Schizophrenia Handbook

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H. Lundbeck A/S 9 Ottiliavej DK - 2500 Valby Copenhagen, Denmark Tel: +45 36 30 13 11 Fax: +45 36 43 89 00 September 2006

This booklet is sponsored by H. Lundbeck A/S an international pharmaceutical company engaged in the research and development, production, marketing and sale of drugs for the treatment of psychiatric and neurological disorders.


Page Foreword What is schizophrenia? What is the frequency of schizophrenia? What causes schizophrenia? How is schizophrenia diagnosed? What are the signs and symptoms of schizophrenia? How is schizophrenia treated? What are the co-morbidities of schizophrenia? What is the social and economic impact of schizophrenia? Further information sources Abbreviations and glossary Index 1 3 9 11 15 19 23 29

31 35 37 41


Even now in the 21st Century, mental illnesses, such as schizophrenia, remain misunderstood, poorly diagnosed, and under-treated. Despite the advances in medical therapies available for this disorder over recent decades, there are still many unmet needs in schizophrenia therapy and we still do not understand the disorder fully.The first major advance for patients, families, carers and physicians alike, would be treatments with increased effectiveness against all subtypes of symptoms, accompanied by fewer side effects. These medications would also have a rapid action with positive effects on the conditions that frequently occur alongside schizophrenia, such as those involving cognition and mood. In addition, there is still a significant group of patients who do not respond to existing therapies, and we should not give up on research to find new treatments which may be effective for these patients. But medication is not the only improvement needed in the therapy for this disorder. Earlier diagnosis would also be helpful, as would better follow-up and more accessible and consistent community care.

Improved communication between the patient, family and physician and the active engagement of families and carers in the treatment and care model are other issues which need to be tackled. Research is ongoing in all these areas, looking at new treatments and healthcare approaches, whilst maintaining the ultimate aims of discovering a cause for the disorder and a cure. In the meantime, education to raise awareness and decrease stigma are other valuable ways to improve the lives of those with schizophrenia. This booklet has been designed as a short synopsis of schizophrenia to provide you with more information on the disorder.

Inger Nilsson, President of EUFAMI

European Federation of Associations of Families of People with Mental Illness1



What is schizophrenia?What is schizophrenia?3

Schizophrenia is the most common form of severe mental illness,1 affecting approximately 24 million people worldwide.2 It is believed to be caused by an imbalance of chemicals in the brain (neurotransmitters), and is characterised by psychotic episodes (delusions, hallucinations, disorganised behaviour) interspersed with periods of blunted emotions, apathy, and withdrawal. However, although the condition is highly treatable, it is complex and poorly understood, and the word schizophrenia is associated with notable stigma and is often misused. A person with schizophrenia experiences a condition where their thoughts (cognition), emotion, and behaviour become disturbed and they may find it difficult to judge reality. These underlying processes produce symptoms that are highly variable, but typically include hallucinations, delusions, apathy, blunted emotions, odd behaviour, poor personal care, and social withdrawal. Consequently, schizophrenia affects most aspects of the human condition, and the resulting symptoms can appear strange and frightening for both the patient and those around them.

Although mental disorders have been studied and described since medical records began, it was the German psychiatrist, Emil Kraepelin (18561926), who first classified mental illness as an actual disease with a specific onset, course and outcome. As part of this classification, Kraepelin described the condition dementia praecox, meaning early mental decline. Dementia praecox was later renamed schizophrenia following extensive study of the symptoms of the disorder by the Swiss psychiatrist, Eugen Bleuler (18571939). The name schizophrenia (from the Greek: schizo=split, phrenos=mind) was chosen to reflect the poor connection between the thought processes (cognition) of a person with the disorder, and other functions of the mind such as emotion, behaviour, and volition (self-will). It is a common misconception that patients with schizophrenia exhibit a split or multiple personality.

