Schizophrenia

MeshName = Schizophrenia
MeshNumber = F03.700.750

Schizophrenia (pron-en|ˌskɪtsəˈfriːniə), from the Greek roots "schizein" (σχίζειν, "to split") and "phrēn", "phren-" (φρήν, φρεν-, "mind") is a psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood,cite journal |author=Castle D, Wesseley S, Der G, Murray RM |year=1991|title=The incidence of operationally defined schizophrenia in Camberwell 1965–84 |journal=British Journal of Psychiatry |volume=159 |pages=790–794 |pmid=1790446 |url=http://bjp.rcpsych.org/cgi/content/abstract/159/6/790 |accessdate=2008-07-05 |doi=10.1192/bjp.159.6.790 |doi_brokendate=2008-07-05] with approximately 0.4–0.6% [cite journal |author=Bhugra D |url=http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0020151 |year=2006 |title=The global prevalence of schizophrenia |journal=PLoS Medicine |volume=2 | issue=5 |pages=372–373 |pmid=15916460 |accessdate=2008-02-24 |doi=10.1371/journal.pmed.0020151] cite journal |author=Goldner EM, Hsu L, Waraich P, Somers JM |year=2002 |title=Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature |journal=Canadian Journal of Psychiatry |volume=47 | issue=9 |pages=833–43 |pmid=12500753 |url=http://ww1.cpa-apc.org:8080/publications/archives/CJP/2002/November/goldner.asp |accessdate=2008-07-05] of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia currently exists.

Studies suggest that genetics, early environment, neurobiology, psychological and social processes are important contributory factors; some recreational and prescription drugs appear to cause or worsen symptoms. Current psychiatric research is focused on the role of neurobiology, but no single organic cause has been found. Due to the many possible combinations of symptoms, there is debate about whether the diagnosis represents a single disorder or a number of discrete syndromes. For this reason, Eugen Bleuler termed the disease "the schizophrenias" (plural) when he coined the name. Despite its etymology, schizophrenia is not the same as dissociative identity disorder, previously known as multiple personality disorder or split personality; in popular culture the two are often confused.

Increased dopamine activity in the mesolimbic pathway of the brain is consistently found in schizophrenic individuals. The mainstay of treatment is antipsychotic medication; this type of drug primarily works by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, although hospital stays are less frequent and for shorter periods than they were in previous years.cite journal |author=Becker T, Kilian R|year=2006 |title=Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? |journal=Acta Psychiatrica Scandinavica Supplement |volume=429 |pages=9–16 |pmid=16445476 |doi=10.1111/j.1600-0447.2005.00711.x]

The disorder is thought to mainly affect cognition, but it also usually contributes to chronic problems with behavior and emotion. People with schizophrenia are likely to have additional (comorbid) conditions, including major depression and anxiety disorders;cite journal |author=Sim K, Chua TH, Chan YH, Mahendran R, Chong SA |title=Psychiatric comorbidity in first episode schizophrenia: a 2 year, longitudinal outcome study |journal=Journal of Psychiatric Research |volume=40 |issue=7 |pages=656–63 |year=2006 |month=October |pmid=16904688 |doi=10.1016/j.jpsychires.2006.06.008|url=http://linkinghub.elsevier.com/retrieve/pii/S0022-3956(06)00122-1 |accessdate=2008-07-05] the lifetime occurrence of substance abuse is around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common. Furthermore, the average life expectancy of people with the disorder is 10 to 12 years less than those without, due to increased physical health problems and a higher suicide rate.cite journal |author=Brown S, Barraclough B, Inskip H|year=2000 |title=Causes of the excess mortality of schizophrenia |journal=British Journal of Psychiatry |volume=177 |pages=212–7 |pmid=11040880 |doi=10.1192/bjp.177.3.212]

igns and symptoms

A person diagnosed with schizophrenia may demonstrate auditory hallucinations, delusions, and disorganized and unusual thinking and speech; this may range from loss of train of thought and subject flow, with sentences only loosely connected in meaning, to incoherence, known as word salad, in severe cases. Social isolation commonly occurs for a variety of reasons. Impairment in social cognition is associated with schizophrenia, as are symptoms of paranoia from delusions and hallucinations, and the negative symptoms of avolition (apathy or lack of motivation). In one uncommon subtype, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are signs of catatonia. No one sign is diagnostic of schizophrenia, and all can occur in other medical and psychiatric conditions. The current classification of psychoses holds that symptoms need to have been present for at least one month in a period of at least six months of disturbed functioning. A schizophrenia-like psychosis of shorter duration is termed a schizophreniform disorder.cite book |author= |title=Diagnostic and statistical manual of mental disorders: DSM-IV |author=American Psychiatric Association |publisher=American Psychiatric Publishing, Inc. |location=Washington, DC |year=2000 |chapter=Schizophrenia |chapterurl=http://www.behavenet.com/capsules/disorders/schiz.htm |isbn=0-89042-024-6 |accessdate=2008-07-04]

Late adolescence and early adulthood are peak years for the onset of schizophrenia. These are critical periods in a young adult's social and vocational development, and they can be severely disrupted. To minimize the effect of schizophrenia, much work has recently been done to identify and treat the prodromal (pre-onset) phase of the illness, which has been detected up to 30 months before the onset of symptoms, but may be present longer.cite journal |author=Addington J |coauthors=Cadenhead KS, Cannon TD, Cornblatt B, McGlashan TH, Perkins DO, Seidman LJ, Tsuang M, Walker EF, Woods SW, Heinssen R |year=2007|title=North American prodrome longitudinal study: a collaborative multisite approach to prodromal schizophrenia research |journal=Schizophrenia Bulletin |volume=33 | issue=3 |pages=665–72 |pmid=17255119|doi=10.1093/schbul/sbl075] Those who go on to develop schizophrenia may experience the non-specific symptoms of social withdrawal, irritability and dysphoria in the prodromal period,cite journal |author=Parnas J |coauthors=Jorgensen A |year=1989 |title=Pre-morbid psychopathology in schizophrenia spectrum |journal=British Journal of Psychiatry |volume=115 |pages=623–7 |pmid=2611591] and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.cite journal |author=Amminger GP |coauthors=Leicester S, Yung AR, Phillips LJ, Berger GE, Francey SM, Yuen HP, McGorry PD |year=2006 |title=Early-onset of symptoms predicts conversion to non-affective psychosis in ultra-high risk individuals |journal=Schizophrenia Research |volume=84 | issue=1 |pages=67–76 |pmid=16677803 |doi=10.1016/j.schres.2006.02.018]

chneiderian classification

The psychiatrist Kurt Schneider (1887–1967) listed the forms of psychotic symptoms that he thought distinguished schizophrenia from other psychotic disorders. These are called "first-rank symptoms" or Schneider's first-rank symptoms, and they include delusions of being controlled by an external force; the belief that thoughts are being inserted into or withdrawn from one's conscious mind; the belief that one's thoughts are being broadcast to other people; and hearing hallucinatory voices that comment on one's thoughts or actions or that have a conversation with other hallucinated voices.Schneider, K. (1959) "Clinical Psychopathology". New York: Grune and Stratton.] The reliability of first-rank symptoms has been questioned,cite journal |author=Bertelsen, A |year=2002 |title=Schizophrenia and Related Disorders: Experience with Current Diagnostic Systems |journal=Psychopathology |volume=35 |pages=89–93 |pmid=12145490 |doi=10.1159/000065125] although they have contributed to the current diagnostic criteria.

Positive and negative symptoms

Schizophrenia is often described in terms of "positive" and "negative" (or deficit) symptoms.cite book |author=Sims A |title=Symptoms in the mind: an introduction to descriptive psychopathology |publisher=W. B. Saunders |location=Philadelphia |year=2002 |isbn=0-7020-2627-1 |accessdate=] Positive symptoms include delusions, auditory hallucinations, and thought disorder, and are typically regarded as manifestations of psychosis. Negative symptoms are so-named because they are considered to be the loss or absence of normal traits or abilities, and include features such as flat or blunted affect and emotion, poverty of speech (alogia), inability to experience pleasure (anhedonia), and lack of motivation (avolition). Despite the appearance of blunted affect, recent studies indicate that there is often a normal or even heightened level of emotionality in schizophrenia, especially in response to stressful or negative events.cite journal |author=Cohen & Docherty |year=2004 |title=Affective reactivity of speech and emotional experience in patients with schizophrenia |journal=Schizophrenia Research |volume=69 | issue=1 |pages=7–14 |pmid=15145465 |doi=10.1016/S0920-9964(03)00069-0] A third symptom grouping, the "disorganization syndrome", is commonly described, and includes chaotic speech, thought, and behavior. There is evidence for a number of other symptom classifications.cite journal |author=Peralta V |coauthors=Cuesta MJ |year=2001 |title=How many and which are the psychopathological dimensions in schizophrenia? Issues influencing their ascertainment |journal=Schizophrenia Research |volume=49 | issue=3 |pages=269–85 |pmid=11356588 |doi=10.1016/S0920-9964(00)00071-2]

Diagnosis

Diagnosis is based on the self-reported experiences of the person, and abnormalities in behavior reported by family members, friends or co-workers, followed by a clinical assessment by a psychiatrist, social worker, clinical psychologist or other mental health professional. Psychiatric assessment includes a psychiatric history and some form of mental status examination.

tandardized criteria

The most widely used standardized criteria for diagnosing schizophrenia come from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the United States and the rest of the world, as well as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian first rank symptoms although, in practice, agreement between the two systems is high.cite journal |author=Jakobsen KD |coauthors=Frederiksen JN, Hansen T, Jansson LB, Parnas J, Werge T |year=2005 |title=Reliability of clinical ICD-10 schizophrenia diagnoses |journal=Nordic Journal of Psychiatry |volume=59 | issue=3 |pages=209–12 |pmid=16195122 | doi = 10.1080/08039480510027698] The WHO has developed the tool "SCAN (Schedules for Clinical Assessment in Neuropsychiatry)" which can be used for diagnosing a number of psychiatric conditions, including schizophrenia.

