| Schizophrenia

NIH Publication No. 99-3517
What Is It?
What Causes Schizophrenia?
How Is It Treated?
How Can Other People Help?
What Is The Outlook?**WHAT IS IT?**
Schizophrenia is a chronic, severe, and disabling brain   disease. Approximately 1 percent of the population develops schizophrenia   during their lifetime – more than 2 million Americans suffer from the illness   in a given year. Although schizophrenia affects men and women with equal frequency,   the disorder often appears earlier in men, usually in the late teens or early   twenties, than in women, who are generally affected in the twenties to early   thirties. People with schizophrenia often suffer terrifying symptoms such as   hearing internal voices not heard by others, or believing that other people   are reading their minds, controlling their thoughts, or plotting to harm them.   These symptoms may leave them fearful and withdrawn. Their speech and behavior   can be so disorganized that they may be incomprehensible or frightening to others.   Available treatments can relieve many symptoms, but most people with schizophrenia   continue to suffer some symptoms throughout their lives; it has been estimated   that no more than one in five individuals recovers completely. 
This is a time of hope for people with schizophrenia and their families. Research   is gradually leading to new and safer medications and unraveling the complex   causes of the disease. Scientists are using many approaches from the study of   molecular genetics to the study of populations to learn about schizophrenia.   Methods of imaging the brain’s structure and function hold the promise   of new insights into the disorder. 
**Schizophrenia As An Illness**
Schizophrenia is found all over the world. The severity of the symptoms and   long-lasting, chronic pattern of schizophrenia often cause a high degree of   disability. Medications and other treatments for schizophrenia, when used regularly   and as prescribed, can help reduce and control the distressing symptoms of the   illness. However, some people are not greatly helped by available treatments   or may prematurely discontinue treatment because of unpleasant side effects   or other reasons. Even when treatment is effective, persisting consequences   of the illness – lost opportunities, stigma, residual symptoms, and medication   side effects – may be very troubling. 
The first signs of schizophrenia often appear as confusing, or even shocking,   changes in behavior. Coping with the symptoms of schizophrenia can be especially   difficult for family members who remember how involved or vivacious a person   was before they became ill. The sudden onset of severe psychotic symptoms is   referred to as an “acute” phase of schizophrenia. “Psychosis,”   a common condition in schizophrenia, is a state of mental impairment marked   by hallucinations, which are disturbances of sensory perception, and/or delusions,   which are false yet strongly held personal beliefs that result from an inability   to separate real from unreal experiences. Less obvious symptoms, such as social   isolation or withdrawal, or unusual speech, thinking, or behavior, may precede,   be seen along with, or follow the psychotic symptoms. 
Some people have only one such psychotic episode; others have many episodes   during a lifetime, but lead relatively normal lives during the interim periods.   However, the individual with “chronic” schizophrenia, or a continuous   or recurring pattern of illness, often does not fully recover normal functioning   and typically requires long-term treatment, generally including medication,   to control the symptoms. 
**Making A Diagnosis**
It is important to rule out other illnesses, as sometimes people suffer severe   mental symptoms or even psychosis due to undetected underlying medical conditions.   For this reason, a medical history should be taken and a physical examination   and laboratory tests should be done to rule out other possible causes of the   symptoms before concluding that a person has schizophrenia. In addition, since   commonly abused drugs may cause symptoms resembling schizophrenia, blood or   urine samples from the person can be tested at hospitals or physicians’   offices for the presence of these drugs. 
At times, it is difficult to tell one mental disorder from another. For instance,   some people with symptoms of schizophrenia exhibit prolonged extremes of elated   or depressed mood, and it is important to determine whether such a patient has   schizophrenia or actually has a manic-depressive (or bipolar) disorder or major   depressive disorder. Persons whose symptoms cannot be clearly categorized are   sometimes diagnosed as having a “schizoaffective disorder.” 
**Can Children Have Schizophrenia?**
Children over the age of five can develop schizophrenia, but it is very rare   before adolescence. Although some people who later develop schizophrenia may   have seemed different from other children at an early age, the psychotic symptoms   of schizophrenia – hallucinations and delusions – are extremely uncommon   before adolescence. 
