Schizophrenia

• What is schizophrenia?
• Who gets schizophrenia?
• When people first become unwell
• Different types of schizophrenia
• Treatment
• Physical health problems
• A new name for schizophrenia?

What is schizophrenia?

People who have schizophrenia at times experience the symptoms of psychosis – delusions, hallucinations and muddled thinking. Mental health professionals describe these as the 'positive symptoms' of schizophrenia.

When people experience these symptoms, they are said to be having an 'episode' of psychosis. Often, people do not feel unwell and do not think they have a mental health problem. Mental health professionals call this 'lack of insight'. As a result, people who are experiencing the symptoms of psychosis may not want to ask for help or treatment.

Between episodes, people with schizophrenia often experience what mental health professionals call 'negative symptoms' and 'cognitive symptoms'. People may have no energy and lose the motivation to do anything; they may lose interest in friends, family members and activities they previously enjoyed. They may no longer care about their personal appearance and become socially isolated and withdrawn.
They may experience memory problems and find it very hard to concentrate.

In addition, people with schizophrenia often experience depression and can become very anxious.

The experiences and symptoms each person has will differ and last for different periods of time. Some people have just one episode of psychosis and are unwell for only a short period. Others go on to experience a number of episodes over a longer period of time. Some people will experience negative and cognitive symptoms (in between episodes, or after a single episode) for months, or even years. 

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Who gets schizophrenia?

About one in every 200 people currently has a diagnosis of schizophrenia.

People can develop schizophrenia at any age, but commonly men first become unwell in their late teens or early 20s. Women tend to develop schizophrenia when they are slightly older, in their late 20s. A small number of people develop schizophrenia in middle age or when they are older.

Anyone can get schizophrenia, though children of a parent who has the illness are slightly more likely to become unwell. Even though genes play a part in the development of schizophrenia, there is no single cause and many contributing factors (see What causes psychosis? page). Just because one person in the family has schizophrenia doesn’t mean that other family members will inevitably develop the illness. 

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When people first become unwell

Sometimes schizophrenia starts suddenly with an acute, and often frightening, episode of psychosis.

However, a first episode of psychosis is often preceded by what health professionals call a ‘prodromal period’ when people’s behaviour begins to change.

During this period, people are often depressed or anxious; they may find it difficult to concentrate or have problems remembering things. They may stop seeing their friends, act in a strange and uncharacteristic way, be less interested in study, work or hobbies, and care less about how they look. They may become socially withdrawn and spend much more time alone.

They also sometimes have experiences resembling the symptoms of psychosis – hearing voices every now and then, being occasionally suspicious and paranoid for example (see Paranoia page). However, not everyone who has these sorts of experiences will go on to have a first episode of psychosis (see Psychotic-like experiences page).

A large proportion of people who experience psychosis for the first time will get better with treatment (see below). Others will improve but may have further episodes.

Research has shown that the earlier treatment is given, the better people recover. People who don’t access mental health services when they first experience symptoms may get better slower, or be less likely to get completely better, and have an increased risk of relapse in the future (see Early intervention services page).

When people experience the symptoms of psychosis for the first time, it may not always be clear if they have schizophrenia, bipolar disorder or schizoaffective disorder. Therefore, a diagnosis will not necessarily be given after a first episode of psychosis.

It is also not unusual for a diagnosis to change. Different diagnoses are given in response to symptoms an individual has at any particular time (see Mental health diagnoses page). 

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Different types of schizophrenia

There are different 'sub-types' of schizophrenia, determined by the most prominent symptoms. The most common sub-type diagnosis is 'paranoid schizophrenia': if someone is given this diagnosis, it means the symptoms they experience most are delusions and paranoia.

The sub-types of schizophrenia are described in two guides that are used by psychiatrists to help them make a diagnosis. One of these guides is called the Diagnostic and Statistical Manual of Mental Disorder (DSM) and is published by the American Psychiatric Association. The other is called the International Classification of Diseases (ICD). It includes a special section on psychiatric illness and is published by the World Health Organisation (see Mental health diagnoses page).

A new updated version of the DSM is to be published in May 2013. One of the proposed changes is to abolish all the sub-types of schizophrenia. Apart from paranoid schizophrenia, the sub-types are rarely diagnosed.

