# One man's look at schizophrenia

This article by Dan Polansky looks at what is called schizophrenia and what was originally called dementia praecox. It is in part overlapping and in part complementary to Wikipedia. The look is going to be critical, aiming to question things.

## Existence

The existence of the nosological entity of schizophrenia is less well established than one might think. It follows from Goel 2011.

## Differential diagnosis

Schizophrenia, an entity that one might as well call major psychotic disorder since the etymology of schizophrenia has almost no bearing on the referent, needs to be distinguished from other psychotic disorders, especially the bipolar disorder. Bipolar is mentioned as potentially confounding or overlapping in Goel 2011. There is also the nosological unit of schizoaffective disorder, which combines symptoms of schizophrenia and affective disorders (mania, depression, bipolar, etc.)

## Symptoms

A quick bulleted structure:
* Positive symptoms
** Hallucinations (visual, auditory, olfactory, etc.)
** Delusions
* Negative symptoms
** Cognitive decline
*** Memory down
*** Attention down
** Executive decline
*** Bad personal hygiene
*** Difficulty making decisions
*** Poor planning/goal-setting?
** Reduced interest in social interaction
** Disorganized thinking
** Emotional blunting/blunt affect
Merck manual considers executive decline to be a species of cognitive decline. The reason I list cognitive on the same level as executive is that the former is intuitively difficulty thinking (and getting to know) while the latter is difficulty doing. On the other hand, it may be true that the difficulty doing has to do with difficulty thining, making decision, memory, attention, etc.
Delusion is one class of symptoms that deserve a note. Following the definitions in the sources, most people on the planet are delusional in so far as they believe in the existence of God or gods. Even one who believes in, say, Christian God has to accept that while he is right, the other believers are delusional. Moreover, religious people sometimes report to talk to God, which would fit under the head of auditory hallucinations (hearing voices). One would think religious people are in permanent psychosis. The reason why they are not so diagnosed is probably that culturally accepted delusions do not count as delusions for diagnostic purposes.

## Treatment

Treatment options as a bulleted outline:
* Antipsychotics
* CBT
* Family therapy
* Arts therapy

## Notable bearers

An arbitrary pick from Wikipedia (characterizations in part based on Wikipedia):
* Robert M. Pirsig – American writer and philosopher, whose "bestseller Zen and the Art of Motorcycle Maintenance was the biggest-selling philosophy book ever" per Guardian
* John Nash – American economist, mathematician and Nobel Prize winner in Economic Sciences
* Eduard Einstein – a son of the physicist Albert Einstein, the quintessential genius noted for his relativistic and counter-intuitive mechanics
The physicist Isaac Newton of the Newtonian mechanics and calculus fame is reported by some sources to have developed psychosis (a key symptom of schizophrenia) at some point in life.
The American novelist and poet Jack Kerouac was diagnosed with dementia praecox (schizophrenia).
The Austrian logician Kurt Gödel, considered to be one of the greatest logicians ever, is not known to have had schizophrenia. Nonetheless, he sufferred from paranoia: "As Gödel aged, he grew more and more paranoid and eventually became convinced that he was being poisoned. He refused to eat unless his wife tasted his food first. When she became ill and had to be hospitalized for an extended period of time, Gödel essentially stopped eating and starved to death." Paranoia is one symptom of schizophrenia or of certain kind of schizophrenia.
An arbitrary pick from Wikipedia for bipolar disorder, which can be confused with schizophrenia (characterizations based on Wikipedia):
* Stephen Fry – actor, comedian, and writer
* Mel Gibson – actor and director
* Ernest Hemingway – American journalist, won the Pulitzer Prize (1953) and the Nobel Prize in Literature (1954) for his novel The Old Man and the Sea
* Emil Post – American mathematician and logician
Georg Cantor, the German mathematician who founded the set theory in the 19th century, is reported by some sources to have had a bipolar disorder; Georg Cantor (Wikipedia) traces the bipolar statement to Dauben 2004, which quotes the psychiatrist Karl Pollitt as stating: "As a young assistant I treated a prominent professor of mathematics [Georg Cantor] who had to be admitted to the clinic because of the recurrence of a cyclic manic-depression."
Ludwig Boltzmann, the Austrian physicist and philosopher noted for statistical mechanics, is reported to possibly have had the bipolar disorder.
Further reading:
* List of people with schizophrenia, wikipedia.org
* List of people with bipolar disorder, wikipedia.org -- of interest, since schizophrenia seems easily confused/confounded with bipolar disorder