**The World of People With Schizophrenia**
- Distorted Perceptions of Reality   People with schizophrenia may have perceptions of reality that are strikingly   different from the reality seen and shared by others around them. Living in   a world distorted by hallucinations and delusions, individuals with schizophrenia   may feel frightened, anxious, and confused. 
In part because of the unusual realities they experience, people with schizophrenia   may behave very differently at various times. Sometimes they may seem distant,   detached, or preoccupied and may even sit as rigidly as a stone, not moving   for hours or uttering a sound. Other times they may move about constantly –   always occupied, appearing wide-awake, vigilant, and alert. 
- Hallucinations and Illusions   Hallucinations and illusions are disturbances of perception that are common   in people suffering from schizophrenia. Hallucinations are perceptions that   occur without connection to an appropriate source. Although hallucinations can   occur in any sensory form – auditory (sound), visual (sight), tactile (touch),   gustatory (taste), and olfactory (smell) – hearing voices that other people   do not hear is the most common type of hallucination in schizophrenia. Voices   may describe the patient’s activities, carry on a conversation, warn of   impending dangers, or even issue orders to the individual. Illusions, on the   other hand, occur when a sensory stimulus is present but is incorrectly interpreted   by the individual. 
- Delusions   Delusions are false personal beliefs that are not subject to reason or contradictory   evidence and are not explained by a person’s usual cultural concepts. Delusions   may take on different themes. For example, patients suffering from paranoid-type   symptoms – roughly one-third of people with schizophrenia – often   have delusions of persecution, or false and irrational beliefs that they are   being cheated, harassed, poisoned, or conspired against. These patients may   believe that they, or a member of the family or someone close to them, are the   focus of this persecution. In addition, delusions of grandeur, in which a person   may believe he or she is a famous or important figure, may occur in schizophrenia.   Sometimes the delusions experienced by people with schizophrenia are quite bizarre;   for instance, believing that a neighbor is controlling their behavior with magnetic   waves; that people on television are directing special messages to them; or   that their thoughts are being broadcast aloud to others. 
**Substance Abuse**
 Substance abuse is a common concern of the family and friends of people         with schizophrenia. Since some people who abuse drugs may show symptoms         similar to those of schizophrenia, people with schizophrenia may be mistaken         for people "high on drugs.” While most researchers do not believe         that substance abuse causes schizophrenia, people who have schizophrenia         often abuse alcohol and/or drugs, and may have particularly bad reactions         to certain drugs. Substance abuse can reduce the effectiveness of treatment         for schizophrenia. Stimulants (such as amphetamines or cocaine) may cause         major problems for patients with schizophrenia, as may PCP or marijuana.         In fact, some people experience a worsening of their schizophrenic symptoms         when they are taking such drugs. Substance abuse also reduces the likelihood         that patients will follow the treatment plans recommended by their doctors.       
- Schizophrenia and Nicotine   The most common form of substance use disorder in people with schizophrenia         is nicotine dependence due to smoking. While the prevalence of smoking         in the U.S. population is about 25 to 30 percent, the prevalence among         people with schizophrenia is approximately three times as high. Research         has shown that the relationship between smoking and schizophrenia is complex.         Although people with schizophrenia may smoke to self medicate their symptoms,         smoking has been found to interfere with the response to antipsychotic         drugs. Several studies have found that schizophrenia patients who smoke         need higher doses of antipsychotic medication. Quitting smoking may be         especially difficult for people with schizophrenia, because the symptoms         of nicotine withdrawal may cause a temporary worsening of schizophrenia         symptoms. However, smoking cessation strategies that include nicotine         replacement methods may be effective. Doctors should carefully monitor         medication dosage and response when patients with schizophrenia either         start or stop smoking.    
- Disordered Thinking   Schizophrenia often affects a person’s ability to “think straight.”   Thoughts may come and go rapidly; the person may not be able to concentrate   on one thought for very long and may be easily distracted, unable to focus attention. 
People with schizophrenia may not be able to sort out what is relevant and   what is not relevant to a situation. The person may be unable to connect thoughts   into logical sequences, with thoughts becoming disorganized and fragmented.   This lack of logical continuity of thought, termed “thought disorder,”   can make conversation very difficult and may contribute to social isolation.   If people cannot make sense of what an individual is saying, they are likely   to become uncomfortable and tend to leave that person alone. 