According to the DSM-IV, to be diagnosed with schizophrenia, three diagnostic criteria must be met.
# Characteristic symptoms: Two or more of the following, each present for much of the time during a one-month period (or less, if symptoms remitted with treatment).
#* Delusions
#* Hallucinations
#* Disorganized speech, which is a manifestation of formal thought disorder
#* Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior
#* Negative symptoms—affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation)
#:If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other, only that symptom is required above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication.
# Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset.
# Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment).

Note that schizophrenia cannot be diagnosed if symptoms of mood disorder or pervasive developmental disorder are present, or the symptoms are the direct result of a general medical condition or a substance, such as abuse of a drug or medication.

Confusion with other conditions

Psychotic symptoms may be present are several other psychiatric illnesses, including bipolar disorder, [cite journal |author=Pope HG |year=1983 |title=Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports |journal=Hospital and Community Psychiatry |volume=34 |pages=322–328 |url=http://psychservices.psychiatryonline.org/cgi/reprint/34/4/322.pdf|format=PDF |accessdate= 2008-02-24] borderline personality disorder, [cite journal |author=McGlashan TH |title=Testing DSM-III symptom criteria for schizotypal and borderline personality disorders |journal=Archives of General Psychiatry |volume=44 |issue=2 |pages=143–8 |year=1987 |month=February |pmid=3813809 |accessdate=2008-07-03] schizoaffective disorder, drug intoxication, brief drug-induced psychosis, and schizophreniform disorder. A more general medical and neurological examination may be needed to rule out medical illnesses which may rarely produce psychotic schizophrenia-like symptoms, such as metabolic disturbance, systemic infection, syphilis, HIV infection, epilepsy, and brain lesions. It may be necessary to rule out a delirium, which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness, and indicates an underlying medical illness. Investigations are not generally repeated for relapse unless there is a specific "medical" indication or possible adverse effects from antipsychotic medication.

ubtypes

The DSM-IV contains five sub-classifications of schizophrenia.
* Paranoid type: Where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent. (DSM code 295.3/ICD code F20.0)
* Disorganized type: Named "hebephrenic schizophrenia" in the ICD. Where thought disorder and flat affect are present together. (DSM code 295.1/ICD code F20.1)
* Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless movement. Symptoms can include catatonic stupor and waxy flexibility. (DSM code 295.2/ICD code F20.2)
* Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met. (DSM code 295.9/ICD code F20.3)
* Residual type: Where positive symptoms are present at a low intensity only. (DSM code 295.6/ICD code F20.5)

The ICD-10 defines two additional subtypes.
* Post-schizophrenic depression: A depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present. (ICD code F20.4)
* Simple schizophrenia: Insidious and progressive development of prominent negative symptoms with no history of psychotic episodes. (ICD code F20.6)

Diagnostic issues and controversies

The definitions used for criteria have been criticized as lacking consistency;cite journal |author=David AS |year=1999 |title=On the impossibility of defining delusions |journal=Philosophy, Psychiatry and Psychology |volume=6 | issue=1 |pages=17–20 |url=http://muse.jhu.edu/journals/philosophy_psychiatry_and_psychology/v006/6.1david.html |accessdate=2008-02-24] this is particularly relevant to the evaluation of delusions and thought disorder. More recently, it has been argued that psychotic symptoms are not a good basis for making a diagnosis of schizophrenia as "psychosis is the 'fever' of mental illness—a serious but nonspecific indicator".cite journal |author=Tsuang MT |coauthors=Stone WS, Faraone SV |year=2000 |title=Toward reformulating the diagnosis of schizophrenia |journal=American Journal of Psychiatry |volume=157 | issue=7 |pages=1041–50 |pmid=10873908 |doi=10.1176/appi.ajp.157.7.1041]

Perhaps because of these factors, studies examining the diagnosis of schizophrenia have typically shown relatively low or inconsistent levels of diagnostic reliability. Most famously, David Rosenhan's 1972 study, published as "On being sane in insane places", demonstrated that the diagnosis of schizophrenia was (at least at the time) often subjective and unreliable. [cite journal |author=Rosenhan D |year=1973 |title=On being sane in insane places |journal=Science |volume=179 |pages=250–8 |pmid=4683124 |doi=10.1126/science.179.4070.250] More recent studies have found agreement between any two psychiatrists when diagnosing schizophrenia tends to reach about 65% at best.cite journal |author=McGorry PD |coauthors=Mihalopoulos C, Henry L, Dakis J, Jackson HJ, Flaum M, Harrigan S, McKenzie D, Kulkarni J, Karoly R |year=1995 |title=Spurious precision: procedural validity of diagnostic assessment in psychotic disorders |journal=American Journal of Psychiatry |volume=152 |issue=2 |pages=220–3 |pmid=7840355] This, and the results of earlier studies of diagnostic reliability (which typically reported even lower levels of agreement) have led some critics to argue that the diagnosis of schizophrenia should be abandoned.cite book |author=Bentall, Richard P.; Read, John E; Mosher, Loren R. |title=Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia |publisher=Brunner-Routledge |location=Philadelphia |year=2004|isbn=1-58391-906-6]

In 2004 in Japan, the Japanese term for schizophrenia was changed from "Seishin-Bunretsu-Byo" (mind-split-disease) to "Tōgō-shitchō-shō" (integration disorder).cite journal |author=Sato M |year=2004 |title=Renaming schizophrenia: a Japanese perspective |journal=World Psychiatry |volume=5 | issue=1 |pages=53–5 |pmid=16757998] In 2006, campaigners in the UK, under the banner of Campaign for Abolition of the Schizophrenia Label, argued for a similar rejection of the diagnosis of schizophrenia and a different approach to the treatment and understanding of the symptoms currently associated with it. [http://news.bbc.co.uk/2/hi/health/6033013.stm Schizophrenia term use 'invalid'.] BBC News Online, (9 October 2006). Retrieved on 2007-05-16. ]

Alternatively, other proponents have put forward using the presence of specific neurocognitive deficits to make a diagnosis. These take the form of a reduction or impairment in basic psychological functions such as memory, attention, executive function and problem solving. It is these sorts of difficulties, rather than the psychotic symptoms (which can in many cases be controlled by antipsychotic medication), which seem to be the cause of most disability in schizophrenia. However, this argument is relatively new and it is unlikely that the method of diagnosing schizophrenia will change radically in the near future.cite book |author=Green, Michael |title=Schizophrenia revealed: from neurons to social interactions |publisher=W.W. Norton |location=New York |year=2001|isbn=0-393-70334-7]

The diagnosis of schizophrenia has been used for political rather than therapeutic purposes; in the Soviet Union an additional sub-classification of sluggishly progressing schizophrenia was created. Particularly in the RSFSR (Russian Soviet Federated Socialist Republic), this diagnosis was used for the purpose of silencing political dissidents or forcing them to recant their ideas by the use of forcible confinement and treatment.cite journal |author=Wilkinson G |year=1986 |title=Political dissent and "sluggish" schizophrenia in the Soviet Union |journal=Br Med J (Clin Res Ed) |volume=293 | issue=6548 |pages=641–2 |pmid=3092963] In 2000 there were similar concerns regarding detention and 'treatment' of practitioners of the Falun Gong movement by the Chinese government. This led the American Psychiatric Association's "Committee on the Abuse of Psychiatry and Psychiatrists" to pass a resolution to urge the World Psychiatric Association to investigate the situation in China.cite journal |author=Lyons D |year=2001 |title=Soviet-style psychiatry is alive and well in the People's Republic |journal=British Journal of Psychiatry |volume=178 |pages=380–381 |pmid=11282823 |doi=10.1192/bjp.178.4.380-b]

Epidemiology

Schizophrenia occurs equally in males and females, although typically appears earlier in men—the peak ages of onset are 20–28 years for males and 26–32 years for females. Onset in childhood is much rarer,cite journal |author=Kumra S |coauthors=Shaw M, Merka P, Nakayama E, Augustin R |year=2001 |title=Childhood-onset schizophrenia: research update |journal=Canadian Journal of Psychiatry |volume=46 | issue=10 |pages=923–30 |pmid=11816313] as is onset in middle- or old age.Hassett A, Ames D, Chiu E (eds) (2005) Psychosis in the Elderly. London: Taylor and Francis. ISBN 18418439446] The lifetime prevalence of schizophrenia—the proportion of individuals expected to experience the disease at any time in their lives—is commonly given at 1%. However, a 2002 systematic review of many studies found a lifetime prevalence of 0.55%. Despite the received wisdom that schizophrenia occurs at similar rates worldwide, its prevalence varies across the world,cite journal |author=Jablensky A |coauthors=Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE, Day R, Bertelsen A |year=1992 |title=Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study |journal=Psychological Medicine Monograph Supplement |volume=20 |pages=1–97 |pmid=1565705] within countries,cite journal |author=Kirkbride JB |coauthors=Fearon P, Morgan C, Dazzan P, Morgan K, Tarrant J, Lloyd T, Holloway J, Hutchinson G, Leff JP, Mallett RM, Harrison GL, Murray RM, Jones PB |year=2006 |title=Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings From the 3-center ÆSOP study |journal=Archives of General Psychiatry |volume=63 | issue=3 |pages=250–58 |pmid=16520429 |doi=10.1001/archpsyc.63.3.250] and at the local and neighbourhood level.cite journal |author=Kirkbride JB |coauthors=Fearon P, Morgan C, Dazzan P, Morgan K, Murray RM, Jones PB |year=2007 |title=Neighbourhood variation in the incidence of psychotic disorders in Southeast London |journal=Social Psychiatry and Psychiatric Epidemiology |volume=42 | issue=6 |pages=438–45 |pmid=17473901 | doi = 10.1007/s00127-007-0193-0] One particularly stable and replicable finding has been the association between living in an urban environment and schizophrenia diagnosis, even after factors such as drug use, ethnic group and size of social group have been controlled for.cite journal |author=Van Os J |year=2004 |title=Does the urban environment cause psychosis? |journal=British Journal of Psychiatry |volume=184 | issue=4 |pages=287–288 |pmid=15056569 |doi=10.1192/bjp.184.4.287] Schizophrenia is known to be a major cause of disability. In a 1999 study of 14 countries, active psychosis was ranked the third-most-disabling condition after quadriplegia and dementia and ahead of paraplegia and blindness.cite journal |author=Ustun TB |coauthors=Rehm J, Chatterji S, Saxena S, Trotter R, Room R, Bickenbach J, and the WHO/NIH Joint Project CAR Study Group |year=1999 |title=Multiple-informant ranking of the disabling effects of different health conditions in 14 countries |journal=The Lancet |volume=354 | issue=9173 |pages=111–15 |pmid=10408486 |doi=10.1016/S0140-6736(98)07507-2]

