handbookSchizophrenia
H. Lundbeck A/S9 Ottiliavej DK - 2500 ValbyCopenhagen, DenmarkTel: +45 36 30 13 11 Fax: +45 36 43 89 00www.lundbeck.comSeptember 2006
This booklet is sponsored by H. Lundbeck A/S – an international pharmaceutical company engagedin the research and development, production, marketing and sale of drugs for the treatment ofpsychiatric and neurological disorders.
Contents
Page
Foreword 1
What is schizophrenia? 3
What is the frequency of schizophrenia? 9
What causes schizophrenia? 11
How is schizophrenia diagnosed? 15
What are the signs and symptoms of schizophrenia? 19
How is schizophrenia treated? 23
What are the co-morbidities of schizophrenia? 29
What is the social and economic
impact of schizophrenia? 31
Further information sources 35
Abbreviations and glossary 37
Index 41
Foreword
1
Fore
wor
d
The first major advance for patients, families,carers and physicians alike, would be treatmentswith increased effectiveness against allsubtypes of symptoms, accompanied by fewerside effects. These medications would also havea rapid action with positive effects on theconditions that frequently occur alongsideschizophrenia, such as those involving cognitionand mood. In addition, there is still a significantgroup of patients who do not respond toexisting therapies, and we should not give up onresearch to find new treatments which may beeffective for these patients.
But medication is not the only improvementneeded in the therapy for this disorder. Earlierdiagnosis would also be helpful, as would betterfollow-up and more accessible and consistentcommunity care.
Even now in the 21st Century,mental illnesses, such asschizophrenia, remainmisunderstood, poorly diagnosed,and under-treated. Despite theadvances in medical therapiesavailable for this disorder overrecent decades, there are still manyunmet needs in schizophreniatherapy and we still do notunderstand the disorder fully.
Improved communication between the patient,family and physician and the activeengagement of families and carers in thetreatment and care model are other issueswhich need to be tackled.
Research is ongoing in all these areas, looking atnew treatments and healthcare approaches,whilst maintaining the ultimate aims ofdiscovering a cause for the disorder and a cure.In the meantime, education to raise awarenessand decrease stigma are other valuable ways toimprove the lives of those with schizophrenia.
This booklet has been designed as a shortsynopsis of schizophrenia to provide you withmore information on the disorder.
Inger Nilsson,President of EUFAMI
European Federationof Associations ofFamilies of People withMental Illness
2
3
Wha
tis
schi
zoph
reni
a?
What is schizophrenia?
Although mental disorders have beenstudied and described since medical recordsbegan, it was the German psychiatrist, EmilKraepelin (1856–1926), who first classifiedmental illness as an actual ‘disease’ with aspecific onset, course and outcome. As partof this classification, Kraepelin describedthe condition ‘dementia praecox’, meaningearly mental decline.
Dementia praecox was later renamed‘schizophrenia’ following extensive study ofthe symptoms of the disorder by the Swisspsychiatrist, Eugen Bleuler (1857–1939).The name schizophrenia (from the Greek:‘schizo’=split, ‘phrenos’=mind) was chosento reflect the poor connection between thethought processes (cognition) of a personwith the disorder, and other functions ofthe mind such as emotion, behaviour, andvolition (self-will). It is a commonmisconception that patients withschizophrenia exhibit a ‘split’ or ‘multiple’personality.
Schizophrenia is the most common form ofsevere mental illness,1 affecting approximately24 million people worldwide.2 It is believed tobe caused by an imbalance of chemicals in thebrain (neurotransmitters), and is characterisedby psychotic episodes (delusions, hallucinations,disorganised behaviour) interspersed withperiods of blunted emotions, apathy, andwithdrawal. However, although the condition ishighly treatable, it is complex and poorlyunderstood, and the word ‘schizophrenia’ isassociated with notable stigma and is oftenmisused.
A person with schizophrenia experiences acondition where their thoughts (cognition),emotion, and behaviour become disturbed andthey may find it difficult to judge reality. Theseunderlying processes produce symptoms thatare highly variable, but typically includehallucinations, delusions, apathy, bluntedemotions, odd behaviour, poor personal care,and social withdrawal. Consequently,schizophrenia affects most aspects of thehuman condition, and the resulting symptomscan appear strange and frightening for both thepatient and those around them.
Emil Kraepelin
(1856–1926)Images courtesy of Max Planck Institute andwww.corbis.com.
Eugen Bleuler
(1857–1939)
4
The course of schizophrenia
The pattern of symptoms and psychoticepisodes in schizophrenia varies from person toperson (Figure 1). In addition, schizophrenia canalso change over time, with different types ofsymptoms 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 ofpsychotic symptoms with longer periods withless pronounced psychotic symptoms, orsometimes recovery, in between. Othersymptoms, such as ‘negative’ and ‘cognitive’symptoms, are often present in both stages ofthe disorder.
25acute episodic
CourseOnset Outcome%
with thispattern
mild or recoveredA
23F other patterns
8acute continuous moderate or severeB
10gradual episodic mild or recoveredC
10gradual continuous mild or recoveredD
24gradualE continuous moderate or severe
Figure 1: Patterns in the development and course of schizophrenia
Adapted from: Target schizophrenia. The Association of the British Pharmaceutical Industry, London, 2003.1
5
The onset of symptoms can be sudden, or maybe preceded by weeks, months or years ofgradually increasing symptoms, known as theprodromal phase. Prodromal signs tend to benon-specific and can include patterns of socialisolation, neglected personal hygiene, loss ofinterest in work/study, and development of oddbehaviour and ideas.
The psychotic episode is characterised by moreso-called ‘positive symptoms’, where anindividual may experience delusions,hallucinations, fear/anxiety, and may lose theperception of reality.
With treatment or, in some cases, leftuntreated, the active phase diminishes, leavingthe person functional again (in remission), orwith varying severities of negative and/orcognitive symptoms. These symptoms includeblunted emotions, lack of drive/interest,
problems with planning or abstract thinking,and a tendency towards isolation. This period ofsuccessful treatment is known as themaintenance phase.
After the first psychotic episode, the course ofthe disorder is unpredictable. As many as 15%of people who experience an acute episode ofschizophrenia will never have another episodeand recover completely.4 However, morecommonly, the person will relapse into furtheractive phases interspersed with residual phases.4
Complete remission (recovery) is less likely oncea long-term pattern of episodes becomesestablished. In addition, 50% of patients withschizophrenia attempt suicide at some pointduring the course of the disorder, leading tofatality in 10% of cases.1 The overall mortalityrate is considerably higher in people withschizophrenia than in the general population(due to coexisting medical problems, as well assuicide).
First visit to a doctorMrs 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 hisbehaviour had started to become unusual. He had lost interest in socialising or contacting hisfriends, and was unresponsive to any attempt at conversation – occasionally mutteringinaudible or cryptic phrases. He would spend most of his time withdrawn in his room, talkingas if he was conversing with some other ‘unseen’ person. Upon meeting James, the doctor wasunable to extract any coherent responses to his questions, and referred him to a psychiatristfor further diagnosis.
6
Who is affected?
Schizophrenia is most common in young adults,with the majority of individuals developing thedisorder between the ages of 15 and 25 years.5
Onset is rare beyond age 40, but it is possiblefor schizophrenia to develop at any time of life.
