Schizophrenia 27790 225549079 2008-07-14T07:13:50Z Vaughan 4704 replace text and add ref for Ebers papyrus {{pp-semi-protected|small=yes}} {{Otheruses}} {{Infobox_Disease | Name = Schizophrenia | Image = Bleuler.png | Caption = [[Eugen Bleuler]] (1857–1939) coined the term "Schizophrenia" in 1908 | Width = 125 | DiseasesDB = 11890 | ICD10 = {{ICD10|F|20||f|20}} | ICD9 = {{ICD9|295}} | ICDO = | OMIM = 181500 | MedlinePlus = 000928 | eMedicineSubj = med | eMedicineTopic = 2072 | eMedicine_mult = {{eMedicine2|emerg|520}} | MeshName = Schizophrenia | MeshNumber = F03.700.750 | }} <!--Para1: Definition, symptoms and diagnosis--> '''Schizophrenia''' (pronounced /{{IPA|ˌskɪtsəˈfriːniə}}/), from the [[Ancient Greek|Greek]] [[Root (linguistics)|roots]] ''schizein'' (σχίζειν, "to split") and ''phrēn'', ''phren-'' (φρήν, φρεν-, "[[mind]]") is a [[psychiatric]] [[diagnosis]] that describes a [[mental disorder]] characterized by abnormalities in the [[perception]] or expression of [[reality]]. It most commonly manifests as auditory [[hallucination]]s, paranoid or bizarre [[delusion]]s or [[thought disorder|disorganized speech and thinking]] in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood,<ref name="castle1991">{{cite journal |author=Castle D, Wesseley S, Der G, Murray RM |year=1991|title=The incidence of operationally defined schizophrenia in Camberwell 1965–84 |journal=[[British Journal of Psychiatry]] |volume=159 |pages=790–794 |pmid=1790446 |url=http://bjp.rcpsych.org/cgi/content/abstract/159/6/790 |accessdate=2008-07-05 |doi=10.1192/bjp.159.6.790 |doi_brokendate=2008-07-05}}</ref> with approximately 0.4–0.6%<ref>{{cite journal |author=Bhugra D |url=http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0020151 |year=2006 |title=The global prevalence of schizophrenia |journal=[[Public Library of Science|PLoS Medicine]] |volume=2 | issue=5 |pages=372–373 |pmid=15916460 |accessdate= 2008-02-24 |doi=10.1371/journal.pmed.0020151}}</ref><ref name="fn_34">{{cite journal |author=Goldner EM, Hsu L, Waraich P, Somers JM |year=2002 |title=Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature |journal=Canadian Journal of Psychiatry |volume=47 | issue=9 |pages=833–43 |pmid=12500753 |url=http://ww1.cpa-apc.org:8080/publications/archives/CJP/2002/November/goldner.asp |accessdate=2008-07-05}}</ref> of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia currently exists.<ref name="DSM-IV-TR" /> <!--Para2:lack of validity/controversies--> Studies suggest that [[genetics]], early environment, [[neurobiology]] and [[Psychology|psychological]] and social processes are important contributory factors. Current psychiatric research is focused on the role of neurobiology, but no single organic cause has been found. Due to 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 synonymous with [[dissociative identity disorder]], previously known as multiple personality disorder or split personality; in [[popular culture]] the two are often confused. <!--Para3: Dopamine hypothesis and treatment--> Increased [[dopamine|dopaminergic activity]] in the [[mesolimbic pathway]] of the brain is consistently found in schizophrenic individuals. The mainstay of treatment is pharmacotherapy with [[antipsychotic]] medications; these primarily work by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, though hospital stays are less frequent and for shorter periods than they were in previous years.<ref name="BeckerKilian2006">{{cite journal |author=Becker T, Kilian R|year=2006 |title=Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? |journal=[[Acta Psychiatrica Scandinavica]] Supplement |volume=429 |pages=9–16 |pmid=16445476 |doi=10.1111/j.1600-0447.2005.00711.x}}</ref> <!--Para4: Impairment/chronicity and Comorbidity--> The disorder is primarily thought to affect [[cognition]], but it also usually contributes to chronic problems with [[human behavior|behavior]] and [[emotion]]. People diagnosed with schizophrenia are likely to be diagnosed with [[Comorbidity|comorbid]] conditions, including [[clinical depression]] and [[anxiety disorders]];<ref name="Sim_et_al_2006">{{cite journal |author=Sim K, Chua TH, Chan YH, Mahendran R, Chong SA |title=Psychiatric comorbidity in first episode schizophrenia: a 2 year, longitudinal outcome study |journal=Journal of Psychiatric Research |volume=40 |issue=7 |pages=656–63 |year=2006 |month=October |pmid=16904688 |doi=10.1016/j.jpsychires.2006.06.008|url=http://linkinghub.elsevier.com/retrieve/pii/S0022-3956(06)00122-1 |accessdate=2008-07-05}}</ref> the lifetime [[prevalence]] of [[substance abuse]] is typically around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common and [[life expectancy]] is decreased; the average life expectancy of people with the disorder is 10 to 12 years less than those without, owing to increased physical health problems and a high [[suicide]] rate.<ref name="Brown_Barraclough_2000">{{cite journal |author=Brown S, Barraclough B, Inskip H|year=2000 |title=Causes of the excess mortality of schizophrenia |journal=[[British Journal of Psychiatry]] |volume=177 |pages=212–7 |pmid=11040880 |doi=10.1192/bjp.177.3.212}}</ref> ==Signs and symptoms== A person diagnosed with schizophrenia may demonstrate [[Thought disorder|disorganized and unusual thinking]] and speech, auditory [[hallucination]]s, and [[delusion]]s. Social isolation commonly occurs for a variety of reasons. Impairment in [[social cognition]] is associated with schizophrenia, as are symptoms of paranoia from delusions and hallucinations, and the negative symptoms of apathy and [[avolition]]. In one uncommon subtype, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are signs of [[catatonia]]. No one sign is diagnostic of schizophrenia, and all can occur in other medical and psychiatric conditions.<ref name="DSM-IV-TR" /> The current classification of psychoses holds that symptoms need to have been present for at least one month in a period of at least six months of disturbed functioning. A schizophrenia-like psychosis of shorter duration is termed a [[schizophreniform disorder]].<ref name="DSM-IV-TR">{{cite book |author= |title=Diagnostic and statistical manual of mental disorders: DSM-IV |author=American Psychiatric Association |publisher=American Psychiatric Publishing, Inc. |location=Washington, DC |year=2000 |chapter=Schizophrenia |chapterurl=http://www.behavenet.com/capsules/disorders/schiz.htm |isbn=0-89042-024-6 |accessdate=2008-07-04}}</ref> Late adolescence and early adulthood are peak years for the onset of schizophrenia. These are critical periods in a young adult's social and vocational development, and they can be severely disrupted. To minimize the effect of schizophrenia, much work has recently been done to identify and treat the [[prodrome|prodromal (pre-onset)]] phase of the illness, which has been detected up to 30 months before the onset of symptoms, but may be present longer.<ref name="Addington_et_al_2007">{{cite journal |author=Addington J |coauthors=Cadenhead KS, Cannon TD, Cornblatt B, McGlashan TH, Perkins DO, Seidman LJ, Tsuang M, Walker EF, Woods SW, Heinssen R |year=2007|title=North American prodrome longitudinal study: a collaborative multisite approach to prodromal schizophrenia research |journal=[[Schizophrenia Bulletin]] |volume=33 | issue=3 |pages=665–72 |pmid=17255119|doi=10.1093/schbul/sbl075}}</ref> Those who go on to develop schizophrenia may experience the non-specific symptoms of social withdrawal, irritability and [[dysphoria]] in the prodromal period,<ref name="ParnasJorgensen1989">{{cite journal |author=Parnas J |coauthors=Jorgensen A |year=1989 |title=Pre-morbid psychopathology in schizophrenia spectrum |journal=[[British Journal of Psychiatry]] |volume=115 |pages=623–7 |pmid=2611591}}</ref> and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.