prevalence and correlates from the NIMH CATIE study. ''Journal of Nervous and Mental Disease'', 194(3), 164-72.<br></ref>

===Amphetamines===

As amphetamines are believed to elevate dopamine production, and that an excess of dopamine is responsible for schizophrenia (known as the ]) the amphetamines may worsen schizophrenia symptoms.

===Hallucinogens===
Schizophrenia can sometimes be triggered by heavy use of ] drugs, although some claim that a predisposition towards developing schizophrenia is needed for this to occur. There is also some evidence suggesting that people suffering schizophrenia but responding to treatment can have relapse because of subsequent drug use. Some widely known cases where hallucinogens have been suspected of precipitating schizophrenia are ] founder-member ] and ] songwriter ].

Drugs such as ], ], and ] have been used to mimic schizophrenia for research purposes, although this has now fallen out of favor with the ], as the differences between the drug induced states and the typical presentation of schizophrenia have become clear.

Hallucinogenic drugs were also briefly tested as possible treatments for schizophrenia by psychiatrists such as ] and ] in the 1950s. It was mainly for this experimental treatment of schizophrenia that LSD administration was legal, briefly before its use as a ] led to its criminalization.

===Cannabis===
There is evidence that ] use can contribute to schizophrenia. Some studies suggest that cannabis is neither a ] factor in developing schizophrenia, but that cannabis may significantly increase the risk of developing schizophrenia and may be, among other things, a significant causal factor. Nevertheless, some previous research in this area has been criticised as it has often not been clear whether cannabis use is a cause or effect of schizophrenia. To address this issue, a recent review of studies from which a causal contribution to schizophrenia can be assessed has suggested that cannabis statistically doubles the risk of developing schizophrenia on the individual level, and may, assuming a causal relationship, be responsible for up to 8% of cases in the population.<ref name="fn_48"> Causal association between cannabis and psychosis: examination of the evidence. ''British Journal of Psychiatry'', 184, 110-7. ()<br></ref>

===Tobacco===
It has been noted that the majority of people with schizophrenia (estimated between 75% and 90%) smoke ]. However, people diagnosed with schizophrenia have a much lower than average chance of developing and dying from ]. While the reason for this is unknown, it may be because of a genetic resistance to the cancer, a side-effect of drugs being taken, or a statistical effect of increased likelihood of dying from causes other than lung cancer.<ref name="fn_49" />

It is argued that the increased level of smoking in schizophrenia may be due to a desire to self-medicate with ]. A recent study of over 50,000 ] conscripts found that there was a small but ] protective effect of smoking cigarettes on the risk of developing schizophrenia later in life.<ref name="fn_50"> Investigating the association between cigarette smoking and schizophrenia in a cohort study. ''American Journal of Psychiatry'', 160 (12), 2216&ndash;21.<br></ref> While the authors of the study stressed that the risks of smoking far outweigh these minor benefits, this study provides further evidence for the 'self-medication' theory of smoking in schizophrenia and may give clues as to how schizophrenia might develop at the molecular level. Furthermore, many people with schizophrenia have smoked tobacco products long before they are diagnosed with the illness, and some groups advocate that the chemicals in tobacco have actually contributed to the onset of the illness and have no benefit of any kind.

It is of interest that cigarette smoking affects liver function such that the ] used to treat schizophrenia are broken down in the blood stream more quickly. This means that smokers with schizophrenia need slightly higher doses of antipsychotic drugs in order for them to be effective than do their non-smoking counterparts.

==Schizophrenia and violence==
===Violence perpetrated by people with schizophrenia===
Although schizophrenia is sometimes associated with violence in the media only a small minority of people with schizophrenia become violent, and only a minority of people who commit criminal violence have been diagnosed with schizophrenia.

Research has suggested that schizophrenia is associated with a slight increase in risk of violence, although this risk is largely due to a small sub-group of individuals for whom violence is associated with concurrent substance abuse and ceasing psychiatric drugs.<ref name="fn_51"> Predicting violence in schizophrenia: a prospective study. ''Schizophrenia Research'', 67(2-3), 247-52. <br></ref> For the most serious acts of violence, long-term independent studies of convicted murderers in both ]<ref name="fn_52"> Homicide and mental illness in New Zealand, 1970-2000. ''British Journal of Psychiatry'', 185, 394-8.<br></ref> and ]<ref name="fn_53"> Psychiatric morbidity among homicide offenders: a Swedish population study. ''American Journal of Psychiatry'', 161(11), 2129-31.<br></ref> found that 3.7%&ndash;8.9% had been given a previous diagnosis of schizophrenia.