## Classification

One source tracking classification is Wikidata. Classification (also includes bipolar) follows.
Questions:
* Into which broader categories is schizophrenia classified?
* How far is schizophrenia in the categorizaztion/classification tree from bipolar disorder?
In ICD-11 ID (Foundation):
* 06 Mental, behavioural or neurodevelopmental disorders
** Schizophrenia or other primary psychotic disorders
*** 6A20 Schizophrenia
** Mood disorders
*** Bipolar or related disorders
As for serious mental illness (SMI), U.S. National Institute of Mental Health (NIMH) defines it as follows: "Serious mental illness (SMI) is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI." Schizophrenia is one of SMIs. The label "serious mental disorder" is sometimes seen in literature; it remains to be clarified whether this is intended to be a synonym of "serious mental illness" (one would think so).
DSM-5: Schizophrenia is classified as "Schizophrenia Spectrum and Other Psychotic Disorders"; bipolar is classified as "Bipolar and Related Disorders".
Further reading:
* Wikidata: schizophrenia
* Serious mental illness, wikipedia.org

## Risk of violence

The following is about the risk that someone diagnosed with schizophrenia commits violence, especially whether the risk is greater than with the baseline general population. (For instance, is it possible that Pr(Murder|Schizo) >> Pr (Murder)?) Such people being subject to violence is a separate question.
As per ox.ac.uk (University of Oxford) 2022, "Researchers at Oxford University’s Department of Psychiatry have found that people with schizophrenia and related disorders are at higher-than-average risk of perpetrating violence, but that the overall risk remains low (less than 1 in 20 in women, and less than 1 in 4 for men over a 35-year period for violent arrests and crimes)."
As per Norton 2009 in Reuters, "People with schizophrenia are responsible for a disproportionate number of homicides; while they account for about 0.5 percent of the world's population, they are estimated to commit 6.5 percent of homicides worldwide, according to Dr. Olav Nielssen of the University of Sydney in Australia, the lead researcher on the new study." As a potential for improvement, it would be preferable to directly quote and reference Niels's study.
Fazel et al. 2009 indicate that "Persons with schizophrenia are thought to be at increased risk of committing violent crime 4 to 6 times the level of general population individuals without this disorder. However, risk estimates vary substantially across studies, and considerable uncertainty exists as to what mediates this elevated risk."
News from Karolinska Institutet 2009 interprets Fazer et al. 2009 as indicating that it is not schizophrenia alone but rather schizophrenia in conjunction with substance abuse that leads to increased rate of violence. Their wording: "A new study from the Swedish medical university Karolinska Institutet and the University of Oxford finds that the severe mental disorder schizophrenia only marginally increases the risk of committing violent crime. Rather, the overrepresentation of individuals with schizophrenia in violent crime is almost entirely attributable to concurrent substance abuse."
Per vic.gov.au, when the violence occurs, it more often occurs toward family members and frieds and less often toward strangers. The link to family members as targets is also given by Norton 2009 in Reuters.
Sapolsky, in 2011, some time after 38:30 into a video says that schizophrenics are less violent that non-schizophrenics. That contradicts the above quotations.
See also Schizophrenia, Criminality, and its Portrayal in the Media.
Further reading:
* Schizophrenia and Dangerous Behaviour, livingwithschizophreniauk.org
* Violence and schizophrenia: Examining the evidence by Walsh, Buchanan and Fahy, 2 Jan 2018, cambridge.org
* Preventing violence in schizophrenia by Olav Nielssen, 2015
* The relationship between rates of homicide by those with schizophrenia and the overall homicide rate; a systematic review and meta-analysis by Matthew Large et al.

## Use of alcohol

NHS indicates caution about the use of alcohol with schizophrenia, although stoping short of stating that alcohol must be avoided at all cost.
Mayo Clinic is stringent with its "Don't use alcohol or drugs."
WebMD has a cautionary tone, including "It’s best not to drink alcohol at all if you’re on antipsychotic medications." However, that does not tell us anything about when not being on medications.