SchizophreniaAccording to the DSM-111 (American Psychiatric Association’s Diagnostic and Statistical Manual, Third Edition),
schizophrenic disorders are mental disorders with a tendency toward chronicity which impairs functioning and
which is characterized by psychotic symptoms involving disturbances of thinking, feeling, and behavior.
Six specific criteria for the diagnosis include (1) certain psychotic symptoms, delusions, hallucinations,
formal thought disorder; (2) deterioration from a previous level of functioning (3) continuous signs of the
illness for at least six months; (4) a tendency towards onset before age 45; (5) not due to mood (affective)
disorders; and (6) not due to organic mental disorder or mental retardation.
The DSM-111 definition eliminates several entities included in the DSM-11 concept Syndromes which look
like schizophrenia but which last less than six months are called schizophreniform. Psychotic syndromes of less
than 2 week duration which follow a significant psycho-social stressor are now called brief reactive psychoses.
History of Disease
In the 17th to 19th century clinicians had many names for schizophrenia ranging from vesania, idiocy,
insanity of puberty, monomania, paranoia, etc.). The early clinicians described the characteristics of family origin,
endogenous cause, early onset, remitting or progressive course, bizarre ideas, dissociation of thought and emotion,
and social withdrawal, thus moving toward a useful psychiatric classification by using the criteria of symptomatology,
course and outcome.
The concept of dementia praexcox was developed from 1896 on, based on the early onset of the tendency
toward a deteriorating course. The name schizophrenia was coined in 1908, referring to the disconnection
or splitting of the psychic functions, believed to be an outstanding symptom of the whole group. It was thought
that the illness need not always begin early and could end in various ways, including a so-called social remission;
but it was not clear that full recoveries occurred without leaving a scar.
Schizophrenia occurs worldwide. Using a relatively narrow concept of the disorder, studies of European
and Asian populations show the lifetime prevalence to be from 0.2% to almost 1%. Higher rates have
been found in the United States of America and the Soviet Union, but the criteria used are much broader.
Schizophrenia most commonly becomes manifest in late adolescence or early adult life, although paranoid
schizophrenia typically has a later onset. (Merck Manual, 15th edition, pg. 1533) Even with available forms of
treatment, schizophrenic patients occupy about ½ of the hospital beds of mentally ill and mentally
retarded patients, and about ¼ of all available hospital beds.
Most cases are now thought to be caused by a complex interaction between inherited and
environmental factors. Several scientific models preempt the field: Those regarding schizophrenia
as primarily biologic in origin (genetic, internal environment, or neurophysiologic model), with the
environmental factors playing only a minor role; and those that consider the cause primarily environmental
(ecologic, developmental, or learning model), with the biological factors playing the minor role. Even in the
most advanced biologic (the genetic) model, no direct evidence exists that the inherited genetic makeup
of the person who develops one or more episodes of schizophrenia is in any way different from that of the
individual who is not subject to such a hazard.
Although no specific personality type is seen in all cases, many patients who develop
schizophrenia show such traits as hypersensitivity, shyness, unsocialability, lack of affect, and paranoid
attitudes. Difficulty in personal relationships and social isolation inevitably result.
Symptoms and Signs of the Disease
Symptoms of schizophrenia vary in type and severity. Generally they are categorized as positive or
negative (deficit) symptoms. Positive symptoms are characterized by an excess or distortion of
normal functions; negative symptoms, by diminution or loss of normal functions. Individual patients
may have symptoms from one or both categories.
Positive symptoms can be further categorized as (1) delusions and hallucinations or (2) thought disorder
and bizarre behavior. Delusions and hallucinations are sometimes referred to as the psychotic dimension
of schizophrenia. Delusions are erroneous beliefs that usually involve misinterpreting experience.
In persecutory delusions, the patient believes he is being tormented, followed, tricked, or spied on.
In delusions of reference, the patient believes that passages from books, newspapers, song lyrics,
or other environmental cues are directed at him. In delusions of thought withdrawal or thought insertion,
the patient believes that others can read his mind, that his thoughts are being transmitted to others,
or that thoughts and impulses are being imposed on him by outside forces. Hallucinations may
occur in any sensory modality (auditory, visual, olfactory, gustatory, or tactile), but auditory hallucinations
are by far the most common and characteristic of schizophrenia. The patient may hear voices
commenting on his behavior, conversing with one another, or making critical and abusive comments.