Schizophrenia affects men and women inapproximately equal numbers. However, mentend to develop the disorder 3–5 years earlierthan women (Figure 2). There is also evidenceto suggest that, in general, men experiencemore severe symptoms than women, althoughwomen appear to have a worsening ofsymptoms during the menopause.
Schizophrenia affects all cultures.5
Well-known individuals with schizophreniahave included Vaclav Nijinsky (balletdancer/choreographer), Syd Barrett(musician, Pink Floyd), Peter Green(musician, Fleetwood Mac), and EduardEinstein (son of physicist, Albert).Schizophrenia has also been portrayed onfilm, in the life stories of John Nash(mathematician/Nobel prize winner – ‘Abeautiful mind’) and David Helpffgott(pianist – ‘Shine’), and in the fictionalaccount of ‘One flew over the cuckoo’snest’.
7
Median25 years
Median28 years
20 25 30 35 40 45
Age (years)
Male
Female
Inci
denc
eof
schi
zoph
reni
a
Figure 2: Relative risk of the onset of schizophrenia versus age
Adapted from: Target schizophrenia. The Association of the British Pharmaceutical Industry, London, 2003.1
8
The consequences ofschizophrenia
As a diverse and serious condition, schizo-phrenia produces complex consequences.
The obvious major consequence is to thepatients themselves, who typically experiencesevere anxiety and fear during psychoticepisodes, prompted by hallucinations, delusionsand general loss of reality. While it is distressingfor the patient to cope with situations thatthey genuinely perceive as ‘real’, it is alsoextremely disturbing for family and friends todeal with this often alarming change inbehaviour. For every person with schizophrenia,around 10 others are affected by itsconsequences.1 This can put a strain onrelationships, leading to inevitably difficultdecisions about care provision, and adding tothe general stress of the situation.
Aside from emotional concerns, schizophreniacan also impact on an individual’s future interms of education, employment and resultingfinancial security. The intermittent andunpredictable nature of symptoms makessteady work and independent living difficult formost individuals. Therefore, information andsupport are necessary for patients and theirfamilies to provide adequate patient care andavoid potential decline into problems such asfamily breakdown, drug and alcohol abuse, andhomelessness. As a result, healthcare costs for
support to patients with schizophrenia are highand wide ranging, with only 1% of the cost ofcare due to drug treatment. Community follow-up of hospital treatment is essential for manyreasons, not least because one of the highestrisk periods for patient suicide is in the first 6weeks after discharge from hospital followingthe initial psychotic episode.
All these difficulties, combined with the socialstigma of this often misunderstood conditioncan compound the issues facing people withschizophrenia and further impair their chancesof regaining their quality of life.
References1. ABPI. Target schizophrenia. May, 2003.
2. World Health Organization (WHO).Schizophrenia. www.who.int/mental_health/management/schizophrenia, accessed March 2006.
3. Marneros A, Deister A, Rohde A. Validity of thenegative/positive dichotomy for schizophrenicdisorders under long-term conditions.Schizophr Res 1992; 7 (2): 117–123.
4. Watt DC, Katz K, Shepherd M. The naturalhistory of schizophrenia: a 5-year prospectivefollow-up of a representative sample ofschizophrenics by means of a standardizedclinical and social assessment. Psychol Med1983; 13 (3): 663–670.
5. NHS National electronic Library for Health.www.nelmh.org/home_schizophrenic.asp?c=10,accessed March 2006.
What is the frequency ofschizophrenia?
9
Freq
uenc
y
Schizophrenia most frequently appears in youngadults (generally between 15 and 25). Althoughmen and women are affected equally,symptoms may appear later in women thanmen (see Figure 2, page 7).1 Schizophrenia is afairly common illness, although estimates of itsfrequency are variable due to worldwidedifferences in diagnosis, methods of estimation,and healthcare provision.
Data from various studies give a prevalence rate(total number of cases in the population) ofabout 0.5%. That is, schizophrenia affects 1 inevery 200 people worldwide.2 However, theprevalence varies with age, increasing until age40, and then declining. The estimate of lifetimerisk is 1% (or 1 in 100 people). This measure isthought to be a more representative value as ittakes into account that the most high-risk agegroup is between 20 and 39 years.2
Studies of the number of new cases ofschizophrenia gave an incidence of 21.8 per100,000 people.2 This gives an incidence rate of0.02%. The incidence rate is lower than theprevalence rate because schizophrenia is apredominantly chronic disorder, and so itspresence in the population is cumulative.3
Where in the world?
The prevalence of schizophrenia does not followa geographical pattern, appearing to begenerally constant across all areas of the world.2
However, there are some variations withinindividual countries, with a higher number ofcases generally found in larger cities.
Unfortunately, although the prevalence ofschizophrenia shows a relatively constantworldwide distribution, treatment levels do not.The World Health Organization (WHO)estimates that 90% of people with untreatedschizophrenia are in developing countries.3
References1. ABPI. Target schizophrenia. May, 2003.
2. Tsuang MT, Faraone SV. Schizophrenia, thefacts. Second edition. Oxford University Press,1997.
3. World Health Organization (WHO).Schizophrenia. www.who.int/mental_health/management/schizophrenia, accessed March 2006.
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11
Cau
ses
What causes schizophrenia?
The exact cause of schizophrenia is not yetknown, although studies point towards acombination of genetic and environmentalfactors that influence the function of the brain.
The disorder process
The symptoms of schizophrenia are associatedwith changes in brain activity, which can beseen using medical imaging techniques thatmeasure electrical activity, as shown in Figure 3.The specific processes of the disorder thatcause these changes remain unclear, but oneaccepted theory is that people withschizophrenia have an imbalance in thechemicals that send signals in the brain(neurotransmitters). For example, visualhallucinations may be due to over-stimulationof certain brain areas by the neurotransmitter,dopamine,1 while the negative symptoms maybe correlated with lowered dopamine activity inother brain regions.
In addition, brain scans of people withschizophrenia have shown that fluid-filled areasof the brain called the ventricles may beenlarged in some types of schizophrenia, withthe amygdala and hippocampus reduced in size(Figure 4).2 How these alterations are connectedto the symptoms of schizophrenia is unknown.
Coloured positron emission tomography (PET) scans ofaxial sections through a healthy brain (left) and aschizophrenic brain (right). The colours show differentlevels of activity within the brain during an attentiontest. Red shows high activity, through yellow and greento black (very low activity). The schizophrenic brainshows much lower activity in the frontal lobes.
Image from the Science Photo Library.
Figure 3: Altered brain activity in patientswith schizophrenia
12
Lateral ventricles
a) Brain ventricles and the central canal
Third ventricle
Fourth ventricle
Central canal
Mammillary bodyof hypothalamus
Anterior nucleusof thalmus
Hippocampus
Area of thalamus(dotted)
b) The limbic system
Amygdala
Corpus callosum
Figure 4: Areas of the brain – in some types of schizophrenia, the ventricles may be enlarged,whilst the amygdala and hippocampus may be reduced in size
13
Is the condition inherited?
The parents or siblings of a person withschizophrenia have a 10-fold higher risk ofdeveloping the disorder than a person in thegeneral population, and this rises to a 15-foldhigher risk for the children of people withschizophrenia (Figure 5).3 However, studies inidentical and non-identical twins have shownthat development of the condition is notentirely explained by genetic inheritance. Inthose cases where one identical twin developedschizophrenia, the second identical twin (whowould have inherited exactly the same genes)developed schizophrenia in only around 50% ofcases.3
The conclusion is that genes (probably acomplex interaction of several) do play animportant part in whether or not an individualwill develop schizophrenia, but that otherfactors must also play a significant role.