- Emotional Expression   People with schizophrenia often show “blunted” or “flat”   affect. This refers to a severe reduction in emotional expressiveness. A person   with schizophrenia may not show the signs of normal emotion, perhaps may speak   in a monotonous voice, have diminished facial expressions, and appear extremely   apathetic. The person may withdraw socially, avoiding contact with others; and   when forced to interact, he or she may have nothing to say, reflecting “impoverished   thought.” Motivation can be greatly decreased, as can interest in or enjoyment   of life. In some severe cases, a person can spend entire days doing nothing   at all, even neglecting basic hygiene. These problems with emotional expression   and motivation, which may be extremely troubling to family members and friends,   are symptoms of schizophrenia – not character flaws or personal weaknesses. 
- Normal Versus Abnormal   At times, normal individuals may feel, think, or act in ways that resemble   schizophrenia. Normal people may sometimes be unable to “think straight.”   They may become extremely anxious, for example, when speaking in front of groups   and may feel confused, be unable to pull their thoughts together, and forget   what they had intended to say. This is not schizophrenia. At the same time,   people with schizophrenia do not always act abnormally. Indeed, some people   with the illness can appear completely normal and be perfectly responsible,   even while they experience hallucinations or delusions. An individual’s   behavior may change over time, becoming bizarre if medication is stopped and   returning closer to normal when receiving appropriate treatment. 
**Schizophrenia Is Not           "Split Personality"**
 

 There is a common notion that schizophrenia is the same as "split           personality” – a Dr. Jekyll-Mr. Hyde switch in character.         
 

 This is not correct.       
**Are People With Schizophrenia Likely To Be Violent?**
 News and entertainment media tend to link mental illness and criminal violence;   however, studies indicate that except for those persons with a record of criminal   violence *before becoming ill*, and those with substance abuse or alcohol   problems, people with schizophrenia are not especially prone to violence. Most   individuals with schizophrenia are not violent; more typically, they are withdrawn   and prefer to be left alone. Most violent crimes are not committed by persons   with schizophrenia, and most persons with schizophrenia do not commit violent   crimes. Substance abuse significantly raises the rate of violence in people   with schizophrenia but also in people who do not have any mental illness. People   with paranoid and psychotic symptoms, which can become worse if medications   are discontinued, may also be at higher risk for violent behavior. When violence   does occur, it is most frequently targeted at family members and friends, and   more often takes place at home. 
**What About Suicide?**
 Suicide is a serious danger in people who have schizophrenia. If an individual   tries to commit suicide or threatens to do so, professional help should be sought   immediately. People with schizophrenia have a higher rate of suicide than the   general population. Approximately 10 percent of people with schizophrenia (especially   younger adult males) commit suicide. Unfortunately, the prediction of suicide   in people with schizophrenia can be especially difficult. 
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**WHAT CAUSES SCHIZOPHRENIA?**
There is no known single cause of schizophrenia. Many diseases, such as heart   disease, result from an interplay of genetic, behavioral, and other factors;   and this may be the case for schizophrenia as well. Scientists do not yet understand   all of the factors necessary to produce schizophrenia, but all the tools of   modern biomedical research are being used to search for genes, critical moments   in brain development, and other factors that may lead to the illness. 
**Is Schizophrenia Inherited?**
 It has long been known that schizophrenia runs in families. People who have   a close relative with schizophrenia are more likely to develop the disorder   than are people who have no relatives with the illness. For example, a monozygotic   (identical) twin of a person with schizophrenia has the highest risk –   40 to 50 percent – of developing the illness. A child whose parent has   schizophrenia has about a 10 percent chance. By comparison, the risk of schizophrenia   in the general population is about 1 percent. 
Scientists are studying genetic factors in schizophrenia. It appears likely   that multiple genes are involved in creating a predisposition to develop the   disorder. In addition, factors such as prenatal difficulties like intrauterine   starvation or viral infections, perinatal complications, and various nonspecific   stressors, seem to influence the development of schizophrenia. However, it is   not yet understood how the genetic predisposition is transmitted, and it cannot   yet be accurately predicted whether a given person will or will not develop   the disorder. 
