Schizophrenia is a heterogeneous disorder that can be characterized by any of the following symptoms: intellectual deterioration, emotional blunting, disorganized speech, disorganized behavior, social isolation, delusions, and/or hallucinations.
Schizophrenia is not a disorder of multiple personalities, as it is often depicted in popular media (that disorder is dissociative identity disorder). Instead, the term means “split mind,” and it was coined by the psychiatrist Eugen Bleuler. This was depicted by Bleuler as a splitting of cognition from personality.
A Severe Mental Health Disorder
The American Psychiatric Association revamped its conceptualization of schizophrenia in 2013 to discontinue the long-standing use of the five major subtypes of schizophrenia. The current conceptualization of schizophrenia regards it as a singular disorder that presents with different symptoms as opposed to five different but related types of the same disorder. Currently, one would be diagnosed with schizophrenia if two or more of the following symptoms were present for a significant length of time:
- Hallucinations: These are distortions of the senses that include seeing or hearing things that are not actually present. The most common hallucinations occurring in people diagnosed with schizophrenia are auditory hallucinations. Most often, the individual hears voices that are not really there. However, the individual can experience other types of hallucinations, such as visual or tactile hallucinations.
- Delusions: Delusions are very fixed beliefs that are simply not true. The most common delusion in people with schizophrenia is the delusional of persecution, formally most often identified with what was called paranoid schizophrenia. However, delusions can be fixed beliefs that cover any domain, including religious-based delusions (e.g., the person believes himself/herself to be Jesus or some other religious figure), grandiose delusions, the illusions of reference (e.g., that most of the events that occur in the world are directly targeted at or directly relevant to the person), etc.
- Disorganized speech: This category consists of a number of speech-related issues, such as being incoherent, tangential (going off in all directions), frequent derailments, etc.
- Disorganized behavior or catatonic behavior: Disorganized behavior occurs when an individual’s actions have no goal or end function. Catatonic behavior consists of spending long periods of time either in a frozen position or repetitively performing a particular movement.
- Negative symptoms: These symptoms are considered to be extremely serious symptoms that reflect serious brain damage. These often are deficiencies of behavior, such as a lack of thoughts, a lack of emotional expression, a lack of motivation, a lack of speech, etc.
In order for a person to be a diagnosed with schizophrenia, the person must exhibit at least two of the above five symptoms for at least a six-month period.
At least one of those symptoms must be hallucinations, delusions, or disorganized speech. The individual must also have a significant period of time since the onset of the symptoms where serious functional issues are present as a result. These can include problems or issues at work, school, issues with interpersonal relationships, etc. There must also be no evidence that the symptoms and issues with functioning are not better explained by some other mental health disorder, the use of drugs or medications, or some other medical condition.
As mentioned above, the disorder is a heterogeneous disorder, indicating that individuals with the disorder may display markedly different presentations. This heterogeneity is even further complicated by the American Psychiatric Association’s dropping the long-standing approach to schizophrenia that identified five specific subtypes of schizophrenia (e.g., paranoid schizophrenia, disorganized schizophrenia, etc.). A good deal of the confusion stems from the fact that most individuals with schizophrenia will display some aspect of both the positive symptoms in schizophrenia (excesses of behavior, such as hallucinations and delusions) and the negative symptoms of behavior (deficiencies of behavior, such as a lack of motivation, difficulty expressing emotions, difficulty expressing thoughts, etc.). As such, there has always been some controversy surrounding the psychiatric conceptualization of schizophrenia despite a relatively stable prevalence of the disorder worldwide.
What Causes Schizophrenia?
The prevalence of schizophrenia is fairly consistent across different countries/cultures and reported at around 1 percent. This relatively stable prevalence of schizophrenia suggests to many mental health researchers that schizophrenia represents a biologically based disorder. There is no formally defined cause for any form of schizophrenia, although many have been proposed. Early attempts to understand schizophrenia implicated such things as inconsistent parenting or influenza in the mother during pregnancy as possible causes.
Modern conceptualizations of schizophrenia denounce poor child-rearing practices or early childhood experiences as causes of schizophrenia; however, the influenza explanation still receives some support. Today, modern psychiatry has pronounced schizophrenia to be a “disease” that is biologically based (the typical psychiatric explanation for nearly any mental state).
According to modern psychiatry, an imbalance of neurotransmitters in the brain is the primary cause of schizophrenia. The “dopamine hypothesis” regarding schizophrenia has long implicated the neurotransmitter dopamine as being a causal factor in at least the expression of the positive symptoms of schizophrenia. The dopamine hypothesis theorizes that it is an overabundance of the neurotransmitter dopamine that results in the expression of schizophrenia. Even though the dopamine hypothesis has been shown to be quite limited and does not offer a complete explanation of the disorder, the notion that schizophrenia represents either an excess or depletion of neurotransmitters that include dopamine, serotonin, glutamate, and perhaps others is still a basic assumption of the psychiatric treatment approach to individuals with schizophrenia. The medications used in the treatment of schizophrenia target dopamine and/or other neurotransmitters.