Causes

While the reliability of the diagnosis introduces difficulties in measuring the relative effect of genes and environment (for example, symptoms overlap to some extent with severe bipolar disorder or major depression), evidence suggests that genetic and environmental factors can act in combination to result in schizophrenia.cite journal |author=Harrison PJ |coauthors=Owen MJ |year=2003 |title=Genes for schizophrenia? Recent findings and their pathophysiological implications |journal=The Lancet |volume=361 | issue=9355 |pages=417–19 |pmid=12573388 |doi=10.1016/S0140-6736(03)12379-3] Evidence suggests that the diagnosis of schizophrenia has a significant heritable component but that onset is significantly influenced by environmental factors or stressors.cite journal |author=Day R |coauthors=Nielsen JA, Korten A, Ernberg G, Dube KC, Gebhart J, Jablensky A, Leon C, Marsella A, Olatawura M, et al. |year=1987 |title=Stressful life events preceding the acute onset of schizophrenia: a cross-national study from the World Health Organization |journal=Culture, Medicine and Psychiatry |volume=11 | issue=2 |pages=123–205 |pmid=3595169 | doi = 10.1007/BF00122563] The idea of an inherent vulnerability (or "diathesis") in some people, which can be unmasked by biological, psychological or environmental stressors, is known as the "stress-diathesis model".cite journal |author=Corcoran C |coauthors=Walker E, Huot R, Mittal V, Tessner K, Kestler L, Malaspina D |year=2003 |title=The stress cascade and schizophrenia: etiology and onset |journal=Schizophrenia Bulletin |volume=29 | issue=4 |pages=671–92 |pmid=14989406] The idea that biological, psychological and social factors are all important is known as the "biopsychosocial" model.

Genetic

Estimates of the heritability of schizophrenia tend to vary owing to the difficulty of separating the effects of genetics and the environment although twin studies have suggested a high level of heritability.cite journal |author=O'Donovan MC |coauthors=Williams NM, Owen MJ |year=2003 |title=Recent advances in the genetics of schizophrenia |journal=Human Molecular Genetics |volume=12 Spec No 2 |pages=R125–33 |pmid=12952866 |doi=10.1093/hmg/ddg302] It is likely that schizophrenia is a condition of complex inheritance, with several genes possibly interacting to generate risk for schizophrenia or the separate components that can co-occur leading to a diagnosis.cite journal |author=Owen MJ |coauthors=Craddock N, O'Donovan MC |year=2005 |title=Schizophrenia: genes at last? |journal=Trends in Genetics |volume=21 | issue=9 |pages=518–25 |pmid=16009449 |doi=10.1016/j.tig.2005.06.011] These genes appear to be non-specific, in that they may raise the risk of developing other psychotic disorders such as bipolar disorder.cite journal |author=Craddock N |coauthors=O'Donovan MC, Owen MJ |year=2006 |title=Genes for schizophrenia and bipolar disorder? Implications for psychiatric nosology|journal=Schizophrenia Bulletin |volume=32 | issue=1 |pages=9–16 |pmid=16319375 |doi=10.1093/schbul/sbj033] cite journal |author=Dalby JT |coauthors=Morgan D, Lee M |year=1986 |title=Schizophrenia and mania in identical twin brothers |journal=Journal of Nervous and Mental Disease |volume=174 |pages=304–308 |pmid=3701318 |doi=10.1097/00005053-198605000-00007] Rare deletions or duplications of tiny DNA sequences within genes (known as copy number variants) may be linked to increased risk for schizophrenia.cite journal |author=Walsh T |coauthors=McClellan JM, McCarthy SE, Addington AM, Pierce SB, Cooper GM, Nord AS, Kusenda M, Malhotra D, Bhandari A, Stray SM, Rippey CF, Roccanova P, Makarov V, Lakshmi B, Findling RL, Sikich L, Stromberg T, Merriman B, Gogtay N, Butler P, Eckstrand K, Noory L, Gochman P, Long R, Chen Z, Davis S, Baker C, Eichler EE, Meltzer PS, Nelson SF, Singleton AB, Lee MK, Rapoport JL, King MC, Sebat J |title=Rare structural variants disrupt multiple genes in neurodevelopmental pathways in schizophrenia |journal=Science |volume=320 |issue=5875 |pages=539–43 |year=2008 |month=April |pmid=18369103 |doi=10.1126/science.1155174 |url=http://www.sciencemag.org/cgi/pmidlookup?view=long&pmid=18369103 |accessdate=2008-07-03]

Prenatal

Causal factors are thought to initially come together in early neurodevelopment to increase the risk of later developing schizophrenia. One curious finding is that people diagnosed with schizophrenia are more likely to have been born in winter or spring, (at least in the northern hemisphere).cite journal |author=Davies G |coauthors=Welham J, Chant D, Torrey EF, McGrath J |year=2003 |title=A systematic review and meta-analysis of Northern Hemisphere season of birth studies in schizophrenia |journal=Schizophrenia Bulletin |volume=29 | issue=3|pages=587–93 |pmid=14609251] There is now evidence that prenatal exposure to infections increases the risk for developing schizophrenia later in life, providing additional evidence for a link between in utero developmental pathology and risk of developing the condition.cite journal |author=Brown AS |year=2006 |title=Prenatal infection as a risk factor for schizophrenia |journal=Schizophrenia Bulletin |volume=32 | issue=2 |pages=200–2 |pmid=16469941 |doi= 10.1093/schbul/sbj052]

ocial

Drugs

Although about half of all patients with schizophrenia abuse drugs or alcohol, a clear causal connection between drug use and schizophrenia has been difficult to prove. The two most often used explanations for this are "substance use causes schizophrenia" and "substance use is a consequence of schizophrenia", and they both may be correct. A relatively strong evidence based on multiple studies suggests that cannabis may play a role in the development of schizophrenia. However, there is no sufficient evidence for the role alcohol or other drugs. On the other hand, that people with schizophrenia are known to use drugs to alleviate the depression, anxiety and loneliness resulting from their disorder. cite journal |author=Gregg L |coauthors=Barrowclough C, Haddock G |year=2007 |title=Reasons for increased substance use in psychosis |journal=Clinical Psychology Review |volume=27 |issue=4 |pages=494–510 |pmid=17240501 | doi = 10.1016/j.cpr.2006.09.004]

Psychological

Neural

Studies using neuropsychological tests and brain imaging technologies such as fMRI and PET to examine functional differences in brain activity have shown that differences seem to most commonly occur in the frontal lobes, hippocampus, and temporal lobes.Green MF (2001) "Schizophrenia Revealed: From Neurons to Social Interactions". New York: W.W. Norton. ISBN 0-393-70334-7] These differences have been linked to the neurocognitive deficits often associated with schizophrenia.cite journal |author=Green MF |year=2006 |title=Cognitive impairment and functional outcome in schizophrenia and bipolar disorder |journal=Journal of Clinical Psychiatry |volume=67 | issue=Suppl 9 |pages=3–8 |pmid=16965182] The role of antipsychotic medication, which nearly all those studied had taken, in causing such abnormalities is unclear. [cite journal |author=Dean CE |url=http://ajp.psychiatryonline.org/cgi/content/full/156/11/1843-b |year=2006 |title=Typical neuroleptics and increased subcortical volumes |journal=American Journal of Psychiatry |volume=156 |issue=11 |pages=1843–4 |pmid=10553769 |accessdate= 2008-02-26]

Particular focus has been placed upon the function of dopamine in the mesolimbic pathway of the brain. This focus largely resulted from the accidental finding that a drug group which blocks dopamine function, known as the phenothiazines, could reduce psychotic symptoms. It is also supported by the fact that amphetamines, which triggers the release of dopamine may exacerbate the psychotic symptoms in schizophrenia.cite journal |author=Laruelle M |coauthors=Abi-Dargham A, van Dyck CH, Gil R, D'Souza CD, Erdos J, McCance E, Rosenblatt W, Fingado C, Zoghbi SS, Baldwin RM, Seibyl JP, Krystal JH, Charney DS, Innis RB |year=1996 |title=Single photon emission computerized tomography imaging of amphetamine-induced dopamine release in drug-free schizophrenic subjects |journal=Proceedings of the National Academy of Sciences of the USA |volume=93 |doi= 10.1073/pnas.93.17.9235 |pages=9235–40 |pmid=8799184] An influential theory, known as the Dopamine hypothesis of schizophrenia, proposed that a malfunction involving dopamine pathways was the cause of (the positive symptoms of) schizophrenia. This theory is now thought to be overly simplistic as a complete explanation, partly because newer antipsychotic medication (called atypical antipsychotic medication) can be equally effective as older medication (called typical antipsychotic medication), but also affects serotonin function and may have slightly less of a dopamine blocking effect.cite journal |author=Jones HM |coauthors=Pilowsky LS |year=2002 |title=Dopamine and antipsychotic drug action revisited |journal=British Journal of Psychiatry |volume=181 |pages=271–275 |pmid=12356650 |doi=10.1192/bjp.181.4.271]

