Schizophrenia is one of the most severe psychological disorders, as well as one of the more common, and possibly the most widely misunderstood. The disorder’s name is partly responsible for the confusion. It is not unusual to ﬁnd people confusing schizophrenia with dissociative identity disorder (multiple personality disorder), perhaps because the word schizophrenia comes from Greek roots meaning “split brain.” The split in this term is actually a reference to the fragmented thinking and emotions experienced by victims of the disorder, not a split personality.
Schizophrenia strikes about one adult in 100 and is slightly more common in men than in women. The disorder also tends to develop earlier and to follow a more severe course in men than in women. The disorder tends to develop in adolescence or early adulthood (almost always before age forty-ﬁve), which lent it the name German psychiatrist Emil Kraepelin ﬁrst gave the disorder, dementia praecox, meaning “youthful insanity.” In the United States, schizophrenia accounts for 75 percent of mental health expenditures.
According to the DSM-IV, schizophrenia is a group of disorders rather than a single syndrome, characterized by disturbances in thought, perception, affect, behavior, and communication, and lasting longer than six months. Common psychotic symptoms include the following:
- Catatonic behavior—bizarre motor behavior marked by a decrease in reactivity to the environment, or hyperactivity that is unrelated to external stimuli.
- Delusions—unfounded beliefs that are thought to be true even in the face of contradictory evidence.
- Hallucinations—a sensory experience in the absence of external stimuli (may affect hearing, taste, vision, smell, or sense of touch).
- Loose associations—disordered thoughts, which seem to follow one upon another without logical connection. In conversation, this produces a pattern of incomprehensible speech sometimes called word salad.
- Flat affect or inappropriate affect—Emotional reactions are either absent, blunted, or inappropriate to the situation (laughing at tragic news, for example).
There are ﬁve recognized types of schizophrenia, showing the above symptoms in varying degrees: catatonic, paranoid, disorganized, undifferentiated, and residual. People with the catatonic subtype sometimes persist in a motionless, stuporous state for hours before abruptly shifting to an agitated, hyperactive state. They may hold a ﬁxed posture for hours without responding to the environment. Less common is the phenomenon of waxy ﬂexibility, in which body position can be molded by others into unusual and uncomfortable positions that will be held for hours. The catatonic type is a rare form.
The paranoid type, conversely, is the most common form of schizophrenia. It is characterized by delusions accompanied by auditory hallucinations. Delusions of grandeur (e.g., believing oneself to be Napoleon or Cleopatra) are common, as are delusions of persecution (believing one is being pursued by the Maﬁa or the CIA, or that the government is reading one’s thoughts electronically, for example) and jealousy (e.g., believing one’s spouse is unfaithful despite a complete lack of evidence).
The disorganized type (formerly known as hebephrenic schizophrenia) involves confused behavior, incoherent speech, frequent vivid hallucinations, inappropriate affect, and disorganized delusions (the delusions of the paranoid subtype, by comparison, tend to be well-organized and consistent), which often have sexual or religious themes. These symptoms are often accompanied by a neglect of personal hygiene, incontinence, and difﬁculty relating to others.
The undifferentiated and residual subtypes may be more properly considered transitional forms than actual subtypes of the disorder. In the undifferentiated type, signs of more than one type of schizophrenia are seen in the same individual. The residual type actually refers to a person in whom some recovery has occurred: the symptoms have largely abated but are not completely gone, with the occasional hallucination or delusional thought still occurring.
Opinion on the causes of schizophrenia has changed fairly dramatically over time. In the ﬁrst half of the twentieth century, schizophrenia was seen as a reactive disorder, with symptoms that resulted from environmental inﬂuences. During the heyday of psychoanalysis, one inﬂuence towered above the others: the mother. Speciﬁcally, the disorder was caused by the poor parenting provided by a schizophrenogenic mother. Such a mother produced schizophrenia by being cold, dominant, overprotective, rejecting, moralistic, and fearful of intimacy.
Seemingly odd in modern eyes, but perfectly in keeping with psychoanalytic theory and tradition, the fathers in these families receive no blame, nor indeed any attention at all from the psychoanalysts.
A growing body of evidence indicates that while schizophrenia may in fact run in families, it is for genetic rather than behavioral reasons. The closer the genetic relationship a person shares with a person with schizophrenia, the greater the likelihood that that person will also develop schizophrenia. For example, whereas the likelihood of anyone having schizophrenia is about 1 percent, the tendency for non-twin siblings of a person with schizophrenia jumps up to about 15 percent. The tendency for a monozygotic (identical) twin to develop the disorder if the other twin has it jumps up to anywhere from 30 to 50 percent, depending on the study. Clearly, then, there is a genetic factor involved in schizophrenia. Just as clearly, however, given the fact that 50 to 70 percent of identical twins of schizophrenics do not develop the disorder, genetic inﬂuences cannot be the only causal factor. What is inherited is a tendency to develop schizophrenia, not the disorder itself. A popular theory regarding the causes of schizophrenia is known as the diathesis-stress model, which suggests that schizophrenia results from the interaction between an inherited predisposition and severe environmental stress.
In addition to the genetic data, the evidence that schizophrenia is best seen as a physiological disease of the brain rather than as a purely psychological problem is fairly overwhelming. The most effective treatment for the symptoms of the disorder, for example, often involves antipsychotic drugs that work by blocking brain receptor sites for dopamine, a major neurotransmitter. Brain imaging techniques such as MRI and CT scans show evidence of abnormal brain development in many schizophrenia patients. The areas that seem to be most affected are the prefrontal cortex and the limbic system. This is unsurprising given the symptoms. The prefrontal cortex is the area responsible for organizing thoughts and behavior and is also involved in judgment and planning, while the limbic system is important in the processing of emotional experiences and memory. (Recognition of the involvement of these areas led to the widespread use of an earlier treatment for psychotic disorders, the prefrontal lobotomy).
Although antipsychotic drugs have rendered such earlier tools as surgery and restraints obsolete, they are not without drawbacks. Long-term use of antipsychotic drugs can lead to a wide range of unpleasant side effects, including weight gain, skin problems, restlessness, Parkinson’s disease-like symptoms, dystonia (involuntary contraction of muscles), and tardive dyskinesia. Tardive dyskinesia is a loss of voluntary muscle control, especially in the face, where it takes the form of involuntary chewing, tongue movements, and lip smacking. About 25 to 40 percent of patients who take antipsychotic medications for at least several years develop tardive dyskinesia. Because of these side effects, the major public health issue facing professionals who work with schizophrenics today is the fact that many schizophrenic patients stop taking their medication and experience a return of symptoms, which of course makes it very difﬁcult for them to function in society. One way to combat this problem is slowly appearing on the market, in the form of longer-lasting, time-released forms of antipsychotic medication. These do not have to be taken as frequently, and are associated with a lower incidence of side effects.
- Fowles, D. C. “Schizophrenia: Diathesis-Stress Revisited.” Annual Review of Psychology, 43 (1992): 303–336;
- World Health Organization. Schizophrenia: An International Follow-Up Study. Chichester, U.K.: Wiley, 1979.