Schizophrenia is a mental illness. Symptoms include hallucinations (such as hearing voices), false ideas (delusions), disordered thoughts and problems with feelings, behaviour and motivation. The cause is not clear. In many people symptoms come back (recur) or persist long-term but some people have just one episode of symptoms that lasts a few weeks. Treatment includes medication, talking treatments and social support.
What is schizophrenia and who gets it?
Schizophrenia is a serious mental health condition that causes disordered ideas, beliefs and experiences. In a sense, people with schizophrenia lose touch with reality and do not know which thoughts and experiences are true and real and which are not.
Some people have wrong ideas about schizophrenia. For instance, it has nothing to do with a split personality. Also, the vast majority of people with schizophrenia are not violent.
You should be aware that some people feel that schizophrenia should be abolished as a concept. They believe that the term is unscientific, stigmatising and does not address the root causes of serious mental distress. However, many members of the medical profession still find the term schizophrenia useful.
Schizophrenia develops in about 1 in 100 people. It can occur in men and women. The most common ages for it first to develop are 15-25 in men and 25-35 in women.
What are the symptoms of schizophrenia?
There are many possible symptoms. They are often classed into positive and negative. Positive symptoms are those that show abnormal mental functions. Negative symptoms are those that show the absence of a mental function that should normally be present.
Positive symptoms include the following
- Delusions. These are false beliefs that a person has and most people from the same culture would agree that they are wrong. Even when the wrongness of the belief is explained, a person with schizophrenia is convinced that they are true. For example, a person with schizophrenia may believe that neighbours are spying on them with cameras in every room, or a famous person is in love with them, or that people are plotting to kill them, or there is a conspiracy about them. These are only a few examples and delusions can be about anything.
- Hallucinations. This means hearing, seeing, feeling, smelling, or tasting things that are not real. Hearing voices is the most common. Some people with schizophrenia hear voices that provide a running commentary on their actions, argue with them, or repeat their thoughts. The voices often say things that are rude, aggressive, unpleasant, or give orders that must be followed. Some people with schizophrenia appear to talk to themselves as they respond to the voices. People with schizophrenia believe that the hallucinations are real.
- Disordered thoughts. Thoughts may become jumbled or blocked. Thought and speech may not follow a normal logical pattern. For example, some people with schizophrenia have one or more of the following:
- Thought echo. This means the person hears his or her own thoughts as if they were being spoken aloud.
- Knight's-move thinking. This means the person moves from one train of thought to another that has no apparent connection to the first.
- Some people with schizophrenia may invent new words (neologisms), repeat a single word or phrase out of context (verbal stereotypy), or use ordinary words to which they attribute a different, special meaning (metonyms).
- Thought insertion. This is when someone believes that the thoughts in their mind are not their own and that they are being put there by someone else.
- Thought withdrawal. This is when someone believes that thoughts are being removed from their mind by an outside agency.
- Thought broadcasting. This is when someone believes that their thoughts are being read or heard by others.
- Thought blocking. This is when there is a sudden interruption of the train of thought before it is completed, leaving a blank. The person suddenly stops talking and cannot recall what he or she has been saying.
Negative symptoms include the following
- Lack of motivation. Everything seems an effort - for example, tasks may not be finished, concentration is poor, there is loss of interest in social activities and the person often wants to be alone.
- Few spontaneous movements and much time doing nothing.
- Facial expressions do not change much and the voice may sound monotonous.
- Changed feelings. Emotions may become flat. Sometimes the emotions may be odd, such as laughing at something sad. Other strange behaviours sometimes occur.
Negative symptoms can make some people neglect themselves. They may not care to do anything and appear to be wrapped up in their own thoughts. Negative symptoms can also lead to difficulty with education, which can contribute to difficulties with employment. For families and carers, the negative symptoms are often the most difficult to deal with. Persistent negative symptoms tend to be the main cause of long-term disability.
Families may only realise with hindsight that the behaviour of a relative has been gradually changing. Recognising these changes can be particularly difficult if the illness develops during the teenage years when it is normal for some changes in behaviour to occur.
Other symptoms that occur in some cases include difficulty planning, memory problems and obsessive-compulsive symptoms.
How is the diagnosis made?
Some of the symptoms that occur in schizophrenia also occur in other mental health conditions such as depression, mania, dissociative identity disorder or after taking some street drugs. Therefore, the diagnosis may not be clear at first. As a rule, the symptoms need to be present for several weeks before a doctor will make a firm diagnosis of schizophrenia.
Not all symptoms are present in all cases. Different forms of schizophrenia occur depending upon the main symptoms that develop. For example, people with paranoid schizophrenia mainly have positive symptoms which include delusions that people are trying to harm them. In contrast, some people mainly have negative symptoms and this is classed as simple schizophrenia. In many cases there is a mix of positive and negative symptoms.
