Schizophrenia

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{{Infobox_Disease |Name = Schizophrenia | Image = Bleuler.png | Caption = [Eugen Bleuler (1857–1939) coined the term "Schizophrenia" in 1908 | Width = 125 | DiseasesDB = 11890 | ICD10 = {{ICD10|F|20||f|20--> | ICD9 = {{ICD9|295--> | ICDO = | OMIM = 181500 | MedlinePlus = 000928 | eMedicineSubj = med | eMedicineTopic = 2072 | eMedicine_mult = {{eMedicine2|emerg|520--> | MeshName = Schizophrenia | MeshNumber = F03.700.750 | -->Schizophrenia, from the Ancient Greek roots schizein (σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-, "mind"), is a psychiatric diagnosis that describes a mental illness characterized by impairments in the perception or expression of reality, most commonly manifesting as auditory hallucinations, paranoid or bizarre delusions or thought disorder in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood,Castle E, Wessely S, Der G, Murray RM (1991). "The incidence of operationally defined schizophrenia in Camberwell 1965–84," British Journal of Psychiatry 159: 790–794. PMID 1790446 with approximately 0.4–0.6%Bhugra, D. (2005). The global prevalence of schizophrenia. PLoS Medicine, 2 (5), 372–373. PMID 15916460Goldner EM, Hsu L, Waraich P, Somers JM (2002). Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature. Canadian Journal of Psychiatry, 47(9), 833–43. PMID 12500753 of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia exists.

Studies suggest that genetics, early environment, neurobiology and psychological and social processes are important contributory factors. Current psychiatric research is focused on the role of neurobiology, but a clear organic cause has not 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 synonymous with dissociative identity disorder, previously known as multiple personality disorder or split personality; in popular culture the two are often confused.

Increased dopamine in the mesolimbic pathway of the brain is a consistent finding. The mainstay of treatment is pharmacotherapy with antipsychotic medications; these primarily work 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, though hospital stays are less frequent and for shorter periods than they were in previous years.

The disorder is primarily thought to affect cognition, but it also usually contributes to chronic problems with human behavior and emotion. People diagnosed with schizophrenia are likely to be diagnosed with Comorbidity conditions, including clinical depression and anxiety disorders; the lifetime prevalence of substance abuse is typically around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common and life expectancy is decreased; the average life expectancy of people with the disorder is 10 to 12 years less than those without, owing to increased physical health problems and a high suicide rate.Brown S, Inskip H, Barraclough B. (2000) Causes of the excess mortality of schizophrenia. Br J Psychiatry, 177, 212-7. PMID 11040880

Signs and symptoms A person experiencing schizophrenia may demonstrate symptoms such as Thought disorder, auditory hallucinations, and delusions. In severe cases, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are medical signs of catatonia. 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.American Psychiatric Association (2004) Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). American Psychiatric Association. ISBN 0890420246. DSM-IV & DSM-IV-TR Schizophrenia criteria No one sign is diagnostic of schizophrenia, and all can occur in other medical and psychiatric conditions.

Social isolation commonly occurs and may be due to a number of factors. Impairment in social cognition is associated with schizophrenia, as are the active symptoms of paranoia from delusions and hallucinations, and the negative symptoms of apathy and avolition. Many people diagnosed with schizophrenia avoid potentially stressful social situations that may exacerbate mental distress.Freeman D, Garety PA, Kuipers E, Fowler D, Bebbington PE, Dunn G. (2007) Acting on persecutory delusions: the importance of safety seeking. Behaviour Research and Therapy, 45 (1), 89–99. PMID 16530161

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 by disease onset. To minimize the impact of schizophrenia, much work has recently been done to identify and treat the prodrome phase of the illness, which has been detected up to 30 months before the onset of symptoms, but may be present longer.Addington J, Cadenhead KS, Cannon TD, Cornblatt B, McGlashan TH, Perkins DO, Seidman LJ, Tsuang M, Walker EF, Woods SW, Heinssen R. (2007) North American prodrome longitudinal study: a collaborative multisite approach to prodromal schizophrenia research. Schizophrenia Bulletin, 33 (3), 665-72. PMID 17255119 Those who go on to develop schizophrenia may experience the non-specific symptoms of social withdrawal, irritability and dysphoria in the prodromal period,Parnas J, Jorgensen A. (1989) Pre-morbid psychopathology in schizophrenia spectrum. British Journal of Psychiatry, 155, 623–7. and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.Amminger GP, Leicester S, Yung AR, Phillips LJ, Berger GE, Francey SM, Yuen HP, McGorry PD. (2006) Early-onset of symptoms predicts conversion to non-affective psychosis in ultra-high risk individuals. Schizophrenia Research, 84 (1), 67–76. PMID 16677803

Schneiderian 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,Bertelsen, A. (2002). Schizophrenia and Related Disorders: Experience with Current Diagnostic Systems. Psychopathology, 35, 89–93. PMID 12145490 although they have contributed to the current diagnostic criteria.