Several regions of the human genome are being investigated to identify genes   that may confer susceptibility for schizophrenia. The strongest evidence to   date leads to chromosomes 13 and 6 but remains unconfirmed. Identification of   specific genes involved in the development of schizophrenia will provide important   clues into what goes wrong in the brain to produce and sustain the illness and   will guide the development of new and better treatments. To learn more about   the genetic basis for schizophrenia, the NIMH has established a Schizophrenia   Genetics Initiative (see Web site at http://www-grb.nimh.nih.gov/gi.html)   that is gathering data from a large number of families of people with the illness. 
**Is Schizophrenia Associated With A Chemical Defect In The Brain?**
 Basic knowledge about brain chemistry and its link to schizophrenia is expanding   rapidly. Neurotransmitters, substances that allow communication between nerve   cells, have long been thought to be involved in the development of schizophrenia.   It is likely, although not yet certain, that the disorder is associated with   some imbalance of the complex, interrelated chemical systems of the brain, perhaps   involving the neurotransmitters dopamine and glutamate. This area of research   is promising. 
**Is Schizophrenia Caused By A Physical Abnormality In The Brain?**
 There have been dramatic advances in neuroimaging technology that permit scientists   to study brain structure and function in living individuals. Many studies of   people with schizophrenia have found abnormalities in brain structure (for example,   enlargement of the fluid-filled cavities, called the ventricles, in the interior   of the brain, and decreased size of certain brain regions) or function (for   example, decreased metabolic activity in certain brain regions). It should be   emphasized that these abnormalities are quite subtle and are not characteristic   of *all* people with schizophrenia, nor do they occur *only* in individuals   with this illness. Microscopic studies of brain tissue after death have also   shown small changes in distribution or number of brain cells in people with   schizophrenia. It appears that many (but probably not all) of these changes   are present before an individual becomes ill, and schizophrenia may be, in part,   a disorder in development of the brain. 
Developmental neurobiologists funded by the National Institute of Mental Health   (NIMH) have found that schizophrenia may be a developmental disorder resulting   when neurons form inappropriate connections during fetal development. These   errors may lie dormant until puberty, when changes in the brain that occur normally   during this critical stage of maturation interact adversely with the faulty   connections. This research has spurred efforts to identify prenatal factors   that may have some bearing on the apparent developmental abnormality. 
In other studies, investigators using brain-imaging techniques have found evidence   of early biochemical changes that may precede the onset of disease symptoms,   prompting examination of the neural circuits that are most likely to be involved   in producing those symptoms. Meanwhile, scientists working at the molecular   level are exploring the genetic basis for abnormalities in brain development   and in the neurotransmitter systems regulating brain function. 
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**HOW IS IT TREATED?**
 Since schizophrenia may not be a single condition and its causes are not yet   known, current treatment methods are based on both clinical research and experience.   These approaches are chosen on the basis of their ability to reduce the symptoms   of schizophrenia and to lessen the chances that symptoms will return. 
**What About Medications?**
 Antipsychotic medications have been available since the mid-1950s. They have   greatly improved the outlook for individual patients. These medications reduce   the psychotic symptoms of schizophrenia and usually allow the patient to function   more effectively and appropriately. Antipsychotic drugs are the best treatment   now available, but they do not “cure” schizophrenia or ensure that   there will be no further psychotic episodes. The choice and dosage of medication   can be made only by a qualified physician who is well trained in the medical   treatment of mental disorders. The dosage of medication is individualized for   each patient, since people may vary a great deal in the amount of drug needed   to reduce symptoms without producing troublesome side effects. 
The large majority of people with schizophrenia show substantial improvement   when treated with antipsychotic drugs. Some patients, however, are not helped   very much by the medications and a few do not seem to need them. It is difficult   to predict which patients will fall into these two groups and to distinguish   them from the large majority of patients who *do* benefit from treatment   with antipsychotic drugs. 
