Title: Schizophrenia Content: Schizophrenia is a condition which may be diagnosed by a psychiatrist. It is a mental disorder where people may see, hear or believe things which are not real. It can be a big problem for people who have it. It may occur at almost any age, but typical onset is between late teens to early 30s. It can show in young people aged from 16 to 30. Self-harm is likely, and confused speech which seems meaningless is a common characteristic. The condition definitely needs psychiatric assessment. Because of the self-harm possibility, no time should be wasted if a young person begins to show the signs. There is a genetic component (which is not well understood). If one child shows clear signs, other children in the family may show some symptoms. Some similar mental illnesses include schizotypal personality disorder, schizoaffective disorder, and schizoid personality disorder. It is a relatively common condition affecting one in 200 people.Ferri F.F. 2019. Ferri's clinical advisor 2019 : 5 books in 1. pp. 1225–1226. ISBN 9780323530422 It is not infectious in any way. There is a danger that the sufferer may self-harm. Its cause is not exactly known. Very often it first appears in teenage years when the sufferer goes through puberty. There is no cure, but there is treatment which can help most of the sufferers. People with this disorder often do not behave the way most people do towards others. They also may not know what is real (this is called psychosis). Some common signs are strange beliefs, unclear or confused thinking and language, hallucinations (such as hearing voices that aren't there), poor interaction with others, less expression of feelings, and not doing much. They also may not care about many things. Schizophrenia is a chronic condition. There is no cure, but a combination of a therapy and certain drugs can allow most people suffering from it to lead a normal life. == Meaning == The word schizophrenia comes from two Greek words that mean to split and mind, because there is a 'split' between what's going on in the person's mind and what is actually happening. A person with schizophrenia does not change between different personalities: they have only one. The condition in which a person has more than one personality, meaning they act like a different person at different times, is dissociative identity disorder. There are no medical tests that can be used to say if a person has schizophrenia or not, so getting a diagnosis depends on which list of symptoms are used. It also depends on the doctor or psychologist who talks to the person. The lists of symptoms include wording like "Disorganized [not organized, or oddly organized] speech present for a significant portion of time". It is difficult to agree on what exactly "disorganized speech" is and how disorganized it has to be. It is also difficult to agree on how long a "significant portion of time" is. Because of this, two doctors or psychologists trying to make a diagnosis may often disagree. One will say that the person is schizophrenic and the other will say he or she is not.American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 5–25. . == About schizophrenia == Schizophrenia has many different symptoms, and not everyone with schizophrenia has all of them. For this reason, some scientists think that schizophrenia is several separate illnesses that have some of the same symptoms. These scientists claim that the research done on schizophrenia is not accurate since different researchers mean different things when they use the word "schizophrenia" in scientific studies. Many medications (licensed drugs to cure or treat an illness) may also cause the same symptoms as schizophrenia. The most common ones are antidepressants (medicines to treat depression) and ADHD medication (medication to treat ADHD, a condition affecting the brain, including memory and focusing on surroundings.) If a person has taken anti-vomiting medication (medication to stop them being sick) for some time and suddenly stops, he or she may get schizophrenia symptoms. Hundreds of medications have schizophrenia symptoms as rare side effects (unintended effects of taking them). Illegal drugs such as LSD, amphetamines, magic mushrooms and cocaine may cause schizophrenia symptoms. Medical illnesses, and treatment with certain medicines, can cause symptoms very similar to that of schizophrenia. In fact, there are over a hundred medical problems that can cause the same symptoms of schizophrenia. For this reason, it is important to rule out the possibility of either of these things being the cause for the person's symptoms. For this reason, the person should have a thorough medical exam to rule out problems like; * Not having enough vitamin B12, magnesium, sodium, or other chemicals the body needs * Sleep disorders * A stroke or brain tumor * A metabolism (chemical reactions keeping the person alive) that is too high or too low == Delusions and hallucinations == People with schizophrenia often have delusions