Positive and negative symptoms Schizophrenia is often described in terms of positive (or productive) and negative (or deficit) symptoms.Sims A (2002) Symptoms in the Mind: An Introduction to Descriptive Psychopathology (3rd edition). Edinburgh: Elsevier Science Ltd. ISBN 0-7020-2627-1 Positive symptoms include delusions, hallucination, 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 communication (alogia), 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.Cohen & Docherty (2004). Affective reactivity of speech and emotional experience in patients with schizophrenia. Schizophr Res, 1;69(1):7–14. PMID 15145465 A third symptom grouping, the disorganization syndrome, is commonly described, and includes chaotic speech, thought, and behaviour. There is evidence for a number of other symptom classifications.Peralta V, Cuesta MJ. (2001) How many and which are the psychopathological dimensions in schizophrenia? Issues influencing their ascertainment. Schizophrenia Research, 30, 49(3), 269-85. PMID 11356588

Diagnosis Diagnosis is based on the self-reported experiences of the person as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, social worker, clinical psychologist or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizophrenia, tests are carried out to exclude medical illnesses which may rarely present with psychotic schizophrenia-like symptoms. These include blood tests measuring Thyroid-stimulating hormone to exclude hypothyroidism or hyperthyroidism, Blood tests#Blood chemistry tests and serum calcium to rule out a metabolic disturbance, Complete blood count including Erythrocyte sedimentation rate to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are Electroencephalography to exclude epilepsy, and a Computed tomography of the head to exclude brain lesions. It is important 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. There are several psychiatric illnesses which may present with psychotic symptoms other than schizophrenia. These include bipolar disorder,Pope HG (1983). Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports. Hospital and Community Psychiatry, 34: 322–328. borderline personality disorder,McGlashan TH (1987) Testing DSM-III symptom criteria for schizotypal and borderline personality disorders. Archives of General Psychiatry, 44: 15–22. drug intoxication, brief drug-induced psychosis, and schizophreniform disorder.

Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, liver function tests if chlorpromazine or CPK to exclude neuroleptic malignant syndrome. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.

The most widely used criteria for diagnosing schizophrenia are from the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization ICD, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian Kurt Schneider#First rank symptoms although, in practice, agreement between the two systems is high.Jakobsen KD, Frederiksen JN, Hansen T, Jansson LB, Parnas J, Werge T (2005) Reliability of clinical ICD-10 schizophrenia diagnoses. Nordic Journal of Psychiatry, 59 (3), 209-12. PMID 16195122 The World Health Organization has developed the tool SCAN (Schedules for Clinical Assessment in Neuropsychiatry) which can be used for diagnosing a number of psychiatric conditions, including schizophrenia.

DSM IV-TR Criteria To be diagnosed with schizophrenia, a person must display:

Characteristic symptoms: Two or more of the following, each present for a significant portion of time during a one-month period (or less, if successfully treated)

delusions
hallucinations
disorganized speech (e.g., frequent derailment or incoherence; speaking in abstraction). See thought disorder.
grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or Catatonia behavior
negative symptoms, i.e., affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation).

Note: Only one of these symptoms is required if delusions are 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.

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 successfully treated).

Additional criteria are also given that exclude the diagnosis; thus schizophrenia cannot be diagnosed if symptoms of mood disorder or pervasive developmental disorder are present, or the symptoms are the direct result of a substance (e.g., abuse of a drug, medication) or a general medical condition.

Subtypes Historically, schizophrenia in the Western world was classified into simple, catatonia, hebephrenic (now known as Disorganized schizophrenia), and paranoid. The Diagnostic and Statistical Manual of Mental Disorders contains five sub-classifications of schizophrenia:

Paranoia#Use in psychiatry: 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 schizophrenia: named 'hebephrenic schizophrenia' in the ICD. Where thought disorder and flat affect are present together (DSM code 295.1/ICD code F20.1)
catatonia: prominent psychomotor disturbances are evident. 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 recognises a further two 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 but progressive development of prominent negative symptoms with no history of psychotic episodes (ICD code F20.6)

Diagnostic issues and controversies Schizophrenia as a diagnostic entity has been criticised as lacking in scientific validity or reliability,Bentall RP (1992) Reconstructing Schizophrenia. London: Routledge. ISBN 0415075246Boyle M (2002) Schizophrenia: A Scientific Delusion?. London: Routledge. ISBN 0415227186 part of a larger Biopsychiatry controversy of the validity of psychiatric diagnoses in general. One alternative suggests that the issues with the diagnosis would be better addressed as individual dimensions along which everyone varies, such that there is a spectrum or continuum rather than a cut-off between normal and ill. This approach appears consistent with research on schizotypy and of a relatively high prevalence of psychotic experiencesVerdoux H, van Os J (2002). Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophrenia Research, 54(1–2), 59–65. PMID 11853979LC, van Os J. (2001). The continuity of psychotic experiences in the general population. Clinical Psychology Review, 21 (8),1125–41. PMID 11702510 and often non-distressing delusional beliefsPeters ER, Day S, McKenna J, Orbach G(2005). Measuring delusional ideation: the 21-item Peters et al. Delusions Inventory (PDI). Schizophrenia Bulletin, 30, 1005–22. PMID 15954204 amongst the general public.Johns LC, van Os J (2001) The continuity of psychotic experiences in the general population. Clinical Psychology Review, 21 (8), 1125–41. PMID 11702510.

