Schizophrenia

Schizophrenia is a serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling.

People with schizophrenia require lifelong treatment. Early treatment may help get symptoms under control before serious complications develop and may help improve the long-term outlook.

Symptoms

Schizophrenia involves a range of problems with thinking (cognition), behavior and emotions. Signs and symptoms may vary, but usually involve delusions, hallucinations or disorganized speech, and reflect an impaired ability to function. Symptoms may include:

• Delusions. These are false beliefs that are not based in reality. For example, you think that you're being harmed or harassed; certain gestures or comments are directed at you; you have exceptional ability or fame; another person is in love with you; or a major catastrophe is about to occur. Delusions occur in most people with schizophrenia.
• Hallucinations. These usually involve seeing or hearing things that don't exist. Yet for the person with schizophrenia, they have the full force and impact of a normal experience. Hallucinations can be in any of the senses, but hearing voices is the most common hallucination.
• Disorganized thinking (speech). Disorganized thinking is inferred from disorganized speech. Effective communication can be impaired, and answers to questions may be partially or completely unrelated. Rarely, speech may include putting together meaningless words that can't be understood, sometimes known as word salad.
• Extremely disorganized or abnormal motor behavior. This may show in a number of ways, from childlike silliness to unpredictable agitation. Behavior isn't focused on a goal, so it's hard to do tasks. Behavior can include resistance to instructions, inappropriate or bizarre posture, a complete lack of response, or useless and excessive movement.
• Negative symptoms. This refers to reduced or lack of ability to function normally. For example, the person may neglect personal hygiene or appear to lack emotion (doesn't make eye contact, doesn't change facial expressions or speaks in a monotone). Also, the person may lose interest in everyday activities, socially withdraw or lack the ability to experience pleasure.

Symptoms can vary in type and severity over time, with periods of worsening and remission of symptoms. Some symptoms may always be present.

In men, schizophrenia symptoms typically start in the early to mid-20s. In women, symptoms typically begin in the late 20s. It's uncommon for children to be diagnosed with schizophrenia and rare for those older than age 45.

Symptoms in teenagers

Schizophrenia symptoms in teenagers are similar to those in adults, but the condition may be more difficult to recognize. This may be in part because some of the early symptoms of schizophrenia in teenagers are common for typical development during teen years, such as:

• Withdrawal from friends and family
• A drop in performance at school
• Trouble sleeping
• Irritability or depressed mood
• Lack of motivation

Also, recreational substance use, such as marijuana, methamphetamines or LSD, can sometimes cause similar signs and symptoms.

Compared with schizophrenia symptoms in adults, teens may be:

• Less likely to have delusions
• More likely to have visual hallucinations

When to see a doctor

People with schizophrenia often lack awareness that their difficulties stem from a mental disorder that requires medical attention. So it often falls to family or friends to get them help.

Helping someone who may have schizophrenia

If you think someone you know may have symptoms of schizophrenia, talk to him or her about your concerns. Although you can't force someone to seek professional help, you can offer encouragement and support and help your loved one find a qualified doctor or mental health professional.

If your loved one poses a danger to self or others or can't provide his or her own food, clothing, or shelter, you may need to call 911 or other emergency responders for help so that your loved one can be evaluated by a mental health professional.

In some cases, emergency hospitalization may be needed. Laws on involuntary commitment for mental health treatment vary by state. You can contact community mental health agencies or police departments in your area for details.

Suicidal thoughts and behavior

Suicidal thoughts and behavior are common among people with schizophrenia. If you have a loved one who is in danger of attempting suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

Causes

It's not known what causes schizophrenia, but researchers believe that a combination of genetics, brain chemistry and environment contributes to development of the disorder.

Problems with certain naturally occurring brain chemicals, including neurotransmitters called dopamine and glutamate, may contribute to schizophrenia. Neuroimaging studies show differences in the brain structure and central nervous system of people with schizophrenia. While researchers aren't certain about the significance of these changes, they indicate that schizophrenia is a brain disease.