Interest has also focused on the neurotransmitter glutamate and the reduced function of the NMDA glutamate receptor in schizophrenia. This has largely been suggested by abnormally low levels of glutamate receptors found in postmortem brains of people previously diagnosed with schizophreniacite journal |author=Konradi C |coauthors=Heckers S |year=2003 |title=Molecular aspects of glutamate dysregulation: implications for schizophrenia and its treatment |journal=Pharmacology and Therapeutics |volume=97 |issue=2 |pages=153–79 |pmid=12559388 |doi=10.1016/S0163-7258(02)00328-5] and the discovery that the glutamate blocking drugs such as phencyclidine and ketamine can mimic the symptoms and cognitive problems associated with the condition.cite journal |author=Lahti AC |coauthors=Weiler MA, Tamara Michaelidis BA, Parwani A, Tamminga CA |year=2001 |title=Effects of ketamine in normal and schizophrenic volunteers |journal=Neuropsychopharmacology |volume=25 |issue=4 |pages=455–67 |pmid=11557159 |doi=10.1016/S0893-133X(01)00243-3] The fact that reduced glutamate function is linked to poor performance on tests requiring frontal lobe and hippocampal function and that glutamate can affect dopamine function, all of which have been implicated in schizophrenia, have suggested an important mediating (and possibly causal) role of glutamate pathways in schizophrenia.cite journal |author=Coyle JT |coauthors=Tsai G, Goff D |year=2003 |title=Converging evidence of NMDA receptor hypofunction in the pathophysiology of schizophrenia |journal=Annals of the New York Academy of Sciences |volume=1003 |pages=318–27 |pmid=14684455 |doi=10.1196/annals.1300.020] Further support of this theory has come from preliminary trials suggesting the efficacy of coagonists at the NMDA receptor complex in reducing some of the positive symptoms of schizophrenia.cite journal |author=Tuominen HJ |coauthors=Tiihonen J, Wahlbeck K |year=2005 |title=Glutamatergic drugs for schizophrenia: a systematic review and meta-analysis |journal=Schizophrenia Research |volume=72 |pages=225–34 |pmid=15560967 |doi=10.1016/j.schres.2004.05.005]

There have also been findings of differences in the size and structure of certain brain areas in schizophrenia, starting with the discovery of ventricular enlargement in those for whom negative symptoms were most prominent.cite journal |author=Johnstone EC |coauthors=Crow TJ, Frith CD, Husband J, Kreel L |year=1976 |title=Cerebral ventricular size and cognitive impairment in chronic schizophrenia |journal=The Lancet |volume=2 |issue=7992 |pages=924–6 |pmid=62160 |doi=10.1016/S0140-6736(76)90890-4] However, this has not proven particularly reliable on the level of the individual person, with considerable variation between patients. More recent studies have shown various differences in brain structure between people with and without diagnoses of schizophrenia.cite journal |author=Flashman LA |coauthors=Green MF |year=2004 |title=Review of cognition and brain structure in schizophrenia: profiles, longitudinal course, and effects of treatment |journal=Psychiatric Clinics of North America |volume=27 |issue=1 |pages=1–18, vii |pmid=15062627 | doi = 10.1016/S0193-953X(03)00105-9 ] While brain structure changes have been found in people diagnosed with schizophrenia who have never been treated with antipsychotic drugscite journal |author=Cahn W, Hulshoff Pol HE, Bongers M, "et al" |title=Brain morphology in antipsychotic-naïve schizophrenia: a study of multiple brain structures |journal=Br J Psychiatry Suppl |volume=43|pages=s66–72 |year=2002 |month=September |pmid=12271803|accessdate=2008-07-03 |doi=10.1192/bjp.181.43.s66] there is evidence that the medication itself might cause additional changes in the brain's structure.cite journal |author=Molina V, Reig S, Sanz J, et al |year=2005 |month=December|title=Increase in gray matter and decrease in white matter volumes in the cortex during treatment with atypical neuroleptics in schizophrenia |journal=Schizophrenia Research |volume=80 |issue=1 |pages=61–71 |pmid=16150576 |doi=10.1016/j.schres.2005.07.031 |url=http://linkinghub.elsevier.com/retrieve/pii/S0920-9964(05)00296-3 |accessdate=2008-07-03] However, as with earlier studies, many of these differences are only reliably detected when comparing groups of people, and are unlikely to predict any differences in brain structure of an individual person with schizophrenia.

Treatment and services

The concept of a cure as such remains controversial, as there is no consensus on the definition, although some criteria for the remission of symptoms have recently been suggested.van Os J, Burns T, Cavallaro R, "et al" (2006). Standardized remission criteria in schizophrenia. "Acta Psychiatrica Scandinavica", 113(2), 91–5. PMID 16423159] The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the most common being the Positive and Negative Syndrome Scale (PANSS).Kay SR, Fiszbein A, Opler LA (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. "Schizophrenia Bulletin", 13(2), 261–76. PMID 3616518] Management of symptoms and improving function is thought to be more achievable than a cure. Treatment was revolutionized in the mid 1950s with the development and introduction of chlorpromazine.cite journal | author=Turner T. | title=Unlocking psychosis | journal=Brit J Med | year=2007 | volume=334 | issue=suppl | pages=s7 | doi=10.1136/bmj.39034.609074.94 | pmid=17204765 ] A recovery model is increasingly adopted, emphasizing hope, empowerment and social inclusion.Bellack AS. (2006) Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. "Schizophrenia Bulletin." Jul;32(3):432-42. PMID 16461575]

Hospitalization may occur with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still occur. Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment [McGurk, SR, Mueser KT, Feldman K, Wolfe R, Pascaris A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. "Am J Psychiatry." Mar;164(3):437–41. PMID 17329468] and patient-led support groups.

In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. Multiple international surveys by the World Health Organization over several decades have indicated that the outcome for people diagnosed with schizophrenia in non-Western countries is on average better there than for people in the West.Kulhara P (1994). Outcome of schizophrenia: some transcultural observations with particular reference to developing countries. "European Archives of Psychiatry and Clinical Neuroscience", 244(5), 227–35. PMID 7893767] Many clinicians and researchers suspect the relative levels of social connectedness and acceptance are the difference, [Shankar Vedantam (2005) [http://www.washingtonpost.com/wp-dyn/content/article/2005/06/26/AR2005062601091.html Social Network's Healing Power Is Borne Out in Poorer Nations] "Washington Post", June 27] although further cross-cultural studies are seeking to clarify the findings.

Medication

The first line psychiatric treatment for schizophrenia is antipsychotic medication.cite web |url=http://www.nice.org.uk/nicemedia/pdf/cg001fullguideline.pdf |format=PDF|title=Schizophrenia: Full national clinical guideline on core interventions in primary and secondary care |accessdate=2008-07-04 |author=National Collaborating Centre for Mental Health |date=2006-01-24 |publisher=Gaskell and the British Psychological Society] These can reduce the positive symptoms of psychosis. Most antipsychotics take around 7–14 days to have their main effect.Although expensive, the newer atypical antipsychotic drugs are usually preferred for initial treatment over the older typical antipsychotics; they are often better tolerated and associated with lower rates of tardive dyskinesia, although they are more likely to induce weight gain and obesity-related diseases.cite journal |author=Lieberman JA, Stroup TS, McEvoy JP, "et al" |title=Effectiveness of antipsychotic drugs in patients with chronic schizophrenia |journal=New England Journal of Medicine |volume=353 |issue=12 |pages=1209–23 |year=2005 |month=September |pmid=16172203 |doi=10.1056/NEJMoa051688 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16172203&promo=ONFLNS19 |accessdate=2008-07-04] Prolactin elevations have been reported in women with schizophrenia taking atypical antipsychotics.cite journal |author=Dickson RA, Dalby JT, Williams R, Edwards AL |title=Risperidone-induced prolactin elevations in premenopausal women with schizophrenia |journal=American Journal of Psychiatry |volume=152 |issue=7 |pages=1102–03 |year=1995 |month=July |pmid=7540803] It remains unclear whether the newer antipsychotics reduce the chances of developing neuroleptic malignant syndrome, a rare but serious and potentially fatal neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs.cite journal |author=Ananth J, Parameswaran S, Gunatilake S, Burgoyne K, Sidhom T |title=Neuroleptic malignant syndrome and atypical antipsychotic drugs |journal=Journal of Clinical Psychiatry |volume=65 |issue=4 |pages=464–70 |year=2004 |month=April |pmid=15119907 |url=http://article.psychiatrist.com/?ContentType=START&ID=10000823 |accessdate=2008-07-04]

The two classes of antipsychotics are generally thought equally effective for the treatment of the positive symptoms. Some researchers have suggested that the atypicals offer additional benefit for the negative symptoms and cognitive deficits associated with schizophrenia, although the clinical significance of these effects has yet to be established. Recent reviews have refuted the claim that atypical antipsychotics have fewer extrapyramidal side effects than typical antipsychotics, especially when the latter are used in low doses or when low potency antipsychotics are chosen.cite journal |author=Leucht S, Wahlbeck K, Hamann J, Kissling W |title=New generation antipsychotics versus low-potency conventional antipsychotics: a systematic review and meta-analysis |journal=Lancet |volume=361 |issue=9369 |pages=1581–89 |year=2003 |month=May |pmid=12747876 |doi=10.1016/S0140-6736(03)13306-5 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(03)13306-5 |accessdate=2008-07-04]

