Schizophrenia is a psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality. Distortions in perception may affect all five senses, including sight, hearing, taste, smell and touch, but most commonly manifest as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood, with approximately 0.4–0.6% of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia currently exists.
Studies suggest that genetics, early environment, neurobiology, psychological and social processes are important contributory factors; some recreational and prescription drugs appear to cause or worsen symptoms. Current psychiatric research is focused on the role of neurobiology, but no single organic cause has been found. As a result of the many possible combinations of symptoms, there is debate about whether the diagnosis represents a single disorder or a number of discrete syndromes. For this reason, Eugen Bleuler termed the disease the schizophrenias (plural) when he coined the name. Despite its etymology, schizophrenia is not the same as dissociative identity disorder, previously known as multiple personality disorder or split personality, with which it has been erroneously confused.
Increased dopamine activity in the mesolimbic pathway of the brain is consistently found in schizophrenic individuals. The mainstay of treatment is antipsychotic medication; this type of drug primarily works by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, and vocational and social rehabilitation are also important. In more serious cases - where there is risk to self and others - involuntary hospitalization may be necessary, although hospital stays are less frequent and for shorter periods than they were in previous times.
The disorder is thought to mainly affect cognition, but it also usually contributes to chronic problems with behavior and emotion. People with schizophrenia are likely to have additional (comorbid) conditions, including major depression and anxiety disorders; the lifetime occurrence of substance abuse is around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common. Furthermore, the average life expectancy of people with the disorder is 10 to 12 years less than those without, due to increased physical health problems and a higher suicide rate.
|St. Elizabeth's Hospital. Wall of room in Ward Retreat 1. Reproductions made by a patient, a disturbed case of dementia precox [praecox?]; pin or fingernail used to scratch paint from wall, top coat of paint buff color, superimposed upon a brick red coat of paint. Pictures symbolize events in patient's past life and represent a mild state of mental regression. Undated, but likely early 20th century. |
Schizophrenia occurs equally in males and females, although typically appears earlier in men - the peak ages of onset are 20–28 years for males and 26–32 years for females. Onset in childhood is much rarer, as is onset in middle- or old age. The lifetime prevalence of schizophrenia - the proportion of individuals expected to experience the disease at any time in their lives - is commonly given at 1%. However, a 2002 systematic review of many studies found a lifetime prevalence of 0.55%. Despite the received wisdom that schizophrenia occurs at similar rates worldwide, its prevalence varies across the world, within countries, and at the local and neighbourhood level. One particularly stable and replicable finding has been the association between living in an urban environment and schizophrenia diagnosis, even after factors such as drug use, ethnic group and size of social group have been controlled for. Schizophrenia is known to be a major cause of disability. In a 1999 study of 14 countries, active psychosis was ranked the third-most-disabling condition after quadriplegia and dementia and ahead of paraplegia and blindness.
Accounts of a schizophrenia-like syndrome are thought to be rare in the historical record prior to the 1800s, although reports of irrational, unintelligible, or uncontrolled behavior were common. There has been an interpretation that brief notes in the Ancient Egyptian Ebers papyrus may imply schizophrenia, but other reviews have not suggested any connection. A review of ancient Greek and Roman literature indicated that although psychosis was described, there was no account of a condition meeting the criteria for schizophrenia. Bizarre psychotic beliefs and behaviors similar to some of the symptoms of schizophrenia were reported in Arabic medical and psychological literature during the Middle Ages. In The Canon of Medicine, for example, Avicenna described a condition somewhat resembling the symptoms of schizophrenia which he called Junun Mufrit (severe madness), which he distinguished from other forms of madness (Junun) such as mania, rabies and manic depressive psychosis. However, no condition resembling schizophrenia was reported in Şerafeddin Sabuncuoğlu's Imperial Surgery, a major Islamic medical textbook of the 15th century. Given limited historical evidence, schizophrenia (as prevalent as it is today) may be a modern phenomenon, or alternatively it may have been obscured in historical writings by related concepts such as melancholia or mania.