Sometimes symptoms develop quickly over a few weeks or so. Family and friends may recognise that the person has a mental health problem. Sometimes symptoms develop slowly over months and the person may gradually become withdrawn, lose friends, jobs, etc, before the condition is recognised.
What is the cause of schizophrenia?
The exact cause is not known. It is thought that the balance of certain brain chemicals (neurotransmitters) is altered. Neurotransmitters are needed to pass messages between brain cells. An altered balance of these may cause the symptoms. It is not clear why changes occur in the neurotransmitters.
Genetic (hereditary) factors are thought to be important. For example, a close family member (child, brother, sister, parent) of someone with schizophrenia has a 1 in 10 chance of also developing the condition. This is 10 times the normal chance. A child born to a mother and father who both have schizophrenia has a 1 in 2 chance of developing it too. However, one or more factors appear to be needed to trigger the condition in people who are genetically prone to it. There are various theories as to what these might be. For example:
- Stress such as relationship problems, financial difficulties, social isolation, bereavement, etc.
- A viral infection during the mother's pregnancy, or in early childhood.
- A lack of oxygen at the time of birth that may damage a part of the brain.
- Illegal or street drugs may trigger the condition in some people. For example, those who use cannabis heavily are four times more likely to develop schizophrenia than non-users. Many other drugs of abuse such as amfetamines, cocaine, ketamine and lysergic acid diethylamide (LSD) can trigger a schizophrenia-like illness.
Are any tests needed?
Blood and urine tests may be done to rule out physical causes of the symptoms or drug/alcohol use. People already diagnosed with schizophrenia may also have tests done if they suddenly become worse.
What are the treatments for schizophrenia?
Treatment and care are usually based in the community rather than at hospitals. The National Institute for Health and Care Excellence (NICE) recommends that the patient's social circumstances be assessed and their family involved as soon as possible. Most areas of the UK have a community mental healthcare team which includes psychiatrists, nurses, psychologists, social workers, etc. A key worker such as a community psychiatric nurse or psychiatric social worker is usually allocated to co-ordinate the care for each person with schizophrenia.
However, some people need to be admitted to hospital for a short time. This is sometimes done when the condition is first diagnosed so that treatment can be started quickly. Hospital admission may also be needed for a while at other times if symptoms become severe. A small number of people have such a severe illness that they remain in hospital long-term.
People with schizophrenia often do not realise or accept that they are ill. Therefore, sometimes when persuasion fails, some people are admitted to hospital for treatment against their will by use of the Mental Health Act. This means that doctors and social workers can force a person to go to hospital. This is only done when the person is thought to be a danger to themself or others.
The main medicines used to treat schizophrenia are called antipsychotics. They work by altering the balance of some brain chemicals (neurotransmitters). Antipsychotic medication is used to relieve the symptoms. Antipsychotic medicines tend to work best to ease positive symptoms and tend not to work so well to ease negative symptoms. Antipsychotic medicines are also used to prevent recurring episodes of symptoms (relapses). Therefore, antipsychotic medication is usually taken on a long-term basis. There are various antipsychotic medicines and different ones may be used in different circumstances. They are broadly divided into two categories:
- Newer or atypical antipsychotics. These are sometimes called second-generation antipsychotics and include amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole. One of these medicines is commonly used first-line for new cases. This is because they seem to have a good balance between chance of success and the risk of side-effects. However, if you are already taking a typical medicine and feel well on it, there is no need to change to a newer one.
- Older typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and include chlorpromazine, trifluoperazine, haloperidol, flupentixol, zuclopenthixol and sulpiride.
There are some differences between the various antipsychotic medicines. Therefore, one may be better for an individual than another. For example, some are more sedating than others. A specialist in psychiatry usually advises on which to use in each case. In most cases, the specialist will start you on either risperidone or olanzapine. The others are usually kept in reserve for people who have problems or do not respond to these medicines.
A good response to antipsychotic medication occurs in about 7 in 10 cases. However, symptoms may take 2-4 weeks to ease after starting medication and it can take several weeks for full improvement. Even when symptoms ease, antipsychotic medication is normally continued long-term. This aims to prevent relapses, or to limit the number and severity of relapses. However, if you only have one episode of symptoms that clears completely with treatment, one option is to try coming off medication after 1-2 years. Your doctor will advise.
Depot injections of an antipsychotic medicine. In some cases, an injection of a long-acting antipsychotic medicine is used once symptoms have eased. The medicine from a depot injection is slowly released into the body and is given every 2-4 weeks. This aims to prevent relapses. The main advantage of depot injections is that you do not have to remember to take tablets every day.
What about side-effects from antipsychotic medicines? Side-effects can sometimes be troublesome. There is often a trade-off between easing symptoms and having to put up with some side-effects from treatment. The different antipsychotic medicines can have different types of side-effects. Also, sometimes one medicine causes side-effects in some people and not in others. Therefore, it is not unusual to try two or more different medicines before one is found that is best suited to an individual.
