Schizophrenia is a severe mental illness that affects 1% of the world’s population. Contrary to popular opinion, schizophrenia is not a “split personality.” Schizophrenia is a chronic disorder in which individuals experience disturbances in thinking and behavior. People with schizophrenia have a higher risk of suicide, and approximately 10% of all people with schizophrenia commit suicide. They also have a higher risk of substance abuse.
Schizophrenia includes psychotic symptoms such as delusions, hallucinations, and thought disorganization. Delusions are beliefs involving a misunderstanding of experiences. The beliefs are held with conviction even when confronted with clear evidence to the contrary. Examples include romantic delusions of jealousy, delusions of being persecuted, or somatic delusions (that something is wrong with their body despite clear evidence that it is not). Delusions may be bizarre; for example, individuals may believe that they receive personal messages from the radio or television, or that their body is under the control of an outside force.
Hallucinations, which are false sensory perceptions, often occur in schizophrenia. Hallucinations may be auditory, visual, tactile, or olfactory. Individuals may hear voices, or see visions, which seem real. These voices may become threatening, or may comment on what they do.
Thinking may become severely disorganized, and individuals may even have problems speaking coherently. Their behavior can also become severely disorganized, including difficulties caring for themselves, showering, or preparing meals, or acting inappropriately in public. Alternatively, individuals with schizophrenia may exhibit “catatonic” behavior, in which they do not react to what is going on around them. For example, patients with catatonic behaviors could appear to be in a stupor, be rigid, resist instruction or movement, or even show excessive purposeless activity.
Associated symptoms that may occur early include social isolation and withdrawal, self-neglect, lack of motivation, and decreased emotional expression. These are known as “negative symptoms,” reflecting loss of normal functioning, and can persist even with treatment.
Symptoms should be present for 6 months to merit a diagnosis of schizophrenia. Symptoms cannot be due to substance abuse, but frequently patients with schizophrenia have substance abuse problems as well, perhaps in attempts to deal with their psychotic symptoms. Symptoms in an individual with schizophrenia are variable, and there are several types of schizophrenia. These types include: paranoid type, disorganized type, catatonic type, undifferentiated type, or residual type. Diagnosis of the specific type of schizophrenia is dependent on the category into which the predominant symptoms fall.
Disorders other than schizophrenia may also cause psychotic symptoms. Clinicians need to consider other possibilities when they are diagnosing schizophrenia. Other considerations include a mood disorder with psychotic features (e.g., severe bipolar disorder), delusional disorder (with nonbizarre delusions), schizoaffec-tive disorder (with both significant mood and psychotic symptoms), and schizophreniform or brief psychotic disorder (which have shorter time courses).
Physicians will perform a physical examination and may check various laboratory tests to ensure that psychotic symptoms are not due to a medical problem.
For example, use of steroids can cause psychotic-type symptoms. Minor structural brain abnormalities have been noted in individuals with schizophrenia; however, there is not currently a diagnostic test for schizophrenia. Relatives of people with schizophrenia have an increased risk of developing the disorder themselves.
Schizophrenia is a chronic illness that often interferes with work, family, and school. Currently, there is no cure for schizophrenia, but medications can treat symptoms and decrease the risk of relapse. In the past decade, many better medications have been developed. Antipsychotic medications include haloperidol (Haldol), fluphenazine (Prolixin), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify). These long-term medications are helpful in treating delusions and hallucinations and may help with social functioning as well. Each medication has its own possible side effects. For example, side effects could include weight gain (with some of the medications), menstrual irregularities, and, in rare instances, a neurologic problem known as tar-dive dyskinesia (which involves abnormal movements and may develop over the course of many years). Some medications are available as injectables for individuals who have difficulties with adherence. Medications should not be discontinued without discussion with the physician, because of the significant risk of relapse of symptoms of schizophrenia.
Medication management is critical in schizophrenia. Other important treatments include individual psychotherapy, group therapy, and family counseling. Regular follow-up is critical. Individuals with schizophrenia may require hospitalization when their symptoms become dangerous to themselves or others, but in general, they can live at home. Additionally, some individuals with schizophrenia can live in group homes or halfway houses.
ISSUES SPECIFIC TO WOMEN WITH SCHIZOPHRENIA
Men and women have the same lifetime risk of schizophrenia, but in women, schizophrenia develops several years later, often from ages 25 to 35. Women may be diagnosed with schizophrenia through menopause as well. Women with schizophrenia tend to have fewer hospital stays and better social functioning than men with schizophrenia. In women, the focus of therapy may be preservation of roles, such as mother or worker. Sometimes women may delay seeking help because of fear that their children may be removed from their care. However, the sooner that a woman seeks help, the more likely help is to be effective.
Women with schizophrenia should discuss pregnancy with their physicians, and try to plan pregnancy if possible. Risks and benefits of medications during pregnancy to mother and baby should be considered, rather than just discontinuing medications. Different doses of medication may be needed during pregnancy and delivery. Breast-feeding also requires special consideration. Throughout the perinatal period, it is important that psychiatrists are in contact with obstetricians and family doctors so that the patient can get the best care possible.
Postpartum psychosis occurs in approximately 1 out of 1,000 women soon after delivery, and occurs in a significant number of women with schizophrenia. There is a strong risk of recurrence with future pregnancies. Surprisingly, there is more risk of postpartum psychosis in bipolar disorder than in schizophrenia. Physicians and the treatment team may suggest which resources in the community services can be most helpful to mothers with schizophrenia.
The course of schizophrenia in women is believed to be related to their estrogen level, which explains increased symptoms of schizophrenia after delivery and at menopause. Schizophrenia can be a debilitating psychotic illness. Increased knowledge about schizophrenia may lead women with symptoms to see their physicians earlier to begin appropriate treatment, so that their lives may be improved.