Another criticism is that the definitions used for criteria lack consistency;David AS (1999) On the impossibility of defining delusions. Philosophy, Psychiatry and Psychology, 6 (1), 17–20 this is particularly relevant to the evaluation of delusion#Diagnostic issues and controversiess and thought disorder#Diagnostic issues and controversies. 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".Tsuang MT, Stone WS, Faraone SV (2000). Toward reformulating the diagnosis of schizophrenia. American Journal of Psychiatry, 157(7), 1041–1050. PMID 10873908

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 1972 study, published as Rosenhan experiment, demonstrated that the diagnosis of schizophrenia was (at least at the time) often subjective and unreliable.Rosenhan D (1973). On being sane in insane places. Science, 179, 250-8. PMID 4683124 Full text as PDF More recent studies have found agreement between any two psychiatrists when diagnosing schizophrenia tends to reach about 65% at best.McGorry PD, Mihalopoulos C, Henry L, Dakis J, Jackson HJ, Flaum M, Harrigan S, McKenzie D, Kulkarni J, Karoly R (1995). Spurious precision: procedural validity of diagnostic assessment in psychotic disorders. American Journal of Psychiatry, 152 (2), 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.Read J (2004) Does 'schizophrenia' exist? Reliability and validity. In Read J, Mosher LR, Bentall RP (eds) Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia. 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).Sato M (2004). Renaming schizophrenia: a Japanese perspective. World Psychiatry, 5(1), 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. 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.Green MF (2001) Schizophrenia Revealed: From Neurons to Social Interactions. New York: W.W. Norton. ISBN 0393703347

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 Russian SFSR (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.Wilkinson G (1986) Political dissent and "sluggish" schizophrenia in the Soviet Union. Br Med J (Clin Res Ed), 293(6548), 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 Committee on the Abuse of Psychiatry and Psychiatrists to pass a resolution to urge the World Psychiatric Association to investigate the situation in People's Republic of China.Lyons D (2001). Soviet-style psychiatry is alive and well in the People's Republic. British Journal of Psychiatry, 178, 380–381. PMID 11282823

Epidemiology Schizophrenia occurs equally in males and females although typically appears earlier in men with the peak ages of onset being 20–28 years for males and 26–32 years for females. Much rarer are instances of childhood-onsetKumra S, Shaw M, Merka P, Nakayama E, Augustin R. (2001) Childhood-onset schizophrenia: research update. Canadian Journal of Psychiatry, 46 (10), 923–30. and late- (middle age) or very-late-onset (old age) schizophrenia.Hassett A, Ames D, Chiu E (eds) (2005) Psychosis in the Elderly. London: Taylor and Francis. ISBN 18418439446 The lifetime prevalence of schizophrenia, that is, the proportion of individuals expected to experience the disease at any time in their lives, is commonly given at 1%. A 2002 systematic review of many studies, however, found a lifetime prevalence of 0.55%. Despite the received wisdom that schizophrenia occurs at similar rates throughout the world, its prevalence varies across the world,Jablensky A, Sartorius N, Ernberg G, et al. (1992) Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychological Medicine Monograph Supplement, 20, 1–97. PMID 1565705 within countries,Kirkbride JB, Fearon P, Morgan C, et al. (2006) Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings From the 3-center ÆSOP study. Archives of General Psychiatry, 63, 250–258. PMID 16520429 and at the local and neighbourhood level.Kirkbride JB, Fearon P, Morgan C, Dazzan P, Morgan K, Murray RM, Jones PB. (2007) Neighbourhood variation in the incidence of psychotic disorders in Southeast London. Social Psychiatry and Psychiatric Epidemiology, 42(6), 438-45. PMID 17473901 One particularly stable and replicable finding has been the association between living in an Urbanization environment and schizophrenia diagnosis, even after factors such as drug use, ethnic group and size of social group have been controlled for.Van Os J. (2004). Does the urban environment cause psychosis? British Journal of Psychiatry, 184 (4), 287–288. PMID 15056569 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 before paraplegia and blindness.Ustun TB, Rehm J, Chatterji S, Saxena S, Trotter R, Room R, Bickenbach J, and the WHO/NIH Joint Project CAR Study Group (1999). Multiple-informant ranking of the disabling effects of different health conditions in 14 countries. The Lancet, 354(9173), 111–115. PMID 10408486