<ref name="Amminger_et_al_2006">{{cite journal |author=Amminger GP |coauthors=Leicester S, Yung AR, Phillips LJ, Berger GE, Francey SM, Yuen HP, McGorry PD |year=2006 |title=Early-onset of symptoms predicts conversion to non-affective psychosis in ultra-high risk individuals |journal=[[Schizophrenia Research]] |volume=84 | issue=1 |pages=67–76 |pmid=16677803 |doi=10.1016/j.schres.2006.02.018}}</ref> ===Schneiderian classification=== The psychiatrist [[Kurt Schneider]] (1887–1967) listed the forms of psychotic symptoms that he thought distinguished schizophrenia from other psychotic disorders. These are called ''first-rank symptoms'' or [[Kurt Schneider#First-rank symptoms|Schneider's first-rank symptoms]], and they include delusions of being controlled by an external force; the belief that thoughts are being inserted into or withdrawn from one's conscious mind; the belief that one's thoughts are being broadcast to other people; and hearing hallucinatory voices that comment on one's thoughts or actions or that have a conversation with other hallucinated voices.<ref name="SchneiderClinicalPsychopathology">Schneider, K. (1959) ''Clinical Psychopathology''. New York: Grune and Stratton.</ref> The reliability of first-rank symptoms has been questioned,<ref name="fn_4">{{cite journal |author=Bertelsen, A |year=2002 |title=Schizophrenia and Related Disorders: Experience with Current Diagnostic Systems |journal=Psychopathology |volume=35 |pages=89–93 |pmid=12145490 |doi=10.1159/000065125}}</ref> although they have contributed to the current diagnostic criteria. ===Positive and negative symptoms=== Schizophrenia is often described in terms of ''positive'' (or productive) and ''negative'' (or deficit) symptoms.<ref name="Sims_2002">{{cite book |author=Sims A |title=Symptoms in the mind: an introduction to descriptive psychopathology |publisher=W. B. Saunders |location=Philadelphia |year=2002 |isbn=0-7020-2627-1 |accessdate=}}</ref> Positive symptoms include [[delusion]]s, [[hallucination|auditory hallucinations]], and [[thought disorder]], and are typically regarded as manifestations of [[psychosis]]. Negative symptoms are so-named because they are considered to be the loss or absence of normal traits or abilities, and include features such as flat or [[blunted affect]] and [[emotion]], poverty of [[Speech communication|speech]] ([[alogia]]), inability to experience pleasure ([[anhedonia]]), and lack of [[motivation]] ([[avolition]]). Despite the appearance of blunted affect, recent studies indicate that there is often a normal or even heightened level of emotionality in schizophrenia, especially in response to stressful or negative events.<ref name="schizophrenia1">{{cite journal |author=Cohen & Docherty |year=2004 |title=Affective reactivity of speech and emotional experience in patients with schizophrenia |journal=[[Schizophrenia Research]] |volume=69 | issue=1 |pages=7–14 |pmid=15145465 |doi=10.1016/S0920-9964(03)00069-0}}</ref> A third symptom grouping, the ''disorganization syndrome'', is commonly described, and includes chaotic speech, thought, and behaviour. There is evidence for a number of other symptom classifications.<ref name="Peralta_Cuesta_2001">{{cite journal |author=Peralta V |coauthors=Cuesta MJ |year=2001 |title=How many and which are the psychopathological dimensions in schizophrenia? Issues influencing their ascertainment |journal=[[Schizophrenia Research]] |volume=49 | issue=3 |pages=269–85 |pmid=11356588 |doi=10.1016/S0920-9964(00)00071-2}}</ref> ==Diagnosis== Diagnosis is based on the self-reported experiences of the person, and possibly abnormalities in behavior reported by family members, friends or co-workers, followed by a clinical assessment by a [[psychiatrist]], [[social worker]], [[clinical psychologist]] or other [[mental health professional]]. Psychiatric assessment typically involves some form of [[mental status examination]] and taking a [[psychiatric history]]. There are standardized criteria for the diagnosis, depending on the presence, severity and duration of certain signs and symptoms.<ref name="DSM-IV-TR" /> There are several psychiatric illnesses other than schizophrenia that may present with psychotic symptoms. These include [[bipolar disorder]],<ref>{{cite journal |author=Pope HG |year=1983 |title=Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports |journal=Hospital and Community Psychiatry |volume=34 |pages=322–328 |url=http://psychservices.psychiatryonline.org/cgi/reprint/34/4/322.pdf|format=PDF |accessdate= 2008-02-24}}</ref> [[borderline personality disorder]],<ref>{{cite journal |author=McGlashan TH |title=Testing DSM-III symptom criteria for schizotypal and borderline personality disorders |journal=[[Archives of General Psychiatry]] |volume=44 |issue=2 |pages=143–8 |year=1987 |month=February |pmid=3813809 |accessdate=2008-07-03}}</ref> [[schizoaffective disorder]], drug intoxication, brief drug-induced psychosis, and [[schizophreniform disorder]]. Assessment sometimes includes general medical and neurological examinations to exclude medical illnesses which may rarely present with psychotic schizophrenia-like symptoms,<ref name="DSM-IV-TR" /> such as [[Metabolic disorder|metabolic disturbance]], [[systemic infection]], [[syphilis]], [[HIV]] infection, [[epilepsy]], and brain lesions. It may be necessary to rule out a [[delirium]], which can be distinguished by visual hallucinations, acute onset and fluctuating [[level of consciousness]], and indicates an underlying medical illness. Investigations are not generally repeated for relapse unless there is a specific ''medical'' indication or possible [[adverse effects]] from [[antipsychotic medication]]. The most widely used criteria for diagnosing schizophrenia are from the [[American Psychiatric Association|American Psychiatric Association's]] [[Diagnostic and Statistical Manual of Mental Disorders]], the current version being DSM-IV-TR, and the [[World Health Organization|World Health Organization's]] [[ICD|International Statistical Classification of Diseases and Related Health Problems]], currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian [[Kurt Schneider#First rank symptoms|first rank symptoms]] although, in practice, agreement between the two systems is high.<ref name="Jakobsen_et_al_2005">{{cite journal |author=Jakobsen KD |coauthors=Frederiksen JN, Hansen T, Jansson LB, Parnas J, Werge T |year=2005 |title=Reliability of clinical ICD-10 schizophrenia diagnoses |journal=Nordic Journal of Psychiatry |volume=59 | issue=3 |pages=209–12 |pmid=16195122 | doi = 10.1080/08039480510027698}}</ref> The [[World Health Organization|WHO]] has developed the tool ''[[SCAN]] (Schedules for Clinical Assessment in Neuropsychiatry)'' which can be used for diagnosing a number of psychiatric conditions, including schizophrenia. ===DSM IV-TR Criteria=== To be diagnosed with schizophrenia, a person must display:<ref name="DSM-IV-TR" /> * '''Characteristic symptoms''': Two or more of the following, each present for much of the time during a one-month period (or less, if symptoms remitted with treatment) ** [[delusion]]s ** [[hallucination]]s ** disorganized speech (e.g., frequent derailment or incoherence; speaking in [[abstraction|abstracts]]). See [[thought disorder]]. ** grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or [[Catatonia|catatonic]] behavior ** negative symptoms, i.e., [[affective flattening]] (lack or decline in emotional response), [[alogia]] (lack or decline in speech), or [[avolition]] (lack or decline in motivation). :Note: If delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other, only that symptom is