or hallucinations. A schizophrenic delusion is a belief that is very different from what other people with the same way of life believe. Hallucinations are usually experiences of hearing voices that don't exist. These voices often say unpleasant things to the person. Many people can hear voices like this without being schizophrenic, for instance right before falling asleep. This is called a hypnagogic hallucination. The brain cannot tell them apart from normal sounds that are heard. This is not yet fully understood by science. == Risk factors == There are many risk factors that may cause a person to develop schizophrenia. They include trauma (damage caused by stressful events) and genetics (schizophrenia running in families). Having a schizophrenic parent may be very stressful, and there may also be genes that influence the development of schizophrenia. It is very easy to show that trauma, such as sexual abuse (forced unwanted sexual behaviour towards somebody) increases the risk, but 40 years of searching for the right genes has not found anything that has been confirmed by independent research groups.Joseph, J. (2003). The Gene Illusion: Genetic Research in Psychiatry and Psychology under the Microscope. PCCS Books. . == Hope == People with schizophrenia may also have other mental health disorders, like depression, anxiety and drug abuse. They often have problems functioning in society, and have difficulty keeping a job. However, there are a number of people with schizophrenia who get well and have earned college degrees and had professional careers. For example, Elyn. R. Saks successfully became a law professor at the University of Southern California and a published author. In a family treatment called "Open dialog" in Finland, eight out of every ten people with schizophrenia "get well." In developing countries, where doctors use less drugs, 2 out of 3 patients get well from schizophrenia. In western countries, where medications are used as treatment, 1 of 3 get well, but many suffer from drug side effects such as diabetes, obesity, and brain damage.Anatomy of an epidemic: magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. Crown, April 13, 2010, ==Treatment== Treatment of schizophrenia may include medication to help treat the symptoms, different types of psychotherapy (therapy by a professional), such as cognitive-behavioral therapy and many rehabilitation therapies (therapies restoring things to how they were before), such as cognitive remediation therapy. Cognitive behavioral therapy, CBT, is a talk therapy that focuses on helping the person to think about their strange ideas (delusions) in more realistic ways. The therapist may design a behavioral experiment for paranoia (false beliefs of danger) that will help the person to find out for example, if there really are cameras everywhere in the house. For hallucinations, cognitive therapy focuses on normalizing: many people hear voices without being stressed, and we all hear voices in the form of thoughts, it is just that people with schizophrenia hear them a bit more clearly than most people.Cognitive therapy of schizophrenia. David G. Kingdon, Douglas TurkingtonGuilford Press, 2005 ==Official guidelines== The British national guidelines for treatment (NICE) suggest the following treatments: * Check for reactions to traumatic experiences * Decide together with a doctor about using medication, taking into account the side effect risk of getting diabetes, becoming seriously overweight, getting brain damage (tardive dyskinesia, 5% risk pr year), men growing breasts, and feelings described as inner torture (akathesia). The guidelines also warn against using more than one antipsychotic drug at the same time. Both for people who are at risk for getting schizophrenia and for people who have got it, they recommend cognitive behavioral therapy (CBT) and family therapy. Getting support from people who have become well from schizophrenia is also strongly recommended. In a family oriented treatment program in Finland, Open Dialog, 8 out of 10 people with schizophrenia get well with no medication or very limited drug use, often only with anxiety medication. ==Symptoms== The symptoms of schizophrenia fall into three main categories: positive symptoms, negative symptoms, and cognitive symptoms.David Sue, Derald Wing Sue, Stanley Sue. Understanding Abnormal Behavior Wadsworth Publishing; 9 edition (2008) p.361 ;Positive symptoms Positive symptoms are thoughts, behaviors, or anything experienced by the senses that are not shared by others - like hearing voices that are not really there. They are called 'positive' not because they are good but because they are "added on". These symptoms may include having strange thoughts that do not make sense (delusions), disorganized thoughts and speech, and feeling, hearing, seeing, smelling, or tasting things that do not exist (hallucinations).Kneisl C. and Trigoboff E.(2009). Contemporary Psychiatric- Mental Health Nursing. 