Risk factors

Although the precise cause of schizophrenia isn't known, certain factors seem to increase the risk of developing or triggering schizophrenia, including:

• Having a family history of schizophrenia
• Some pregnancy and birth complications, such as malnutrition or exposure to toxins or viruses that may impact brain development
• Taking mind-altering (psychoactive or psychotropic) drugs during teen years and young adulthood

Complications

Left untreated, schizophrenia can result in severe problems that affect every area of life. Complications that schizophrenia may cause or be associated with include:

• Suicide, suicide attempts and thoughts of suicide
• Anxiety disorders and obsessive-compulsive disorder (OCD)
• Depression
• Abuse of alcohol or other drugs, including nicotine
• Inability to work or attend school
• Financial problems and homelessness
• Social isolation
• Health and medical problems
• Being victimized
• Aggressive behavior, although it's uncommon

Prevention

There's no sure way to prevent schizophrenia, but sticking with the treatment plan can help prevent relapses or worsening of symptoms. In addition, researchers hope that learning more about risk factors for schizophrenia may lead to earlier diagnosis and treatment.

Diagnosis

Diagnosis of schizophrenia involves ruling out other mental health disorders and determining that symptoms are not due to substance abuse, medication or a medical condition. Determining a diagnosis of schizophrenia may include:

• Physical exam. This may be done to help rule out other problems that could be causing symptoms and to check for any related complications.
• Tests and screenings. These may include tests that help rule out conditions with similar symptoms, and screening for alcohol and drugs. The doctor may also request imaging studies, such as an MRI or CT scan.
• Psychiatric evaluation. A doctor or mental health professional checks mental status by observing appearance and demeanor and asking about thoughts, moods, delusions, hallucinations, substance use, and potential for violence or suicide. This also includes a discussion of family and personal history.
• Diagnostic criteria for schizophrenia. A doctor or mental health professional may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Treatment

Schizophrenia requires lifelong treatment, even when symptoms have subsided. Treatment with medications and psychosocial therapy can help manage the condition. In some cases, hospitalization may be needed.

A psychiatrist experienced in treating schizophrenia usually guides treatment. The treatment team also may include a psychologist, social worker, psychiatric nurse and possibly a case manager to coordinate care. The full-team approach may be available in clinics with expertise in schizophrenia treatment.

Medications

Medications are the cornerstone of schizophrenia treatment, and antipsychotic medications are the most commonly prescribed drugs. They're thought to control symptoms by affecting the brain neurotransmitter dopamine.

The goal of treatment with antipsychotic medications is to effectively manage signs and symptoms at the lowest possible dose. The psychiatrist may try different drugs, different doses or combinations over time to achieve the desired result. Other medications also may help, such as antidepressants or anti-anxiety drugs. It can take several weeks to notice an improvement in symptoms.

Because medications for schizophrenia can cause serious side effects, people with schizophrenia may be reluctant to take them. Willingness to cooperate with treatment may affect drug choice. For example, someone who is resistant to taking medication consistently may need to be given injections instead of taking a pill.

Ask your doctor about the benefits and side effects of any medication that's prescribed.

Second-generation antipsychotics

These newer, second-generation medications are generally preferred because they pose a lower risk of serious side effects than do first-generation antipsychotics. Second-generation antipsychotics include:

• Aripiprazole (Abilify)
• Asenapine (Saphris)
• Brexpiprazole (Rexulti)
• Cariprazine (Vraylar)
• Clozapine (Clozaril, Versacloz)
• Iloperidone (Fanapt)
• Lurasidone (Latuda)
• Olanzapine (Zyprexa)
• Paliperidone (Invega)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)

First-generation antipsychotics

These first-generation antipsychotics have frequent and potentially significant neurological side effects, including the possibility of developing a movement disorder (tardive dyskinesia) that may or may not be reversible. First-generation antipsychotics include:

• Chlorpromazine
• Fluphenazine
• Haloperidol
• Perphenazine

These antipsychotics are often cheaper than second-generation antipsychotics, especially the generic versions, which can be an important consideration when long-term treatment is necessary.

Long-acting injectable antipsychotics

Some antipsychotics may be given as an intramuscular or subcutaneous injection. They are usually given every two to four weeks, depending on the medication. Ask your doctor about more information on injectable medications. This may be an option if someone has a preference for fewer pills and may help with adherence.