required above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication. * '''Social/occupational dysfunction''': For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset. * '''Duration''': Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment). Schizophrenia cannot be diagnosed if symptoms of [[mood disorder]] or [[pervasive developmental disorder]] are present, or the symptoms are the direct result of a general medical condition or a substance, such as abuse of a drug or medication. ===Subtypes=== Historically, schizophrenia in the [[Western world|West]] was classified into simple, [[catatonia|catatonic]], hebephrenic (now known as [[Disorganized schizophrenia|disorganized]]), and paranoid. The [[Diagnostic and Statistical Manual of Mental Disorders|DSM]] contains five sub-classifications of schizophrenia: * [[Paranoia#Use in psychiatry|'''paranoid type''']]: where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent (DSM code 295.3/ICD code F20.0) * [[Disorganized schizophrenia|'''disorganized type''']]: named 'hebephrenic schizophrenia' in the ICD. Where thought disorder and flat affect are present together (DSM code 295.1/ICD code F20.1) * [[catatonia|'''catatonic type''']]: prominent psychomotor disturbances are evident. Symptoms can include catatonic stupor and [[waxy flexibility]] (DSM code 295.2/ICD code F20.2) * '''undifferentiated type''': psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met (DSM code 295.9/ICD code F20.3) * '''residual type''': where positive symptoms are present at a low intensity only (DSM code 295.6/ICD code F20.5) The ICD-10 recognises a further two subtypes: * '''post-schizophrenic depression''': a depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present (ICD code F20.4) * '''simple schizophrenia''': insidious but progressive development of prominent negative symptoms with no history of psychotic episodes (ICD code F20.6) ===Diagnostic issues and controversies=== Schizophrenia as a diagnostic entity has been criticised as lacking in scientific validity or reliability,<ref name="Bentall1992">{{cite book |author=Bentall, Richard P. |title=Reconstructing schizophrenia |publisher=Routledge |location=New York |year=1992 |pages= |isbn=0-415-07524-6 }}</ref><ref name="Boyle2002">{{cite book |author=Boyle, Mary |title=Schizophrenia: a scientific delusion? |publisher=Routledge |location=New York |year=2002 |isbn=0-415-22718-6}}</ref> part of a larger [[Biopsychiatry controversy|criticism]] of the validity of psychiatric diagnoses in general. One alternative suggests that the issues with the diagnosis would be better addressed as individual dimensions along which everyone varies, such that there is a [[spectrum disorder|spectrum]] or continuum rather than a cut-off between normal and ill. This approach appears consistent with research on [[schizotypy]] and of a relatively high prevalence of psychotic experiences<ref name="fn_5">{{cite journal |author=Verdoux H |coauthors=van Os J |year=2002 |title=Psychotic symptoms in non-clinical populations and the continuum of psychosis |journal=[[Schizophrenia Research]] |volume=54 | issue=1-2 |pages=59–65 |pmid=11853979 |doi=10.1016/S0920-9964(01)00352-8}}</ref><ref name="fn_65">{{cite journal |author=Johns LC |coauthors=van Os J |year=2001 |title=The continuity of psychotic experiences in the general population |journal=Clinical Psychology Review |volume=21 | issue=8 |pages=1125–41 |pmid=11702510 |doi=10.1016/S0272-7358(01)00103-9}}</ref> and often non-distressing delusional beliefs<ref name="fn_67">{{cite journal |author=Peters ER |coauthors=Day S, McKenna J, Orbach G |year=2005 |title=Measuring delusional ideation: the 21-item Peters et al. Delusions Inventory (PDI) |journal=[[Schizophrenia Bulletin]] |volume=30 |pages=1005–22 |pmid=15954204}}</ref> amongst the general public. Another criticism is that the definitions used for criteria lack consistency;<ref name="David1999">{{cite journal |author=David AS |year=1999 |title=On the impossibility of defining delusions |journal=Philosophy, Psychiatry and Psychology |volume=6 | issue=1 |pages=17–20 |url=http://muse.jhu.edu/journals/philosophy_psychiatry_and_psychology/v006/6.1david.html |accessdate=2008-02-24}}</ref> this is particularly relevant to the evaluation of [[delusion#Diagnostic issues and controversies|delusions]] and [[thought disorder#Diagnostic issues and controversies|thought disorder]]. More recently, it has been argued that psychotic symptoms are not a good basis for making a diagnosis of schizophrenia as "psychosis is the 'fever' of mental illness—a serious but nonspecific indicator".<ref name="fn_6">{{cite journal |author=Tsuang MT |coauthors=Stone WS, Faraone SV |year=2000 |title=Toward reformulating the diagnosis of schizophrenia |journal=[[American Journal of Psychiatry]] |volume=157 | issue=7 |pages=1041–1050 |pmid=10873908 |doi=10.1176/appi.ajp.157.7.1041}}</ref> Perhaps because of these factors, studies examining the [[diagnosis]] of schizophrenia have typically shown relatively low or inconsistent levels of diagnostic reliability. Most famously, [[David Rosenhan|David Rosenhan's]] 1972 study, published as ''[[Rosenhan experiment|On being sane in insane places]]'', demonstrated that the diagnosis of schizophrenia was (at least at the time) often subjective and unreliable.<ref>{{cite journal |author=Rosenhan D |year=1973 |title=On being sane in insane places |journal=[[Science (journal)|Science]] |volume=179 |pages=250–8 |pmid=4683124 |doi=10.1126/science.179.4070.250}}</ref> More recent studies have found agreement between any two psychiatrists when diagnosing schizophrenia tends to reach about 65% at best.<ref name="fn_7">{{cite journal |author=McGorry PD |coauthors=Mihalopoulos C, Henry L, Dakis J, Jackson HJ, Flaum M, Harrigan S, McKenzie D, Kulkarni J, Karoly R |year=1995 |title=Spurious precision: procedural validity of diagnostic assessment in psychotic disorders |journal=[[American Journal of Psychiatry]] |volume=152 |issue=2 |pages=220–3 |pmid=7840355}}</ref> This, and the results of earlier studies of diagnostic reliability (which typically reported even lower levels of agreement) have led some critics to argue that the diagnosis of schizophrenia should be abandoned.<ref name="fn_8">{{cite book |author=Bentall, Richard P.; Read, John E; Mosher, Loren R. |title=Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia |publisher=Brunner-Routledge |location=Philadelphia |year=2004|isbn=1-58391-906-6}}</ref> In 2004 in Japan, the Japanese term for schizophrenia was changed from ''Seishin-Bunretsu-Byo'' (mind-split-disease) to ''Tōgō-shitchō-shō'' ([[integration disorder]]).<ref name="Sato">{{cite journal |author=Sato M |year=2004 |title=Renaming schizophrenia: a Japanese perspective |journal=World Psychiatry |volume=5 | issue=1 |pages=53–5 |pmid=16757998}}</ref> In 2006, campaigners in the UK, under the banner of Campaign for Abolition of the Schizophrenia Label, argued for a similar rejection of the diagnosis of schizophrenia and a different approach to the treatment and understanding of the symptoms currently associated with it.<ref name="schizophrenia_invalid">[http://news.bbc.co.uk/2/hi/health/6033013.stm Schizophrenia term use 'invalid'.] BBC News Online, ([[9 October]] [[2006]]). Retrieved on [[2007-05-16]]. </ref> Alternatively, other proponents have put forward using the presence of specific [[neurocognitive deficit]]s to make a diagnosis. These take the form of a reduction or impairment in basic psychological functions such as [[memory]], [[attention]], [[executive function]] and [[problem solving]]. It is these sorts of difficulties, rather than the psychotic symptoms (which can in many cases be controlled by [[antipsychotic]] medication), which seem to be the cause of most [[disability]] in schizophrenia. However, this argument is relatively new and it is unlikely that the method of diagnosing schizophrenia will change radically in the near future.