2nd edition. London: Pearson Prentice Ltd. p. 371 Positive symptoms often respond to drug treatmentAmerican Psychiatric Association. Task Force on DSM-IV. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. American Psychiatric Pub. . p. 299 and cognitive behavioral therapy, CBT. Stopping anti-psychotic or anti-vomiting drugs too quickly may also cause these symptoms.Breggin, P. (2008) Brain- Disabling Treatments in Psychiatry: Drugs, Electroshock, and the Psychopharmaceutical Complex Springer Publishing Co, New York ;Negative symptoms Negative symptoms are thoughts, behaviors or emotions normally present in a healthy person that a person with a mental disorder has less of or may not have at all; they are 'minus' these. The sign for minus is -; it is also the sign for the word "negative". Negative symptoms includes a 'flat affect'; having a blank inexpressive look on the face and/or monosyllabic speech (speech always sounding the same) spoken in a slow monotone, few gestures, lack of interest in anything including other people, and an inability to act spontaneously or feel pleasure. These problems are also side effects of anti-psychoctic drugs. They may also be symptoms of many medical problems such as a metabolism that is too low. ;Cognitive symptoms (or cognitive deficits) Cognitive symptoms are problems with attention, certain types of memory, the concept of time, and with the ability to plan and organize. Cognitive deficits caused by schizophrenia can also be difficult to recognize as part of the disorder. They are the most disabling of the symptoms because cognitive problems affect everyday functioning. These problems may also be side effects of anti-psychotic drugs, antidepressants, sleeping medication and anti-anxiety drugs. ==Causes== thumb|400px|Schizophrenia risk factors. A combination of what has happened to a person and the person’s genes may play a role in the development of schizophrenia. People who have family members with schizophrenia and who experienced a brief period of psychotic symptoms have a 20 to 40 percent chance of being diagnosed one year later. This may be both the result of stressful events because of the family member and possibly a genetic effect. ;Inherited factors It is difficult to know if schizophrenia is inherited because it is hard to find out whether something comes from genes or the environment. Those who have a parent, a brother or sister with schizophrenia have a higher risk of developing schizophrenia. The risk is even higher if you have an identical twin with schizophrenia. This may seem to show that schizophrenia is inherited. However, it may be the stress of living with a schizophrenic family member that is traumatic. Identical twins are much closer and are treated much more in the same way, and this may be the reason why one of them is more likely to get schizophrenia if the other has it. Dr Jay Joseph has found many problems with the scientific studies of inheriting schizophrenia, including false reporting of results. Joseph also claims that 40 years of the search for the schizophrenia gene has not found a single gene that independent research groups have confirmed. ;Environmental factors There are may environmental risk factors factors for schizophrenia such as drug use, stress before birth and in some cases exposure to infectious diseases (a disease that spreads from person to person). In addition, living in a city during childhood or as an adult has been found to double the risk of schizophrenia . This is true even after taking into account drug use, race, and the size of one’s social group. Other factors that play an important role include whether the person feels socially isolated, as well as social adversity, racial discrimination (treating a person badly because of their race), the person's family not working properly, unemployment, and poor housing conditions. There is evidence that childhood experiences of abuse or trauma are risk factors for developing schizophrenia later in life. ;Substance abuse Several drugs have been linked with the development of schizophrenia and the abuse (harmful use) of certain drugs can cause symptoms like those of schizophrenia. About half of those people who have schizophrenia use too much drugs or alcohol, possibly to deal with depression, anxiety, boredom, or loneliness. Frequent marijuana use may double the risk of serious mental illness, including schizophrenia. ;Smoking More people with schizophrenia smoke than the general population; it is estimated that at least 60% to as many as 90% of people with schizophrenia smoke. Recent research suggests that cigarette smoking may be a risk factor for developing schizophrenia. Smoking also reduces the effects and side effects of anti-psychotic drugs, and this may be one of the reasons for the high smoking rate. Patients taking anti- psychotic drugs die up to 20 years earlier than others, possibly because the medication makes them overweight, gives diabetes and leads to them smoking. ;Pre-birth factors Factors such as lack of oxygen, infection, or stress and