Response of symptoms to medication is variable; "Treatment-resistant schizophrenia" is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics. [cite journal |author=Meltzer HY |title=Treatment-resistant schizophrenia--the role of clozapine |journal=Current Medical Research and Opinion |volume=14 |issue=1 |pages=1–20 |year=1997 |pmid=9524789] Patients in this category may be prescribed clozapine, [cite journal |author=Wahlbeck K, Cheine MV, Essali A |title=Clozapine versus typical neuroleptic medication for schizophrenia |journal=The Cochrane Database of Systematic Reviews |volume= |issue=2 |pages=CD000059 |publisher=John Wiley and Sons, Ltd. |year=2007 |pmid=10796289 |doi=10.1002/14651858.CD000059 |issn=1464-780X] a medication of superior effectiveness but several potentially lethal side effects including agranulocytosis and myocarditis. [cite journal | author = Haas SJ, Hill R, Krum H | title = Clozapine-associated myocarditis: a review of 116 cases of suspected myocarditis associated with the use of clozapine in Australia during 1993–2003 | journal = Drug Safety | volume = 30 | pages = 47–57 | year = 2007 | pmid=17194170 | doi = 10.2165/00002018-200730010-00005 ] Clozapine may have the additional benefit of reducing propensity for substance abuse in schizophrenic patients. [cite journal |author = Lee M, Dickson RA, Campbell M, Oliphant J, Gretton H, Dalby JT. |title = Clozapine and substance abuse in patients with schizophrenia |journal = Canadian Journal of Psychiatry |volume = 43 |pages = 855–856 |year = 1998 ] For other patients who are unwilling or unable to take medication regularly, long-acting depot preparations of antipsychotics may be given every two weeks to achieve control. The United States of America and Australia are two countries with laws allowing the forced administration of this type of medication on those who refuse but are otherwise stable and living in the community. Some findings have found that in the longer-term some individuals may do better not taking antipsychotics. [cite journal |author=Harrow M, Jobe TH |title=Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study |journal=Journal of Nervous and Mental Disease |volume=195 |issue=5 |pages=406–414 |year=2007 |month=May |pmid=17502806] Despite the promising results of early pilot trials,cite journal |author=Peet M, Brind J, Ramchand CN, Shah S, Vankar GK |title=Two double-blind placebo-controlled pilot studies of eicosapentaenoic acid in the treatment of schizophrenia |journal=Schizophrenia Research |volume=49 |issue=3 |pages=243–51 |year=2001 |pmid=11356585| doi = 10.1016/S0920-9964(00)00083-9] omega-3 fatty acids failed to improve schizophrenic symptoms, according to the most recent meta-analysis.cite journal |author=Freeman MP, Hibbeln JR, Wisner KL, Davis JM, Mischoulon D, Peet M, Keck PE, Marangell LB, Richardson AJ, Lake J, Stoll AL |title=Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry |journal=Journal of Clinical Psychiatry |volume=67 |issue=12 |pages=1954–67 |year=2006 |pmid=17194275 |doi=]

Psychological and social interventions

Psychotherapy is also widely recommended and used in the treatment of schizophrenia, although services may often be confined to pharmacotherapy because of reimbursement problems or lack of training. [Moran, M (2005). [http://pn.psychiatryonline.org/cgi/content/full/40/22/24-b Psychosocial Treatment Often Missing From Schizophrenia Regimens.] "Psychiatr News" November 18, 2005, Volume 40, Number 22, page 24. Retrieved on 2007-05-17.]

Cognitive behavioral therapy (CBT) is used to reduce symptoms and improve related issues such as self-esteem, social functioning, and insight. Although the results of early trials were inconclusive,cite journal |author=Cormac I, Jones C, Campbell C |title=Cognitive behaviour therapy for schizophrenia |journal=Cochrane Database of systematic reviews |volume= |issue=1 |pages=CD000524 |year=2002 |pmid=11869579 |doi=10.1002/14651858.CD000524|accessdate=2008-07-03] more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia.cite journal |author=Zimmermann G, Favrod J, Trieu VH, Pomini V |title=The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis |journal=Schizophrenia Research |volume=77 |issue=1 |pages=1–9 |year=2005 |month=September |pmid=16005380 |doi=10.1016/j.schres.2005.02.018 |url=http://linkinghub.elsevier.com/retrieve/pii/S0920-9964(05)00084-8|accessdate=2008-07-03] Another approach is cognitive remediation therapy, a technique aimed at remediating the neurocognitive deficits sometimes present in schizophrenia. Based on techniques of neuropsychological rehabilitation, early evidence has shown it to be cognitively effective, with some improvements related to measurable changes in brain activation as measured by fMRI.cite journal |author=Wykes T, Brammer M, Mellers J, "et al" |title=Effects on the brain of a psychological treatment: cognitive remediation therapy: functional magnetic resonance imaging in schizophrenia |journal=British Journal of Psychiatry |volume=181 |issue= |pages=144–52 |year=2002 |month=August |pmid=12151286 |url=http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=12151286 |accessdate=2008-07-03 |doi=10.1192/bjp.181.2.144 |doi_brokendate=2008-07-08] A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy. [cite journal |author=Hogarty GE, Flesher S, Ulrich R, "et al" |title=Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior |journal=Arch. Gen. Psychiatry |volume=61 |issue=9 |pages=866–76 |year=2004 |month=September |pmid=15351765 |doi=10.1001/archpsyc.61.9.866 |url=http://archpsyc.ama-assn.org/cgi/pmidlookup?view=long&pmid=15351765|accessdate=2008-07-03]

Family therapy or education, which addresses the whole family system of an individual with a diagnosis of schizophrenia, has been consistently found to be beneficial, at least if the duration of intervention is longer-term. [cite journal |author=McFarlane WR, Dixon L, Lukens E, Lucksted A |title=Family psychoeducation and schizophrenia: a review of the literature |journal=J Marital Fam Ther |volume=29 |issue=2 |pages=223–45 |year=2003 |month=April |pmid=12728780 |doi=10.1111/j.1752-0606.2003.tb01202.x ] [cite journal |author=Glynn SM, Cohen AN, Niv N |title=New challenges in family interventions for schizophrenia |journal=Expert Review of Neurotherapeutics |volume=7 |issue=1 |pages=33–43 |year=2007 |month=January |pmid=17187495 |doi=10.1586/14737175.7.1.33 |url=http://www.future-drugs.com/doi/abs/10.1586/14737175.7.1.33?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dncbi.nlm.nih.gov|accessdate=2008-07-03] [Pharoah F, Mari J, Rathbone J, Wong W. (2006) [http://www.cochrane.org/reviews/en/ab000088.html Family intervention for schizophrenia] Cochrane Database of Systematic Reviews, Issue 4] Aside from therapy, the impact of schizophrenia on families and the burden on carers has been recognized, with the increasing availability of self-help books on the subject. [cite book |author=Jones S, Hayward P |title=Coping with Schizophrenia: A Guide for Patients, Families and Caregivers | publisher = Oneworld Pub. | year = 2004 | location = Oxford, England |isbn=1-85168-344-5] [cite book |author=Torrey EF |title=Surviving Schizophrenia: A Manual for Families, Consumers, and Providers |edition=5th Edition |publisher=HarperCollins |year=2006 | isbn=0-06-084259-8] There is also some evidence for benefits from social skills training, although there have also been significant negative findings. [cite journal |author=Kopelowicz A, Liberman RP, Zarate R |title=Recent advances in social skills training for schizophrenia |journal=Schizophrenia Bulletin |volume=32 Suppl 1 |issue= |pages=S12–23 |year=2006 |month=October |pmid=16885207 |doi=10.1093/schbul/sbl023 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16885207|accessdate=2008-07-03] [American Psychiatric Association (2004) Practice Guideline for the Treatment of Patients With Schizophrenia. Second Edition.] Some studies have explored the possible benefits of music therapy and other creative therapies. [cite journal |author=Talwar N, Crawford MJ, Maratos A, Nur U, McDermott O, Procter S |title=Music therapy for in-patients with schizophrenia: exploratory randomised controlled trial |journal=The British Journal of Psychiatry |volume=189 |issue= |pages=405–9 |year=2006 |month=November |pmid=17077429 |doi=10.1192/bjp.bp.105.015073 |url=http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=17077429|accessdate=2008-07-03] [Ruddy R, Milnes D. (2005) [http://www.cochrane.org/reviews/en/ab000088.html Art therapy for schizophrenia or schizophrenia-like illnesses.] Cochrane Database of Systematic Reviews, Issue 4] [Ruddy RA, Dent-Brown K. (2007) [http://www.cochrane.org/reviews/en/ab005378.html Drama therapy for schizophrenia or schizophrenia-like illnesses.] Cochrane Database of Systematic Reviews, Issue 1.]