A detailed case report in 1797 concerning James Tilly Matthews, and accounts by Phillipe Pinel published in 1809, are often regarded as the earliest cases of schizophrenia in the medical and psychiatric literature. Schizophrenia was first described as a distinct syndrome affecting teenagers and young adults by Bénédict Morel in 1853, termed démence précoce (literally 'early dementia'). The term dementia praecox was used in 1891 by Arnold Pick to in a case report of a psychotic disorder. In 1893 Emil Kraepelin introduced a broad new distinction in the classification of mental disorders between dementia praecox and mood disorder (termed manic depression and including both unipolar and bipolar depression). Kraepelin believed that dementia praecox was primarily a disease of the brain, and particularly a form of dementia, distinguished from other forms of dementia, such as Alzheimer's disease, which typically occur later in life. Kraepelin's classification slowly gained acceptance. There were objections to the use of the term "dementia" despite cases of recovery, and some defence of diagnoses it replaced such as adolescent insanity.
The word schizophrenia - which translates roughly as "splitting of the mind" and comes from the Greek roots schizein (σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-, "mind") - was coined by Eugen Bleuler in 1908 and was intended to describe the separation of function between personality, thinking, memory, and perception. Bleuler described the main symptoms as 4 A's: flattened Affect, Autism, impaired Association of ideas and Ambivalence. Bleuler realized that the illness was not a dementia as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead.
The term schizophrenia is commonly misunderstood to mean that affected persons have a "split personality". Although some people diagnosed with schizophrenia may hear voices and may experience the voices as distinct personalities, schizophrenia does not involve a person changing among distinct multiple personalities. The confusion arises in part due to the meaning of Bleuler's term schizophrenia (literally "split" or "shattered mind"). The first known misuse of the term to mean "split personality" was in an article by the poet T. S. Eliot in 1933.
In the first half of the twentieth century schizophrenia was considered to be a hereditary defect, and sufferers were subject to eugenics in many countries. Hundreds of thousands were sterilized, with or without consent - the majority in Nazi Germany, the United States, and Scandinavian countries. Along with other people labeled "mentally unfit", many diagnosed with schizophrenia were murdered in the Nazi "Action T4" program.
In the early 1970s, the diagnostic criteria for schizophrenia was the subject of a number of controversies which eventually led to the operational criteria used today. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe. This was partly due to looser diagnostic criteria in the US, which used the DSM-II manual, contrasting with Europe and its ICD-9. David Rosenhan's 1972 study, published in the journal Science under the title On being sane in insane places, concluded that the diagnosis of schizophrenia in the US was often subjective and unreliable. These were some of the factors in leading to the revision not only of the diagnosis of schizophrenia, but the revision of the whole DSM manual, resulting in the publication of the DSM-III in 1980. Since the 1970s more than 40 diagnostic criteria for schizophrenia have been proposed and evaluated.
In the Soviet Union the diagnosis of schizophrenia has also been used for political purposes. The prominent Soviet psychiatrist Andrei Snezhnevsky created and promoted an additional sub-classification of sluggishly progressing schizophrenia. This diagnosis was used to discredit and expeditiously imprison political dissidents while dispensing with a potentially embarrassing trial. The practice was exposed to Westerners by a number of Soviet dissidents, and in 1977 the World Psychiatric Association condemned the Soviet practice at the Sixth World Congress of Psychiatry. Rather than defending his theory that a latent form of schizophrenia caused dissidents to oppose the regime, Snezhnevsky broke all contact with the West in 1980 by resigning his honorary positions abroad.
Social stigma has been identified as a major obstacle in the recovery of patients with schizophrenia. In a large, representative sample from a 1999 study, 12.8% of Americans believed that individuals with schizophrenia were "very likely" to do something violent against others, and 48.1% said that they were "somewhat likely" to. Over 74% said that people with schizophrenia were either "not very able" or "not able at all" to make decisions concerning their treatment, and 70.2% said the same of money management decisions. The perception of individuals with psychosis as violent has more than doubled in prevalence since the 1950s, according to one meta-analysis.
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