lack of healthy foods in the mother during pregnancy, might result in a slight increase in the risk of schizophrenia later in life. People who have schizophrenia are more likely to have been born in winter or spring (at least in the northern half of the world). This might relate to increased rates of exposures to viruses before birth. This difference is about 5 to 8 percent. ;Brain structure thumb|250px|Enlarged lateral ventricles in schizophrenia Some people who have schizophrenia have differences in their brain structure compared to those who do not have the disorder. These differences are often in the parts of the brain that manage memory, organization, emotions, the control of impulsive behavior, and language. For example, there is less brain volume in the frontal cortex and temporal lobes, and problems within the corpus callosum, the band of nerve fibers which connects the left side and the right side of the brain. People with schizophrenia also tend to have larger lateral and third ventricles. The ventricles are spaces within the brain filled with cerebrospinal fluid. ;Brain wiring The human brain has 100 billion neurons; each one of these neurons are connected to many other neurons. One neuron may have as many as 20,000 connections; there is between 100 trillion and 500 trillion neural connections in the adult human brain. There are many different parts or 'regions' of the brain. To complete a task - like recalling a memory - usually more than one region of the brain is involved, and they are connected by neural networks which is like the brain's wiring. It is believed that there are problems with the brain's wiring in schizophrenia. ==Diagnosis== The DSM-IV-TR or the ICD-10 criteria are used to determine whether a person has schizophrenia. These criteria use the self-reported experiences of the person and reported abnormalities (unusual occurrences) in the behavior of the person, followed by a clinical assessment. A person can be determined to have the disease only if the symptoms are severe.  ===Differential diagnosis=== There are various medical conditions, other psychiatric conditions and drug abuse related reactions that may mimic the symptoms of schizophrenia (meaning they have some or all of the same symptoms). For example, delirium can cause visual hallucinations, or an unpredictable changing levels of consciousness. Schizophrenia occurs along with obsessive-compulsive disorder (OCD), a disorder in which a person becomes obsessed with certain ideas or actions. However, separating the obsessions of OCD from the delusions of schizophrenia can be difficult. ==Prevention== There is no clear evidence that treating schizophrenia with anti-psychotic drugs early is effective. The British NICE guidelines recommend cognitive behavioural talk therapy for all people at risk. In recent research, 76 patients at risk for schizophrenia were divided into two groups. One group got omega3 for 3 months and the other got a dummy pill (food oil). After 12 months only 4.9% of the omega 3 group had got schizophrenia compared to 27.5% in the other group. There is some evidence which shows that early treatment with drugs improves short term outcomes for people who have a serious episode of mental illness. These measures show little benefit five years later. Attempting to prevent schizophrenia in the pre-onset phase with anti-psychotic drugs is of uncertain benefit and so is not recommended (as of 2009). Prevention is difficult because there is no reliable way to find out in advance who will get schizophrenia. ==Management== The treatment of schizophrenia is based upon the phase of the illness the person is in. There are three treatment phases: * Acute Phase There are some goals during the acute phase of treatment. Some of these goals are to prevent harm. To prevent harm, the person being treated will have the severity of psychosis and it's symptoms reduced. These symptoms include agitation, aggression, negative symptoms, self-disorder, and thought disorders. Another goal is to find and treat the things that led to the episode of psychosis. Then, the person will be treated by trying to go back to how they were before psychosis. Lastly, the person will be helped by forming social connections and finding out what treatment plans work for them. Some treatment plans can be for a long time, and others can be for a short time. * Stabilization Phase The stabilization phase also has goals. One is to reduce the stress the person feels. Another is to prevent the person from experiencing psychosis again. Then, the person is helped further with social connection and getting better. If the person has improved with a medication, it is recommended they keep taking it for at least 6 months. * Stable Phase The last phase of treatment is to make sure that the person is improving. If the treatment has bad side effects, it may be changed in this phase. Some treatments during this stage are psychotherapy and medication. Antipsychotic medications greatly reduce the risk of the person