<ref name="GreenSchizophreniaBook">{{cite book |author=Green, Michael |title=Schizophrenia revealed: from neurons to social interactions |publisher=W.W. Norton |location=New York |year=2001|isbn=0-393-70334-7}}</ref> The diagnosis of schizophrenia has been used for political rather than therapeutic purposes; in the [[Soviet Union]] an additional sub-classification of [[sluggishly progressing schizophrenia]] was created. Particularly in the [[Russian SFSR|RSFSR]] (Russian Soviet Federated Socialist Republic), this diagnosis was used for the purpose of silencing political dissidents or forcing them to recant their ideas by the use of forcible confinement and treatment.<ref name="Wilkinson1986">{{cite journal |author=Wilkinson G |year=1986 |title=Political dissent and "sluggish" schizophrenia in the Soviet Union |journal=[[British Medical Journal|Br Med J (Clin Res Ed)]] |volume=293 | issue=6548 |pages=641–2 |pmid=3092963}}</ref> In 2000 there were similar concerns regarding [[Persecution of Falun Gong#Use of psychiatry and claims of abuse|detention and 'treatment']] of practitioners of the [[Falun Gong]] movement by the Chinese government. This led the [[American Psychiatric Association|American Psychiatric Association's]] ''Committee on the Abuse of Psychiatry and Psychiatrists'' to pass a resolution to urge the [[World Psychiatric Association]] to investigate the situation in [[People's Republic of China|China]].<ref name="Lyons2001">{{cite journal |author=Lyons D |year=2001 |title=Soviet-style psychiatry is alive and well in the People's Republic |journal=[[British Journal of Psychiatry]] |volume=178 |pages=380–381 |pmid=11282823 |doi=10.1192/bjp.178.4.380-b}}</ref> ==Epidemiology== Schizophrenia occurs equally in males and females although typically appears earlier in men with the peak ages of onset being 20–28 years for males and 26–32 years for females.<ref name="castle1991" /> Much rarer are instances of childhood-onset<ref name="Kumra_et_al_2001">{{cite journal |author=Kumra S |coauthors=Shaw M, Merka P, Nakayama E, Augustin R |year=2001 |title=Childhood-onset schizophrenia: research update |journal=Canadian Journal of Psychiatry |volume=46 | issue=10 |pages=923–30 |pmid=11816313}}</ref> and late- (middle age) or very-late-onset (old age) schizophrenia.<ref name="Howard_2005">Hassett A, Ames D, Chiu E (eds) (2005) Psychosis in the Elderly. London: Taylor and Francis. ISBN 18418439446</ref> The [[lifetime prevalence]] of schizophrenia, that is, the proportion of individuals expected to experience the disease at any time in their lives, is commonly given at 1%. A 2002 [[systematic review]] of many studies, however, found a lifetime prevalence of 0.55%.<ref name="fn_34" /> Despite the received wisdom that schizophrenia occurs at similar rates throughout the world, its prevalence varies across the world,<ref name="Jablensky_et_al_1992">{{cite journal |author=Jablensky A |coauthors=Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE, Day R, Bertelsen A |year=1992 |title=Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study |journal=Psychological Medicine Monograph Supplement |volume=20 |pages=1–97 |pmid=1565705}}</ref> within countries,<ref name="Kirkbride_et_al_2006">{{cite journal |author=Kirkbride JB |coauthors=Fearon P, Morgan C, Dazzan P, Morgan K, Tarrant J, Lloyd T, Holloway J, Hutchinson G, Leff JP, Mallett RM, Harrison GL, Murray RM, Jones PB |year=2006 |title=Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings From the 3-center ÆSOP study |journal=[[Archives of General Psychiatry]] |volume=63 | issue=3 |pages=250–258 |pmid=16520429 |doi=10.1001/archpsyc.63.3.250}}</ref> and at the local and neighbourhood level.<ref name="Kirkbride_et_al_2007">{{cite journal |author=Kirkbride JB |coauthors=Fearon P, Morgan C, Dazzan P, Morgan K, Murray RM, Jones PB |year=2007 |title=Neighbourhood variation in the incidence of psychotic disorders in Southeast London |journal=Social Psychiatry and Psychiatric Epidemiology |volume=42 | issue=6 |pages=438–45 |pmid=17473901 | doi = 10.1007/s00127-007-0193-0 <!--Retrieved from CrossRef by DOI bot-->}}</ref> One particularly stable and replicable finding has been the association between living in an [[Urbanization|urban]] environment and schizophrenia diagnosis, even after factors such as [[drug use]], [[ethnic group]] and size of [[social group]] have been controlled for.<ref name="fn_19">{{cite journal |author=Van Os J |year=2004 |title=Does the urban environment cause psychosis? |journal=[[British Journal of Psychiatry]] |volume=184 | issue=4 |pages=287–288 |pmid=15056569 |doi=10.1192/bjp.184.4.287}}</ref> 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 before [[paraplegia]] and [[blindness]].<ref name="fn_35">{{cite journal |author=Ustun TB |coauthors=Rehm J, Chatterji S, Saxena S, Trotter R, Room R, Bickenbach J, and the [[World Health Organization|WHO]]/[[National Institutes of Health|NIH]] Joint Project CAR Study Group |year=1999 |title=Multiple-informant ranking of the disabling effects of different health conditions in 14 countries |journal=[[The Lancet]] |volume=354 | issue=9173 |pages=111–115 |pmid=10408486 |doi=10.1016/S0140-6736(98)07507-2}}</ref> ==Causes== {{main|Causes of schizophrenia}} [[Image:Schizophrenia PET scan.jpg|frame|left|Data from a [[Positron emission tomography|PET]] study<ref name="fn_25">;{{cite journal |author=Meyer-Lindenberg A |coauthors=Miletich RS, Kohn PD, Esposito G, Carson RE, Quarantelli M, Weinberger DR, Berman KF |year=2002 |title=Reduced prefrontal activity predicts exaggerated striatal dopaminergic function in schizophrenia |journal=[[Nature Neuroscience]] |volume=5 |pages=267–71 |pmid=11865311 |doi=10.1038/nn804}}</ref> suggests that the less the [[frontal lobe]]s are activated (<font color="red">red</font>) during a [[working memory]] task, the greater the increase in abnormal [[dopamine]] activity in the [[striatum]] (<font color="green">green</font>), thought to be related to the [[neurocognitive deficit]]s in schizophrenia.]] While the reliability of the diagnosis introduces difficulties in measuring the relative effect of genes and environment (for example, symptoms overlap to some extent with severe [[bipolar disorder]] or [[Clinical depression|major depression]]), evidence suggests that genetic and [[environmental factor]]s can act in combination to result in schizophrenia.<ref name="fn_12">{{cite journal |author=Harrison PJ |coauthors=Owen MJ |year=2003 |title=Genes for schizophrenia? Recent findings and their pathophysiological implications |journal=[[The Lancet]] |volume=361 | issue=9355 |pages=417–9 |pmid=12573388 |doi=10.1016/S0140-6736(03)12379-3}}</ref> Evidence suggests that the diagnosis of schizophrenia has a significant heritable component but that onset is significantly influenced by environmental factors or stressors.<ref name="fn_15">{{cite journal |author=Day R |coauthors=Nielsen JA, Korten A, Ernberg G, Dube KC, Gebhart J, Jablensky A, Leon C, Marsella A, Olatawura M, et al. |year=1987 |title=Stressful life events preceding the acute onset of schizophrenia: a cross-national study from the World Health Organization |journal=Culture, Medicine and Psychiatry |volume=11 | issue=2 |pages=123–205 |pmid=3595169 | doi = 10.1007/BF00122563 <!--Retrieved from CrossRef by DOI bot-->}}</ref> The idea of an inherent vulnerability (or ''diathesis'') in some people, which can be unmasked by biological, psychological or environmental stressors, is known as the stress-diathesis model.