Risk of developing schizophrenia (%)
Affected relative
Parent
Identical twin
Non-identical twin
Brother or sister
Grandparent
Aunt or uncle
Cousin
None
0 10 20 30 40 50
Figure 5: Family patterns of schizophreniadevelopment
Adapted from: Target schizophrenia. The Association ofthe British Pharmaceutical Industry, London, 2003.4
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Can the environment be a riskfactor?
In the ‘nature versus nurture’ argument, if genes(‘nature’) do not cause schizophrenia everytime (as shown by the twin studies), then theenvironment (‘nurture’), must also be involvedin some way – perhaps acting as a trigger forthe genetic factors.
Male gender and winter birth are known to beconnected with earlier development of, andhigher rates of schizophrenia, respectively. Butthe mechanism underlying these links isunknown.2 Long-term use of drugs (inparticular, use of cannabis and stimulants) isthought to carry increased risk, alcohol mayalso alter the brain chemistry to produceschizophrenia.5 Other proposed environmentaltriggers include stress, viral infection, exposureto toxins, physical injury (prenatal or inchildhood), or difficult family dynamics, but theconnection between these factors andschizophrenia is less well established.
References1. Kandel ER, Schwartz JH, Jessell TM. Principles
of neural science. Fourth edition. McGraw Hill,2000.
2. Frith C, Johnstone E. Schizophrenia. A very shortintroduction. Oxford University Press, 2003.
3. Tsuang MT, Faraone SV. Schizophrenia, the facts.Second edition. Oxford University Press, 1997.
4. ABPI. Target schizophrenia. May, 2003.
5. NHS National electronic Library for Health.www.nelmh.org/home_schizophrenic.asp?c=10,accessed March 2006.
Dia
gnos
is
Schizophrenia is a complex disorder to diagnosedue to the variation in symptoms and the lackof a defect measurable by a laboratory orclinical method. Therefore, schizophrenia isgenerally diagnosed by a psychiatrist, speakingto the patient about their experiences of thecondition. The specialist will also aim toestablish how long the symptoms have beenpresent, how they are affecting everyday life,and will try to speak to the patient’s family andfriends. It may not be possible to diagnoseschizophrenia at an early stage if the symptomsare mild and non-specific, and some physiciansmay be unwilling to offer a definite earlydiagnosis due to the immediate social andpersonal consequences of being labelled withschizophrenia.
Diagnosis
There are two main sets of clinical guidelinesthat provide standard rules for the diagnosis ofschizophrenia. These are:
• International Classification of Diseases, 10th
edition (ICD-10), which is issued by theWorld Health Organization and is frequentlyused in Europe1
• Diagnostic and Statistical Manual, 4th edition(DSM-IV), which is issued by the AmericanPsychiatric Association and is morefrequently used as a guide in the US.2
These classification systems outline therequirements for diagnosis. The first of these isa combination of core symptoms, such ashallucinations, delusions, and disruption inthought processes, along with evidence offunctional decline (work, social, self-care). Inaddition, these symptoms must have beenpresent for a particular duration, which rangesfrom 1–6 months, depending on the scale used.Finally, the patient must display no exclusioncriteria, that is, the physician must ensure thatthe symptoms are not being caused by anothercondition, e.g., drug-use, brain tumour, epilepsy,or mood disorder. In this way, the physician canmake a differential diagnosis of schizophrenia.
15
How is schizophrenia diagnosed?
16
References1.World Health Organization. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria
for research. Geneva, Switzerland. © World Health Organization, 1992.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fourth edition.Washington, USA © American Psychiatric Association, 1994.
3. Tsuang MT, Faraone SV. Schizophrenia, the facts. Second edition. Oxford University Press, 1997.
Differentiating schizophrenia from other disorders
Several other conditions may producesymptoms that are very similar to thoseobserved in schizophrenia. For effectivemanagement, it is extremely important thatschizophrenia is differentiated from these otherconditions, some of which are described in thetable opposite.
Schizoaffective disorder
Some patients show equal measures ofsymptoms of both mood-based (affective)disorders and schizophrenia. In such cases, aschizoaffective disorder may be diagnosed,although it has not yet been establishedwhether these are entirely separate conditions,or different extremes of the same disorder.3
17
Table 1: Disorders producing similar symptoms to schizophrenia
Condition type Examples Differentiating factors
Drug-induced Known use of drugs such as LSD, Symptoms subside upon withdrawalcannabis, amphetamines, cocaine, of the drug/alcohol.ecstasy.
Alcohol abuse.
Physical Viral infection of the brain Brain scans or analysis of cerebro-(encephalitis), epilepsy, brain injury, spinal fluid (CSF) show evidence of a loss of brain cells in old age, brain distinct physical cause.tumour.
Non-brain related impairmentsin thyroid, liver or kidney function,or diabetes.
Mood-based Manic depression (bipolar disorder), Like schizophrenia, they have no known(affective) social anxiety disorder, obsessive– defect that can be confirmed by
compulsive disorder, personality and physical examination. Instead, carefuldelusional disorders. observation of symptoms is required.
In contrast to schizophrenia in whichmood is blunted or disjointed, mooddisorders show high levels of emotion.For example, patients with bipolardisorder cycle from ‘high’ cheerfulnessand excitability to ‘low’ depression.
Note that, long-term abuse of these substances can lead to permanentbrain changes that may induceschizophrenia.
Similarly, physical analysis of the bloodand organ function (kidney, liver, etc.),will highlight any other causes.
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Lundbeck Belgium Art Collection
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What are the signs and symptomsof schizophrenia?
Figure 6: Hallucinations in schizophrenia
Sign
s&
sym
ptom
s
MRI/PET image showing areas of visual and auditorybrain activity (orange) during hallucination.
Image from the Science Photo Library.
DelusionsDelusions are basically false or unrealisticbeliefs. Some delusions are called ‘secondary’,which refers to them being interpretations ofillusions of hallucinations. For example, if apatient has auditory hallucinations and ishearing voices or ‘hearing’ thoughts then asecondary interpretation may be that the voicesare coming from a transmitter in the fan, in thetelevision set, or even in the persons head.Furthermore, the patient can make theinterpretation that an organisation, the CIA forexample, is sending the thoughts or voices. Inthis way the delusion of being undersurveillance by the CIA is created. Delusions canalso be ‘primary’. These are often unrealisticbeliefs that seem to arise from nowhere. For
The symptoms of schizophrenia are usuallydivided into ‘positive’ and ‘negative’ groups, asdescribed below.
Positive symptoms
The positive symptoms of schizophrenia mainlyoccur in the active periods of psychosis. Theyare called ‘positive’ because they are addedeffects created by the process of the disorder,and therefore tend to be the most outwardlynoticeable symptoms.
HallucinationsThe most common type of hallucination inschizophrenia is auditory (heard). This ofteninvolves the person hearing voices ‘in theirhead’ having conversations, arguing orcommenting on/criticising their actions. Thesevoices may be regular characters to which theperson attributes identities. Other less commontypes of hallucination (that are more often seenin other types of mental disorder) involvetasting, smelling, feeling or seeing things thatare not really there.
