But you’re also far from correct. “If four percent of the general population exhibits violent behavior, maybe seven percent of the schizophrenic population does,” says William T. Carpenter, MD, one of the foremost experts on schizophrenia in the U.S. and a professor of psychiatry at the University of Maryland School of Medicine in Baltimore. “There is a large stigma associated with this disease, and a lot of that is fed by a lack of understanding of what schizophrenia really is.” So what is it, exactly?
What is schizophrenia?
Despite how it has been depicted to the public for more than 100 years, schizophrenia is not a single-entity disease, says Dr. Carpenter. “We don’t know how many pathways there are for someone to develop the disease, but we do know that different people can develop schizophrenia for different reasons,” he says. Because of this, experts refer to it as a syndrome. “Schizophrenia is a clinical syndrome characterized clinically by various combinations of so-called positive symptoms, negative symptoms, cognitive difficulties and impairment in ability to function,” says Russell Margolis, M.D., clinical director of the Johns Hopkins Schizophrenia Center in Baltimore. In a nutshell, people with schizophrenia may hear and see things that are not there, lose interest in things happening around them and have trouble focusing. They may also exhibit physical behaviors—from repetitive motions to skipping—that are out of touch with their current environment. “People with schizophrenia often feel like their movements are being made for them by someone outside their body,” says Dr. Carpenter. “Their experience of reality is different than the reality they are in.”
Schizophrenia symptoms
That altered reality is an overarching symptom of the disease and one most people think of when they hear the word “schizophrenic.” There are other symptoms, which psychiatrists divide into three camps: positive, negative and disorganized. (Positive meaning the presence of additional behaviors and negative meaning the absence of them.)
Positive symptoms
Positive psychotic symptoms for the disorder are what most people think of when they think of schizophrenia. According to the National Institute of Mental Health, these include hallucinations (a person sees or hears things that are not really there), delusions (firmly held beliefs that do not align with facts) and exaggerated or distorted thinking.
Negative symptoms
The negative symptoms associated with schizophrenia can limit a person’s ability to function on a day-to-day level, according to the Cleveland Clinic in Ohio. For instance, a person with negative symptoms may experience loss of motivation and interest in the world around him. Sometimes, this emotional “paralysis” of sorts can turn into a literal physical one—where the body becomes rigid and can’t move, known as a catatonic state. Other negative symptoms include cutting off contact with friends and family, a disinterest in washing or grooming and having dulled emotions. Some of these negative symptoms may be related to a lack of sleep, or insomnia, which up to 44 percent of people with schizophrenia experience, according to a recent study in The Journal of Clinical Psychiatry. The study found a direct correlation between insomnia in schizophrenia patients and risk of suicide (5 to 10 percent of people with the disorder die by suicide).
Disorganized symptoms
This grouping of symptoms refers to thinking that is not linear or necessarily logical, and behaviors that appear random, like repetitive movements or childlike gestures. People with schizophrenia may be confused in their thoughts and say things that feel inappropriate or at odds with the current reality.
Early Signs of Schizophrenia
For reasons scientists are still sorting out, schizophrenia first appears in men at an earlier age that in women—often in a man’s early 20s or even late teens. (In women, onset usually occurs in their late 20s and early 30s.) These early symptoms may show up as mood swings or disorders like depression, and can include things like difficulty in relationships, poor academic performance and lack of motivation. It’s often unclear, says Dr. Carpenter, that these symptoms are linked with schizophrenia until much later.
Schizophrenia causes
One of the biggest challenges with schizophrenia is how little scientists still know about the root causes of the disease. “If you look at Parkinson’s or multiple sclerosis, scientists can tell you a lot about the neurology or basic mechanisms,” says Dr. Carpenter. “But with schizophrenia, we can’t do an MRI and point to ‘there it is’ in the brain. We can assume certain networks are not functional optimally, but we have yet to define the nature of the dysfunction. We can see signs of it but it doesn’t tell us the biologic mechanism.” Still, scientists are getting closer. A 2020 study by researchers at the MRC London Institute of Medical Sciences found lower levels of a protein in the synapses that connect brain neurons in people with schizophrenia. While experts have believed for a while that faulty connections in the brain play a role in the disease, this study was the first to capture it on a brain scan. Other research at Harvard Medical School suggests that a breakdown in connectivity between two regions of the brain (specifically, the dorsolateral prefrontal cortex-to-cerebellum network) may lead to some of the negative schizophrenic symptoms, like lack of communication. In their study, researchers found that using non-invasive transcranial magnetic stimulation was able to restore some of this brain function, reducing negative symptoms. Even with this knowledge, there is still no single test for schizophrenia, says Dr. Carpenter. “Imaging techniques will show differences in the brains of people with the disease versus the control, but it’s not consistent enough to be used as a biomarker,” he explains.
Is schizophrenia genetic?