<ref name="Corcoran_et_al_2003">{{cite journal |author=Corcoran C |coauthors=Walker E, Huot R, Mittal V, Tessner K, Kestler L, Malaspina D |year=2003 |title=The stress cascade and schizophrenia: etiology and onset |journal=[[Schizophrenia Bulletin]] |volume=29 | issue=4 |pages=671–92 |pmid=14989406}}</ref> The idea that biological, psychological and social factors are all important is known as the "biopsychosocial" model. ===Genetic=== Estimates of the [[heritability]] of schizophrenia tend to vary owing to the difficulty of separating the effects of genetics and the environment although [[twin studies]] have suggested a high level of heritability.<ref name="ODonovan_et_al_2003">{{cite journal |author=O'Donovan MC |coauthors=Williams NM, Owen MJ |year=2003 |title=Recent advances in the genetics of schizophrenia |journal=[[Human Molecular Genetics]] |volume=12 Spec No 2 |pages=R125–33 |pmid=12952866 |doi=10.1093/hmg/ddg302}}</ref> It is likely that schizophrenia is a condition of complex inheritance, with several [[genes]] possibly interacting to generate risk for schizophrenia or the separate components that can co-occur leading to a diagnosis.<ref name="fn_75">{{cite journal |author=Owen MJ |coauthors=Craddock N, O'Donovan MC |year=2005 |title=Schizophrenia: genes at last? |journal=[[Trends (journals)|Trends in Genetics]] |volume=21 | issue=9 |pages=518–25 |pmid=16009449 |doi=10.1016/j.tig.2005.06.011}}</ref> Genetic studies have suggested that genes that raise the risk for developing schizophrenia are non-specific, and may also raise the risk of developing other psychotic disorders such as [[bipolar disorder]].<ref name="Craddock_et_al_2006">{{cite journal |author=Craddock N |coauthors=O'Donovan MC, Owen MJ |year=2006 |title=Genes for schizophrenia and bipolar disorder? Implications for psychiatric nosology|journal=[[Schizophrenia Bulletin]] |volume=32 | issue=1 |pages=9–16 |pmid=16319375 |doi=10.1093/schbul/sbj033}}</ref><ref name="Dalby_et_al_1986">{{cite journal |author=Dalby JT |coauthors=Morgan D, Lee M |year=1986 |title=Schizophrenia and mania in identical twin brothers |journal=[[Journal of Nervous and Mental Disease]] |volume=174 |pages=304–308 |pmid=3701318 |doi=10.1097/00005053-198605000-00007}}</ref> Recent research has suggested that rare deletions or duplications of tiny DNA sequences within genes (known as [[Gene copy number|copy number variants]]) are also linked to increased risk for schizophrenia.<ref name="Walsh T_et_al_2008">{{cite journal |author=Walsh T |coauthors=McClellan JM, McCarthy SE, Addington AM, Pierce SB, Cooper GM, Nord AS, Kusenda M, Malhotra D, Bhandari A, Stray SM, Rippey CF, Roccanova P, Makarov V, Lakshmi B, Findling RL, Sikich L, Stromberg T, Merriman B, Gogtay N, Butler P, Eckstrand K, Noory L, Gochman P, Long R, Chen Z, Davis S, Baker C, Eichler EE, Meltzer PS, Nelson SF, Singleton AB, Lee MK, Rapoport JL, King MC, Sebat J |title=Rare structural variants disrupt multiple genes in neurodevelopmental pathways in schizophrenia |journal=[[Science (journal)|Science]] |volume=320 |issue=5875 |pages=539–43 |year=2008 |month=April |pmid=18369103 |doi=10.1126/science.1155174 |url=http://www.sciencemag.org/cgi/pmidlookup?view=long&pmid=18369103 |accessdate=2008-07-03}}</ref> ===Prenatal=== It is thought that causal factors can initially come together in early [[neurodevelopment]], including during pregnancy, to increase the risk of later developing schizophrenia. One curious finding is that people diagnosed with schizophrenia are more likely to have been born in winter or spring, (at least in the [[northern hemisphere]]).<ref name="fn_21">{{cite journal |author=Davies G |coauthors=Welham J, Chant D, Torrey EF, McGrath J |year=2003 |title=A systematic review and meta-analysis of Northern Hemisphere season of birth studies in schizophrenia |journal=[[Schizophrenia Bulletin]] |volume=29 | issue=3|pages=587–93 |pmid=14609251}}</ref> There is now evidence that [[prenatal]] exposure to infections increases the risk for developing schizophrenia later in life, providing additional evidence for a link between in utero developmental pathology and risk of developing the condition.<ref name="fn_73">{{cite journal |author=Brown AS |year=2006 |title=Prenatal infection as a risk factor for schizophrenia |journal=[[Schizophrenia Bulletin]] |volume=32 | issue=2 |pages=200–2 |pmid=16469941 |doi= 10.1093/schbul/sbj052}}</ref> ===Social=== Living in an [[Urban area|urban]] environment has been consistently found to be a risk factor for schizophrenia.<ref name="vanOs_et_al_2005">{{cite journal |author=van Os J, Krabbendam L, Myin-Germeys I, Delespaul P |title=The schizophrenia envirome |journal=Current Opinion in Psychiatry |volume=18 |issue=2 |pages=141–5 |year=2005 |month=March |pmid=16639166 |url=http://www.co-psychiatry.com/pt/re/copsych/abstract.00001504-200503000-00006.htm |accessdate=2008-07-06}}</ref><ref name="fn_19" /> Social disadvantage has been found to be a risk factor, including poverty<ref>{{cite journal |author=Mueser KT, McGurk SR |year=2004 |title=Schizophrenia |journal=[[The Lancet]] |volume=363 |issue=9426 |pages=2063–72 |pmid=15207959 |doi=10.1016/S0140-6736(04)16458-1}}</ref> and migration related to social adversity, racial discrimination, family dysfunction, unemployment or poor housing conditions.<ref name="Selten_et_al_2007">{{cite journal |author=Selten JP, Cantor-Graae E, Kahn RS |year=2007 |month=March |title=Migration and schizophrenia |journal=Current Opinion in Psychiatry |volume=20 |issue=2 |pages=111–115 |pmid=17278906 |url=http://www.co-psychiatry.com/pt/re/copsych/abstract.00001504-200703000-00003.htm |accessdate=2008-07-06 |doi=10.1097/YCO.0b013e328017f68e}}</ref> Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life.<ref name="Schenkel_et_al_2005">{{cite journal |author=Schenkel LS |coauthors=Spaulding WD, Dilillo D, Silverstein SM |year=2005 |title=Histories of childhood maltreatment in schizophrenia: Relationships with premorbid functioning, symptomatology, and cognitive deficits |journal=[[Schizophrenia Research]] |volume=76 |issue=2-3 |pages=273–286 |pmid=15949659 |doi=10.1016/j.schres.2005.03.003}}</ref><ref name="Janssen_et_al_2004">{{cite journal |author=Janssen |coauthors=Krabbendam L, Bak M, Hanssen M, Vollebergh W, de Graaf R, van Os J |year=2004 |title=Childhood abuse as a risk factor for psychotic experiences |journal=[[Acta Psychiatrica Scandinavica]] |volume=109 |pages=38–45 |pmid=14674957 |doi=10.1046/j.0001-690X.2003.00217.x}}</ref> Parenting is not held responsible for schizophrenia but unsupportive dysfunctional relationships may contribute to an increased risk.<ref name="Bentall_et_al_2007"/><ref>{{cite journal |author=Subotnik, KL |coauthors=Goldstein, MJ, Nuechterlein, KH, Woo, SM and Mintz, J |year=2002 |title=Are Communication Deviance and Expressed Emotion Related to Family History of Psychiatric Disorders in Schizophrenia? |journal=[[Schizophrenia Bulletin]] |volume=28 |issue=4 |pages=719–29 |pmid=12795501}}</ref> ===Substance use=== {{Seealso|Dual diagnosis}} The relationship between schizophrenia and drug use is complex, meaning that a clear causal connection between drug use and schizophrenia has been difficult to distinguish. There is strong evidence that using certain drugs can trigger either the onset or relapse of schizophrenia in some people. It may also be the case, however, that people with schizophrenia use drugs to overcome negative feelings associated with both the commonly prescribed antipsychotic medication and the condition itself, where negative emotion, [[paranoia]] and [[anhedonia]] are all considered to be core features.