Causes studyMeyer-Lindenberg A, Miletich RS, Kohn PD, et al (2002). Reduced prefrontal activity predicts exaggerated striatal dopaminergic function in schizophrenia. Nature Neuroscience, 5, 267–71. PMID 11865311 suggests that the less the frontal lobes are activated (red) during a working memory task, the greater the increase in abnormal dopamine activity in the striatum (green), thought to be related to the neurocognitive deficits in schizophrenia.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 Clinical depression), evidence suggests that genetic and environmental factors can act in combination to result in schizophrenia.Harrison PJ, Owen MJ. (2003). Genes for schizophrenia? Recent findings and their pathophysiological implications. Lancet, 361(9355), 417–9. PMID 12573388 Evidence suggests that the diagnosis of schizophrenia has a significant heritable component but that onset is significantly influenced by environmental factors or stressors.Day R, Nielsen JA, Korten A, Ernberg G, et al (1987). Stressful life events preceding the acute onset of schizophrenia: a cross-national study from the World Health Organization. Culture, Medicine and Psychiatry, 11 (2), 123–205. PMID 3595169 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.Corcoran C, Walker E, Huot R, Mittal V, Tessner K, Kestler L, Malaspina D. (2003) The stress cascade and schizophrenia: etiology and onset.Schizophr Bull, 29 (4), 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.O'Donovan MC, Williams NM, Owen MJ. (2003) Recent advances in the genetics of schizophrenia. Human Molecular Genetics, 12 Spec No 2, R125-33. PMID 12952866 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.Owen MJ, Craddock N, O'Donovan MC. (2005). Schizophrenia: genes at last? Trends in Genetics, 21(9), 518–25. PMID 16009449 Recent work has suggested that genes that raise the risk for developing schizophrenia are non-specific, and may also raise the risk of developing other psychotic disorders such as bipolar disorder.Craddock N, O'Donovan MC, Owen MJ. (2006) Genes for schizophrenia and bipolar disorder? Implications for psychiatric nosology. Schizophrenia Bulletin, 32 (1), 9–16. PMID 16319375 Dalby JT, Morgan D, Lee M. (1986) Schizophrenia and mania in identical twin brothers.Journal of Nervous and Mental Disease,174,304-308. PMID 3701318

Prenatal It is thought that causal factors can initially come together in early neurodevelopment, including during pregnancy, 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 (season), (at least in the northern hemisphere).Davies G, Welham J, Chant D, Torrey EF, McGrath J. (2003). A systematic review and meta-analysis of Northern Hemisphere season of birth studies in schizophrenia. Schizophrenia Bulletin, 29 (3), 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.Brown, A.S. (2006). Prenatal infection as a risk factor for schizophrenia. Schizophrenia Bulletin, 32 (2), 200–2. PMID 16469941

Social Living in an Urban area environment has been consistently found to be a risk factor for schizophrenia.van Os J, Krabbendam L, Myin-Germeys I, Delespaul P (2005) The schizophrenia envirome. Current Opinion in Psychiatry, 18 (2), 141-5. PMID 16639166 Social disadvantage has been found to be a risk factor, including povertyMueser KT & McGurk SR. (2004) Schizophrenia. Lancet. June 19;363(9426):2063-72. PMID 15207959 and migration related to social adversity, racial discrimination, family dysfunction, unemployment or poor housing conditions.Selten JP, Cantor-Graae E, Kahn RS. (2007) Migration and schizophrenia. Current Opininion in Psychiatry, 20 (2), 111-5. PMID 17278906 Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life.Schenkel LS, Spaulding WD, Dilillo D, Silverstein SM (2005). Histories of childhood maltreatment in schizophrenia: Relationships with premorbid functioning, symptomatology, and cognitive deficits. Schizophrenia Research, 76(2–3), 273–286. PMID 15949659Janssen I, Krabbendam L, Bak M, Hanssen M, et al (2004). Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatrica Scandinavica, 109, 38–45. PMID 14674957 Parenting is not held responsible for schizophrenia but unsupportive dysfunctional relationships may contribute to an increased risk.Subotnik, KL, Goldstein, MJ, Nuechterlein, KH, Woo, SM and Mintz, J. (2002) Are Communication Deviance and Expressed Emotion Related to Family History of Psychiatric Disorders in Schizophrenia? Schizophr Bull. 28(4):719-29 PMID 12795501

Substance use The relationship between schizophrenia and drug use is complex, meaning that a clear causal connection between drug use and schizophrenia has been difficult to tease apart. There is strong evidence that using certain drugs can trigger either the onset or relapse of schizophrenia in some people. It may also be the case, however, that people with schizophrenia use drugs to overcome negative feelings associated with both the commonly prescribed antipsychotic medication and the condition itself, where negative emotion, paranoia and anhedonia are all considered to be core features.Gregg L, Barrowclough C, Haddock G. (2007) Reasons for increased substance use in psychosis. Clinical Psychology Review, 27 (4), 494–510. PMID 17240501 Amphetamines trigger the release of dopamine and excessive dopamine function is believed to be responsible for many symptoms of schizophrenia (known as the dopamine hypothesis of schizophrenia), amphetamines may worsen schizophrenia symptoms.Laruelle, M., Abi-Dargham, A., Van-Dyck, C. H., et al (1996) Single photon emission computerized tomography imaging of amphetamine-induced dopamine release in drug-free schizophrenic subjects. Proceedings of the National Academy of Sciences of the USA, 93, 9235–9240. PMID 8799184 Full text Schizophrenia can be triggered by heavy use of Psychedelics, dissociatives and deliriants or stimulant drugs.Mueser KT, Yarnold PR, Levinson DF, et al (1990). Prevalence of substance abuse in schizophrenia: demographic and clinical correlates. Schizophrenic Bulletin, 16(1), 31–56. PMID 2333480 One study suggests that cannabis (drug) use can contribute to psychosis, though the researchers suspected cannabis use was only a small component in a broad range of factors that can cause psychosis.Arseneault L, Cannon M, Witton J, Murray RM (2004). Causal association between cannabis and psychosis: examination of the evidence. British Journal of Psychiatry, 184, 110-7. PMID 14754822 Full text