The bottom line is that schizophrenia is a disorder that does appear to have significant biologically based associations; however, a complete view of the research indicates that there are environmental factors that contribute to the development of the disorder in addition to biological influences.
Schizophrenia and Crime
Because individuals with schizophrenia are often vilified in the media, it is important to mention that the vast majority of individuals with schizophrenia are not involved in serious criminal activities. The most common crime associated with individuals who have schizophrenia is vagrancy due to homelessness. While some infamous serial killers were diagnosed with schizophrenia, it is not true that most serial killers have schizophrenia, nor is it true that most people who are diagnosed with schizophrenia are dangerous.
- Schizophrenia and Substance Abuse
There are several disorders that are commonly comorbid with schizophrenia (comorbid is a clinical term used to signify disorders occurring together). According to the American Psychiatric Association, anxiety disorders, obsessive-compulsive disorder, and several other disorders are noted to often be comorbid with schizophrenia. However, the most common disorder that is comorbid with schizophrenia is some type of substance use disorder.
The most commonly abused substance in individuals with schizophrenia is tobacco. Individuals with schizophrenia are much more likely to smoke (and smoke very heavily) than individuals with any other mental health disorder or individuals in the general population. There is research to indicate that nicotine affects many of the cognitive deficits in schizophrenia in a positive manner and may be why individuals with schizophrenia have such high levels of tobacco use disorders. However, the health risks associated with smoking far away outweigh any benefits that these individuals receive.
Individuals with schizophrenia also have high rates of cannabis abuse. It appears that heavy cannabis abuse is associated with more severe outcomes in schizophrenia; however, there is no definitive understanding as to why this is the case.
Alcohol abuse is also often comorbid with schizophrenia.
Other drugs of abuse may be used by people with schizophrenia, such as prescription medications and illicit drugs like cocaine, heroin, and so forth.
Individuals with schizophrenia are also at higher risk for earlier mortality than the general population. When these individuals have a comorbid substance use disorder, the risk for early death is increased further. The best treatment option for these individuals is a program that integrates treatment for schizophrenia and substance abuse.
- Treatment for Schizophrenia and Comorbid Substance Abuse
The first line intervention in the treatment of schizophrenia is the use of some type of antipsychotic medication. These medications are typically dispensed by a psychiatrist and given to the individual based on their particular symptom profile. Oftentimes, medications are determined on a trial-and-error basis, as doctors discover which one appears to be working best for the individual. Older antipsychotic medications that primarily affected the neurotransmitter dopamine were also associated with serious neurological side effects (e.g., a neurological disorder known as tardive dyskinesia where the individual eventually developed facial tics, such as repetitive lip smacking, licking, etc., as well as rigidity of the joints, tremors, and spasms that were irreversible). Newer generations of antipsychotic medications are not linked with this risk as strongly but do have potential side effects associated with them.
Because antipsychotic medications represent a rather large and diverse group of medications, their side effect profiles can be quite distinct. Some of the more common side effects associated with the newer antipsychotic medications include:
- Blurred vision
- Drowsiness and dizziness
- Sensitivity to light
- Weight gain
- Increased risk for diseases like diabetes
- Issues with high cholesterol
Other potential serious side effects are also possible. It is important to note that the one of the major reasons that individuals diagnosed with schizophrenia discontinue treatment is due to the side effects of the medications they take. Thus, a team of medical professionals who regularly assess the client should strictly supervise treatment for schizophrenia.
Controlling psychosis is crucial. While individuals with substance use disorders will need treatment, until any hallucinations or delusions are relatively controlled, other behavioral treatments will be difficult to implement and manage. The effects of any potential withdrawal symptoms can be managed medically.
While the symptoms of schizophrenia are addressed with medication, individuals with schizophrenia will eventually benefit from therapy to assist with adjustment issues, offer support, and develop proactive living skills, such as problem-solving skills, communication skills, etc. The use of psychologically based therapy alone to treat individuals with schizophrenia is no longer a common practice.
Therapy typically involves integrating the person back in the society and helping the person with practical aspects of living. Some individuals with schizophrenia, especially those with predominantly negative symptoms, will need very strong support to help them adjust to their medication regime and to interact with others.
Treatment for comorbid substance abuse issues is best accomplished in an integrated manner, using pharmacological and behavioral interventions when possible. Such treatment would consist of medication management for cravings if this can be successfully integrated into the individual’s medication regime. There is also some evidence to suggest that when individuals with schizophrenia are treated with antipsychotic medications, any comorbid substance abuse issues may also begin to resolve. However, an approach that directly addresses the comorbid substance abuse issue after psychotic symptoms are managed is the preferential approach to avoid potential relapses.
Support groups, such as 12-Step groups, substance abuse support groups, or groups that are composed specifically of individuals with schizophrenia, are also useful in the treatment of comorbid substance abuse. For some individuals, the use of Cognitive Behavioral Therapy (CBT) can also be helpful; however, it may be difficult to implement some of the CBT techniques with individuals who have primarily negative symptoms. Therapists may need to design individually based programs for comorbid substance abuse and schizophrenia to address the level of functioning of a particular client. Using these techniques in a group format may be appropriate as well.