Recordings of brain activity have shown that,during visual or auditory hallucinations, thebrain activity of the patient with schizophreniaappears to be the same as that of a realstimulus. In other words, in terms of their brainactivity, the patient is experiencing thehallucination as if they were realsensations/experiences (see Figure 6).
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example, ‘I am god’, or ‘My brain is made ofgold’. These kinds of primary delusions are seenas ‘bizarre’, meaning that they are completelyunrealistic. Delusions occur at some stage inmore than 90% of patients with schizophrenia.1
Disorganised speech, behaviour and thoughtAnother class of positive symptoms involveschanges in the pattern of speech, behaviour,and thought. There is a loosening of associationbetween thought and speech, making speechmuddled, with illogical jumps between ideas,and producing a disjointed mix of words.Behaviour is also disorganised, with increasedagitation and childlike silliness.
Negative symptoms
This class of symptoms is known as ‘negative’,because they represent the absence of a usualtrait. Negative symptoms occur with varyingduration and severity in the periods betweenactive psychotic phases.
Negative symptoms include:
• emotional blunting (affective flattening) –impairment of all expression of emotion, e.g.,facial expression, body language, vocal tone
• poverty of speech (alogia) – speech that isbrief, rarely initiated, or containing littlemeaningful content
• avolition – general apathy and lack of driveto perform any actions
• anhedonia – inability to experience pleasure
• social withdrawal – avoidance of thecompany of others, extending to includeavoidance of romantic attachments or sexualinterest
• catatonic behaviour – unusual postures,mannerisms and rigidity. Interestingly,catatonia was once a characteristic feature ofschizophrenia worldwide, but is nowpredominantly seen in patients fromdeveloping countries.2 This class of symptomalso includes negativism, which is a refusal tocomply with reasonable requests.
Positive symptomsSarah – a 30 year-old single woman withschizophrenia, living with her parents – hadbeen repeatedly admitted to hospitalfollowing experiences of delusions andhallucinations. Most recently, she had beenfound wandering the streets in a distressedstate as she believed that her every movewas being ‘watched’ through the walls inher own house. However, she was alsohearing voices, and these continued outsidethe house, criticising her behaviour andencouraging her to harm herself. Thesetypes of symptoms had been presentintermittently for many years, but werenow becoming increasingly frequent andmore severe.
Types of schizophrenia
Due to the large variety of symptoms seen indifferent patients with schizophrenia,sometimes the disorder is divided into distinctsubtypes according to the symptoms thatpredominate. The three most commonlydescribed subtypes are:
• paranoid schizophrenia – mainly involvingthoughts of persecution and being plottedagainst. Occurs more frequently in men thanin women
• disorganised (hebephrenic) schizophrenia –consisting of inappropriate/disturbedemotions, and a profound deterioration ofpersonality. This type of schizophrenia has anearly onset
• catatonic schizophrenia – involving extremewithdrawal, lack of speech, and abnormalbody positions that can remain fixed for longperiods of time.3 The state is sometimesdescribed as a ‘waking coma’.
21
Negative symptomsChristopher was hospitalised one year ago,aged 21, in a state of anxiety, andagitation, with persecutory delusions, andauditory hallucinations. He was dischargedafter two months of successful treatmentwith an antipsychotic drug. He has sincelived with his parents. He was recentlypersuaded to visit the doctor by his sister,who was concerned about the apparentlysevere change in his personality. He hasgiven up his regular job for no logicalreason, and has become a virtual recluse,spending most of the day in bed. Hisappearance is unkempt, and he hasobviously not washed or shaved for sometime. He had previously been close to hisfamily, but in recent months he has mainlystayed in his room and he has oftenrefused to even speak with his sister orparents. As far as his family can say, he hascontinued his antipsychotic treatment.
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Assessing symptoms inschizophrenia
In addition to the classification systems used indiagnosis, clinical scales may be used byphysicians to follow the progress of a patient’ssymptoms over time. These include the BriefPsychiatric Rating Scale (BPRS), the Positive andNegative Syndrome Scale (PANSS), and theCalgary Depression Scale (CDS).6,7,8
References1. Hirsch SR, Weinberger DR. Schizophrenia.
Second edition. Blackwell Publishing, 2005.
2. Concise Medical Dictionary. Sixth edition.Oxford University Press, 2003.
3. Kandel ER, Schwartz JH, Jessell TM. Principles ofneural science. Fourth edition. McGraw Hill,2000.
4. ABPI. Target schizophrenia. May, 2003.
5. Frith C, Johnstone E. Schizophrenia. A very shortintroduction. First edition. Oxford UniversityPress, 2003.
6. Overall JE, Gorham DR. The Brief PsychiatricRating Scale. Psychological Reports 1962; 10:799–812.
7. Kay SR, Fiszbein A, Opler LA. The positive andnegative syndrome scale (PANSS) forschizophrenia. Schizophr Bull 1987; 13 (2):261–276.
8. Addington D, Addington J, Maticka-Tyndale E.Specificity of the Calgary Depression Scale forschizophrenics. Schizophr Res 1994; 11 (3):239–244.
Cognitive impairment
Cognitive impairment can be considered to be aseparate condition from schizophrenia, or issometimes classed as a third category ofsymptom, alongside the positive and negativesigns. Cognition refers to the thought processesthat allow functions such as learning, memory,attention, speed of thought, problem solving,planning, and situation assessment. Cognitiveimpairment reduces the ability to use logicalthought, and markedly diminishes quality oflife. Cognitive problems are common in patientswith schizophrenia, with one study showingthat 85% of patients who were almost fullyrecovered from schizophrenia, still experiencedcognitive difficulties.4
Patients with schizophrenia tend to performbadly on a variety of different ‘intellectual’tests. Whilst routine, well-learned tasks such asreading and mental arithmetic are oftenunimpaired, other cognitive tasks, especiallythose which require a flexible approach toproblem solving, are often severely impaired.There is general agreement that patients withschizophrenia exhibit impairment in three maincognitive areas – memory, attention, andexecutive function.5
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How is schizophrenia treated?
Trea
tmen
tCurrently, there is no cure for schizophrenia, butthere are many treatments available to helpcontrol symptoms of the disorder and toprevent relapse into psychotic episodes. Thiscontrol is extremely valuable, and can help aperson with schizophrenia to restore elementsof normal life. Treatment usually consists of acombination of medication and psychosocialtherapy, with a period in hospital oftennecessary for care and monitoring duringpsychotic episodes.
Treatment for schizophrenia is long-term over aperiod of years, and appears to be mosteffective when started early in the course of thedisorder.1 However, despite the treatable natureof the disorder, approximately one third ofpatients are not improved following standardtreatment.2
Drug therapy
Drug treatment for schizophrenia pre-dominantly involves the use of antipsychoticmedications, which help to restore the balanceof neurotransmitters in the brain.
Antipsychotic medication for schizophrenia wasfirst used in the 1950s, and was shown to beeffective in controlling the positive symptomsof the disorder (hallucinations, delusions, etc.).Research has since shown that these ‘typical’antipsychotic drugs block the action of theneurotransmitter, dopamine, in the brain (seeFigure 7).