Psychological A number of psychological mechanisms have been implicated in the development and maintenance of schizophrenia. Cognitive biases that have been identified in those with a diagnosis or those at risk, especially when under stress or in confusing situations, include excessive attention to potential threats, jumping to conclusions, making external Attribution (psychology), impaired reasoning about social situations and Theory of mind, difficulty distinguishing inner speech from speech from an external source, and difficulties with early visual processing and maintaining concentration.Broome MR, Woolley JB, Tabraham P, Johns LC, et al (2005). What causes the onset of psychosis? Schizophr Res, 79(1), 23–34. PMID 16198238 Lewis R (2004). Should cognitive deficit be a diagnostic criterion for schizophrenia? Journal of Psychiatry and Neuroscience March; 29(2): 102–113. PMID 15069464 Brune M, Abdel-Hamid M, Lehmkamper C, Sonntag C (2007). Mental state attribution, neurocognitive functioning, and psychopathology: What predicts poor social competence in schizophrenia best? Schizophr Res. March 6 PMID 17346931Sitskoorn MM, Aleman A, Ebisch SJH, Appels MCM, Khan RS (2004). Cognitive deficits in relatives of patients with schizophrenia: a meta-analysis. Schizophrenia Research, Volume 71, Issue 2, Pages 285–295. PMID 15474899 Some cognitive features may reflect global neurocognitive deficits in memory, attention, problem solving, executive function or social cognition, while others may be related to particular issues and experiences.Kurtz MM. (2005) Neurocognitive impairment across the lifespan in schizophrenia: an update. Schizophrenia Research, 74 (1), 15–26. PMID 15694750Bentall RP, Fernyhough C, Morrison AP, Lewis S, Corcoran R. (2007) Prospects for a cognitive-developmental account of psychotic experiences. Br J Clin Psychol. Jun;46(Pt 2):155-73. PMID 17524210 Despite a common appearance of "blunted affect", recent findings indicate that many individuals diagnosed with schizophrenia are highly emotionally responsive, particularly to stressful or negative stimuli, and that such sensitivity may cause vulnerability to symptoms or to the disorder.Cohen & Docherty (2004). Affective reactivity of speech and emotional experience in patients with schizophrenia. Schizophr Res, 1;69(1):7–14. PMID 15145465 Horan WP, Blanchard JJ. (2003) Emotional responses to psychosocial stress in schizophrenia: the role of individual differences in affective traits and coping. Schizophr Res. April 1;60(2-3):271-83. PMID 12591589Barrowclough C, Tarrier N, Humphreys L, Ward J, Gregg L, Andrews B (2003). Self-esteem in schizophrenia: relationships between self-evaluation, family attitudes, and symptomatology. J Abnorm Psychol. 112(1):92–9. PMID 12653417 Some evidence suggests that the content of delusional beliefs and psychotic experiences can reflect emotional causes of the disorder, and that how a person interprets such experiences can influence symptomology.Birchwood M, Meaden A, Trower P, Gilbert P, Plaistow J (2000). The power and omnipotence of voices: subordination and entrapment by voices and significant others. Psychol Med. Mar;30(2):337–44. PMID 10824654Smith B, Fowler DG, Freeman D, et al (2006). Emotion and psychosis: links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations. Schizophr Res. Sep;86(1–3):181–8. PMID 16857346Beck, AT (2004). A Cognitive Model of Schizophrenia, Journal of Cognitive Psychotherapy, 18 (3), 281–288. Retrieved on 2007-05-16.Bell V, Halligan PW, Ellis HD. (2006) Explaining delusions: a cognitive perspective. Trends Cogn Sci. May;10(5):219-26. PMID 16600666 Further evidence for the role of psychological mechanisms comes from the effects of therapies on symptoms of schizophrenia.Kuipers E, Garety P, Fowler D, Freeman D, Dunn G, Bebbington P. (2006) Cognitive, emotional, and social processes in psychosis: refining cognitive behavioral therapy for persistent positive symptoms. Schizophr Bull. Oct;32 Suppl 1:S24-31. PMID 16885206

Neural and other brain imaging technologies allow for the study of differences in brain activity among people diagnosed with schizophrenia.