<ref name="Gregg_et_al_2007">{{cite journal |author=Gregg L |coauthors=Barrowclough C, Haddock G |year=2007 |title=Reasons for increased substance use in psychosis |journal=Clinical Psychology Review |volume=27 |issue=4 |pages=494–510 |pmid=17240501 | doi = 10.1016/j.cpr.2006.09.004 <!--Retrieved from CrossRef by DOI bot-->}}</ref> [[Amphetamine]]s trigger the release of dopamine and excessive dopamine function is believed to be at least partly responsible for the psychotic symptoms of schizophrenia (a theory known as the [[dopamine hypothesis of schizophrenia]]). This is, in part, supported by the fact that amphetamines reliably worsen the symptoms of schizophrenia.<ref name="Laruelle_et_al_1996">{{cite journal |author=Laruelle M |coauthors=Abi-Dargham A, van Dyck CH, Gil R, D'Souza CD, Erdos J, McCance E, Rosenblatt W, Fingado C, Zoghbi SS, Baldwin RM, Seibyl JP, Krystal JH, Charney DS, Innis RB |year=1996 |title=Single photon emission computerized tomography imaging of amphetamine-induced dopamine release in drug-free schizophrenic subjects |journal=Proceedings of the National Academy of Sciences of the USA |volume=93 |doi= 10.1073/pnas.93.17.9235 |pages=9235–40 |pmid=8799184}}</ref> Schizophrenia can be triggered by heavy use of [[Psychedelics, dissociatives and deliriants|hallucinogenic]] or stimulant drugs.<ref>{{cite journal |author=Mueser KT |coauthors=Yarnold PR, Levinson DF, Singh H, Bellack AS, Kee K, Morrison RL, Yadalam KG |year=1990 |title=Prevalence of substance abuse in schizophrenia: demographic and clinical correlates |journal=[[Schizophrenia Bulletin]] |volume=16 |issue=1 |pages=31–56 |pmid=2333480}}</ref> One study suggests that [[cannabis (drug)|cannabis]] use can contribute to psychosis, though the researchers suspected cannabis use was only a small component in a broad range of factors.<ref name="fn_48">{{cite journal |author=Arseneault L |coauthors=Cannon M, Witton J, Murray RM |year=2004 |title=Causal association between cannabis and psychosis: examination of the evidence |journal=[[British Journal of Psychiatry]] |volume=184 |doi= 10.1192/bjp.184.2.110 |pages=110–7 |pmid=14754822}}</ref> ===Psychological=== A number of psychological mechanisms have been implicated in the development and maintenance of schizophrenia. [[Cognitive bias]]es that have been identified in those with a diagnosis or those at risk, especially when under stress or in confusing situations, include excessive attention to potential threats, jumping to conclusions, making external [[Attribution (psychology)|attributions]], impaired reasoning about social situations and [[Theory of mind|mental states]], difficulty distinguishing inner speech from speech from an external source, and difficulties with early visual processing and maintaining concentration.<ref>{{cite journal |author=Broome MR |coauthors=Woolley JB, Tabraham P, Johns LC, Bramon E, Murray GK, Pariante C, McGuire PK, Murray RM |year=2005 |title=What causes the onset of psychosis? |journal=[[Schizophrenia Research]] |volume=79 | issue=1 |pages=23–34 |pmid=16198238 |doi=10.1016/j.schres.2005.02.007}}</ref><ref>{{cite journal |author= Lewis R|year=2004 |title=Should cognitive deficit be a diagnostic criterion for schizophrenia? |journal=Journal of Psychiatry and Neuroscience |volume=29 | issue=2 |pages=102–113 |pmid=15069464}}</ref><ref>{{cite journal |author=Brune M |coauthors=Abdel-Hamid M, Lehmkamper C, Sonntag C |year=2007 |title=Mental state attribution, neurocognitive functioning, and psychopathology: What predicts poor social competence in schizophrenia best? |journal=[[Schizophrenia Research]] |volume=92| issue=1-2 |pages=151–9 |pmid=17346931 |doi=10.1016/j.schres.2007.01.006}}</ref><ref>{{cite journal |author=Sitskoorn MM |coauthors=Aleman A, Ebisch SJH, Appels MCM, Khan RS |year=2004 |title=Cognitive deficits in relatives of patients with schizophrenia: a meta-analysis |journal=[[Schizophrenia Research]] |volume=71 | issue=2 |pages=285–295 |pmid= 15474899 |doi=10.1016/j.schres.2004.03.007}}</ref> Some cognitive features may reflect global [[neurocognitive deficit]]s in [[memory]], [[attention]], [[problem solving|problem-solving]], [[executive function]] or [[social cognition]], while others may be related to particular issues and experiences.<ref name="Kurtz_2005">{{cite journal |author=Kurtz MM |year=2005 |title=Neurocognitive impairment across the lifespan in schizophrenia: an update |journal=[[Schizophrenia Research]] |volume=74 | issue=1 |pages=15–26 |pmid=15694750 |doi=10.1016/j.schres.2004.07.005}}</ref><ref name="Bentall_et_al_2007">{{cite journal |author=Bentall RP |coauthors=Fernyhough C, Morrison AP, Lewis S, Corcoran R |year=2007 |title=Prospects for a cognitive-developmental account of psychotic experiences |journal=Br J Clin Psychol |volume=46 | issue=Pt 2 |pages=155–73 |pmid=17524210 | doi = 10.1348/014466506X123011}}</ref> Despite a common appearance of "blunted affect", recent findings indicate that many individuals diagnosed with schizophrenia are highly emotionally responsive, particularly to stressful or negative stimuli, and that such sensitivity may cause vulnerability to symptoms or to the disorder.<ref name="schizophrenia1"/><ref>{{cite journal |author=Horan WP |coauthors=Blanchard JJ |year=2003 |title=Emotional responses to psychosocial stress in schizophrenia: the role of individual differences in affective traits and coping |journal=[[Schizophrenia Research]] |volume=60 | issue=2-3 |pages=271–83 |pmid=12591589 |doi=10.1016/S0920-9964(02)00227-X}}</ref><ref>{{cite journal |author=Barrowclough C |coauthors=Tarrier N, Humphreys L, Ward J, Gregg L, Andrews B |year=2003 |title=Self-esteem in schizophrenia: relationships between self-evaluation, family attitudes, and symptomatology |journal=J Abnorm Psychol |volume=112 | issue=1 |pages=92–9 |pmid=12653417 | doi = 10.1037/0021-843X.112.1.92}}</ref> Some evidence suggests that the content of delusional beliefs and psychotic experiences can reflect emotional causes of the disorder, and that how a person interprets such experiences can influence symptomology.<ref>{{cite journal |author=Birchwood M |coauthors=Meaden A, Trower P, Gilbert P, Plaistow J |year=2000 |title=The power and omnipotence of voices: subordination and entrapment by voices and significant others |journal=Psychol Med |volume=30 | issue=2 |pages=337–44 |pmid=10824654 | doi = 10.1017/S0033291799001828}}</ref><ref>{{cite journal |author=Smith B |coauthors=Fowler DG, Freeman D, Bebbington P, Bashforth H, Garety P, Dunn G, Kuipers E |year=2006 |title=Emotion and psychosis: links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations |journal=[[Schizophrenia Research]] |volume=86 | issue=1-3 |pages=181–8 |pmid=16857346 |doi=10.1016/j.schres.2006.06.018}}</ref><ref>{{cite journal |author=Beck, AT |year=2004 |title=A Cognitive Model of Schizophrenia |journal=Journal of Cognitive Psychotherapy |volume=18 | issue=3 |pages=281–88 | doi = 10.1891/jcop.18.3.281.65649}}</ref><ref>{{cite journal |author=Bell V |coauthors=Halligan PW, Ellis HD |year=2006 |title=Explaining delusions: a cognitive perspective |journal=[[Trends (journals)|Trends in Cognitive Science]] |volume=10 | issue=5 |pages=219–26 |pmid=16600666 |doi=10.1016/j.tics.2006.03.004}}</ref> The use of "[[safety|safety behaviors]]" to avoid imagined threats may contribute to the chronicity of delusions.<ref name="Freeman_BRT_2007">{{cite journal |author=Freeman D |coauthors=Garety PA, Kuipers E, Fowler D, Bebbington PE, Dunn G |year=2007 |title=Acting on persecutory delusions: the importance of safety seeking |journal=Behaviour Research and Therapy |volume=45 | issue=1 |pages=89–99 |pmid=16530161 |doi=10.1016/j.brat.2006.01.014}}</ref> Further evidence for the role of psychological mechanisms comes from the effects of therapies on symptoms of schizophrenia.