Dopamineterminal
DopamineDopamine(D2) receptor
Chlorpromazine(typical antipsychotic) –blocks dopamine binding to dopamine (D2) receptor,preventing signal transmission
Figure 7: Dopamine in neurotransmission
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Newer antipsychotics block both dopamine andserotonin pathways, although the additionaleffects on the serotonin pathway are, as yet,not so well understood. The serotonin block isbelieved to contribute to the lower levels ofextrapyramidal symptom (EPS) side effects.Increased dopamine in the meso-corticalpathway is thought to be the main reason forpositive symptoms. Amphetamines, whichstimulate the dopamine pathway, cause similarsymptoms which may be indistinguishable fromschizophrenia.2 However, the action ofantipsychotics to block this pathway can leadto EPS (see ‘Side effects with antipsychotictreatment’).
In recent years, new ‘atypical’ antipsychoticshave been developed. These are at least aseffective on the positive symptoms ofschizophrenia as the typical antipsychotics, aswell as indicating a possibility of being moreeffective on the negative symptoms. Atypicalantipsychotics also work by alteringneurotransmitter (dopamine, serotonin)function in the brain. Their mechanisms ofaction tend to be different from the typicalagents, and this may be related to the atypicalantipsychotics’ tendency to cause fewer severeEPS side effects (see opposite), although theyare not free of side effects in general.
Drug selection must, therefore, not only takeinto account the symptoms and needs of thepatient, but also balance the risk–benefit interms of effectiveness and side effects.
Side effects with antipsychotic treatmentSide effects occur when the antipsychotic druginfluences systems other than those involved inschizophrenia. The occurrence of side effectsvaries from drug to drug, as well as between thegeneral drug classes. A description of some sideeffects associated with antipsychotic drug useis given in the table opposite.
*Antipsychotic drugs are marketed under a variety ofbrand names – the names given in brackets are thegeneric (non-proprietary) names. Some may also beknown under other proprietary names.
Table 2: Examples of antipsychotic drugs*
Typical (conventional) Atypical (new)antipsychotics antipsychotics
Largactil®/Thorazine® Solian® (chlorpromazine) (amisulpride)
Modecate®/Moditen® Abilify®(fluphenazine) (aripiprazole)
Depixol® Clozaril® (flupentixol) (clozapine)
Haldol® Zyprexa® (haloperidol) (olanzapine)
Loxapac®/Loxitane® Seroquel®(loxapine) (quetiapine)
Fentazin® Risperdal® (perphenazine) (risperidone)
Navane® Serdolect® (thiothixene) (sertindole)
Mellaril® Geodon®/Zeldox®(thioridazine) (ziprasidone)
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Table 3: Side effects of antipsychotic drugs
Side effect Description
Extrapyramidal symptoms (EPS) Set of movement-related side effects (e.g., tremor,stiffness, cramps, involuntary movements, restlessness),that are caused primarily by typical antipsychotic drugsinfluencing pathways in the brain that control movement,in addition to the psychosis-related pathways.
Long-term use of antipsychotic drugs can produce an often irreversible side effect called ‘tardive dyskinesia’,which involves uncontrollable muscle movements, usuallyof the face.
Anticholinergic effects, e.g., dry Effects caused by the antipsychotic acting non-specifically,mouth, blurred vision, constipation, and blocking the action of the neurotransmitter,dizziness acetylcholine.
Sedation Common effect of many antipsychotics.
Seizures Antipsychotic drugs can lower the threshold for seizures.Patients with a history of seizures may have an increased risk.
Weight gain Common effect of many antipsychotics.
Raised prolactin levels Elevated levels of the hormone, prolactin, may promotemilk production, suppress ovulation, and reduce sexual drive in women. In men, higher prolactin levels can lowersexual drive and may induce impotence.
Neuroleptic malignant syndrome Very rare, but potentially fatal effect that produces (NMS) problems with breathing and heart rate.
26
The most common side effects of antipsychoticdrugs are EPS side effects: caused by the effectof the antipsychotic on the part of the brainthat helps to control movement. There are threebasic types of EPS effect: dystonia, akasthisia,and pseudo-parkinsonism. These effects mayoccur in up to 40–60% of patients.2
Other less common side effects includesedation, weight gain, and raised prolactin levels(leading to disruption of sexual function) (seeTable 3), although not all of the side effectslisted here occur with every drug. There isevidence that some antipsychotics may impaircognitive function, and this has potentiallyconfused the classification of this type ofschizophrenia symptom.
Shortcomings of antipsychotictreatments
Recent evidence suggests that the majority ofpatients with schizophrenia (74%) willdiscontinue their medication before 18 monthsof treatment.3 Patients stop taking theirmedication for a number of reasons, includinginefficacy and intolerable side effects. Eachpatient has a different profile of symptoms, andeach antipsychotic a different profile of sideeffects, thus it might be expected that there isno simple answer to drug therapy. A goodrelationship between clinician and patient willprevent the patient from ceasing medicationbefore an alternative can be offered, andswitching medication is common before thebest balance between symptoms control andside effects is met.
Side effects of drug treatmentAt age 28, Charlotte had been diagnosed with schizophrenia. Now, aged 50, she has receiveddrug treatment for many years, which has provided reasonable control of symptoms. However,lapses in taking her medication have led to regular admissions to hospital. The reason for herrisking stopping the treatment was a feeling of emotional ‘numbness’, like being constantly‘blue’. This is a side effect of her medication, interpreted as a very painful mental componentof the EPS-syndrome. This has caused social withdrawal and severe lack of motivation, whichhas often been seen as depression. Her doctor has tried to reduce the dose of her medicationto avoid this effect, but this increased her schizophrenia symptoms, leading to the return ofdisturbing hallucinations.
27
Psychosocial and cognitive/behavioural therapies
Psychological, including behavioural therapies,form a key part of schizophrenia treatment andrehabilitation. These therapies cannot generallyhelp in dealing with acute psychotic phases ofillness, but have been shown to reduce the rateof relapse.4 Used in combination withmedication, they can help a person withschizophrenia to rebuild their social, functional,and communication skills. Psychosocial supportand psychoeducation can be very helpful forthe families of people with schizophrenia.
Psychotherapy involves regular meetingsbetween the patient and a therapist to talkabout their problems and concerns in general,which may or may not be related directly tothe schizophrenia. The types of psychotherapydiffer, and range from dealing with specific day-to-day problems, to the recall of previousevents to guide the patient to insights in theirlife.2 Behavioural therapy seeks exclusively tochange the behaviour of the patient, with theprimary aim of addressing the patient’s abilityto deal with social situations.2 Cognitivebehavioural psychotherapy focuses on helpingthe patient to find ways of changing corebeliefs and/or thought patterns that causediscomfort, anxiety, depression, or in some wayinterfere with their life situation.
The supportive nature of these therapies canalso encourage patients to comply with theirdrug treatment – a significant concern in thispatient population, where approximately 50%of patients fail to take their medication oncedischarged from hospital.2
Future therapies
Despite innumerable advances in drugtreatments over recent decades, there are stillmany unmet needs in schizophrenia therapy.Obvious improvements would be treatmentswith increased effectiveness against all types ofsymptoms, fewer side effects, and rapid action.In addition, treatments are required for patientswith symptoms that do not respond to existingtherapies (i.e., are refractory). Earlier diagnosiswould also be helpful, along with therapies thatoffered positive effects on conditions thatfrequently occur alongside schizophrenia suchas those involving cognition and mood (seenext section – ‘ What are the co-morbidities ofschizophrenia?’).
