The Who, What and Why of Schizophrenia

“My good fortune is not that I’ve recovered from mental illness. I have not, nor will I ever. My good fortune lies in having found my life.”

Elyn Saks- Successful lawyer who has schizophrenia

 

When people hear of a Schizophrenic, they generally have a strong, fearful reaction. Many view these individuals as dangerous, unpredictable, and just plain crazy. Interestingly, we are all susceptible to psychosis. In fact, 15% of “normal” people will experience an episode of psychosis in their lifetime. Bereavement, sleep deprivation, and substance use are all potential inducers of psychotic experiences. Psychosis may also occur in severe depression, anxiety, and bipolar disorder. Studies show that people with schizophrenia are not more dangerous than the average person, but are more likely to have people take advantage of them.

What is Schizophrenia?

Schizophrenia is a chronic condition in which people experience changes in perception, emotion, cognition, thinking and behavior. “Positive” symptoms include hallucinations, delusions, and disorganized behaviors or speech. “Negative” symptoms include decreased motivation, feelings that nothing matters, inability to experience pleasure, and lack of emotions or speech. Cognitive symptoms include decreased memory, attention and processing speeds and inability to use language properly or interpret other people’s actions.

 

How Many People Have Schizophrenia and Who is Most Likely to Develop it?

Schizophrenia occurs in 1% of the population and has an average onset age of twenty-five. Women generally develop the disorder later than men and have better outcomes. Risk factors include being born to a father greater than 40 years of age, living in a heavily populated area, smoking marijuana, having a birth complication, or being born in the late winter or early spring. This last risk factor may be related to contracting the flu during the third trimester.

 

What is the Course of the Illness?

A prodromal phase is often retroactively observed months to years prior to diagnosis. Importantly, not everyone with these symptoms will develop Schizophrenia. In this phase, people begin to have a cognitive decline, negative symptoms such as isolating and mild positive symptoms such as strong belief in conspiracy theories. They may seem increasingly odd to their friends and family. It often occurs with a life transition such as going away to college, the death of a loved one or experimenting with illegal substances.  About 20% of people diagnosed with schizophrenia will go on to be symptom-free or only have mild symptoms for the rest of their lives. There are several examples of people with schizophrenia who have had successful careers as lawyers, doctors, Nobel prize winners, and musicians. Positive symptoms tend to diminish as individuals get older, while negative and cognitive symptoms stay the same or worsen.

 

What Causes Schizophrenia?

Brain imaging has shown a neuronal loss in the cerebrum, limbic system, and thalamus. There is also decreased activity in the frontal lobe and hippocampus. Recently, it has been hypothesized that schizophrenia is an autoimmune disease that causes excessive synaptic pruning in our brain.

 

Multiple neurotransmitters are postulated to be abnormal in schizophrenia. The primary one is dopamine which is the target of antipsychotic medications and is the cause of psychotic symptoms in people using cocaine or methamphetamine. Other Neurotransmitters that may play a role include serotonin, norepinephrine, GABA, glutamate, acetylcholine and nicotine.

 

Psychoanalytic theory proposes that schizophrenia develops from needs that are not met early in life, leading to the development of symbolic defense mechanisms. Those with poor mother-child relationships have a six-fold increased risk of developing schizophrenia.

 

If My Relative Has Schizophrenia Will I also Get it?

There are over 100 identified genes that play a role in schizophrenia. Many of the same genes that predict an increased risk for bipolar disorder, depression and autism spectrum disorder are also associated with schizophrenia. First degree relatives of someone with schizophrenia have a 10 times greater risk of developing the disorder compared to the general population.

 

What Are the Long-Term Risks of Having Schizophrenia?

People with schizophrenia have decreased life expectancy due to an increased rate of dying from natural causes, accidents, and suicide. Having schizophrenia significantly increases the risk of homelessness and decreases a person’s quality of life. The personal and societal financial burden of schizophrenia is greater than that of all cancers combined. For these reasons, it is imperative that society ensures treatment for these individuals to improve their health and reduce the long-term costs.

 

What Are the Treatment Options

There are several treatments and they work best when used in concert. Antipsychotic medications treat positive symptoms fairly well and lead to a 70% remission rate when taken as prescribed. Unfortunately, half of people with Schizophrenia are not compliant with their medications. Further, over 90% of these people use nicotine, which decreases the effectiveness of many antipsychotics. Interestingly, nicotine has also been shown to independently improve cognitive and positive symptoms. Electroconvulsive therapy has been shown to be as effective as antipsychotics and more effective than psychotherapy.

 

Cognitive behavioral therapy has shown modest ability to improve insight into delusions and hallucinations, decrease their frequency, and improve the likelihood of medication compliance. Family oriented therapy focuses on explaining the disease and encouraging proper support of the person with schizophrenia. Social skills training and vocational therapy have proven to be effective in helping the individual successfully reintegrate into everyday life. Group therapy is effective in reducing social isolation, increasing cohesiveness and improving reality testing.

 

Numerous studies have shown that the people with schizophrenia who do best are those who receive early treatment, have an intact family and a supportive social network. Cultures that view people with schizophrenia in a more positive light have a higher remission rate.

 

Conclusion

The take home points are that psychosis is not as abnormal a phenomenon as we might believe, people with schizophrenia are not inherently dangerous, and with proper treatment, these individuals are capable of living fulfilling lives.

 

What do you think? Have you had any experiences with psychosis? Share your thoughts and questions below.

Ariel Mintz, MD
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Ariel Mintz, MD

Founder and President at Refuat Hanefesh
Dr. Ariel Mintz grew up in Minneapolis, Minnesota. After spending two years learning in Israel, at Derech Eitz Chaim and Shaalivim, he earned his BA in Psychology at Yeshiva Univesity in New York. He went on to obtain his MD at Oakland University William Beaumont School of medicine. He is currently a licensed physician working to complete his training in General Psychiatry at Hennepin County Medical Center in Minneapolis. After that, he hopes to subspecialize in Child and Adolescent Psychiatry. He has a supportive and talented wife and two wonderful children. He is very passionate about destigmatizing mental illness in the Jewish community and bringing comfort to those who are suffering. Ariel can be reached at [email protected]
Ariel Mintz, MD
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