experiencing psychosis again. They are strongly recommended. ===Medication=== thumb|left|140px|A 1960s era ad for Thorazine, a commonly used antipsychotic The first-line psychiatric treatment for schizophrenia is antipsychotic medication, which can reduce the positive symptoms in about seven to fourteen days. However, medication fails to improve negative symptoms or problems in thinking significantly. Many antipsychotics are Dopamine antagonists (a substance interfering with how another substance works.) High concentrations of Dopamine are thought to be the cause of hallucinations and delusions. For this reason blocking Dopamine reception helps against hallucinations and delusions. The British national guidelines for treatment (NICE) suggest checking for reactions to traumatic experiences, deciding together with a doctor about using medication, taking into account the side effect risks of getting diabetes, becoming seriously overweight, getting brain damage (tardive dyskinesia, 5% risk per year), men growing breasts, and feelings described as inner torture (akathesia). The guidelines warn against using more than one antipsychotic drug at the same time. Some reviews of research sponsored by the makers of antipsychotic drugs claim that about 40 to 50 percent of people have a good response to medication, 30 to 40 percent have a partial response, and 20 percent have an unsatisfactory response (after 6 weeks on two or three different drugs). Other research from The British Journal of Psychiatry were more negative and claimed that "the clinical relevance of antipsychotics is in fact limited". This study included 22 428 patients and 11 antipsychotic drugs. A drug called clozapine is an effective treatment for people who respond poorly to other drugs, but clozapine can lower the white blood cell count in 1 to 4 percent of people who take it. This is a serious side effect. For people who are unwilling or unable to take drugs regularly, injectable long-acting preparations of antipsychotics can be used. When used in combination with mental and social interventions (treatment), such preparations can help people to continue their treatment. ===Psychosocial therapies=== Numerous mental and social interventions can be useful in treating schizophrenia. Such interventions include various types of therapy, community-based treatments, supported employment, skills training, token economic interventions, and mental interventions for drug or alcohol use and weight management. Family therapy or education, which addresses the whole family system of an individual, might reduce a return of symptoms or the need for hospitalizations (having to go into hospital.) There is growing evidence for the effectiveness of cognitive behavioral therapy (also known as “talk therapy”) . The British national guidelines for treatment (NICE) recommend for both people are at risk of getting schizophrenia and people who have got it, cognitive behavioral therapy (CBT) and family therapy. Getting support from people who have become well from schizophrenia is also strongly recommended. In a family oriented treatment program in Finland, Open Dialog, 8 out of 10 people with schizophrenia get well with no medication or very limited drug use, often only anxiety medication. ==Outlook== Schizophrenia has great human and economic costs. The condition results in a decreased life expectancy of 12 to 15 years, primarily because of its association with being overweight, not exercising, and smoking cigarettes. An increased rate of suicide (a person killing themself) plays a lesser role. These differences in life expectancy increased between the 1970s and 1990s. Schizophrenia is a major cause of disability, with active psychosis ranked as the third-most-disabling condition. Approximately three-fourths of people with schizophrenia have an ongoing disability with symptoms that keep coming back. Some people do recover completely and others function well in society. Most people with schizophrenia live independently, with community support. In people with a first episode of serious mental symptoms, 42 percent have a good long-term outcome, 35 percent have an intermediate outcome and 27 percent have a poor outcome. Outcomes for schizophrenia appear better in the developing world than in the developed world, although that conclusion has been questioned. The suicide rate of people who have schizophrenia is estimated to be about 4.9 percent, most often occurring in the period following the first appearance of symptoms or the first hospital admission. 20 to 40 percent try to kill themselves at least once. Schizophrenia and smoking have shown a strong association in studies worldwide. Use of cigarettes is especially high in individuals who have schizophrenia, with estimates ranging from 80 to 90 percent of these people being regular smokers, compared to 20 percent of the general population. Those individuals who smoke tend to smoke heavily and to smoke cigarettes with a high nicotine content.American Psychiatric Association. Task Force on DSM-IV. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. American Psychiatric Pub. . p. 304 Research continues on schizophrenia. In the spring of 2013, genetics associations were shown between five major psychiatric disorders: autism, ADHD, bipolar disorder, depression, and schizophrenia per recent study.doi:10.1016/S0140-6736(08)61345-8 In the summer of 2013, for the first time, brain tissue development was replicated in three dimensions by scientists cloning a human "mini-brain" using stem cells. This could help with schizophrenia and autism neurological research (research related to the brain.) ==Likelihood== As of 2011, schizophrenia affects around 0.3% to 0.7% of people, or 24 million people worldwide, at some point in their lives. More men are affected than women: the number of males with the disorder is 1.4 times greater than that of females. Schizophrenia usually appears earlier in men. For males the symptoms usually start from 20 to 28 years of age, and in females it is 26 to 32 years of age. Symptoms that start in childhood, middle or old age are much rarer. Despite the received wisdom that schizophrenia occurs at similar rates worldwide, its rate of likelihood varies across the world, within countries, and at the local level. The disorder causes approximately 1% of worldwide disability adjusted life years (in other words, years spent with a disability). The rate of schizophrenia varies depending on how it is defined. ==History== thumb|Insulin coma therapy was often used for schizophrenia. Large doses of insulin would be injected into a person being treated causing them to go into a coma. Then glucose would be given to bring them back out of the coma.Thomas Bewle. Madness to Mental Illness: A History of the Royal College of Psychiatrists RCPsych Publications; 1 edition (2008) p.52 Accounts of a schizophrenia-like syndrome are rare before the 19th century. Detailed case reports from 1797 and 1809, are regarded as the earliest cases of the disorder. Schizophrenia was first described as a distinct syndrome affecting teenagers and young adults by Bénédict Morel in 1853, termed démence précoce (literally 'early dementia'). The term dementia praecox was used in 1891 by Arnold Pick in a case report of a psychotic disorder. In 1893 Emil Kraepelin introduced a new distinction in the classification of mental disorders between dementia praecox and mood disorder (termed manic depression and including both unipolar and bipolar depression). Kraepelin believed that dementia praecox was primarily a disease of the brain, and a form of dementia, different from other forms of dementia such as Alzheimer's disease which usually happen later in life. Eugen Bleuler coined the term ”schizophrenia”, which translates roughly as "split mind", in 1908. The word was intended to describe the separation of functioning between personality, thinking, memory, and perception. Bleuler realized that the illness was not a dementia because some of his patients improved rather than got worse. In the early 1970s, the criteria for determining schizophrenia were the subject of numerous controversies. Schizophrenia was diagnosed far more often in the United States than in Europe. This difference was partly the result of looser criteria for determining whether someone had the condition in the United States, where the DSM-II manual was used. In Europe, the ICD-9 manual was used. A 1972 study, published in the journal Science, concluded that the diagnosis of schizophrenia in the United States was often unreliable. These factors resulted in the publication of the DSM-III in 1980 with a stricter and more defined criteria for the diagnosis. ==Society and culture== Negative social judgment has been identified as a major obstacle in the recovery of people who have schizophrenia. In 2002, the term for schizophrenia in Japan was changed from “Seishin-Bunretsu-Byō” 精神分裂病 (“mind-split-disease”) to “Tōgō-shitchō-shō” 統合失調症 (“integration disorder”), in an attempt to reduce feelings of shame or embarrassment. The idea that the disease is caused by multiple factors (not just one mental cause) inspired the new name. The change increased the percentage of people who were informed of the diagnosis from 37 percent to 70 percent over three years. In the United States in 2002, the cost of schizophrenia, including direct costs (people who were not hospitalized, people who were hospitalized, medicines, and long-term care) and non- healthcare costs (law enforcement, reduced workplace productivity, and unemployment), was estimated to be $62.7 billion. The book “A Beautiful Mind” and the film of the same name are about the life of John Forbes Nash, an American mathematician and Nobel Prize winner who has schizophrenia. The movie “The Soloist” is based on the life of Nathaniel Ayers, a gifted musician who dropped out of the Julliard School, in New York City after the symptoms of schizophrenia began. He later became homeless in Los Angeles, California, in the notorious Skid Row section.