Schizophrenia has been called the “cancer of mental illness,” because we do not know what causes it or how to prevent it. In the 1990s there have been some developments supporting the existence of a solid biological basis for schizophrenia. Among them were advances in brain imaging and neuropathological techniques that have suggested that the limbic system is central to the pathophysiology of schizophrenia and new drugs that are very effective in reducing negative symptoms of schizophrenia with fewer adverse neurological effects. Nevertheless, it remains a chronic illness that is very costly, both emotionally and financially, to patient and family. There is now increased interest in the psychosocial factors that may affect onset, intervention, and relapse prevention. Schizophrenia is increasingly viewed as a neurodevelopmental disease.
The syndrome has been recognized for more than 3,500 years and has carried a variety of labels. The Greeks termed it dementia, and in the nineteenth century several psychoses were identified and labeled demence precoce, hehephrenia, paranoia, and catatonia. In 1896 a German psychiatrist, Emil Kraepelin, identified symptoms common to these disorders and postulated that there was only one disorder, dementia praecox, which afflicted a variety of patients with poor prognoses. Eugene Bleuler published a monograph in 1911 titled Dementia Praecox or the Group of Schizophrenias, which disagreed with Kraepelin’s belief that the illness was a form of dementia, that it always had an early onset, and that it always led to significant deterioration. Bleuler felt that there was not one illness, dementia praecox, but rather a spectrum of syndromes, the schizophrenias, taken from a Greek word meaning “splitting of the mind.” The most prominent feature was a tearing apart (splitting) of psychic functions, especially evident in the loosening of associations between ideas, inappropriate behavior, and disorganization of thought, affect, and actions.
Current thinking supports the idea of a spectrum of disorders, and DSM recognizes five forms of schizophrenia. Debate continues, however, over whether it is a single disorder, a group of related diseases, or a set of symptoms stemming from causes unique to each case.
It is estimated that 1.3 percent of people aged eighteen to fifty-four in the United States suffer from schizophrenia. One hundred thousand to 150,000 new cases are diagnosed annually. Approximately 25 percent of all hospital beds are occupied by people with schizophrenia and 50 percent of all psychiatric beds. It is estimated that this illness accounts for 75 percent of all expenditures for mental health. The disorder affects equal numbers of men and women, and the age of onset of the initial schizophrenic episode is usually between fifteen and twenty-five for men and between twenty-five and thirty-five for women, although it can occur later in life. Men tend generally to have a worse prognosis. There appears to be a higher incidence of schizophrenia in urban ghettos; according to one theory, the higher incidence may result from the stress of severe socioeconomic pressures, whereas another theory holds that people who have schizophrenia drift into these communities because of their inability to function in middle-class society.
Schizophrenia: Differential Diagnosis
Organic mental disorders often have symptoms resembling schizophrenia, such as hallucinations, delusions, and incoherence. Therefore, during assessment it is essential to rule out organic factors that might be responsible for the symptoms. Although the person may experience confusion at the beginning of the active phase, the ongoing disorientation and memory loss seen in organic mental disorders or drug-induced psychosis are not present in schizophrenia.
As previously noted, depression frequently accompanies schizophrenia, and thus it may be difficult to distinguish schizophrenia from psychotic forms of mood disorders and schizoaffective disorder. If periods of depression or mania are brief in relation to schizophrenia, the diagnosis of schizophrenia can be made. If they are lengthy, mood disorder or schizoaffective disorder should be considered as the diagnosis. Usually depression will begin after the onset of schizophrenia, where the latter is the primary diagnosis; if depression is identified before the onset or if there is concomitant onset, then a mood disorder should be suspected. When a person experiences symptoms of a mood disorder followed by hallucinations or delusions without mood symptoms, the diagnosis is schizoaffective disorder. Family history may show the presence of both schizophrenia and mood disorders, and the prognosis for schizoaffective disorder is better than that for schizophrenia, but worse than that for mood disorders.
People with schizotypal, borderline, schizoid, and paranoid personality disorders may experience transient psychotic symptoms that will diminish, allowing a return to the usual level of functioning within hours or days. These transient psychotic symptoms frequently result from psychosocial stressors. It is important to evaluate the content of paranoid ideation to see if there is a delusional quality serious enough to warrant the diagnosis of schizophrenia.
A disorder with psychotic symptoms lasting less than six months, but with prodromal, active, and residual phases, is a schizophreniform disorder. The prognosis for this type of disorder is more hopeful than that for schizophrenia.
Schizophrenia is a diagnostic label applied to a mixed collection of disorders with varying etiology, pathology, dynamics, and clinical course. Social stress, social class, and gender affect incidence and recovery rates. There is genetic vulnerability as well as an indication of deficits in brain structure. Thus it is a disorder that frequently results from the effect of environmental stressors on a person who is genetically vulnerable. Diagnosis may be difficult, as similar symptoms can be found in other mental or physical disorders; thus a thorough assessment is essential. This complex picture has led some to think that schizophrenia would be better labeled “prolonged psychiatric illness.”
People with schizophrenia — and their families — need to be connected to a broad range of programs and resources. Social workers, trained in an ecosystems perspective, are best equipped to serve as case managers to assist in meeting these needs, although cutbacks in funding make this role a difficult task.