Common medications that are available as an injection include:

• Aripiprazole (Abilify Maintena, Aristada)
• Fluphenazine decanoate
• Haloperidol decanoate
• Paliperidone (Invega Sustenna, Invega Trinza)
• Risperidone (Risperdal Consta, Perseris)

Psychosocial interventions

Once psychosis recedes, in addition to continuing on medication, psychological and social (psychosocial) interventions are important. These may include:

• Individual therapy. Psychotherapy may help to normalize thought patterns. Also, learning to cope with stress and identify early warning signs of relapse can help people with schizophrenia manage their illness.
• Social skills training. This focuses on improving communication and social interactions and improving the ability to participate in daily activities.
• Family therapy. This provides support and education to families dealing with schizophrenia.
• Vocational rehabilitation and supported employment. This focuses on helping people with schizophrenia prepare for, find and keep jobs.

Most individuals with schizophrenia require some form of daily living support. Many communities have programs to help people with schizophrenia with jobs, housing, self-help groups and crisis situations. A case manager or someone on the treatment team can help find resources. With appropriate treatment, most people with schizophrenia can manage their illness.

Hospitalization

During crisis periods or times of severe symptoms, hospitalization may be necessary to ensure safety, proper nutrition, adequate sleep and basic hygiene.

Electroconvulsive therapy

For adults with schizophrenia who do not respond to drug therapy, electroconvulsive therapy (ECT) may be considered. ECT may be helpful for someone who also has depression.

Coping and support

Coping with a mental disorder as serious as schizophrenia can be challenging, both for the person with the condition and for friends and family. Here are some ways to cope:

• Learn about schizophrenia. Education about the disorder can help the person with schizophrenia understand the importance of sticking to the treatment plan. Education can help friends and family understand the disorder and be more compassionate with the person who has it.
• Stay focused on goals. Managing schizophrenia is an ongoing process. Keeping treatment goals in mind can help the person with schizophrenia stay motivated. Help your loved one remember to take responsibility for managing the disorder and working toward goals.
• Avoid alcohol and drug use. Using alcohol, nicotine or recreational drugs can make it difficult to treat schizophrenia. If your loved one is addicted, quitting can be a real challenge. Get advice from the health care team on how best to approach this issue.
• Ask about social services assistance. These services may be able to assist with affordable housing, transportation and other daily activities.
• Learn relaxation and stress management. The person with schizophrenia and loved ones may benefit from stress-reduction techniques such as meditation, yoga or tai chi.
• Join a support group. Support groups for people with schizophrenia can help them reach out to others facing similar challenges. Support groups may also help family and friends cope.

Preparing for an appointment

If you're seeking help for someone with schizophrenia, you may start by seeing his or her family doctor or health care professional. However, in some cases when you call to set up an appointment, you may be referred immediately to a psychiatrist.

What you can do

To prepare for the appointment, make a list of:

• Any symptoms your loved one is experiencing, including any that may seem unrelated to the reason for the appointment
• Key personal information, including any major stresses or recent life changes
• Medications, vitamins, herbs and other supplements that he or she is taking, including the dosages
• Questions to ask the doctor

Go with your loved one to the appointment. Getting the information firsthand will help you know what you're facing and what you need to do for your loved one.

For schizophrenia, some basic questions to ask the doctor include:

• What's likely causing the symptoms or condition?
• What are other possible causes for the symptoms or condition?
• What kinds of tests are needed?
• Is this condition likely temporary or lifelong?
• What's the best treatment?
• What are the alternatives to the primary approach you're suggesting?
• How can I be most helpful and supportive?
• Do you have any brochures or other printed material that I can have?
• What websites do you recommend?

Don't hesitate to ask any other questions during your appointment.

What to expect from your doctor

The doctor is likely to ask you a number of questions. Anticipating some of these questions can help make the discussion productive. Questions may include:

• What are your loved one's symptoms, and when did you first notice them?
• Has anyone else in your family been diagnosed with schizophrenia?
• Have symptoms been continuous or occasional?
• Has your loved one talked about suicide?
• How well does your loved one function in daily life — is he or she eating regularly, going to work or school, bathing regularly?
• Has your loved one been diagnosed with any other medical conditions?
• What medications is your loved one currently taking?

The doctor or mental health professional will ask additional questions based on responses, symptoms and needs.

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