Studies using neuropsychological tests and brain imaging technologies such as Functional magnetic resonance imaging and Positron emission tomography 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.Green MF. (2006) Cognitive impairment and functional outcome in schizophrenia and bipolar disorder. Journal of Clinical Psychiatry, 67, Suppl 9, 3–8. PMID 16965182

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. 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.Jones HM, Pilowsky LS (2002) Dopamine and antipsychotic drug action revisited. British Journal of Psychiatry, 181, 271–275. PMID 12356650

Interest has also focused on the neurotransmitter glutamate and the reduced function of the NMDA receptor in schizophrenia. This has largely been suggested by abnormally low levels of glutamate receptors found in postmortem brains of people previously diagnosed with schizophreniaKonradi C, Heckers S. (2003). Molecular aspects of glutamate dysregulation: implications for schizophrenia and its treatment. Pharmacology and Therapeutics, 97(2), 153–79. PMID 12559388 and the discovery that the glutamate blocking drugs such as phencyclidine and ketamine can mimic the symptoms and cognitive problems associated with the condition.Lahti AC, Weiler MA, Tamara Michaelidis BA, Parwani A, Tamminga CA. (2001). Effects of ketamine in normal and schizophrenic volunteers. Neuropsychopharmacology, 25(4), 455–67. PMID 11557159 The fact that reduced glutamate function is linked to poor performance on tests requiring frontal lobe and hippocampus 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.Coyle JT, Tsai G, Goff D. (2003). Converging evidence of NMDA receptor hypofunction in the pathophysiology of schizophrenia. Annals of the New York Academy of Sciences, 1003, 318–27. PMID 14684455 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.Tuominen HJ, Tiihonen J, Wahlbeck K. (2005). Glutamatergic drugs for schizophrenia: a systematic review and meta-analysis. Schizophr Res, 72:225–34. PMID 15560967

There have also been findings of differences in the size and structure of certain brain areas in Schizohrenia, starting with the discovery of ventricular system enlargement in those for whom negative symptoms were most prominent.Johnstone EC, Crow TJ, Frith CD, Husband J, Kreel L. (1976). Cerebral ventricular size and cognitive impairment in chronic schizophrenia. Lancet, 30;2 (7992), 924–6. PMID 62160 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.Flashman LA, Green MF (2004). Review of cognition and brain structure in schizophrenia: profiles, longitudinal course, and effects of treatment. Psychiatric Clinics of North America, 27 (1), 1–18, vii. PMID 15062627 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 , which revolutionized treatment of schizophrenia in the 1950s.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 PANSS (PANSS).Kay SR, Fiszbein A, Opler LA (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–76. PMID 3616518Management 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. 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. Schizophr Bull. 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.Becker T, Kilian R. (2006) 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? Acta Psychiatrica Scandinavica Supplement, 429, 9–16. PMID 16445476 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 employmentMcGurk, 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. The outcome for people diagnosed with schizophrenia in non-Western countries may actually be better 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 The reasons for this effect are not clear, although cross-cultural studies are being conducted.

Medication The mainstay of psychiatric treatment for schizophrenia is an antipsychotic medication.The Royal College of Psychiatrists & The British Psychological Society (2003). Schizophrenia. Full national clinical guideline on core interventions in primary and secondary care (PDF). London: Gaskell and the British Psychological Society. Retrieved on 2007-05-17. These can reduce the "positive" symptoms of psychosis. Most antipsychotics take around 7–14 days to have their main effect. (trade name Risperdal) is a common atypical antipsychotic medication.Though expensive, the newer atypical antipsychotic drugs are usually preferred for first-line 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.Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK, Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. The New England Journal of Medicine, 353 (12), 1209–23. PMID 16172203 Prolactin elevations have been reported in women with schizophrenia taking atypical antipsychotics.Dickson RA, Dalby JT, Williams R, Edwards AL. (1995) Risperidone induced prolactin elevations in premenopausal women with schizophrenia. American Journal of Psychiatry,152,1102-1103. PMID 7540803It 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.Ananth J, Parameswaran S, Gunatilake S, Burgoyne K, Sidhom T. (2004) Neuroleptic malignant syndrome and atypical antipsychotic drugs. Journal of Clinical Psychiatry, 65 (4), 464-70. PMID 15119907

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.Leucht S, Wahlbeck K, Hamann J, Kissling W (2003). New generation antipsychotics versus low-potency conventional antipsychotics: a systematic review and meta-analysis. The Lancet, 361(9369), 1581–9. PMID 12747876

Response of symptoms to mediation is variable; "Treatment-resistant schizophrenia" is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics. Patients in this category may be prescribed clozapine, a medication of superior effectiveness but several potentially lethal side effects including agranulocytosis and myocarditis. Clozapine may have the additional benefit of reducing propensity for substance abuse in schizophrenic patients. For other patients who are unwilling or unable to take medication regularly, long-acting Typical antipsychotic#Depot injections preparations of antipsychotics may be given every two weeks to achieve control. America and Australia are two countries with Outpatient commitment allowing the forced administration of this type of medication on those who refuse but are otherwise stable and living in the community. Nevertheless, some findings indicate that in the longer-term many individuals do better without taking antipsychotics.Harrow M, Jobe TH. (2007) Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. J Nerv Ment Dis. May;195(5):406-14. PMID 17502806

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). 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,Cormac I, Jones C, Campbell C (2002). Cognitive behaviour therapy for schizophrenia. Cochrane Database of systematic reviews, (1), CD000524. PMID 11869579 more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia.Zimmermann G, Favrod J, Trieu VH, Pomini V (2005). The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research, 77, 1–9. PMID 16005380 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.Wykes T, Brammer M, Mellers J, et al (2002). Effects on the brain of a psychological treatment: cognitive remediation therapy: functional magnetic resonance imaging in schizophrenia. British Journal of Psychiatry, 181, 144–52. PMID 12151286 A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy.Hogarty GE, Flesher S, Ulrich R, Carter M, et al (2004). Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior. Arch Gen Psychiatry. Sep;61(9):866–76.PMID 15351765