Images courtesy of Max Planck Institute and

Emil Kraepelin (18561926)

Eugen Bleuler (18571939)

The course of schizophreniaThe pattern of symptoms and psychotic episodes in schizophrenia varies from person to person (Figure 1). In addition, schizophrenia can also change over time, with different types of symptoms becoming predominant.3 In general, the course of the disorder is long-term

(chronic), consisting of recurrent short-term (acute) episodes characterised by high levels of psychotic symptoms with longer periods with less pronounced psychotic symptoms, or sometimes recovery, in between. Other symptoms, such as negative and cognitive symptoms, are often present in both stages of the disorder.

Figure 1: Patterns in the development and course of schizophrenia

Onset Aacute


Outcomemild or recovered

% with this pattern





moderate or severe





mild or recovered





mild or recovered





moderate or severe



other patterns


Adapted from: Target schizophrenia. The Association of the British Pharmaceutical Industry, London, 2003.1

The onset of symptoms can be sudden, or may be preceded by weeks, months or years of gradually increasing symptoms, known as the prodromal phase. Prodromal signs tend to be non-specific and can include patterns of social isolation, neglected personal hygiene, loss of interest in work/study, and development of odd behaviour and ideas. The psychotic episode is characterised by more so-called positive symptoms, where an individual may experience delusions, hallucinations, fear/anxiety, and may lose the perception of reality. With treatment or, in some cases, left untreated, the active phase diminishes, leaving the person functional again (in remission), or with varying severities of negative and/or cognitive symptoms. These symptoms include blunted emotions, lack of drive/interest,

problems with planning or abstract thinking, and a tendency towards isolation. This period of successful treatment is known as the maintenance phase. After the first psychotic episode, the course of the disorder is unpredictable. As many as 15% of people who experience an acute episode of schizophrenia will never have another episode and recover completely.4 However, more commonly, the person will relapse into further active phases interspersed with residual phases.4 Complete remission (recovery) is less likely once a long-term pattern of episodes becomes established. In addition, 50% of patients with schizophrenia attempt suicide at some point during the course of the disorder, leading to fatality in 10% of cases.1 The overall mortality rate is considerably higher in people with schizophrenia than in the general population (due to coexisting medical problems, as well as suicide).

First visit to a doctor Mrs Johnson requested an appointment with her general practitioner to speak about her son, James, who was aged 18. James was a physically fit young man, but in recent months his behaviour had started to become unusual. He had lost interest in socialising or contacting his friends, and was unresponsive to any attempt at conversation occasionally muttering inaudible or cryptic phrases. He would spend most of his time withdrawn in his room, talking as if he was conversing with some other unseen person. Upon meeting James, the doctor was unable to extract any coherent responses to his questions, and referred him to a psychiatrist for further diagnosis.5

Who is affected?Schizophrenia is most common in young adults, with the majority of individuals developing the disorder between the ages of 15 and 25 years.5 Onset is rare beyond age 40, but it is possible for schizophrenia to develop at any time of life. Schizophrenia affects men and women in approximately equal numbers. However, men tend to develop the disorder 35 years earlier than women (Figure 2). There is also evidence to suggest that, in general, men experience more severe symptoms than women, although women appear to have a worsening of symptoms during the menopause. Schizophrenia affects all cultures.5 Well-known individuals with schizophrenia have included Vaclav Nijinsky (ballet dancer/choreographer), Syd Barrett (musician, Pink Floyd), Peter Green (musician, Fleetwood Mac), and Eduard Einstein (son of physicist, Albert). Schizophrenia has also been portrayed on film, in the life stories of John Nash (mathematician/Nobel prize winner A beautiful mind) and David Helpffgott (pianist Shine), and in the fictional account of One flew over the cuckoos nest.


Figure 2: Relative risk of the onset of schizophrenia versus age

Incidence of schizophrenia

Female Male

Median 25 years 20 25

Median 28 years 30 Age (years) 35 40 45