A number of new antipsychotic drugs (the so-called “atypical antipsychotics”)   have been introduced since 1990. The first of these, clozapine (Clozaril�),   has been shown to be more effective than other antipsychotics, although the   possibility of severe side effects – in particular, a condition called   agranulocytosis (loss of the white blood cells that fight infection) –   requires that patients be monitored with blood tests every one or two weeks.   Even newer antipsychotic drugs, such as risperidone (Risperdal�) and olanzapine   (Zyprexa�), are safer than the older drugs or clozapine, and they also may be   better tolerated. They may or may not treat the illness as well as clozapine,   however. Several additional antipsychotics are currently under development. 
Antipsychotic drugs are often very effective in treating certain symptoms of   schizophrenia, particularly hallucinations and delusions; unfortunately, the   drugs may not be as helpful with other symptoms, such as reduced motivation   and emotional expressiveness. Indeed, the older antipsychotics (which also went   by the name of “neuroleptics”), medicines like haloperidol (Haldol�)   or chlorpromazine (Thorazine�), may even produce side effects that resemble   the more difficult to treat symptoms. Often, lowering the dose or switching   to a different medicine may reduce these side effects; the newer medicines,   including olanzapine (Zyprexa�), quetiapine (Seroquel�), and risperidone (Risperdal�),   appear less likely to have this problem. Sometimes when people with schizophrenia   become depressed, other symptoms can appear to worsen. The symptoms may improve   with the addition of an antidepressant medication. 
Patients and families sometimes become worried about the antipsychotic medications   used to treat schizophrenia. In addition to concern about side effects, they   may worry that such drugs could lead to addiction. However, antipsychotic medications   do not produce a “high” (euphoria) or addictive behavior in people   who take them. 
Another misconception about antipsychotic drugs is that they act as a kind   of mind control, or a “chemical straitjacket.” Antipsychotic drugs   used at the appropriate dosage do not “knock out” people or take away   their free will. While these medications can be sedating, and while this effect   can be useful when treatment is initiated particularly if an individual is quite   agitated, the utility of the drugs is not due to sedation but to their ability   to diminish the hallucinations, agitation, confusion, and delusions of a psychotic   episode. Thus, antipsychotic medications should eventually help an individual   with schizophrenia to deal with the world more rationally. 
**How Long Should People With Schizophrenia Take Antipsychotic Drugs?**
 Antipsychotic medications reduce the risk of future psychotic episodes in   patients who have recovered from an acute episode. Even with continued drug   treatment, some people who have recovered will suffer relapses. Far higher relapse   rates are seen when medication is discontinued. In most cases, it would not   be accurate to say that continued drug treatment “prevents” relapses;   rather, it reduces their intensity and frequency. The treatment of severe psychotic   symptoms generally requires higher dosages than those used for maintenance treatment.   If symptoms reappear on a lower dosage, a temporary increase in dosage may prevent   a full-blown relapse. 
Because relapse of illness is more likely when antipsychotic medications are   discontinued or taken irregularly, it is very important that people with schizophrenia   work with their doctors and family members to adhere to their treatment plan.   *Adherence* to treatment refers to the degree to which patients follow   the treatment plans recommended by their doctors. Good adherence involves taking   prescribed medication at the correct dose and proper times each day, attending   clinic appointments, and/or carefully following other treatment procedures.   Treatment adherence is often difficult for people with schizophrenia, but it   can be made easier with the help of several strategies and can lead to improved   quality of life. 
There are a variety of reasons why people with schizophrenia may not adhere   to treatment. Patients may not believe they are ill and may deny the need for   medication, or they may have such disorganized thinking that they cannot remember   to take their daily doses. Family members or friends may not understand schizophrenia   and may inappropriately advise the person with schizophrenia to stop treatment   when he or she is feeling better. Physicians, who play an important role in   helping their patients adhere to treatment, may neglect to ask patients how   often they are taking their medications, or may be unwilling to accommodate   a patient’s request to change dosages or try a new treatment. Some patients   report that side effects of the medications seem worse than the illness itself.   Further, substance abuse can interfere with the effectiveness of treatment,   leading patients to discontinue medications. When a complicated treatment plan   is added to any of these factors, good adherence may become even more challenging. 