Research is ongoing in all of these areas, lookingat new approaches to treatment, andmaintaining the ultimate aims of discovering acause and a cure. In the meantime, educationto raise awareness and decrease stigma areother valuable ways to improve the lives ofthose with schizophrenia.
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References1. National Alliance for Research on Schizophrenia
and Depression (NARSAD). Understandingschizophrenia. © NARSAD, 2003. Accessedonline, March 2006.
2. Tsuang MT, Faraone SV. Schizophrenia, the facts.Second edition. Oxford University Press, 1997.
3. Lieberman JA, Stroup TS, McEvoy JP, et al.Effectiveness of antipsychotic drugs in patientswith chronic schizophrenia. NEJM 2005; 353(12): 1209–1223.
4. Tarrier N. Cognitive behaviour therapy forschizophrenia – a review of development,evidence and implementation. PsychotherPsychosom 2005; 74 (3): 136–144.
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Co-
mor
bidi
ties
What are the co-morbidities ofschizophrenia?
In addition to the symptoms of schizophrenia,some patients will experience co-morbidity –that is, additional illness alongside theirschizophrenia. The most frequent conditionsassociated with schizophrenia are mooddisorders, such as depression and anxiety. Theco-morbidity of substance abuse amongindividuals with schizophrenia is also high, andaround 50–70% abuse one or moresubstances.1
People with schizophrenia and manicdepression (bipolar disorder) have higher risksof certain physical conditions than average:2
• 2–4 times the rate of cardiovascular diseases
• 2–4 times the rate of respiratory disease
• 5 times the rate of diabetes
• 8 times the rate of Hepatitis C
• 15 times the rate of HIV.
Mood disorders
Mood disorders such as anxiety and depressionshow a high co-morbidity with schizophrenia.Approximately 75% of patients withschizophrenia will experience depression duringtheir lifetime, and this is thought to contributeto an increased risk of suicide.3
Co-morbidity with depressionDuring his teenage years, Michael hadexperienced mood disorders, and had aproblem with obesity. Early in his twenties,he had also been diagnosed withschizophrenia, mainly characterised by thenegative signs of isolation and avolition.At this time, Michael received treatmentfor schizophrenia, along with anantidepressant. Unfortunately, whileaddressing certain of his symptoms, thistherapy increased his weight further,potentiating some of his original problemsand impacting upon his health and qualityof life.
30
References1. Kosten T, Ziedonis D. Substance abuse and schizophrenia: editor’s introduction. Schizophrenia Bulletin 1997;
23: 181–185.
2. www.rethink.org
3. ABPI. Target schizophrenia. May, 2003.
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Soci
al&
econ
omic
impa
ct
What is the social and economicimpact of schizophrenia?
Social and economic effects form an importantpart of living with, and treating, schizophrenia.Schizophrenia is often a difficult disorder forsociety to accept and deal with, as it influencesbehaviour, emotion, communication andfunctional capacity. To live with thesesymptoms, a person with schizophrenia requiresattentive care, which understandably entailsextensive costs – both personal and financial.
Social factors
Social interactionA person with schizophrenia often finds itdifficult to integrate socially. This may bebecause of fear, anxiety or distressing beliefs, orbecause of symptoms such as poverty ofspeech and withdrawal, which are notconducive with social activity. In addition, manypositive symptoms can be worsened by beingexposed to arguments, emotional discussions orlarge crowds.
Poor communication can be a particularhindrance when trying to converse with aphysician, making it more difficult for patientsto express their needs, and for physicians toassess the disorder severity.
EmploymentThe severity and intermittent nature of positivesymptoms can make employment practicallydifficult for a person with schizophrenia. Inaddition, negative symptoms such as apathy,
poor articulation, and withdrawal, do not oftenfit in with a work environment. Further to this,the stress of having to attend work, as well asany stress associated with the work itself, canmake symptoms worse. For these reasons,schizophrenia frequently generates a barrier toemployment.
EducationIt is under some debate whether patients withschizophrenia suffer a decline in IQ as aconsequence of their disorder since, in mostcases, an IQ test for the patient prior todiagnosis is not available for comparison.However, a lower IQ is known to be associatedwith a poorer prognosis.1
HomelessnessApproximately 40% of homeless people arethought to suffer from mental illnesses,including schizophrenia.1 Homelessness can be aresult of many factors affecting people withschizophrenia, including difficulty fitting into ashared home, broken relationships, loss ofemployment, desire for isolation, paranoidthoughts and delusions, and a lack of financialsupport.
Drugs, alcohol and violenceAbuse of drugs and/or alcohol can be aconsequence of the withdrawal from society,loss of employment and homelessness thatmay affect a person with schizophrenia.
32
Estimates indicate that up to 50% of peoplewith schizophrenia are periodic drug or alcoholabusers.
Further consequences of this abuse may be anincreased likelihood of violence, accidents,financial poverty, and deterioration inappearance. However, patients withschizophrenia are not inherently violent, withanxiety or the side effects of medication oftenmisread as aggression.
Suicide and mortalitySuicidal behaviour is a common complication ofschizophrenia. Some 50% of individuals withschizophrenia will attempt suicide at sometime, and it is the cause of death for 6–13% ofpatients.2 Along with natural causes,predominantly affecting the heart/bloodsystem, this distressing statistic contributes tothe 2.4-fold raised mortality risk in people withschizophrenia.
Social impactAt age 24, Carola felt the significant socialimpact of her recent diagnosis withschizophrenia. She was finding itincreasingly difficult to hide her symptoms(changes in behaviour, hallucinations) fromher work colleagues in the office where shewas employed. The symptoms occurredintermittently, and it was almostimpossible for her to predict when herbehaviour would change. She was unwillingto speak to her employer about hersituation in case she lost her job. Outsidework, she felt similarly isolated and lessinclined to socialise. Although her friendshad noticed some changes in her, shedidn’t want to tell them about herdiagnosis, because of the stigma that isassociated with the condition, and thepotential change in attitude towards herthat this might bring about.
Economic factors
The estimated cost of treating a person withschizophrenia for a year is over €100,000.Overall, this is likely to account forapproximately 2% of total hospital costs. Thisincludes both pharmacological and non-pharmacological costs. Only 1% of this totalcost of care per patient is attributable to thecost of medications, and demonstrates the hugelevel of non-pharmacological support requiredby patients with schizophrenia. Althoughindividuals with schizophrenia usually require aperiod of hospitalisation during their psychoticepisodes, there is a rising trend to treat morepatients outside the hospital environment – atrend that is driven by the increasedeffectiveness of antipsychotic drugs, as well aschanging political priorities. Consequently, thenumber of hospital beds allocated to patientswith schizophrenia in Western Europe has fallenby 30–50% over the past 10 years.
In addition to direct expenses of care, economicevaluation also takes into account the indirectcost of lost productivity – for both the personwith schizophrenia, and any friend or familymember who has had to limit work in order toact as a carer. These factors all contribute to aconsiderable association of schizophrenia withpoverty.
References1. Tsuang MT, Faraone SV. Schizophrenia, the facts.
Second edition. Oxford University Press, 1997.
2. ABPI. Target schizophrenia. May, 2003.
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34Lundbeck Belgium Art Collection
Index
31
This section includes a selection of websitesand books that provide further informationabout schizophrenia.