The Soteria model is alternative to inpatient hospital treatment using a minimal medication approach. It is described as a milieu-therapeutic recovery method, characterized by its founder as "the 24 hour a day application of interpersonal phenomenologic interventions by a nonprofessional staff, usually without neuroleptic drug treatment, in the context of a small, homelike, quiet, supportive, protective, and tolerant social environment."cite journal |author=Mosher LR |title=Soteria and other alternatives to acute psychiatric hospitalization: a personal and professional review |journal=Journal of Nervous and Mental Disease |volume=187 |issue=3 |pages=142–9 |year=1999 |month=March |pmid=10086470 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0022-3018&volume=187&issue=3&spage=142 |issn= |accessdate=2008-07-03 |doi=10.1097/00005053-199903000-00003] Although research evidence is limited, a 2008 systematic review found the programme equally as effective as treatment with medication in people diagnosed with first and second episode schizophrenia.cite journal |author=Calton T, Ferriter M, Huband N, Spandler H |title=A systematic review of the Soteria paradigm for the treatment of people diagnosed with schizophrenia |journal=Schizophrenia Bulletin |volume=34 |issue=1 |pages=181–92 |year=2008 |month=January |pmid=17573357 |doi=10.1093/schbul/sbm047 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17573357|accessdate=2008-07-03]

Other

Electroconvulsive therapy is not considered a first line treatment but may be prescribed in cases where other treatments have failed. It is more effective where symptoms of catatonia are present, [cite journal |author=Greenhalgh J, Knight C, Hind D, Beverley C, Walters S |year=2005 |month=March |title= Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies|journal= Health Technol Assess.|volume= 9|issue=9 |pages=1–156 |url=http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15774232 (abstract) |accessdate= 2007-06-17] and is recommended for use under NICE guidelines in the UK for catatonia if previously effective, though there is no recommendation for use for schizophrenia otherwise. [cite web |url=http://www.nice.org.uk/page.aspx?o=TA059 |title= The clinical effectiveness and cost effectiveness of electroconvulsive Therapy (ECT) for depressive illness, schizophrenia, catatonia and mania.|accessdate=2007-06-17 |year= 2003|month=April |publisher= National Institute for Health and Clinical Excellence] Psychosurgery has now become a rare procedure and is not a recommended treatment.cite journal |author=Mashour GA, Walker EE, Martuza RL |title=Psychosurgery: past, present, and future |journal=Brain Res. Brain Res. Rev. |volume=48 |issue=3 |pages=409–19 |year=2005 |month=June |pmid=15914249 |doi=10.1016/j.brainresrev.2004.09.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S0165-0173(04)00129-8 |accessdate=2008-07-04]

Service-user led movements have become integral to the recovery process in Europe and the United States; groups such as the Hearing Voices Network and the Paranoia Network have developed a self-help approach that aims to provide support and assistance outside the traditional medical model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of criteria for mental illness or mental health, they aim to destigmatize the experience and encourage individual responsibility and a positive self-image. Partnerships between hospitals and consumer-run groups are becoming more common, with services working toward remediating social withdrawal, building social skills and reducing rehospitalization. [cite journal |author=Goering P, Durbin J, Sheldon CT, Ochocka J, Nelson G, Krupa T |title=Who uses consumer-run self-help organizations? |journal=American Journal of Orthopsychiatry |volume=76 |issue=3 |pages=367–73 |year=2006 |month=July |pmid=16981815 |doi=10.1037/0002-9432.76.3.367 |url=http://content.apa.org/journals/ort/76/3/367 |accessdate=2008-07-04]

Prognosis

Course

Coordinated by the World Health Organization and published in 2001, The International Study of Schizophrenia (ISoS) was a long-term follow-up study of 1633 individuals diagnosed with schizophrenia around the world. The striking difference in course and outcomes was noted; a half of those available for follow-up had a favourable outcome and 16% had a delayed recovery after an early unremitting course. More usually, the course in the first two years predicted the long-term course. Early social intervention was also related to a better outcome. The findings were held as important in moving patients, carers and clinicians away from the prevalent belief of the chronic nature of the condition.cite journal |author=Harrison G, Hopper K, Craig T, "et al" |title=Recovery from psychotic illness: a 15- and 25-year international follow-up study |journal=British Journal of Psychiatry |volume=178 |issue= |pages=506–17 |year=2001 |month=June |pmid=11388966 |url=http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=11388966 |accessdate=2008-07-04 |doi=10.1192/bjp.178.6.506] A review of major longitudinal studies in North America also noted this large variation in outcomes, although outcome was on average worse than for other psychotic and psychiatric disorders. A moderate number of patients with schizophrenia were seen to remit and remain well; the review raised the question that some may not require maintenance medication.cite journal |author=Jobe TH, Harrow M |title=Long-term outcome of patients with schizophrenia: a review |journal=Canadian Journal of Psychiatry |volume=50 |issue=14 |pages=892–900 |year=2005 |month=December |pmid=16494258 |url=http://ww1.cpa-apc.org:8080/Publications/Archives/CJP/2005/december/cjp-dec-05-Harrow-IR.pdf|format=PDF |accessdate=2008-07-05]

A clinical study using strict recovery criteria (concurrent remission of positive and negative symptoms and adequate social and vocational functioning continuously for two years) found a recovery rate of 14% within the first five years.cite journal |author=Robinson DG, Woerner MG, McMeniman M, Mendelowitz A, Bilder RM |title=Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder |journal=American Journal of Psychiatry |volume=161 |issue=3 |pages=473–9 |year=2004 |month=March |pmid=14992973 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=14992973 |accessdate=2008-07-04 |doi=10.1176/appi.ajp.161.3.473] A 5-year community study found that 62% showed overall improvement on a composite measure of clinical and functional outcomes. [cite journal |author=Harvey CA, Jeffreys SE, McNaught AS, Blizard RA, King MB |year=2007 |month= |title=The Camden Schizophrenia Surveys III: Five-Year Outcome of a Sample of Individuals From a Prevalence Survey and the Importance of Social Relationships |journal=International Journal of Social Psychiatry |volume=53 |issue=4 |pages=340–356 |url=http://isp.sagepub.com/cgi/content/abstract/53/4/340 |accessdate=2008-07-04 |doi=10.1177/0020764006074529]

World Health Organization studies have noted that individuals diagnosed with schizophrenia have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (USA, UK, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia),cite journal |author=Hopper K, Wanderling J |title=Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia |journal=Schizophrenia Bulletin |volume=26 |issue=4 |pages=835–46 |year=2000 |pmid=11087016 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=11087016 |accessdate=2008-07-04] despite antipsychotic drugs not being widely available.

Defining recovery

Rates are not always comparable across studies because exact definitions of remission and recovery have not been widely established. A "Remission in Schizophrenia Working Group" has proposed standardized "remission" criteria involving "improvements in core signs and symptoms to the extent that any remaining symptoms are of such low intensity that they no longer interfere significantly with behavior and are below the threshold typically utilized in justifying an initial diagnosis of schizophrenia." [cite journal |author=Andreasen NC, Carpenter WT, Kane JM, Lasser RA, Marder SR, Weinberger DR |title=Remission in schizophrenia: proposed criteria and rationale for consensus |journal=The American Journal of Psychiatry |volume=162 |issue=3 |pages=441–9 |year=2005 |month=March |pmid=15741458 |doi=10.1176/appi.ajp.162.3.441 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=15741458 |accessdate=2008-07-07] Standardized "recovery" criteria have also been proposed by a number of different researchers, with the stated DSM definitions of a "complete return to premorbid levels of functioning” or "complete return to full functioning" seen as inadequate, impossible to measure, incompatible with the variability in how society defines normal psychosocial functioning, and contributing to self-fulfilling pessimism and stigma. [cite journal |author=Liberman RP, Kopelowicz A|year=2005 |month=June |title=Recovery From Schizophrenia: A Concept in Search of Research |journal=Psychiatric Services |volume=56 |issue=6 |pages=735–742 |url=http://psychservices.psychiatryonline.org/cgi/content/full/56/6/735 |accessdate=2008-07-07 |doi=10.1176/appi.ps.56.6.735 |pmid=15939952] Some mental health professionals may have quite different basic perceptions and concepts of recovery than individuals with the diagnosis, including those in the consumer/survivor movement. [cite journal |author=Davidson L, Schmutte T, Dinzeo T, Andres-Hyman R |title=Remission and recovery in schizophrenia: practitioner and patient perspectives |journal=Schizophrenia Bulletin |volume=34 |issue=1 |pages=5–8 |year=2008 |month=January |pmid=17984297 |doi=10.1093/schbul/sbm122 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17984297 |accessdate=2008-07-07] One notable limitation of nearly all the research criteria is failure to address the person's own evaluations and feelings about their life. Schizophrenia and recovery often involve a continuing loss of self-esteem, alienation from friends and family, interruption of school and career, and social stigma, "experiences that cannot just be reversed or forgotten." An increasingly influential model defines recovery as a process, similar to being "in recovery" from drug and alcohol problems, and emphasizes a personal journey involving factors such as hope, choice, empowerment, social inclusion and achievement.

Predictors

Several factors have been associated with a better overall prognosis: Being female, rapid (vs. insidious) onset of symptoms, older age of first episode, predominantly positive (rather than negative) symptoms, presence of mood symptoms, and good pre-illness functioning.cite journal |author=Davidson L, McGlashan TH |title=The varied outcomes of schizophrenia |journal=Canadian Journal of Psychiatry |volume=42 |issue=1 |pages=34–43 |year=1997 |month=February |pmid=9040921 ] cite journal |author=Lieberman JA, Koreen AR, Chakos M, "et al" |title=Factors influencing treatment response and outcome of first-episode schizophrenia: implications for understanding the pathophysiology of schizophrenia |journal=Journal of Clinical Psychiatry |volume=57 Suppl 9 |issue= |pages=5–9 |year=1996 |pmid=8823344] The strengths and internal resources of the individual concerned, such as determination or psychological resilience, have also been associated with better prognosis. The attitude and level of support from people in the individual's life can have a significant impact; research framed in terms of the negative aspects of this—the level of critical comments, hostility, and intrusive or controlling attitudes, termed high 'Expressed emotion'—has consistently indicated links to relapse.cite journal |author=Bebbington P, Kuipers L |title=The predictive utility of expressed emotion in schizophrenia: an aggregate analysis |journal=Psychological Medicine |volume=24 |issue=3 |pages=707–18 |year=1994 |month=August |pmid=7991753] Most research on predictive factors is correlational in nature, however, and a clear cause-and-effect relationship is often difficult to establish.

Mortality

In a study of over 168,000 Swedish citizens undergoing psychiatric treatment, schizophrenia was associated with an average life expectancy of approximately 80–85% of that of the general population; women were found to have a slightly better life expectancy than men, and a diagnosis of schizophrenia was associated with an overall better life expectancy than substance abuse, personality disorder, heart attack and stroke.cite journal |author=Hannerz H, Borgå P, Borritz M |title=Life expectancies for individuals with psychiatric diagnoses |journal=Public Health |volume=115 |issue=5 |pages=328–37 |year=2001 |month=September |pmid=11593442 |doi=10.1038/sj.ph.1900785 ] Other identified factors include smoking, poor diet, little exercise and the negative health effects of psychiatric drugs.