While scientists work to pinpoint the specific mechanisms that cause the disease, one thing they do know are the risk factors. Top of the list: your gene pool. “Schizophrenia is largely genetic,” says Dr. Margolis. “Genetics contributes to about 70 to 80 percent of the risk of developing schizophrenia.” It’s important to note, though, that while having a parent who has the disease increases your likelihood of developing it, too, it’s no fait accompli. Except in rare individuals, says Dr. Margolis, no single genetic variation or mutation causes schizophrenia. Rather, a person may inherit multiple subtle genetic variations, which—when combined together and with certain environmental risk factors—can lead to the development of the disease. The possible genetic variations are many—a study in the scientific journal Nature of more than 36,000 people with schizophrenia found 128 genetic variants for the disease.
How common is schizophrenia?
Despite its popularity as a movie theme (see: A Beautiful Mind, The Soloist and The Fisher King) and its wide recognition in popular culture, schizophrenia is a fairly rare disease, affecting less than one percent of the general population. “Population-based evidence suggests that somewhere in the neighborhood of 0.5 to 0.6 percent of people are going to end up with a schizophrenia diagnosis,” says Dr. Carpenter. That works out to about 20 million people worldwide, 69 percent of which are not receiving adequate care for their disorder, according to the World Health Organization. Moreover, 90 percent of people with untreated schizophrenia live in lower income neighborhoods where access to quality care may be limited. Clinical and emotional support is essential for helping people in these communities stay ahead of their disease.
Types of schizophrenia
As researchers continue to learn more about the mechanisms at the root of this disorder, the way clinicians diagnose and refer to it has evolved as well. Ten years ago, for instance, the DSM-IV—the diagnostic manual used by clinicians for psychiatric illnesses—divided schizophrenia into five types:
Paranoid: Preoccupation with delusions and hallucinations.Disorganized: Speech and behavior is random, not well organized and/or inappropriate.Catatonic: Lack of emotional, mental and physical response. People may remain motionless and withdrawn for extended periods of time, according to the Cleveland Clinic.Undifferentiated: A vague set of symptoms that do not neatly fit into one of the other categories. A person may feel anxious or depressed.Residual: Negative symptoms and odd beliefs dominate; hallucinations and delusions are less common.
In 2013, however, the new DSM-V dropped these sub-classes of the disease. “We now know that these are meaningless subdivisions, as individuals with schizophrenia may have different symptoms over time,” says Dr. Margolis. “Now, the issue is much more about schizophrenia versus schizoaffective disorder or forms of bipolar disorder.” The hope, he adds, is that today’s research in brain imaging, genetics and other biological measurements may provide better ways for doctors to classify the disease.
Is schizophrenia curable?
Well, no. Until researchers discover the underlying biological mechanisms in the brain that trigger schizophrenic behavior, a cure is not likely. But it’s not all depressing news: Some people respond well to treatment, says Dr. Carpenter: “About 20 percent of people with schizophrenia are treatment-responsive, meaning after receiving treatment for an initial psychotic episode they may recover and are not ill again, or are very treatable.” These people will go through life seeming like everybody else. “Then, maybe 40 percent of patients are continuously having low level symptoms or relapses,” he says. “It’s not a kiss of death diagnosis, they can still be treated.” But other people will develop a condition that may only partially respond to current treatments, says Dr. Margolis. For these people, schizophrenia is both self-stigmatizing and stigmatized by society as well. “You cannot imagine a country filling prisons with people who have had strokes or MS,” says Dr. Carpenter. “But people with schizophrenia and other psychotic disorders are way over represented in jails because we do not have a healthcare system that supports them.”
How to treat schizophrenia
If there is a ray of hope for people with schizophrenia, it’s that progress has been made in developing drug therapies that ease symptoms without as severe side effects as medications from a generation ago. Some of the antipsychotic therapies are able to decrease the number or severity of hallucinations and delusions, while other medication works to restore a person’s focus and clarity in thinking. “Progress has indeed been made on many fronts,” says Dr. Margolis. “New medicines may help those who were not helped by older medicines, or have fewer side effects. And perhaps the biggest improvements have been in the realm of psychosocial treatments—there is now widespread recognition that early intervention, with therapy, career and educational support and family guidance can make a major difference in someone’s outcome with this disorder.” Up next, learn more with the Top 25 Schizophrenia Podcasts, Books, Instagram Accounts and Documentaries
Sources
William T. Carpenter, M.D., schizophrenia expert and professor of psychiatry at the University of Maryland School of Medicine in BaltimoreRussell Margolis, M.D., clinical director of the Johns Hopkins Schizophrenia Center in Baltimore.Nature Communications: “Synaptic density marker SV2A is reduced in schizophrenia patients and unaffected by antipsychotics in rats.”National Institute of Mental Health: “Schizophrenia.”Cleveland Clinic: “Schizophrenia.”The Journal of Clinical Psychiatry: “Insomnia, Suicidal Ideation, and Suicide Attempts in the Clinical Antipsychotic Trials of Intervention Effectiveness.”The American Journal of Psychiatry: “Cerebellar-Prefrontal Network Connectivity and Negative Symptoms in Schizophrenia.”Nature: “Biological insights from 108 schizophrenia-associated genetic loci.”World Health Organization: “Schizophrenia.”Brown University: “Schizophrenia (DSM-IV-TR #295.1–295.3, 295.90).”National Center for Biotechnology Information: “Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health.”Cleveland Clinic: “What Are the Four Types of Schizophrenia and How Can They Affect You?”