Websites
General information onschizophrenia
EUFAMIwww.eufami.org
EUFAMI is a European network of family andcarer associations with the mission to achieve acontinuous improvement throughout Europe inmental health, and in the quality of care andwelfare, for people affected by mental illnesses;to campaign continuously for the rights offamilies and carers of people with mentalillnesses across the whole of Europe; and tosupport and strengthen member organisations– 48 national and regional voluntaryassociations in 27 countries – in their fight forbetter health care for those affected by mentalillnesses.
National Institute of Mental Health (NIMH)www.nimh.nih.gov
The National Institute of Mental Health (NIMH)is one of 27 components of the NationalInstitutes of Health (NIH) – the United StatesFederal government’s principal biomedical andbehavioural research agency. NIH is part of theUS Department of Health and Human Services.
The NIMH mission is to reduce the burden ofmental illness and behavioural disorders throughresearch on mind, brain, and behaviour. NIMHfunds research by scientists across the US aswell as in NIMH studies in the internal researchprogramme. Through its extramural programme,NIMH supports more than 2,000 research grantsand contracts at universities and otherinstitutions across the country and overseas.
Schizophrenia.comwww.schizophrenia.com
Schizophrenia.com is a US-based non-profit-making web community that providesinformation, support and education to thefamily members, caregivers and individualswhose lives have been affected by schizophrenia.The site contains articles on all aspects of lifewith schizophrenia, as well as related newsitems. The site also has discussion and chatboards on various topics, as well as nationaldiscussion groups from across the world.
Rethinkwww.rethink.org
Rethink is the largest severe mental illnesscharity in the UK, and aims to improve the livesof all those affected by severe mental illness,whether as a patient, carer, or healthcareworker/professional. Rethink provides a range ofcommunity services including employmentprojects, supported housing, day services,helplines, residential care, and respite centres.
Furt
her
info
rmat
ion
35
Further information sources
36
National Alliance for Research onSchizophrenia and Depression (NARSAD)www.narsad.org
NARSAD is a charity organisation that raisesfunds for scientific research into the causes,cures, treatments and prevention of severepsychiatric brain disorders, such asschizophrenia and depression. The site containsa brochure on schizophrenia, as well as adviceand case stories from people suffering with theillness.
Lundbeck Institutewww.cnsforum.com
The Lundbeck Institute aims to improve thequality of life of people affected by centralnervous system disorders, through education.The site contains a section on schizophreniaand a ‘brain explorer’ animation, which is avisual aid describing disorders of the brain.
Schizophrenia Treatment and EvaluationProgramme (STEP)www.ncartsforhealth.org/STEP.htm
The STEP art gallery displays artwork andpoetry by inpatients and clinic outpatients fromthe University of North Carolina STEPprogramme. They hope to decrease the stigmaassociated with mental illness and demonstratethat people with serious mental illnesses(particularly schizophrenia and bipolar disorder)can be creative and productive.
Corporate information
H. Lundbeck A/Swww.lundbeck.com
This comprehensive site gives a completeoverview of Lundbeck, including companyhistory, vision, mission, and product pipeline.Corporate information such as share prices,sales figures and other financial tools are alsoavailable.
Books
Birchwood M, Jackson C. Schizophrenia.Psychology Press, 2001.
Frith C, Johnstone E. Schizophrenia. A very shortintroduction. Oxford University Press, 2003.
Hirsch SR, Weinberger DR (eds). Schizophrenia.Second edition. Blackwell Science (UK), 2003.
McKenna PJ. Schizophrenia and relatedsyndromes. Taylor Francis Group, 1997.
Schiller L, Bennett A. The quiet room: journeyout of the torment of madness. Little, Brownand Company, 1996.
Tsuang MT, Faraone SV. Schizophrenia, the facts.Second edition. Oxford University Press, 1997.
Williamson P. Mind, brain, and schizophrenia.Oxford University Press, 2005.
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Abbreviations and glossary
Abb
revi
atio
ns&
glos
sary
AmygdalaA roughly almond-shaped mass of grey matterdeep in each cerebral hemisphere. Theamygdala have extensive connections with theolfactory system, and also the hypothalamus.The functions of the amygdala are apparentlyconcerned with mood, feeling, instinct, andpossibly memory for recent events.
AnhedoniaA negative symptom of schizophrenia whichmanifests as an inability to experience pleasure.
AvolitionA general lack of drive to perform activity ofany kind, including those which mightconstitute ‘daily living’.
Brief Psychiatric Rating Scale (BPRS)BPRS is a 16-item scale with nine generalsymptom items, five positive-symptom items,and two negative-symptom items. Completedby the physician, each item is scored on aseven-point severity scale (the higher thenumber, the more severe the symptom),resulting in a range of possible scores from 16to 112. For example, the average patient withschizophrenia entering a clinical trial mighttypically score 33.
Catatonic behaviourA negative symptom of schizophrenia involvingunusual postures, mannerisms or rigidity.
ABPI Association of the BritishPharmaceutical Industry
APA American Psychiatric Association
BPRS Brief Psychiatric Rating Scale
CDS Calgary Depression Scale
CIA Central Intelligence Agency (USagency)
CSF cerebrospinal fluid
DSM-IV Diagnostic and Statistical Manual, 4th
edition
EPS extrapyramidal symptoms
EUFAMI European Federation of Associationsof Families of people with MentalIllness
HIV Human Immunodeficiency Virus
ICD-10 International Classification ofDiseases, 10th edition
IQ intelligence quotient
MRI magnetic resonance imaging
NARSAD National Alliance for Research onSchizophrenia and Depression
NHS National Health Service (of theUnited Kingdom)
NIH National Institutes of Health (USmedical agency)
NIMH National Institutes of Mental Health(US)
NMS neuroleptic malignant syndrome
PANSS Positive and Negative Syndrome Scale
PET positron emission tomography
STEP Schizophrenia Treatment andEvaluation Programme
WHO World Health Organization
38
Co-morbidityA term used to refer to a disease or disorderthat is not directly caused by another disorderbut occurs at the same time.
DelusionFalse or unrealistic belief.
DopamineOne of many chemicals (neurotransmitters)that send messages between nerve cells.
DystoniaA dysfunction of the muscles, characterised byspasms or abnormal muscle contraction.
Extrapyramidal symptoms (EPS)A set of movement-related side effectscommon with antipsychotics, e.g., tremor,stiffness, cramps, involuntary movements, andrestlessness.
HallucinationSymptom that can be produced by a disease ormedications, which makes a person believe theyare seeing, hearing, or feeling things that arenot really there.
HippocampusAn area of the floor of the lateral ventricle ofthe brain. It contains complex foldings ofcortical tissue and is involved in the limbicsystem.
HypothalamusA region of the forebrain, linked with thethalamus and pituitary gland. It containscentres controlling body temperature, thirst,hunger, water balance, and sexual function. It isalso closely connected with emotional activity.
Limbic systemA complex system of nerve pathways andnetworks in the brain that is involved in theexpression of instinct and mood. It includes theactivities of the amygdala, hippocampus andhypothalamus.
MRI scanMagnetic resonance imaging (MRI) is a type ofscan that uses radio waves to generate animage of body tissues. It is especially useful forexamining the nervous system, muscles, andbones.
Negative symptomsSymptoms which represent the absence ofsome usual trait, such as blunted emotions,apathy, or social withdrawal.
Neuroleptic malignant syndrome (NMS)A very rare, but potentially fatal side effect ofsome antipsychotics.