There is a higher than average suicide rate associated with schizophrenia. This has been cited at 10%, but a more recent analysis of studies and statistics revises the estimate at 4.9%, most often occurring in the period following onset or first hospital admission. [Palmer BA, Pankratz VS, Bostwick JM. (2005) The lifetime risk of suicide in schizophrenia: a reexamination. Archives of General Psychiatry. 2005 Mar;62(3):247-53. PMID 15753237] Several times more attempt suicide.cite journal |author=Radomsky ED, Haas GL, Mann JJ, Sweeney JA |title=Suicidal behavior in patients with schizophrenia and other psychotic disorders |journal=American Journal of Psychiatry |volume=156 |issue=10 |pages=1590–5 |year=1999 |month=October |pmid=10518171 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=10518171 |accessdate=2008-07-04] There are a variety of reasons and risk factors.cite journal |author=Caldwell CB, Gottesman II |title=Schizophrenics kill themselves too: a review of risk factors for suicide |journal=Schizophr Bull |volume=16 |issue=4 |pages=571–89 |year=1990 |pmid=2077636] cite book |author=Dalby JT, Williams RJ |title=Depression in schizophrenics |publisher=Plenum Press |location=New York |year=1989 |isbn=0-306-43240-4]

Violence

The occurrence of psychosis in schizophrenia has sometimes been linked to a higher risk of violent acts. Findings on the specific role of delusions or hallucinations have been inconsistent, but have focused on delusional jealousy, perception of threat and command hallucinations. It has been proposed that a certain type of individual with schizophrenia may be most likely to offend, characterized by a history of educational difficulties, low IQ, conduct disorder, early-onset substance misuse and offending prior to diagnosis.

creening and prevention

There are no reliable markers for the later development of schizophrenia although research is being conducted into how well a combination of genetic risk plus non-disabling psychosis-like experience predicts later diagnosis.cite journal |author=Cannon TD, Cornblatt B, McGorry P |title=The empirical status of the ultra high-risk (prodromal) research paradigm |journal=Schizophrenia Bulletin |volume=33 |issue=3 |pages=661–4 |year=2007 |month=May |pmid=17470445 |doi=10.1093/schbul/sbm031 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17470445 |accessdate=2008-07-06] People who fulfill the 'ultra high-risk mental state' criteria, that include a family history of schizophrenia plus the presence of transient or self-limiting psychotic experiences, have a 20–40% chance of being diagnosed with the condition after one year.cite journal |author=Drake RJ, Lewis SW |title=Early detection of schizophrenia |journal=Current Opinion in Psychiatry |volume=18 |issue=2 |pages=147–50 |year=2005 |month=March |pmid=16639167|url=http://www.co-psychiatry.com/pt/re/copsych/abstract.00001504-200503000-00007.htm |accessdate=2008-07-06 |doi=10.1097/00001504-200503000-00007] The use of psychological treatments and medication has been found effective in reducing the chances of people who fulfill the 'high-risk' criteria from developing full-blown schizophrenia.cite journal |author=Van Os J, Delespaul P |title=Toward a world consensus on prevention of schizophrenia |journal=Dialogues Clin Neurosci |volume=7 |issue=1 |pages=53–67 |year=2005 |pmid=16060596] However, the treatment of people who may never develop schizophrenia is controversial, in light of the side-effects of antipsychotic medication; particularly with respect to the potentially disfiguring tardive dyskinesia and the rare but potentially lethal neuroleptic malignant syndrome.cite journal |author=Haroun N, Dunn L, Haroun A, Cadenhead KS |title=Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research |journal=Schizophrenia Bulletin |volume=32 |issue=1 |pages=166–78 |year=2006 |month=January |pmid=16207892 |doi=10.1093/schbul/sbj007 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16207892 |accessdate=2008-07-06] The most widely used form of preventative health care for schizophrenia takes the form of public education campaigns that provide information on risk factors, early detection and treatment options.cite journal |author=Häfner H, Maurer K, Ruhrmann S, "et al" |title=Early detection and secondary prevention of psychosis: facts and visions |journal=European Archives of Psychiatry and Clinical Neuroscience |volume=254 |issue=2 |pages=117–28 |year=2004 |month=April |pmid=15146341 |doi=10.1007/s00406-004-0508-z |accessdate=2008-07-06]

Alternative approaches

An approach broadly known as the anti-psychiatry movement, most active in the 1960s, opposes the orthodox medical view of schizophrenia as an illness.cite book |author=Cooper, David A. |title=The Dialectics of Liberation (Pelican) |publisher=Penguin Books Ltd |location=London, England |year=1969 |isbn=0-14-021029-6] Psychiatrist Thomas Szasz argued that psychiatric patients are not ill, but rather individuals with unconventional thoughts and behavior that make society uncomfortable.cite book |author=Szasz, Thomas Stephen |title=The myth of mental illness: foundations of a theory of personal conduct |publisher=Harper & Row |location=San Francisco |year=1974|isbn=0-06-091151-4] He argues that society unjustly seeks to control them by classifying their behavior as an illness and forcibly treating them as a method of social control. According to this view, "schizophrenia" does not actually exist but is merely a form of social construction, created by society's concept of what constitutes normality and abnormality. Szasz has never considered himself to be "anti-psychiatry" in the sense of being against psychiatric treatment, but simply believes that treatment should be conducted between consenting adults, rather than imposed upon anyone against his or her will. Similarly, psychiatrists R. D. Laing, Silvano Arieti, Theodore Lidz and others have argued that the symptoms of what is called mental illness are comprehensible reactions to impossible demands that society and particularly family life places on some sensitive individuals. Laing, Arieti and Lidz were notable in valuing the "content" of psychotic experience as worthy of interpretation, rather than considering it simply as a secondary and essentially meaningless marker of underlying psychological or neurological distress. Laing described eleven case studies of people diagnosed with schizophrenia and argued that the content of their actions and statements was meaningful and logical in the context of their family and life situations. [R.D. Laing's and Aaron Esterson. "Sanity, Madness and the Family" (1964)] In 1956, Palo Alto, Gregory Bateson and his colleagues Paul Watzlawick, Donald Jackson, and Jay Haley [cite journal |author=Bateson G, Jackson DD, Haley J, Weakland JH|year=1956 |title=Toward a theory of schizophrenia |journal=Behavioral Science |volume=1 |pages=251–264] articulated a theory of schizophrenia, related to Laing's work, as stemming from double bind situations where a person receives different or contradictory messages. Madness was therefore an expression of this distress and should be valued as a cathartic and transformative experience. In the books "Schizophrenia and the Family" and "The Origin and Treatment of Schizophrenic Disorders" Lidz and his colleagues explain their belief that parental behaviour can result in mental illness in children. Arieti's "Interpretation of Schizophrenia" won the 1975 scientific National Book Award in the United States.

The concept of schizophrenia as a result of civilization has been developed further by psychologist Julian Jaynes in his 1976 book "The Origin of Consciousness in the Breakdown of the Bicameral Mind"; he proposed that until the beginning of historic times, schizophrenia or a similar condition was the normal state of human consciousness.cite book |author =Jaynes J |title=The origin of consciousness in the breakdown of the bicameral mind |publisher=Houghton Mifflin |location=Boston |year=1976 |isbn=0-395-20729-0] This would take the form of a "bicameral mind" where a normal state of low affect, suitable for routine activities, would be interrupted in moments of crisis by "mysterious voices" giving instructions, which early people characterized as interventions from the gods. Researchers into shamanism have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman;cite journal |author=Polimeni J, Reiss JP |title=How shamanism and group selection may reveal the origins of schizophrenia |journal=Med. Hypotheses |volume=58 |issue=3 |pages=244–8 |year=2002 |month=March |pmid=12018978 |doi=10.1054/mehy.2001.1504 |url=http://linkinghub.elsevier.com/retrieve/pii/S030698770191504X |accessdate=2008-07-07] the experience of having access to multiple realities is not uncommon in schizophrenia, and is a core experience in many shamanic traditions. Equally, the shaman may have the skill to bring on and direct some of the altered states of consciousness psychiatrists label as illness. Psychohistorians, on the other hand, accept the psychiatric diagnoses. However, unlike the current medical model of mental disorders they may argue that poor parenting in tribal societies causes the shaman's schizoid personalities. [cite book |author=DeMause L|title=Emotional Life of Nations |publisher=Other Press (NY) |location= |year=2002 |isbn=1-892746-98-0 |chapter=The seven stages of historical personality |chapterurl=http://primal-page.com/ps2.htm |accessdate=2008-07-07] Commentators such as Paul Kurtz and others have endorsed the idea that major religious figures experienced psychosis, heard voices and displayed delusions of grandeur. [cite book |author=Kurtz P |title=The transcendental temptation: a critique of religion and the paranormal |publisher=Prometheus Books |location=Buffalo, N.Y |year=1991 |isbn=0-87975-645-4]

Alternative medical treatments

History

Accounts of a schizophrenia-like syndrome are thought to be rare in the historical record prior to the 1800s, although reports of irrational, unintelligible, or uncontrolled behavior were common.cite journal |author=Heinrichs RW |title=Historical origins of schizophrenia: two early madmen and their illness |journal=J Hist Behav Sci |volume=39 |issue=4 |pages=349–63 |year=2003 |pmid=14601041 |doi=10.1002/jhbs.10152] There has been an interpretation that brief notes in the Ancient Egyptian Ebers papyrus may imply schizophrenia, [Okasha, A., Okasha, T. (2000) [http://hpy.sagepub.com/cgi/content/refs/11/44/413 Notes on mental disorders in Pharaonic Egypt] History of Psychiatry, 11: 413-424] but other reviews have not suggested any connection. [Nasser, M. (1987) [http://pb.rcpsych.org/cgi/reprint/11/12/420.pdf Psychiatry in Ancient Egypt] Bulletin Of The Royal College Of Psychiatrists, Vol 11, December.] A review of ancient Greek and Roman literature indicated that although psychosis was described, there was no account of a condition meeting the criteria for schizophrenia.cite journal |author=Higgins ES, Kose S |title=Absence of schizophrenia in a 15th-century Islamic medical textbook |journal=Am J Psychiatry |volume=164 |issue=7 |pages=1120; author reply 1120–1 |year=2007 |month=July |pmid=17606667 |doi=10.1176/appi.ajp.164.7.1120 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=17606667] Given limited historical evidence, schizophrenia (as prevalent as it is today) may be a modern phenomenon, or alternatively it may have been obscured in historical writings by related concepts such as melancholia or mania.