Fortunately, there are many strategies that patients, doctors, and families   can use to improve adherence and prevent worsening of the illness. Some antipsychotic   medications, including haloperidol (Haldol�), fluphenazine (Prolixin�), perphenazine   (Trilafon�) and others, are available in long-acting injectable forms that eliminate   the need to take pills every day. A major goal of current research on treatments   for schizophrenia is to develop a wider variety of long-acting antipsychotics,   especially the newer agents with milder side effects, which can be delivered   through injection. Medication calendars or pill boxes labeled with the days   of the week can help patients and caregivers know when medications have or have   not been taken. Using electronic timers that beep when medications should be   taken, or pairing medication taking with routine daily events like meals, can   help patients remember and adhere to their dosing schedule. Engaging family   members in observing oral medication taking by patients can help ensure adherence.   In addition, through a variety of other methods of adherence monitoring, doctors   can identify when pill taking is a problem for their patients and can work with   them to make adherence easier. It is important to help motivate patients to   continue taking their medications properly. 
In addition to any of these adherence strategies, patient and family education   about schizophrenia, its symptoms, and the medications being prescribed to treat   the disease is an important part of the treatment process and helps support   the rationale for good adherence. 
**What About Side Effects?**
 Antipsychotic drugs, like virtually all medications, have unwanted effects   along with their beneficial effects. During the early phases of drug treatment,   patients may be troubled by side effects such as drowsiness, restlessness, muscle   spasms, tremor, dry mouth, or blurring of vision. Most of these can be corrected   by lowering the dosage or can be controlled by other medications. Different   patients have different treatment responses and side effects to various antipsychotic   drugs. A patient may do better with one drug than another. 
The long-term side effects of antipsychotic drugs may pose a considerably more   serious problem. Tardive dyskinesia (TD) is a disorder characterized by involuntary   movements most often affecting the mouth, lips, and tongue, and sometimes the   trunk or other parts of the body such as arms and legs. It occurs in about 15   to 20 percent of patients who have been receiving the older, “typical”   antipsychotic drugs for many years, but TD can also develop in patients who   have been treated with these drugs for shorter periods of time. In most cases,   the symptoms of TD are mild, and the patient may be unaware of the movements. 
Antipsychotic medications developed in recent years all appear to have a much   lower risk of producing TD than the older, traditional antipsychotics. The risk   is not zero, however, and they can produce side effects of their own such as   weight gain. In addition, if given at too high of a dose, the newer medications   may lead to problems such as social withdrawal and symptoms resembling Parkinson’s   disease, a disorder that affects movement. Nevertheless, the newer antipsychotics   are a significant advance in treatment, and their optimal use in people with   schizophrenia is a subject of much current research. 
**What About Psychosocial Treatments?**
 Antipsychotic drugs have proven to be crucial in relieving the psychotic symptoms   of schizophrenia – hallucinations, delusions, and incoherence – but   are not consistent in relieving the behavioral symptoms of the disorder. Even   when patients with schizophrenia are relatively free of psychotic symptoms,   many still have extraordinary difficulty with communication, motivation, self-care,   and establishing and maintaining relationships with others. Moreover, because   patients with schizophrenia frequently become ill during the critical career-forming   years of life (e.g., ages 18 to 35), they are less likely to complete the training   required for skilled work. As a result, many with schizophrenia not only suffer   thinking and emotional difficulties, but lack social and work skills and experience   as well. 
It is with these psychological, social, and occupational problems that psychosocial   treatments may help most. While psychosocial approaches have limited value for   acutely psychotic patients (those who are out of touch with reality or have   prominent hallucinations or delusions), they may be useful for patients with   less severe symptoms or for patients whose psychotic symptoms are under control.   Numerous forms of psychosocial therapy are available for people with schizophrenia,   and most focus on improving the patient’s social functioning – whether   in the hospital or community, at home, or on the job. Some of these approaches   are described here. Unfortunately, the availability of different forms of treatment   varies greatly from place to place. 
- Rehabilitation    Broadly defined, rehabilitation includes a wide array of non-medical interventions   for those with schizophrenia. Rehabilitation programs emphasize social and vocational   training to help patients and former patients overcome difficulties in these   areas. Programs may include vocational counseling, job training, problem-solving   and money management skills, use of public transportation, and social skills   training. These approaches are important for the success of the community-centered   treatment of schizophrenia, because they provide discharged patients with the   skills necessary to lead productive lives outside the sheltered confines of   a mental hospital. 