<ref>{{cite journal |author=Kuipers E |coauthors=Garety P, Fowler D, Freeman D, Dunn G, Bebbington P |year=2006 |title=Cognitive, emotional, and social processes in psychosis: refining cognitive behavioral therapy for persistent positive symptoms |journal=[[Schizophrenia Bulletin]] |volume=32 | issue=Suppl 1 |pages=S24–31 |pmid=16885206 |doi=10.1093/schbul/sbl014}}</ref> ===Neural=== [[Image:FMRI.jpg|thumb|[[Functional magnetic resonance imaging]] and other [[brain imaging]] technologies allow for the study of differences in brain activity among people diagnosed with schizophrenia.]] Studies using [[neuropsychological test]]s and [[brain imaging]] technologies such as [[Functional magnetic resonance imaging|fMRI]] and [[Positron emission tomography|PET]] to examine functional differences in brain activity have shown that differences seem to most commonly occur in the [[frontal lobe]]s, [[hippocampus]], and [[temporal lobe]]s.<ref name="fn_31">Green MF (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0-393-70334-7</ref> These differences have been linked to the [[neurocognitive deficit]]s often associated with schizophrenia.<ref name="Green2006">{{cite journal |author=Green MF |year=2006 |title=Cognitive impairment and functional outcome in schizophrenia and bipolar disorder |journal=Journal of Clinical Psychiatry |volume=67 | issue=Suppl 9 |pages=3–8 |pmid=16965182}}</ref> The role of antipsychotic medication, which nearly all those studied had taken, in causing such abnormalities is also unclear.<ref>{{cite journal |author=Dean CE |url=http://ajp.psychiatryonline.org/cgi/content/full/156/11/1843-b |year=2006 |title=Typical neuroleptics and increased subcortical volumes |journal=[[American Journal of Psychiatry]] |volume=156 |issue=11 |pages=1843–4 |pmid=10553769 |accessdate= 2008-02-26}}</ref> Particular focus has been placed upon the function of dopamine in the [[mesolimbic pathway]] of the brain. This focus largely resulted from the accidental finding that a drug group which blocks dopamine function, known as the [[phenothiazines]], could reduce psychotic symptoms. An influential theory, known as the [[Dopamine hypothesis of schizophrenia]], proposed that a malfunction involving dopamine pathways was the cause of (the positive symptoms of) schizophrenia. This theory is now thought to be overly simplistic as a complete explanation, partly because newer antipsychotic medication (called [[atypical antipsychotic]] medication) can be equally effective as older medication (called [[typical antipsychotic]] medication), but also affects [[serotonin]] function and may have slightly less of a [[dopamine]] blocking effect.<ref name="JonesPilowsky2002">{{cite journal |author=Jones HM |coauthors=Pilowsky LS |year=2002 |title=Dopamine and antipsychotic drug action revisited |journal=[[British Journal of Psychiatry]] |volume=181 |pages=271–275 |pmid=12356650 |doi=10.1192/bjp.181.4.271}}</ref> Interest has also focused on the neurotransmitter [[glutamate]] and the reduced function of the [[NMDA receptor|NMDA glutamate receptor]] in schizophrenia. This has largely been suggested by abnormally low levels of [[glutamate receptor]]s found in postmortem brains of people previously diagnosed with schizophrenia<ref name="fn_27">{{cite journal |author=Konradi C |coauthors=Heckers S |year=2003 |title=Molecular aspects of glutamate dysregulation: implications for schizophrenia and its treatment |journal=Pharmacology and Therapeutics |volume=97 |issue=2 |pages=153–79 |pmid=12559388 |doi=10.1016/S0163-7258(02)00328-5}}</ref> and the discovery that the glutamate blocking drugs such as [[phencyclidine]] and [[ketamine]] can mimic the symptoms and cognitive problems associated with the condition.<ref name="fn_59">{{cite journal |author=Lahti AC |coauthors=Weiler MA, Tamara Michaelidis BA, Parwani A, Tamminga CA |year=2001 |title=Effects of ketamine in normal and schizophrenic volunteers |journal=[[Neuropsychopharmacology]] |volume=25 |issue=4 |pages=455–67 |pmid=11557159 |doi=10.1016/S0893-133X(01)00243-3}}</ref> The fact that reduced glutamate function is linked to poor performance on tests requiring [[frontal lobe]] and [[hippocampus|hippocampal]] function and that glutamate can affect [[dopamine]] function, all of which have been implicated in schizophrenia, have suggested an important mediating (and possibly causal) role of glutamate pathways in schizophrenia.<ref name="fn_28">{{cite journal |author=Coyle JT |coauthors=Tsai G, Goff D |year=2003 |title=Converging evidence of NMDA receptor hypofunction in the pathophysiology of schizophrenia |journal=Annals of the [[New York Academy of Sciences]] |volume=1003 |pages=318–27 |pmid=14684455 |doi=10.1196/annals.1300.020}}</ref> Further support of this theory has come from preliminary trials suggesting the efficacy of coagonists at the NMDA receptor complex in reducing some of the positive symptoms of schizophrenia.<ref name="fn_60">{{cite journal |author=Tuominen HJ |coauthors=Tiihonen J, Wahlbeck K |year=2005 |title=Glutamatergic drugs for schizophrenia: a systematic review and meta-analysis |journal=[[Schizophrenia Research]] |volume=72 |pages=225–34 |pmid=15560967 |doi=10.1016/j.schres.2004.05.005}}</ref> There have also been findings of differences in the size and structure of certain brain areas in schizophrenia, starting with the discovery of [[ventricular system|ventricular]] enlargement in those for whom negative symptoms were most prominent.<ref name="fn_29">{{cite journal |author=Johnstone EC |coauthors=Crow TJ, Frith CD, Husband J, Kreel L |year=1976 |title=Cerebral ventricular size and cognitive impairment in chronic schizophrenia |journal=[[The Lancet]] |volume=2 |issue=7992 |pages=924–6 |pmid=62160 |doi=10.1016/S0140-6736(76)90890-4}}</ref> However, this has not proven particularly reliable on the level of the individual person, with considerable variation between patients. More recent studies have shown various differences in brain structure between people with and without diagnoses of schizophrenia.<ref name="fn_30">{{cite journal |author=Flashman LA |coauthors=Green MF |year=2004 |title=Review of cognition and brain structure in schizophrenia: profiles, longitudinal course, and effects of treatment |journal=Psychiatric Clinics of North America |volume=27 |issue=1 |pages=1–18, vii |pmid=15062627 | doi = 10.1016/S0193-953X(03)00105-9 <!--Retrieved from CrossRef by DOI bot-->}}</ref> While brain structure changes have been found in people diagnosed with schizophrenia who have never been treated with antipsychotic drugs<ref name="Cahn_et_al_2002">{{cite journal |author=Cahn W, Hulshoff Pol HE, Bongers M, ''et al'' |title=Brain morphology in antipsychotic-naïve schizophrenia: a study of multiple brain structures |journal=Br J Psychiatry Suppl |volume=43|pages=s66–72 |year=2002 |month=September |pmid=12271803|accessdate=2008-07-03 |doi=10.1192/bjp.181.43.s66}}</ref> there is evidence that the medication itself might cause additional changes in the brain's structure.<ref name="Molina_et_al_2005">{{cite journal |author=Molina V, Reig S, Sanz J, et al |year=2005 |month=December|title=Increase in gray matter and decrease in white matter volumes in the cortex during treatment with atypical neuroleptics in schizophrenia |journal=Schizophrenia Research |volume=80 |issue=1 |pages=61–71 |pmid=16150576 |doi=10.1016/j.schres.2005.07.031 |url=http://linkinghub.elsevier.com/retrieve/pii/S0920-9964(05)00296-3 |accessdate=2008-07-03}}</ref> However, as with earlier studies, many of these differences are only reliably detected when comparing groups of people, and are unlikely to predict any differences in brain structure of an individual person with schizophrenia. ==Treatment and services== {{main|Treatment of schizophrenia}} [[Image:Chlorpromazine-3D-vdW.png|thumb|Molecule of [[chlorpromazine]], which revolutionized treatment of schizophrenia in the 1950s.]] The concept of a cure as such remains controversial, as there is no consensus on the definition, although some criteria for the remission of symptoms have recently been suggested.