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.McFarlane WR, Dixon L, Lukens E, Lucksted A (2003). Family psychoeducation and schizophrenia: a review of the literature. J Marital Fam Ther. Apr;29(2):223–45. PMID 12728780 Glynn SM, Cohen AN, Niv N (2007). New challenges in family interventions for schizophrenia. Expert Rev Neurother. Jan;7(1):33–43. PMID 17187495Pharoah F, Mari J, Rathbone J, Wong W. (2006) 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 increa {{Infobox_Disease |Name = Schizophrenia | Image = Bleuler.png | Caption = [Eugen Bleuler (1857–1939) coined the term "Schizophrenia" in 1908 | Width = 125 | DiseasesDB = 11890 | ICD10 = {{ICD10|F|20||f|20--> | ICD9 = {{ICD9|295--> | ICDO = | OMIM = 181500 | MedlinePlus = 000928 | eMedicineSubj = med | eMedicineTopic = 2072 | eMedicine_mult = {{eMedicine2|emerg|520--> | MeshName = Schizophrenia | MeshNumber = F03.700.750 | -->Schizophrenia, from the Ancient Greek roots schizein (σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-, "mind"), is a psychiatric diagnosis that describes a mental illness characterized by impairments in the perception or expression of reality, most commonly manifesting as auditory hallucinations, paranoid or bizarre delusions or thought disorder in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood,Castle E, Wessely S, Der G, Murray RM (1991). "The incidence of operationally defined schizophrenia in Camberwell 1965–84," British Journal of Psychiatry 159: 790–794. PMID 1790446 with approximately 0.4–0.6%Bhugra, D. (2005). The global prevalence of schizophrenia. PLoS Medicine, 2 (5), 372–373. PMID 15916460Goldner EM, Hsu L, Waraich P, Somers JM (2002). Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature. Canadian Journal of Psychiatry, 47(9), 833–43. PMID 12500753 of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia exists.

Studies suggest that genetics, early environment, neurobiology and psychological and social processes are important contributory factors. Current psychiatric research is focused on the role of neurobiology, but a clear organic cause has not 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 synonymous with dissociative identity disorder, previously known as multiple personality disorder or split personality; in popular culture the two are often confused.

Increased dopamine in the mesolimbic pathway of the brain is a consistent finding. The mainstay of treatment is pharmacotherapy with antipsychotic medications; these primarily work 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, though hospital stays are less frequent and for shorter periods than they were in previous years.

The disorder is primarily thought to affect cognition, but it also usually contributes to chronic problems with human behavior and emotion. People diagnosed with schizophrenia are likely to be diagnosed with Comorbidity conditions, including clinical depression and anxiety disorders; the lifetime prevalence of substance abuse is typically around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common and life expectancy is decreased; the average life expectancy of people with the disorder is 10 to 12 years less than those without, owing to increased physical health problems and a high suicide rate.Brown S, Inskip H, Barraclough B. (2000) Causes of the excess mortality of schizophrenia. Br J Psychiatry, 177, 212-7. PMID 11040880

Signs and symptoms A person experiencing schizophrenia may demonstrate symptoms such as Thought disorder, auditory hallucinations, and delusions. In severe cases, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are medical signs of catatonia. 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.American Psychiatric Association (2004) Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). American Psychiatric Association. ISBN 0890420246. DSM-IV & DSM-IV-TR Schizophrenia criteria No one sign is diagnostic of schizophrenia, and all can occur in other medical and psychiatric conditions.

Social isolation commonly occurs and may be due to a number of factors. Impairment in social cognition is associated with schizophrenia, as are the active symptoms of paranoia from delusions and hallucinations, and the negative symptoms of apathy and avolition. Many people diagnosed with schizophrenia avoid potentially stressful social situations that may exacerbate mental distress.Freeman D, Garety PA, Kuipers E, Fowler D, Bebbington PE, Dunn G. (2007) Acting on persecutory delusions: the importance of safety seeking. Behaviour Research and Therapy, 45 (1), 89–99. PMID 16530161

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 by disease onset. To minimize the impact of schizophrenia, much work has recently been done to identify and treat the prodrome phase of the illness, which has been detected up to 30 months before the onset of symptoms, but may be present longer.Addington J, Cadenhead KS, Cannon TD, Cornblatt B, McGlashan TH, Perkins DO, Seidman LJ, Tsuang M, Walker EF, Woods SW, Heinssen R. (2007) North American prodrome longitudinal study: a collaborative multisite approach to prodromal schizophrenia research. Schizophrenia Bulletin, 33 (3), 665-72. PMID 17255119 Those who go on to develop schizophrenia may experience the non-specific symptoms of social withdrawal, irritability and dysphoria in the prodromal period,Parnas J, Jorgensen A. (1989) Pre-morbid psychopathology in schizophrenia spectrum. British Journal of Psychiatry, 155, 623–7. and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.Amminger GP, Leicester S, Yung AR, Phillips LJ, Berger GE, Francey SM, Yuen HP, McGorry PD. (2006) Early-onset of symptoms predicts conversion to non-affective psychosis in ultra-high risk individuals. Schizophrenia Research, 84 (1), 67–76. PMID 16677803

Schneiderian 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,Bertelsen, A. (2002). Schizophrenia and Related Disorders: Experience with Current Diagnostic Systems. Psychopathology, 35, 89–93. PMID 12145490 although they have contributed to the current diagnostic criteria.