- Individual Psychotherapy    Individual psychotherapy involves regularly scheduled talks between the patient   and a mental health professional such as a psychiatrist, psychologist, psychiatric   social worker, or nurse. The sessions may focus on current or past problems,   experiences, thoughts, feelings, or relationships. By sharing experiences with   a trained empathic person – talking about their world with someone outside   it – individuals with schizophrenia may gradually come to understand more   about themselves and their problems. They can also learn to sort out the real   from the unreal and distorted. Recent studies indicate that supportive, reality-oriented,   individual psychotherapy, and cognitive-behavioral approaches that teach coping   and problem-solving skills, can be beneficial for outpatients with schizophrenia.   However, psychotherapy is not a substitute for antipsychotic medication, and   it is most helpful once drug treatment first has relieved a patient’s psychotic   symptoms. 
- Family Education    Very often, patients with schizophrenia are discharged from the hospital into   the care of their family; so it is important that family members learn all they   can about schizophrenia and understand the difficulties and problems associated   with the illness. It is also helpful for family members to learn ways to minimize   the patient’s chance of relapse – for example, by using different   treatment adherence strategies – and to be aware of the various kinds of   outpatient and family services available in the period after hospitalization.   Family “psychoeducation,” which includes teaching various coping strategies   and problem-solving skills, may help families deal more effectively with their   ill relative and may contribute to an improved outcome for the patient. 
- Self-Help Groups    Self-help groups for people and families dealing with schizophrenia are becoming   increasingly common. Although not led by a professional therapist, these groups   may be therapeutic because members provide continuing mutual support as well   as comfort in knowing that they are not alone in the problems they face. Self-help   groups may also serve other important functions. Families working together can   more effectively serve as advocates for needed research and hospital and community   treatment programs. Patients acting as a group rather than individually may   be better able to dispel stigma and draw public attention to such abuses as   discrimination against the mentally ill. 
Family and peer support and advocacy groups are very active and provide useful   information and assistance for patients and families of patients with schizophrenia   and other mental disorders. A list of some of these organizations is included   at the end of this document. 
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**HOW CAN OTHER PEOPLE HELP?**
 A patient's support system may come from several sources, including the family,   a professional residential or day program provider, shelter operators, friends   or roommates, professional case managers, churches and synagogues, and others.   Because many patients live with their families, the following discussion frequently   uses the term "family." However, this should not be taken to imply   that families ought to be the primary support system. 
There are numerous situations in which patients with schizophrenia may need   help from people in their family or community. Often, a person with schizophrenia   will resist treatment, believing that delusions or hallucinations are real and   that psychiatric help is not required. At times, family or friends may need   to take an active role in having them seen and evaluated by a professional.   The issue of civil rights enters into any attempts to provide treatment. Laws   protecting patients from involuntary commitment have become very strict, and   families and community organizations may be frustrated in their efforts to see   that a severely mentally ill individual gets needed help. These laws vary from   State to State; but generally, when people are dangerous to themselves or others   due to a mental disorder, the police can assist in getting them an emergency   psychiatric evaluation and, if necessary, hospitalization. In some places, staff   from a local community mental health center can evaluate an individual's illness   at home if he or she will not voluntarily go in for treatment. 
Sometimes only the family or others close to the person with schizophrenia   will be aware of strange behavior or ideas that the person has expressed. Since   patients may not volunteer such information during an examination, family members   or friends should ask to speak with the person evaluating the patient so that   all relevant information can be taken into account. 
Ensuring that a person with schizophrenia continues to get treatment after   hospitalization is also important. A patient may discontinue medications or   stop going for follow-up treatment, often leading to a return of psychotic symptoms.   Encouraging the patient to continue treatment and assisting him or her in the   treatment process can positively influence recovery. Without treatment, some   people with schizophrenia become so psychotic and disorganized that they cannot   care for their basic needs, such as food, clothing, and shelter. All too often,   people with severe mental illnesses such as schizophrenia end up on the streets   or in jails, where they rarely receive the kinds of treatment they need. 
Those close to people with schizophrenia are often unsure of how to respond   when patients make statements that seem strange or are clearly false. For the   individual with schizophrenia, the bizarre beliefs or hallucinations seem quite   real – they are not just "imaginary fantasies." Instead of “going   along with” a person's delusions, family members or friends can tell the   person that they do not see things the same way or do not agree with his or   her conclusions, while acknowledging that things may appear otherwise to the   patient. 