The following are the main side-effects that sometimes occur. However, you should read the information leaflet that comes in each medicine packet for a full list of possible side-effects.
- Common side-effects include: dry mouth, blurred vision, flushing and constipation. These may ease off when you get used to the medicine.
- Drowsiness (sedation) is also common but may be an indication that the dose is too high. A reduced dose may be an option.
- Some people develop weight gain. Weight gain may increase the risk of developing diabetes and heart problems in the longer term. This appears to be a particular problem with the atypical antipsychotics, notably clozapine and olanzapine.
Movement disorders develop in some cases. These include:
- Parkinsonism - this can cause symptoms similar to those that occur in people with Parkinson's disease. For example, tremor and muscle stiffness.
- Akathisia - which is like a restlessness of the legs.
- Dystonia - which means abnormal movements of the face and body.
- Tardive dyskinesia - which is a movement disorder that can occur if you take antipsychotics for several years. It causes rhythmical, involuntary movements. These are usually lip-smacking and tongue-rotating movements, although it can affect the arms and legs too. About 1 in 5 people treated with typical antipsychotics eventually develop tardive dyskinesia.
Atypical antipsychotic medicines are thought to be less likely to cause movement disorder side-effects than typical antipsychotic medicines. Reduced incidence of movement disorder is the main reason why an atypical antipsychotic medicine is often used first-line. Atypicals do, however, have their own risks. In particular, the risk of weight gain. If movement disorder side-effects occur then other medicines may be used to try to counteract them.
Cognitive behavioural therapy (CBT). Psychological treatments include a variety of talking treatments, in particular a treatment called cognitive behavioural therapy (CBT). CBT is used as a treatment for various mental health and physical problems and is being increasingly used as a treatment for schizophrenia. CBT aims to help you to change the way that you think, feel and behave. CBT is actually a wide term which includes various types of therapy. You may be asked to keep a diary of important events in your life and the way you feel about them. Your therapist may challenge your beliefs and ask you to explain them. You may be asked to try out new ways of behaving and reacting.
CBT and other talking treatments are not alternatives to medicines. They are used in some cases in addition to medication. NICE recommends up to 16 CBT sessions. This is because studies have found that, on average, CBT reduces the chance of being admitted or re-admitted to hospital, can reduce symptom severity and can improve social functioning.
Family intervention. This may be offered and consists of about 10 therapy sessions for relatives of patients with schizophrenia. It has been found to reduce hospital admissions and the severity of symptoms for up to two years after treatment.
Art therapy. This has been found to be helpful, particularly if you have negative symptoms.
Social and community support
This is very important. Often the key worker plays a vital role. However, families, friends and local support groups can also be major sources of help. Contact details of the head offices of the main support organisations are listed in links at the end of this leaflet. However, these organisations also have many local groups throughout the UK.
Encouraging physical health
It is quite common for people with schizophrenia not to look after themselves so well. Such things as smoking, lack of exercise, obesity and an unhealthy diet are more common than average in people with schizophrenia. Weight gain may be a side-effect of antipsychotic medicines. All of these factors may lead to an increased chance of developing heart disease and diabetes in later life.
Therefore, as with everyone else in the population, people with schizophrenia are encouraged to adopt a healthy lifestyle - not to smoke, to take regular exercise, to eat healthily, etc.
What is the outlook (prognosis)?
- In most cases there are recurring episodes of symptoms (relapses). Most people in this group live relatively independently with varying amounts of support. The frequency and duration of each relapse can vary. Some people recover completely between relapses. Some people improve between relapses but never quite fully recover. Treatment often prevents relapses, or limits their number and severity.
- In some cases, there is only one episode of symptoms that lasts a few weeks or so. This is followed by a complete recovery, or substantial improvement without any further relapses. It is difficult to give an exact figure as to how often this occurs. Perhaps 2 in 10 cases or fewer.
- Up to 2 in 10 people with schizophrenia are not helped much by treatment and need long-term dependent care. For some, this is in secure accommodation.
- Depression is a common complication of schizophrenia.
- It is thought that up to a third of people with schizophrenia abuse alcohol and/or illegal drugs. Helping or treating such people can be difficult.
- About 1 in 10 people with schizophrenia commit suicide.
The outlook is thought to be better if:
- Treatment is started soon after symptoms begin.
- Symptoms develop quickly over several weeks rather than slowly over several months.
- The main symptoms are positive symptoms rather than negative symptoms.
- The condition develops in a relatively older person (aged over 25).
- Symptoms ease well with medication.
- Treatment is taken as advised (that is, compliance with treatment is good).
- There is good family and social support which reduces anxiety and stress.
- Abuse of illegal drugs or alcohol does not occur.
Newer medicines and better psychological treatments give hope that the outlook is improving.
Dr Tim Kenny
Dr Laurence Knott
Dr John Cox