Thought disorder and bizarre behavior are termed the disorganized symptom cluster. Thought disorder
involves disorganized thinking, evidenced primarily by speech that is rambling, shifts from one topic to
another, and is non-goal-directed. Speech can range from mildly disorganized to incoherent and
incomprehensible. Bizarre behavior may include childlike silliness, agitation, and inappropriate appearance,
hygiene, or conduct. Catatonic motor behavior is an extreme form of bizarre behavior that can include
maintaining a rigid posture and resisting efforts to be moved or engaging in purposeless and unstimulated
Negative (deficit) symptoms include blunted affect, poverty of speech, anhedonia, and asociality.
With blunted affect (flattening of emotions), the patient's face may appear immobile, with poor eye contact
and lack of expressiveness. Poverty of speech refers to a diminution of thought reflected in
decreased speech and terse replies to questions, creating the impression of inner emptiness.
Anhedonia (diminished capacity to experience pleasure) may be reflected by a lack of interest in
activities with substantial time spent in purposeless activity. Asociality refers to a lack of interest in
relationships. Negative symptoms are often associated with a general loss of motivation and
diminished sense of purpose and goals.
In some patients with schizophrenia, cognitive functioning declines, with impaired attention, abstract thinking,
and problem solving. Severity of cognitive impairment is a major determinant of overall disability in these patients.
Symptoms of schizophrenia typically impair the ability to function and are often severe enough to
markedly interfere with work, social relations, and self-care. Unemployment, social isolation, deteriorated
familial relationships, and diminished quality of life are common outcomes.
Types of Schizophrenia
Some investigators believe schizophrenia is a single disorder; others believe it is a syndrome
that comprises numerous underlying disease entities. Classical subtypes used to classify patients into
more uniform groups include paranoid, disorganized (hebephrenic), catatonic, and undifferentiated.
Paranoid schizophrenia is characterized by preoccupation with delusions or auditory hallucinations,
without prominent disorganized speech or inappropriate affect. Disorganized schizophrenia is characterized
by disorganized speech, disorganized behavior, and flat or inappropriate affect.
In catatonic schizophrenia, physical symptoms, including either immobility or excessive motor
activity and the assumption of bizarre postures, predominate. In undifferentiated schizophrenia, symptoms
are mixed. Patients with paranoid schizophrenia tend to be less severely disabled and more responsive to
Schizophrenia can also be classified based on the presence and severity of negative symptoms,
such as blunted affect, lack of motivation, and diminished sense of purpose. Patients with deficit
subtype have prominent negative symptoms unaccounted for by other factors (eg, depression,
anxiety, an understimulating environment, drug side effects). These patients are typically more disabled,
have a poorer prognosis, and are more resistant to treatment than those with nondeficit subtype,
who may have delusions, hallucinations, and thought disorders but are relatively free of negative symptoms.
Among individual patients, subtype may change over time, generally from paranoid to disorganized or
undifferentiated or from nondeficit to deficit.
No definitive test for schizophrenia exists. Diagnosis is based on a comprehensive assessment of clinical
history, symptoms, and signs. Information from ancillary sources, such as family, friends, and teachers, is
often important in establishing chronology of illness onset. According to Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV), two or more characteristic symptoms (delusions, hallucinations,
disorganized speech, disorganized behavior, negative symptoms) for a significant portion of a 1-mo period
are required for the diagnosis, and prodromal or attenuated signs of illness with social, occupational, or
self-care impairments must be evident for a 6-mo period that includes 1 mo of active symptoms.
Psychotic disorders due to physical disorders or associated with substance abuse and primary mood
disorders with psychotic features must be ruled out by clinical examination and history. Additionally,
laboratory tests can rule out underlying medical, neurologic, and endocrine disorders that can present as
psychosis (eg, vitamin deficiencies, uremia, thyrotoxicosis, electrolyte imbalance).
Structural brain abnormalities that can be seen on MRI or CT scans are consistently found in
patients with schizophrenia as a group but are insufficiently specific to have diagnostic value for
individual patients. In general, medial and superior temporal lobe abnormalities are associated
with positive symptoms; frontal cortical and ventricular system abnormalities, with negative symptoms.
n functional studies of regional brain glucose or oxygen utilization, diminished activation in the prefrontal
cortex and mesolimbic regions is associated with negative symptoms and cognitive dysfunction in
patients with schizophrenia.
Vulnerability to schizophrenia may be manifest before the onset of illness as poor premorbid
functioning, poor social skills, odd and eccentric behavior, and isolation or withdrawal. Onset of
schizophrenia may be sudden (over days or weeks) or slow and insidious (over years).