There is some evidence to suggest that in some people, the drugs used to treat schizophrenia may produce an increased risk for violence, largely due to agitation induced by ], a ] sometimes associated with ] medication.<ref name="fn_54"> Neuroleptic-induced akathisia and violence: a review. ''Journal of Forensic Science'', 48<br></ref> Similarly, abuse experienced in childhood may contribute both to a slight increase in risk for violence in adulthood, as well as the development of schizophrenia.<ref name="fn_16" />

===Violence against people with schizophrenia===
Research has shown that a person diagnosed with schizophrenia is more likely to be a victim of violence (4.3% in a one month period) than the perpetrator.<ref name="fn_55"> Victimization of patients with schizophrenia and related disorders. ''Australia and New Zealand Journal of Psychiatry'', 39(3), 169-74. (1), 187-9.<br></ref>

==Alternative approaches to schizophrenia==
An approach broadly known as the ] movement, notably most active in the 1960s, has opposed the orthodox medical view of schizophrenia as an illness.

Psychiatrist ] argues that psychiatric patients are not ill but are just individuals with unconventional thoughts and behavior that make society uncomfortable. He argues that society unjustly seeks to control such individuals by classifying their behavior as an illness and forcibly treating them as a method of ]. It is worth noting that Szasz has never considered himself to be "anti-psychiatry" in the sense of being against psychiatric treatment, but simply believes that it should be conducted between consenting adults, rather than imposed upon anyone against his or her will. Szasz co-founded the anti-psychiatry group ] with the ], who are well-noted for their anti-psychiatric stance.

Similarly, psychiatrists ], ], ] and other mental health professionals have argued that the symptoms of what is normally called mental illness are comprehensible reactions to impossible demands that society and particularly family life places on some sensitive individuals. Laing, Arieti and Lidz were revolutionary 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's work, co-authored with Aaron Esterson, ''Sanity, Madness and the Family'' (1964) 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. Arieti's '']'' won the 1975 scientific ] in the United States. 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.

In the 1976 book '']'', psychologist ] proposed that until the beginning of historic times, schizophrenia or a similar condition was the normal state of human consciousness. 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. This theory was briefly controversial. Continuing research has failed to either further confirm or refute the thesis.

Psychiatrist ] has argued that schizophrenia may be the evolutionary price we pay for a left brain hemisphere specialization for ].<ref name="fn_56"> Schizophrenia as failure of hemispheric dominance for language. ''Trends in Neurosciences'', 20(8), 339&ndash;343.<br></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.

Researchers into ] have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman<ref name="fn_57"> How shamanism and group selection may reveal the origins of schizophrenia. ''Medical Hypothesis'', 58(3), 244&ndash;8.<br></ref>. Certainly, 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. Speculations regarding primary and important religious figures as having schizophrenia abound. Some commentators have endorsed the idea that major religious figures experienced psychosis, heard voices and displayed delusions of grandeur.

] tends to hold the view that schizophrenia is primarily caused by imbalances in the body's reserves and absorption of ]s, ]s, fats, and/or the presence of excessive levels of toxic ]. The body's adverse reactions to ] are also strongly implicated in some alternative theories (see ]).

One theory put forward by psychiatrists ] and R.H. Yolken is that the parasite ] leads to some, if not many, cases of schizophrenia.<ref name="fn_58"> Toxoplasma gondii and schizophrenia. ''Emerging Infectious Diseases'', 9 (11), 1375-80.</ref> This is supported by evidence that significantly higher levels of Toxoplasma antibodies in schizophrenia patients compared to the general population.<ref>Wang HL, ''et al.'' (2006) , ''Acta Psychiatrica Scandinavica'', 114 (1), 40-48.</ref>

An additional approach is suggested by the work of ] who argues that "The usual difference between someone who hallucinates and someone who visualizes normally, is that the person who hallucinates doesn't know he's doing it or doesn't have any choice about it." ('']'', p107). He suggests that because visualization is a sophisticated mental capability, schizophrenia is a skill, albeit an involuntary and dysfunctional one that is being used but not controlled. He therefore suggests that a significant route to treating schizophrenia might be to teach the missing skill - how to distinguish created reality from consensus external reality, to reduce its maladaptive impact, and ultimately how to exercise appropriate control over the vizualization or auditory process. Hypnotic approaches have been explored by the physician ] as a means of facilitating this.