A detailed case report in 1797 concerning James Tilly Matthews, and accounts by Phillipe Pinel published in 1809, are often regarded as the earliest cases of schizophrenia in the medical and psychiatric literature. 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 to in a case report of a psychotic disorder. In 1893 Emil Kraepelin introduced a broad 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,Kraepelin E. (1907) "Text book of psychiatry (7th ed)" (trans. A.R. Diefendorf). London: Macmillan.] and particularly a form of dementia, distinguished from other forms of dementia, such as Alzheimer's disease, which typically occur later in life.cite book |author=Hansen RA, Atchison B |title=Conditions in occupational therapy: effect on occupational performance |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2000 |isbn=0-683-30417-8] Kraepelin's classification slowly gained acceptance. There were objections to the use of the term "dementia" despite cases of recovery, and some defence of diagnoses it replaced such as adolescent insanity. [McConaghey, J.C. (1905) [http://bjp.rcpsych.org/cgi/content/citation/51/213/340 Adolescent Insanity: A Protest against the Use of the Term "Dementia Præcox"] Journal of Mental Science (1905) 51: 340-348.]

The word "schizophrenia"—which translates roughly as "splitting of the mind" and comes from the Greek roots "schizein" (σχίζειν, "to split") and "phrēn", "phren-" (φρήν, φρεν-, "mind") [cite journal |author=Kuhn R; tr. Cahn CH |title=Eugen Bleuler's concepts of psychopathology |journal=Hist Psychiatry |volume=15 |issue=3 |year=2004 |pages=361–6 |doi=10.1177/0957154X04044603 |pmid=15386868] —was coined by Eugen Bleuler in 1908 and was intended to describe the separation of function between personality, thinking, memory, and perception. Bleuler described the main symptoms as 4 "A"'s: flattened "Affect", "Autism", impaired "Association" of ideas and "Ambivalence".cite journal |author=Stotz-Ingenlath G |title=Epistemological aspects of Eugen Bleuler's conception of schizophrenia in 1911 |journal=Medicine, Health Care and Philosophy |volume=3 |issue=2 |pages=153–9 |year=2000 |pmid=11079343|url=http://www.kluweronline.com/art.pdf?issn=1386-7423&volume=3&page=153|format=PDF |accessdate=2008-07-03 |doi=10.1023/A:1009919309015] Bleuler realized that the illness was not a dementia as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead.

The term "schizophrenia" is commonly misunderstood to mean that affected persons have a "split personality". Although some people diagnosed with schizophrenia may hear voices and may experience the voices as distinct personalities, schizophrenia does not involve a person changing among distinct multiple personalities. The confusion arises in part due to the meaning of Bleuler's term "schizophrenia" (literally "split" or "shattered mind"). The first known misuse of the term to mean "split personality" was in an article by the poet T. S. Eliot in 1933.cite book |author=Porter, Roy; Berrios, G. E. |title=A history of clinical psychiatry: the origin and history of psychiatric disorders |publisher=Athlone Press |location=London |year=1995 |pages= |isbn=0-485-24211-7]

In the first half of the twentieth century schizophrenia was considered to be a hereditary defect, and sufferers were subject to eugenics in many countries. Hundreds of thousands were sterilized, with or without consent—the majority in Nazi Germany, the United States, and Scandinavian countries.cite journal |author=Allen GE |title=The social and economic origins of genetic determinism: a case history of the American Eugenics Movement, 1900-1940 and its lessons for today |journal=Genetica |volume=99 |issue=2-3 |pages=77–88 |year=1997 |pmid=9463076 |url=http://www.kluweronline.com/art.pdf?issn=0016-6707&volume=99&page=77 |format=PDF|accessdate=2008-07-03 |doi=10.1007/BF02259511] cite book |author=Bentall RP, Read JE, Mosher LR |title=Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia |publisher=Brunner-Routledge |location=Philadelphia |year=2004 |isbn=1-58391-906-6] Along with other people labeled "mentally unfit", many diagnosed with schizophrenia were murdered in the Nazi "Action T4" program.cite book |author=Lifton, Robert Jay |title=The Nazi doctors: medical killing and the psychology of genocide |publisher=Basic Books |location=New York |year=1986 |isbn=0-465-04905-2]

The diagnostic description of schizophrenia has changed over time. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe.cite journal |author=Wing JK |title=International comparisons in the study of the functional psychoses |journal=British Medical Bulletin |volume=27 |issue=1 |pages=77–81 |year=1971 |month=January |pmid=4926366] This was partly due to looser diagnostic criteria in the US, which used the DSM-II manual, contrasting with Europe and its ICD-9. This was one of the factors in leading to the revision not only of the diagnosis of schizophrenia, but the revision of the whole DSM manual, resulting in the publication of the DSM-III.cite journal |author=Wilson M |title=DSM-III and the transformation of American psychiatry: a history |journal=American Journal of Psychiatry |volume=150 |issue=3 |pages=399–410 |year=1993 |month=March |pmid=8434655 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=8434655 |accessdate=2008-07-03]

ociety and culture

Social stigma has been identified as a major obstacle in the recovery of patients with schizophrenia. [McGorry, Patrick (2003). "The Influence of Stigma on Preventive Efforts in Psychotic Disorders," in "Schizophrenia (WPA Series in Evidence & Experience in Psychiatry)", p. 292.] In a large, representative sample from a 1999 study, 12.8% of Americans believed that individuals with schizophrenia were "very likely" to do something violent against others, and 48.1% said that they were "somewhat likely" to. Over 74% said that people with schizophrenia were either "not very able" or "not able at all" to make decisions concerning their treatment, and 70.2% said the same of money management decisions. [cite journal |author=Pescosolido BA, Monahan J, Link BG, Stueve A, Kikuzawa S |title=The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems |journal=Am J Public Health |volume=89 |issue=9 |pages=1339–45 |year=1999 |month=September |pmid=10474550 |pmc=1508769 |doi= |url=http://www.ajph.org/cgi/pmidlookup?view=long&pmid=10474550 |accessdate=2008-07-03] The perception of individuals with psychosis as violent has more than doubled in prevalence since the 1950s, according to one meta-analysis. [cite journal |author=Phelan JC, Link BG, Stueve A, Pescosolido BA|year=2000 |month=June |title=Public Conceptions of Mental Illness in 1950 and 1996: What Is Mental Illness and Is It to be Feared? |journal=Journal of Health and Social Behavior |volume=41 |issue=2 |pages=188–207 |doi=10.2307/2676305]

The book and film "A Beautiful Mind" chronicled the life of John Forbes Nash, a Nobel Prize-winning mathematician who was diagnosed with schizophrenia. The Marathi film "Devrai" (featuring Atul Kulkarni) is a presentation of a patient with schizophrenia. The film, set in the Konkan region of Maharashtra in Western India, shows the behavior, mentality, and struggle of the patient as well as his loved-ones. It also portrays the treatment of this mental illness using medication, dedication and plenty of patience by the close relatives of the patient. Other factual books have been written by relatives on family members; Australian journalist Anne Deveson told the story of her son's battle with schizophrenia in "Tell me I'm Here", [cite book |author=Deveson A |title=Tell Me I'm Here |publisher=Penguin |year=1991 |pages= |isbn=0-14-027257-7] later made into a movie.

In Bulgakov's "The Master and Margarita" the poet Ivan Bezdomnyj is institutionalized and diagnosed with schizophrenia after witnessing the devil (Woland) predict Berlioz's death. The book "The Eden Express" by Mark Vonnegut recounts his struggle with schizophrenia and his recovering journey.

References

Further reading

External links

;News, information and further description
* [http://www.npr.org/programs/atc/features/2002/aug/schizophrenia/ NPR: the sight and sounds of schizophrenia]
* [http://www.who.int/mental_health/management/schizophrenia/en/ The current World Health Organisation definition of Schizophrenia]
* [http://www.archive.org/details/Symptoms1940 Symptoms in Schizophrenia] Film made in 1940 showing some of the symptoms of Schizophrenia.
* [http://www.wcr.ab.ca/news/2006/1127/mental112706.shtml Schizophrenics call to Church for understanding, Western Catholic Reporter]
* [http://www.world-schizophrenia.org World Fellowship for Schizophrenia and Allied Disorders] - 'Information for families caring for people with mental illness';Critical approaches to schizophrenia
* Leo, Jonathan Ph.D., & Jay Joseph, Psy. D. [http://www.icspp.org/index.php?option=com_content&task=view&id=128&Itemid=72 Schizophrenia: Medical students are taught it's all in the genes, but are they hearing the whole story?]

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schizophrenia — (n.) 1912, from Modern Latin, lit. a splitting of the mind, from Ger. Schizophrenie, coined in 1910 by Swiss psychiatrist Eugen Bleuler (1857 1939), from Gk. skhizein to split (see SHED (Cf. shed) (v.)) + phren (gen. phrenos) diaphragm, heart,… … Etymology dictionary
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schizophrenia — [skit΄sə frē′nē ə, skiz΄əfrē′nē ə; skit΄se fren′ē ə, skiz΄əfren′ē ə] n. [ModL < SCHIZO + Gr phrēn, the mind + IA] 1. a major mental disorder of unknown cause typically characterized by a separation between the thought processes and the… … English World dictionary
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