Schizophrenia

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Schizophrenia is less common than many other major psychiatric disorders, like major depressive disorder or bipolar disorder. It affects about 1% of the population in the United States. Every year, one person in 10,000 will be diagnosed with schizophrenia. Full recovery is rare, and intensity may depend on age of onset, sex, and environment.

There is no sex-related difference for the prevalence of schizophrenia among men and women. The average age of onset, however, differs slightly. For men, it is usually between 15 and 25, while women typically experience its onset between 25 and 35. Onset before age 15 and after age 50 is rare.

Prevalence in other countries is difficult to determine, because cultural perceptions change the way we define schizophrenia and its symptoms. However, an international pilot study on schizophrenia conducted by the World Health Organization established a global risk of 1%, with rare exception. It is estimated that people with schizophrenia occupy 10% of hospital beds in the United States, and that 30% of people with the disease are hospitalized. Roughly 10% of people with schizophrenia commit suicide, though as many as 50% of them may attempt it.

Schizophrenia worsens in 75% of people after its onset. About 25% of people experience an abrupt onset of sudden psychosis. However, most people enter a phase known as the prodromal phase, during which certain signs and symptoms precipitate an acute episode. The following signs are common:

• Eccentric ideas
• Erratic behavior (e.g., angry outbursts)
• Loss of interest or volition
• Persecutory thoughts
• Poor hygiene
• Social withdrawal
• Strange emotional affect

These behaviors worsen gradually and eventually become psychotic symptoms. An acute episode of psychosis typically features one or many positive symptoms and leads to notable dysfunction, which is usually chronic.

A person with schizophrenia rarely returns to normalcy and regains complete function after an acute psychotic episode, especially men. Recurrence of acute episodes is likely.

Changes in mood often occur with schizophrenia. More than 50% of people are depressed during their illness. Some of these people are also diagnosed with schizoaffective disorder, which may feature depressive or manic episodes.

Positive outcome is associated with an acute (quick and brief) and deeply symptomatic onset, particularly if it occurs after teens and features obvious positive symptoms. The following factors more often result in poor prognosis:

• Gradual onset (especially at a young age)
• No obvious precipitating signs
• Predominance of negative symptoms
• Family history
• CT abnormalities

Computerized tomography (CT scan) shows abnormal brain structure in many, but not all, people with schizophrenia. Abnormalities of the brain are also associated with early onset, negative symptoms, poor prognosis, and men.

Subtypes
As schizophrenia progresses, its symptoms can change. Its course is categorized clinically by whatever type of behavior is prominent during an episode. The following five main subtypes are used:

• Catatonic
• Paranoid
• Disorganized
• Undifferentiated
• Residual

People with catatonic type assume peculiar postures and are usually speechless. They may be both rigid and motionless, or they may seem agitated and move around excessively, but always without external stimulus. Catatonic people may also have strange facial expressions, may mimic the behavior of others, and may repeat words that others say. Catatonic behavior is also seen in mood disorders, like bipolar disorder and major depressive disorder, and occasionally in diseases of the central nervous system, like Parkinson's disease.

Paranoid schizophrenia is marked primarily by delusions that follow a theme, like persecution or grandeur. Auditory hallucinations may accompany a delusion and are, therefore, usually related to its theme. Symptoms common to other subtypes, like disorganized speech and flattened affect, are not usually prominent in episodes of paranoia, but anger, irritability, and extreme anxiety are. People suffering from paranoid delusions become particularly preoccupied with them and may be especially prone to violence.

Interestingly, people with paranoid schizophrenia may experience less dysfunction than people with other subtypes. They are often able to live, work, and care for themselves. The onset of paranoid schizophrenia is often later in life, and, with time, it may characterize most or all episodes.

Disorganized type, which is marked by disorganized speech, behavior, and flattened affect is particularly disruptive. The disorganized episode (also known as hebephrenic schizophrenia) often features fragmented speech and inappropriate or unexpected behavior that does not reflect ideas expressed verbally. Strange mannerisms, gestures, and surprising behavior are common. This type of schizophrenia typically causes significant dysfunction in daily life, self-care, and interaction with others, as well as notable thought disturbance and loss of goal-directed behavior. People in the midst of a disorganized episode show no catatonic signs.

Undifferentiated schizophrenia is the type given to a lack of catatonia, paranoia, or disorganized speech. Undifferentiated schizophrenia might resemble other illnesses, including neurological disorders. However, people suffering from nonpsychiatric diseases typically have insight into their condition and they understand the medical basis for its presence.

Finally, the residual type of schizophrenia is diagnosed when positive symptoms like delusions, hallucinations, and grossly disorganized behavior have disappeared. Negative symptoms remain and may be interrupted only briefly by mildly disorganized speech or strange behavior. When delusions or hallucinations occur, even if infrequently, they are not serious enough to cause severe dysfunction. The residual evidence of schizophrenia is apparent by the presence of a flattened affect, loose speech, and a general loss of goal-directed interests. Residual symptoms can last indefinitely, or they can lead to complete recovery, though this is rare.

Generally, 20% of people experience significantly improved function, 40% improve with intermittent periods of impairment, and 40% remain severely affected or incapacitated. Variation depends on adherence to treatment and the factors that seem to prefigure the course of the disease.

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