Positive and negative symptoms Schizophrenia is often described in terms of positive (or productive) and negative (or deficit) symptoms.Sims A (2002) Symptoms in the Mind: An Introduction to Descriptive Psychopathology (3rd edition). Edinburgh: Elsevier Science Ltd. ISBN 0-7020-2627-1 Positive symptoms include delusions, hallucination, 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 communication (alogia), 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.Cohen & Docherty (2004). Affective reactivity of speech and emotional experience in patients with schizophrenia. Schizophr Res, 1;69(1):7–14. PMID 15145465 A third symptom grouping, the disorganization syndrome, is commonly described, and includes chaotic speech, thought, and behaviour. There is evidence for a number of other symptom classifications.Peralta V, Cuesta MJ. (2001) How many and which are the psychopathological dimensions in schizophrenia? Issues influencing their ascertainment. Schizophrenia Research, 30, 49(3), 269-85. PMID 11356588

Diagnosis Diagnosis is based on the self-reported experiences of the person as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, social worker, clinical psychologist or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizophrenia, tests are carried out to exclude medical illnesses which may rarely present with psychotic schizophrenia-like symptoms. These include blood tests measuring Thyroid-stimulating hormone to exclude hypothyroidism or hyperthyroidism, Blood tests#Blood chemistry tests and serum calcium to rule out a metabolic disturbance, Complete blood count including Erythrocyte sedimentation rate to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are Electroencephalography to exclude epilepsy, and a Computed tomography of the head to exclude brain lesions. It is important 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. There are several psychiatric illnesses which may present with psychotic symptoms other than schizophrenia. These include bipolar disorder,Pope HG (1983). Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports. Hospital and Community Psychiatry, 34: 322–328. borderline personality disorder,McGlashan TH (1987) Testing DSM-III symptom criteria for schizotypal and borderline personality disorders. Archives of General Psychiatry, 44: 15–22. drug intoxication, brief drug-induced psychosis, and schizophreniform disorder.

Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, liver function tests if chlorpromazine or CPK to exclude neuroleptic malignant syndrome. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.

The most widely used criteria for diagnosing schizophrenia are from the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization ICD, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian Kurt Schneider#First rank symptoms although, in practice, agreement between the two systems is high.Jakobsen KD, Frederiksen JN, Hansen T, Jansson LB, Parnas J, Werge T (2005) Reliability of clinical ICD-10 schizophrenia diagnoses. Nordic Journal of Psychiatry, 59 (3), 209-12. PMID 16195122 The World Health Organization has developed the tool SCAN (Schedules for Clinical Assessment in Neuropsychiatry) which can be used for diagnosing a number of psychiatric conditions, including schizophrenia.

DSM IV-TR Criteria To be diagnosed with schizophrenia, a person must display:

Characteristic symptoms: Two or more of the following, each present for a significant portion of time during a one-month period (or less, if successfully treated)

delusions
hallucinations
disorganized speech (e.g., frequent derailment or incoherence; speaking in abstraction). See thought disorder.
grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or Catatonia behavior
negative symptoms, i.e., affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation).

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 successfully treated).

Paranoia#Use in psychiatry: 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 schizophrenia: named 'hebephrenic schizophrenia' in the ICD. Where thought disorder and flat affect are present together (DSM code 295.1/ICD code F20.1)
catatonia: prominent psychomotor disturbances are evident. 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 recognises a further two 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 but progressive development of prominent negative symptoms with no history of psychotic episodes (ICD code F20.6)

Schizophrenia Introduction - Health encyclopaedia - NHS Direct
Chronic mental health condition causing hallucinations and delusions ... What is schizophrenia? Schizophrenia is a chronic mental health condition that causes a range of different ...

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Schizophrenia.com, Indepth Schizophrenia Information and Support
Provides patients, family members, and caregivers with information on a variety of important mental health topics including schizophrenia and other common mental illnesses.

BBC NEWS | Health | Medical notes | Schizophrenia
Schizophrenia is a severe and complex mental illness with a wide range of symptoms. ... Schizophrenia is one of the most chronic and disabling of the major mental illnesses.

BBC NEWS | Health | Drug disorder schizophrenia link
Almost half of patients treated for a cannabis related mental disorder will develop a schizophrenic illness.

Schizophrenia - TheSite.org
Information about schizophrenia from TheSite.org. Find out about the symptoms and causes, how to get help and treatment and what to do if a friend or family member has this ...

Schizophrenia
Schizophrenia is a major mental illness that causes changes in perception, thoughts and behaviour.

NIMH · Schizophrenia
Schizophrenia is a chronic, severe, and disabling brain disorder that affects about 1.1 percent of the U.S. population age 18 and older in a given year.