39
NeurologicalDescribing any condition or symptom thataffects the nervous system.
NeurotransmitterType of chemical that is present in the nervoussystem to carry messages between differentnerve cells. Examples of neurotransmittersinclude dopamine, acetylcholine, andnoradrenaline.
PET scanPositron emission tomography (PET) is a type ofscan that can detect chemicals in the brain. It issometimes used to produce pictures (scans)showing the arrangement of dopamine-producing nerve cells.
Positive and Negative Syndrome Scale(PANSS)PANSS is a 30-item scale with 16 generalpsychopathology symptom items, 7 positive-symptom items, and 7 negative-symptomitems. Completed by a physician, each item isscored on a 7-point severity scale, resulting in arange of possible scores from 30 to 210. Thepositive- and negative-symptom item groupsare often reported separately, with a possiblerange of 7 to 49. For example, a patient withschizophrenia entering a clinical trial mighttypically score 91.
Positive symptomsSymptoms considered to be added effects ofthe disorder, such as hallucinations, delusions,and disorganised speech.
ProlactinA hormone that stimulates milk productionafter childbirth and also stimulates productionof the ‘male’ hormone progesterone. Excessivesecretion of prolactin can give rise to abnormalproduction of milk in both sexes.
Substantia nigraArea of the brain where dopamine is produced.
40
41
Index
Inde
x
Abilify® (aripiprazole) 24
Active period 19
Acute 4, 5, 27
Age of onset 6, 7, 9
Alcohol abuse 8, 14, 31, 32
Alogia 20
American Psychiatric Association (APA) 15
Amisulpride 24
Amygdala 11, 12, 37, 38
Anhedonia 20, 37
Antidepressant 29
Antipsychotic drugs 21, 23- atypical 24- discontinuation 26, 27- side effects 24, 25, 26- switching 26- typical 23
Anxiety 5, 8, 21, 29
Apathy 3, 20, 31, 38
Aripiprazole 24
Avolition 20, 29, 37
Bipolar disorder 17, 29
Bleuler, Eugen 3
Blunted emotions 3, 5, 20
Brain tumour 15, 17
Brief Psychiatric Rating Scale (BPRS) 22, 37
Calgary Depression Scale (CDS) 22
Catatonic 20, 21, 37
Cause(s) 11–14- genetic 11, 13- environmental 11, 14
Chloropromazine 24
Chronic 4, 9
Clinical scales 22
Clozapine 24
Clozaril® (clozapine) 24
Cognitive impairment 3, 22, 26
Cognitive symptoms 4, 5, 22
Co-morbidities 5, 27, 29- cardiovascular disease 29- respiratory disease 29- diabetes 29- hepatitis C 29- HIV 29
Core symptoms 15
Course 4, 5
Definitions 37–39
Delusions 3, 5, 15, 17, 19–20, 21, 23, 38
Dementia praecox 3
Depixal® (flupentixol) 24
Depression 17, 26, 27, 29
Development 4, 5, 6, 13
Diagnosis 9, 15
Disease course 4
Disease development 4, 5, 6, 13
Disorganised (hebephrenic) schizophrenia 21
Dopamine 11, 23, 24, 38
Drug abuse 8, 14, 15, 29, 31, 32
DSM-IV 15
Dystonia 38
Economic factors 8, 32, 33- hospitalisation 33
42
Epilepsy 15, 17
European Federation of Associations of Families ofPeople with Mental Illness (EUFAMI) 35
Exclusion criteria 15
Extrapyramidal symptom side (EPS) effects 24, 25, 38- dystonia 26- akasthisia 26- pseudo-parkinsonism 26
Fentazin® (perphenazine) 24
Flupentixol 24
Fluphenazine 24
Frequency 3, 9
Gender 6, 7, 9, 14
Genetic 11, 13
Geodon® (ziprasidone) 24
H. Lundbeck A/S 36
Haldol® (haloperidol) 24
Hallucinations 3, 5, 11, 15, 19, 21, 23, 38
Haloperidol 24
Hebephrenic see Disorganised (hebephrenic)schizophrenia 21
Hippocampus 11, 12, 38
Hypothalamus 38
ICD-10 15
Imaging 11, 17
Incidence 7, 9
Kraepelin, Emil 3
Largactil® (chlorpromazine) 24
Loxapac® (loxapine) 24
Loxapine 24
Loxitane® (loxapine) 24
Lundbeck Institute 36
Magnetic resonance imaging (MRI) 19, 38
Maintenance phase 5
Medication 23
Mellaril® (thioridazine) 24
Meso-cortical pathway 24
Modecate® (fluphenazine) 24
Moditen® (fluphenazine) 24
Mood disorder 15, 29
Mortality 5, 32
MRI See Magnetic resonance imaging
National Alliance for Research on Schizophrenia andDepression (NARSAD) 36
National Institute of Mental Health (NIMH) 35
National Institutes of Health (NIH) 35
Navane® (thiothixene) 24
Negative symptoms 4, 5, 11, 19, 20, 24, 38
Neuroleptic malignant syndrome (NMS) 25, 38
Neurotransmitters 3, 11, 23, 24, 39
Obsessive–compulsive disorder 17
Olanzapine 24
Paranoid 21, 31
Perphenazine 24
Personality disorder 17
PET See Positron Emission Tomography
Positive and Negative Syndrome Scale (PANSS) 22, 39
Positive symptoms 5, 19–20, 23, 24, 39
Positron Emission Tomography (PET) 11, 19, 39
Prevalence 9- geographical 9
Prodomal phase 5
Psychiatrist 3, 5, 15
Psychosocial therapy 23, 27
Psychotic episode 3, 4, 5, 8, 23, 33
Quality of life 8, 29
Quetiapine 24
Relative risk 7
Remission 5
Risperidol® (risperidone) 24
Risperidone 24
Schizoaffective disorder 16
schizophrenia.com 35
Schizophrenia Treatment and Evaluation Programme(STEP) 36
Self-care 3, 5, 15, 21
Serdolect® (sertindole) 24
Seroquel® (quetiapine) 24
Serotonin 24
Sertindole 24
Side effects 24, 25, 26- anticholinergic effects 25- extrapyramidal symptoms (EPS) 24, 25, 38- sedation 25- seizures 25- weight gain 25, 29- prolactin 25, 26, 39- neuroleptic malignant syndrome 25, 38- sexual 20, 25, 26, 38
Social anxiety disorder 17
Social factors 8, 31- social interaction 31- employment 8, 31- education 8, 31- homelessness 8, 31- drugs, alcohol and violence 31–32- suicide and mortality 32
Social withdrawal 3, 20
Solian® (amisulpride) 24
Stigma 3, 8, 27, 32
Suicide 5, 8, 29, 32
Symptoms 3, 4- core 15- cognitive 4, 5, 22- negative 4, 5, 11, 19, 20, 21, 23, 24, 37, 38, 39- positive 5, 19–20, 22, 23, 24, 31, 37, 39
Thioridazine 24
Thiothixene 24
Thorazine® (chloropromazine) 24
Treatment 23 See antipsychotic drugs; psychosocialtherapy- costs 8, 31, 33
Unmet needs 27
Ventricles 11, 12
Viral infection 14, 17
Winter birth 14
World Health Organization (WHO) 9, 15
Zeldox® (ziprasidone) 24
Ziprasidone 24
Zyprexa® (olanzapine) 24
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