Regarding schizophrenia as a waking dreamer syndrome, Jie Zhang hypothesizes that the hallucinations of schizophrenia are caused by the activation of the continual-activation mechanism during waking, a mechanism that induces dreaming while asleep, due to the malfunction of the continual-activation thresholds in the conscious part of brain.<ref name="fn_69">Zhang, Jie (2005) , Dynamical Psychology.<br></ref>

==Portrayals of schizophrenia in the arts==
The book and film '']'' chronicled the life of ], a ]-winning mathematician who was diagnosed with schizophrenia.

The effects of untreated schizophrenia on the family are documented in Virginia Holman's autobiography, Rescuing Patty Hearst, (Simon & Schuster 2003) The book also discusses the legal impediments to treatment that faces many schizophrenics and their families.

In Bulgakov's ''Master and Margarita'' the poet Ivan Bezdomnyj is institutionalized and diagnosed with schizophrenia after witnessing the devil (Woland) predict Berlioz's death.

==See also==
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Further information about schizophrenia and approaches to it, suggested by authors such as ], ], ], ], ], ], ] and ], as well as books, can be found within the articles for those authors.

==References==
<div class="references-small" style="-moz-column-count:2; column-count:2;">
<references />
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==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
* Boyle, Mary, (1993), ''Schizophrenia: A Scientific Delusion'', Routledge, ISBN 0-415-09700-2 ().
* Deveson, Anne (1991), "Tell Me I'm Here" NON-FICTION: Schizophrenics - biography - family relationships. ISBN 0-14-027257-7 PENGUIN GROUP Australia. Printed 1991 & 1998.
* ] et. al. (2003) ''The Neuroanatomy of Schizophrenia: Circuitry and Neurotransmitter Systems.'' Clinical Neuroscience Research 3:77-107.
* Green, M.F. (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0-393-70334-7
* Jones, S. and Hayward, P. (2004) ''Coping with Schizophrenia: A Guide for Patients, Families and Caregivers''. ISBN 1-85168-344-5
* ''Schizophrenia: orthodoxy and heresies. A review of alternative possibilities.'' Journal of Psychiatric and Mental Health Nursing, 1999, 6, 415-424. . An article reviewing the dominant (orthodox) and alternative (heretical) theories, hypotheses and beliefs about schizophrenia.
* 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.
* ] (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 (])
* ] (2006) ''Surviving Schizophrenia: A Manual for Families, Consumers, and Providers (5th Edition)''. Quill (HarperCollins Publishers) ISBN 0-06-084259-8
* ] ''The Eden Express''. ISBN 0-553-02755-7. A personal account of schizophrenia.
</div>

==External links==
===News, information and further description===
* - DSM V scholarly debates on schizophrenia
* - NPR: the sight and sounds of schizophrenia
*
* - A factsheet from the mental health charity ''Mind''
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* from 'The World Health Report 2001. Mental Health: New Understanding, New Hope'
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* by ] (pharmaceutical company sponsored).
* - information and support site
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* Film made in 1940 showing some of the symptoms of Schizophrenia.
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===Charities and support groups===
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* UK mental health charity focused on schizophrenia that supports sufferers, runs a helpline and carries out research into mental illness
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* The Campaign for Abolition of the Schizophrenia Label.

===Critical approaches to schizophrenia===
* A website critical of Schizophrenia as a disorder, with many links and resources, by ], psychologist Ph.D.
* by Lawrence Stevens, J.D
* Loren Mosher, M.D. (Chief of the Center for Studies of Schizophrenia at the U.S. National Institute of Mental Health 1969-1980)
* Bola, John R., Ph.D.; & Mosher, Loren R., M.D. (2003). Treatment of Acute Psychosis Without Neuroleptics: Two-Year Outcomes From the Soteria Project. ''The Journal of Nervous and Mental Disease'', (191: 219-229). .
* Jonathan Leo, Ph.D., & Jay Joseph, Psy.D.

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Revision as of 17:17, 13 November 2006

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