What is schizophrenia?

By Alan Koenigsberg, M.D.

I’ve been asked to write about anxiety disorders, depressive disorders, alcohol and opioid conditions and now schizophrenia. This disease is somewhat different than the others in several distinct ways.

While the prevalence of schizophrenia is much lower than other psychiatric disorders, about 1% as opposed to 10%, the disability caused by this condition is usually far more debilitating.

When I was in training in the 1980s, half of the hospital beds in the country were occupied by people with schizophrenia, because most of them would be hospitalized for years or decades. The percentage is much lower now, given that many state hospitals and other long-term facilities have been shuttered for people with this illness.

Schizophrenia is a lifelong illness that usually is diagnosed when people are in their late teens or early 20s. The most common symptoms fall within three main groups: psychotic, which are disorders of thinking; negative symptoms, which are disorders of feeling; and disorders of behavior.

Psychotic symptoms: These include hallucinations, which are perceptions of any of the five senses which do not exist externally. In other words, the person may see things which are not there; hear things which are not there; smell, taste or feel things which are not externally present.

A person may have a conversation with someone who is not present or taste poison in a medication. This is a distortion of perception.

Delusions are psychotic symptoms which are distortions of processing information. An example is a person believing, in spite of clear evidence to the contrary, that a television person is talking to them or sending special messages to them. Paranoid delusions, believing that people are out to hurt them, are common.

Thought disorders, in which a person demonstrates clearly illogical or irrational thinking, are another psychotic symptom. They may have difficulty having rational conversations or maintaining coherent sentences. They may have concrete thinking, which is a lack of the ability to abstract. Humorous understanding can be difficult or impossible.

Negative symptoms: These symptoms include lack of joy and pleasure, minimal spontaneous speech, poor attention and concentration, poor memory, difficulty following other people’s conversations, lack of motivation, difficulty planning and executing routine daily activities, such as shopping for food. A generally pervasive, low level of energy is common.

Behavioral symptoms: These include a variety of absence of “normal” expressions, such as a flat affect or lack of emotion, dull voice, limited facial expressions, avoiding social interactions, having minimal social contacts and conversations. Some patients will talk to themselves or have odd or puzzling movements. Violent behavior, contrary to popular opinion, is rare in this illness.

Causes: Frustratingly, we don’t have a solid understanding of what causes schizophrenia. There are clear genetic influences, but no clear genes and no clear degree of prediction. There are known environmental factors, such as infections during pregnancy or other pregnancy complications, drug use and so on, but again, no clear set of causes.

To diagnose this condition, a detailed family history is taken along with a detailed evaluation of the patient’s symptoms. Blood tests and brain scans may be done to rule out other illnesses, but currently, there are no tests or scans to diagnose this illness.

Treatments: The treatments for schizophrenia are medications to reduce the psychotic symptoms, along with various forms of supportive psychotherapy, as well as substantial social support. The person may need to live in some kind of assisted-living environment. 

Current research suggests that monthly injectable forms of antipsychotic medications, when initiated early in treatment, produce better and longer-lasting benefits than daily oral medications, which many patients stop taking and relapse.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas. He can be reached at akoenigsberg@mac.com.

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