It may also be useful for those who know the person with schizophrenia well   to keep a record of what types of symptoms have appeared, what medications (including   dosage) have been taken, and what effects various treatments have had. By knowing   what symptoms have been present before, family members may know better what   to look for in the future. Families may even be able to identify some "early   warning signs" of potential relapses, such as increased withdrawal or changes   in sleep patterns, even better and earlier than the patients themselves. Thus,   return of psychosis may be detected early and treatment may prevent a full-blown   relapse. Also, by knowing which medications have helped and which have caused   troublesome side effects in the past, the family can help those treating the   patient to find the best treatment more quickly. 
In addition to involvement in seeking help, family, friends, and peer groups   can provide support and encourage the person with schizophrenia to regain his   or her abilities. It is important that goals be attainable, since a patient   who feels pressured and/or repeatedly criticized by others will probably experience   stress that may lead to a worsening of symptoms. Like anyone else, people with   schizophrenia need to know when they are doing things right. A positive approach   may be helpful and perhaps more effective in the long run than criticism. This   advice applies to everyone who interacts with the person. 
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**WHAT IS THE OUTLOOK?**
 The outlook for people with schizophrenia has improved over the last 25 years.   Although no totally effective therapy has yet been devised, it is important   to remember that many people with the illness improve enough to lead independent,   satisfying lives. As we learn more about the causes and treatments of schizophrenia,   we should be able to help more patients achieve successful outcomes. 
Studies that have followed people with schizophrenia for long periods, from   the first episode to old age, reveal that a wide range of outcomes is possible.   When large groups of patients are studied, certain factors tend to be associated   with a better outcome – for example, a pre-illness history of normal social,   school, and work adjustment. However, the current state of knowledge, does not   allow for a sufficiently accurate prediction of long-term outcome. 
Given the complexity of schizophrenia, the major questions about this disorder   – its cause or causes, prevention, and treatment – must be addressed   with research. The public should beware of those offering "the cure"   for (or "the cause" of) schizophrenia. Such claims can provoke unrealistic   expectations that, when unfulfilled, lead to further disappointment. Although   progress has been made toward better understanding and treatment of schizophrenia,   continued investigation is urgently needed. As the lead Federal agency for research   on mental disorders, NIMH conducts and supports a broad spectrum of mental illness   research from molecular genetics to large-scale epidemiologic studies of populations.   It is thought that this wide-ranging research effort, including basic studies   on the brain, will continue to illuminate processes and principles important   for understanding the causes of schizophrenia and for developing more effective   treatments. 
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**Resources**
 Information, support, and advocacy organizations: 
**NAMI**Colonial Place Three2107 Wilson Blvd., Suite 300Arlington, VA 22201-3042  Phone: 1-800-950-NAMI (6264) or (703) 524-7600  Internet: http://www.nami.org
**National Mental Health Association (NMHA)**  1021 Prince Street  Alexandria, VA 22314-2971  Phone: 1-800-969-6942 or (703) 684-7722  Internet: http://www.nmha.org
**National Mental Health Consumers' Self-Help Clearinghouse**  1211 Chestnut Street, Suite 1000   Philadelphia, PA 19107   Phone: 1-800-553-4key (4539) or (215) 751-1810  Internet: http://www.mhselfhelp.org/index2.html
**National Alliance for Research on Schizophrenia and Depression (NARSAD)**  60 Cutter Mill Road, Suite 404  Great Neck, NY 11021  Phone: (516) 829-0091  Internet: http://www.narsad.org
 

 For more information on research into the brain, behavior, and mental disorders   contact: 
**National Institute of Mental Health (NIMH)**  Office of Communication and Public Liaison  Information Resources and Inquiries Branch  6001 Executive Boulevard, Rm. 8184, MSC 9663  Bethesda, MD 20892-9663  Phone: 301-443-4513  Fax: 301-443-4279  E-mail: [email protected]  Fax back system: Mental Health FAX4U at 301-443-5158  Web site address: http://www.nimh.nih.gov                       |
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