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Treatment

People who are experiencing an episode of psychosis will be prescribed antipsychotic medication (see Antipsychotic medication page). This type of medication is the main treatment for schizophrenia.

The National Institute of Health and Care Excellence (NICE) also recommends people with schizophrenia should be offered cognitive behaviour therapy and family therapy, and that mental health professionals should consider offering arts therapies. However, talking therapies and arts therapies are not available everywhere.

After an acute episode of psychosis, people will be encouraged to take antipsychotic medication for some time. If they stop taking the drugs too soon, symptoms may return. Some people will continue to take antipsychotics for many years, even for life, but this not the case for everyone who is given a diagnosis of schizophrenia.

If people with schizophrenia experience depression and anxiety, they may also be prescribed antidepressants or medication that tackles anxiety. Sometimes people end up taking a large number of drugs.

Antipsychotic drugs can diminish the 'positive' symptoms of psychosis, and sometimes make them go away completely.

However, antipsychotic drugs don’t work for some people. Mental health professionals call their illness ‘treatment-resistant’, or ‘refractory’ schizophrenia.

The antipsychotic clozapine may be prescribed for people who are 'treatment-resistant.' Clozapine can suppress the symptoms of psychosis in people who have not got better after taking other antipsychotics. People who are prescribed clozapine must have regular blood tests and be monitored because this particular drug can damage white blood cells.

There is no medication that effectively treats the negative and cognitive symptoms of psychosis – lack of attention and motivation, apathy, slow thinking, memory problems and difficulties interacting with other people and everyday situations. Cognitive behaviour therapy for psychosis has been proven to help improve these symptoms and other talking therapies are being developed and tested (see Other treatments page).

Researchers around the world also continue to test different sorts of drugs to treat both negative and cognitive symptoms of schizophrenia.

These include, for example, research to test the effectiveness of the antibiotic minocycline, and antidepressants like citalopram and mirtazapine.

Several drugs licensed to treat other illnesses and conditions have been/continue to be tested in trials to see if they can help people with schizophrenia concentrate better and improve their thinking skills and memory – such as the stimulant modafanil. One study is investigating the use of modafanil together with 'brain training' exercises.

Other researchers are testing drugs used to treat Alzheimer's disease  (acetylcholinesterase inhibitors) to see if they can improve memory in people with schizophrenia. See the Medication page.

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Physical health problems

People with schizophrenia are more likely to develop physical health problems, including weight gain, high blood pressure, heart disease and diabetes.

These problems are caused by changes in lifestyle as a result of the symptoms of the illness – research has shown that people with schizophrenia and other serious mental health conditions tend to look after themselves less well, are more likely to smoke, and less likely to eat healthy food and take regular exercise.

Long-term use of antipsychotic medication can also lead to weight gain and also increase the risk of cardiovascular disease and diabetes.

Research has shown that these physical health problems contribute to premature death: people who have a serious mental health problem like schizophrenia have shorter lives compared to the national average (some early deaths are because of suicide).

GPs should check the physical health of people with schizophrenia once a year, including their weight, blood pressure, blood sugar and cholesterol levels. People should be given treatment for any physical health problems and encouraged to raise any such problems with their GP.

The charity Rethink Mental Illness has developed a 'Physical Health Check' designed to help mental health professionals make sure the physical health needs of people they support are addressed. Mental health professionals, family members and people with experience of schizophrenia can download the questionnaire free of charge from the Rethink Mental Illness website. 

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A new name for schizophrenia?

Some researchers and people with personal experience of schizophrenia think that the name should be changed.

Those in favour of a new name say 'schizophrenia' is associated with discriminatory attitudes. They say the word, first used a century ago when nothing was known about the illness apart from its symptoms, is unsuitable because of today's greater scientific understanding of factors that contribute to its development.

The diagnostic categories used by mental health professionals are currently being updated (see Mental health diagnoses page) and there is a debate about whether the term 'schizophrenia' should be retained in both the American Diagnostic and Statistical Manual of Mental Disorders and the World Health Organisation's International Classification of Diseases.

The Japanese Society of Psychiatry and Neurology introduced a change in terminology in 2002: the name of the illness is now 'Togo Shitcho Sho' (integration disorder). It was previously 'Seishin Bunretsu Byo' (mind split disease). The change was made 'to avoid stigma and better express the complexity of the disorder,' says the Society's president Masatoshi Takeda (July 2012).