The natural history of schizophrenia can be described in sequential phases. In the premorbid phase,
the influence of risk factors and developmental vulnerabilities may be detectable. In the prodromal phase,
subclinical signs and symptoms--such as withdrawal, irritability, suspiciousness, and disorganization--develop
before manifest illness, signaling impending decompensation. In the early illness phase, onset of positive
symptoms, deficit symptoms, and functional disabilities leads to the diagnosis of schizophrenia. In the
middle phase, symptomatic periods may be episodic (with identifiable exacerbations and remissions) or
continuous (without identifiable remissions); functional deficits worsen. In the late illness phase, the illness
pattern may be established, disability levels stabilized, or late improvements manifested.
Of patients who have one episode of schizophrenia, 60 to 70% ultimately have subsequent episodes.
The course may be continuous or intermittent. During the first 5 years of illness, functioning may deteriorate
and social and work skills may decline, with progressive neglect of self-care; negative symptoms may
increase in severity and cognitive functioning may decline, particularly for patients with deficit forms.
Thereafter, the level of disability tends to plateau. Some evidence suggests that severity of illness may
lessen in later life, particularly among women. Spontaneous movement disorders may develop in patients
who have severe negative symptoms and cognitive dysfunction, even when antipsychotic drugs are not used.
Schizophrenia is associated with about a 10% risk of suicide. Suicide is the major cause of premature death
among persons with schizophrenia, and on average the disorder reduces the life span of those affected by
10 yr. Patients who have paranoid forms with late onset and good premorbid functioning--the very patients
with the best prognosis for recovery--are also at the greatest risk for suicide. Because these patients retain
the capacity for grief and anguish, they may be more prone to act in despair, based on a realistic recognition
of the effect of their disorder.
Schizophrenia is a relatively modest risk factor for violent behavior; the level of risk is much less than
that conveyed by substance abuse. Threats of violence and minor aggressive outbursts are far more
common than dangerous behavior occurring when a patient obeys hallucinatory voices or attacks an
imagined persecutor. Very rarely, a severely depressed, isolated, paranoid person attacks or murders
someone who is perceived as the single source of his difficulties (eg, an authority, a celebrity, his spouse).
Patients with schizophrenia may present in an emergency setting with threats of violence to obtain
food, shelter, or needed medical or psychiatric care. A thorough, ongoing assessment of dangerousness
and suicidal risk should be included in the evaluation and treatment of patients with schizophrenia.
Over a 1-yr period, prognosis is closely related to adherence to prescribed psychoactive drugs. Over longer periods,
prognosis varies. Overall, 1/3 of patients achieve significant and lasting improvement; 1/3 improve some but have
intermittent relapses and residual disability; and 1/3 are severely and permanently incapacitated. Factors
associated with a good prognosis include relatively good premorbid functioning, late and/or sudden onset
of illness, a family history of mood disorders rather than schizophrenia, minimal cognitive impairment, and
paranoid or nondeficit subtype. Factors associated with a poor prognosis include early age of onset, poor
premorbid functioning, a family history of schizophrenia, and disorganized or deficit subtype with many
negative symptoms. Men have poorer outcomes than women; women respond better to treatment with
Schizophrenia can occur with other mental disorders. When associated with significant obsessive-compulsive
symptoms, it has a particularly poor prognosis; with symptoms of borderline personality disorder, a better prognosis.
Substance abuse is a significant problem in up to 50% of patients with schizophrenia. Comorbid substance
abuse is a significant predictor of poor outcome and may lead to drug noncompliance, repeated relapse,
frequent rehospitalization, declining function, and loss of social support, including homelessness.
Patients with schizophrenia tend to develop psychotic symptoms an average of 12 to 24 months before
presenting for medical care. The time between onset of psychotic symptoms and first treatment, termed
duration of untreated psychosis, correlates with the rapidity of initial treatment response, quality of
treatment response, and severity of negative symptoms. When treated early, patients tend to respond
more quickly and fully. Without prophylactic antipsychotic drugs, 70 to 80% of patients who have had
a schizophrenia episode have a subsequent episode during the next 12 months. Continuous prophylactic
antipsychotic drugs can reduce the 1-yr relapse rate to about 30%.
General goals of treatment are to reduce the severity of psychotic symptoms, prevent
recurrences of symptomatic episodes and associated deterioration of functioning, and help
patients function at the highest level possible. Antipsychotic drugs, rehabilitation with community
support services, and psychotherapy are the major components of treatment.
Please Note: As with all depressive illnesses, it is important that Muslims attempt to get advice from a
Muslim psychologist, psychiatrist, physician, or counselor. For patients that are unable to find a Muslim
physician in their area specializing in psychology, it would still be helpful if they were able to consult with
a Muslim clinician and receive advice or assistant with ensuring that the treatment program outlined is in
accordance with Islamic principles.
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