<ref name="fn_63">van Os J, Burns T, Cavallaro R, ''et al'' (2006). Standardized remission criteria in schizophrenia. ''Acta Psychiatrica Scandinavica'', 113(2), 91–5. PMID 16423159</ref> <!-- and they are...?--> The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the most common being the [[Positive and Negative Syndrome Scale]] (PANSS).<ref name="fn_68">Kay SR, Fiszbein A, Opler LA (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. ''[[Schizophrenia Bulletin]]'', 13(2), 261–76. PMID 3616518</ref> Management of symptoms and improving function is thought to be more achievable than a cure. Treatment was revolutionized in the mid 1950s with the development and introduction of [[chlorpromazine]].<ref name="Turner2007">{{cite journal | author=Turner T. | title=Unlocking psychosis | journal=Brit J Med | year=2007 | volume=334 | issue=suppl | pages=s7 | doi=10.1136/bmj.39034.609074.94 | pmid=17204765 }}</ref> A [[recovery model]] is increasingly adopted, emphasizing hope, empowerment and social inclusion.<ref name="Bellack06">Bellack AS. (2006) Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. ''[[Schizophrenia Bulletin]].'' Jul;32(3):432-42. PMID 16461575</ref> Hospitalization may occur with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or [[involuntary commitment]]). Long-term inpatient stays are now less common due to [[deinstitutionalization]], although can still occur.<ref name="BeckerKilian2006" /> Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or [[Assertive Community Treatment]] team, supported employment<ref>McGurk, SR, Mueser KT, Feldman K, Wolfe R, Pascaris A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. ''Am J Psychiatry.'' Mar;164(3):437–41. PMID 17329468</ref> and patient-led support groups. In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. The outcome for people diagnosed with schizophrenia in non-Western countries may actually be better than for people in the West.<ref name="fn_41">Kulhara P (1994). Outcome of schizophrenia: some transcultural observations with particular reference to developing countries. ''European Archives of Psychiatry and Clinical Neuroscience'', 244(5), 227&ndash;35. PMID 7893767</ref> The reasons for this effect are not clear, although [[cross-cultural studies]] are being conducted. ===Medication=== The mainstay of psychiatric treatment for schizophrenia is an [[antipsychotic]] (aka "[[neuroleptic]]") medication.<ref name="fn_72">{{cite web |url=http://www.nice.org.uk/nicemedia/pdf/cg001fullguideline.pdf |format=PDF|title=Schizophrenia: Full national clinical guideline on core interventions in primary and secondary care |accessdate=2008-07-04 |author=National Collaborating Centre for Mental Health |date=2006-01-24 |publisher=Gaskell and the British Psychological Society}}</ref> These can reduce the "positive" symptoms of psychosis. Most antipsychotics take around 7–14 days to have their main effect. [[Image:Risperdal tablets.jpg|thumb|left|150px|[[Risperidone]] (trade name Risperdal) is a common [[atypical antipsychotic]] medication.]] Though expensive, the newer [[atypical antipsychotic]] drugs are usually preferred for [[first-line treatment|initial treatment]] over the older [[typical antipsychotic]]s; they are often better tolerated and associated with lower rates of [[tardive dyskinesia]], although they are more likely to induce weight gain and [[obesity]]-related diseases.<ref name="fn_62">{{cite journal |author=Lieberman JA, Stroup TS, McEvoy JP, ''et al'' |title=Effectiveness of antipsychotic drugs in patients with chronic schizophrenia |journal=N. Engl. J. Med. |volume=353 |issue=12 |pages=1209–23 |year=2005 |month=September |pmid=16172203 |doi=10.1056/NEJMoa051688 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16172203&promo=ONFLNS19 |accessdate=2008-07-04}}</ref> Prolactin elevations have been reported in women with schizophrenia taking atypical antipsychotics.<ref name="Dickson_et_al_1995">{{cite journal |author=Dickson RA, Dalby JT, Williams R, Edwards AL |title=Risperidone-induced prolactin elevations in premenopausal women with schizophrenia |journal=Am J Psychiatry |volume=152 |issue=7 |pages=1102–3 |year=1995 |month=July |pmid=7540803}}</ref> It remains unclear whether the newer antipsychotics reduce the chances of developing [[neuroleptic malignant syndrome]], a rare but serious and potentially fatal neurological disorder most often caused by an adverse reaction to [[neuroleptic]] or antipsychotic drugs.<ref name="Ananth_et_al_2004">{{cite journal |author=Ananth J, Parameswaran S, Gunatilake S, Burgoyne K, Sidhom T |title=Neuroleptic malignant syndrome and atypical antipsychotic drugs |journal=J Clin Psychiatry |volume=65 |issue=4 |pages=464–70 |year=2004 |month=April |pmid=15119907 |url=http://article.psychiatrist.com/?ContentType=START&ID=10000823 |accessdate=2008-07-04}}</ref> The two classes of antipsychotics are generally thought equally effective for the treatment of the positive symptoms. Some researchers have suggested that the atypicals offer additional benefit for the negative symptoms and cognitive deficits associated with schizophrenia, although the clinical significance of these effects has yet to be established. Recent reviews have refuted the claim that atypical antipsychotics have fewer extrapyramidal side effects than typical antipsychotics, especially when the latter are used in low doses or when low potency antipsychotics are chosen.<ref name="fn_36">{{cite journal |author=Leucht S, Wahlbeck K, Hamann J, Kissling W |title=New generation antipsychotics versus low-potency conventional antipsychotics: a systematic review and meta-analysis |journal=Lancet |volume=361 |issue=9369 |pages=1581–9 |year=2003 |month=May |pmid=12747876 |doi=10.1016/S0140-6736(03)13306-5 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(03)13306-5 |accessdate=2008-07-04}}</ref> Response of symptoms to medication is variable; "Treatment-resistant schizophrenia" is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics.<ref>{{cite journal |author=Meltzer HY |title=Treatment-resistant schizophrenia--the role of clozapine |journal=Current Medical Research and Opinion |volume=14 |issue=1 |pages=1–20 |date=1997 |pmid=9524789}}</ref> Patients in this category may be prescribed [[clozapine]],<ref>{{cite journal |author=Wahlbeck K, Cheine MV, Essali A |title=Clozapine versus typical neuroleptic medication for schizophrenia |journal=The Cochrane Database of Systematic Reviews |volume= |issue=2 |pages=CD000059 |publisher=John Wiley and Sons, Ltd. |year=2007 |pmid=10796289 |doi=10.1002/14651858.CD000059 |issn=1464-780X}}</ref> a medication of superior effectiveness but several potentially lethal side effects including [[agranulocytosis]] and [[myocarditis]].<ref>{{cite journal | author = Haas SJ, Hill R, Krum H | title = Clozapine-associated myocarditis: a review of 116 cases of suspected myocarditis associated with the use of clozapine in Australia during 1993–2003 | journal = Drug Safety | volume = 30 | pages = 47–57 | date = 2007 | pmid=17194170 | doi = 10.2165/00002018-200730010-00005 }}</ref> Clozapine may have the additional benefit of reducing propensity for substance abuse in schizophrenic patients.<ref>{{cite journal |author = Lee M, Dickson RA, Campbell M, Oliphant J, Gretton H, Dalby JT. |title = Clozapine and substance abuse in patients with schizophrenia |journal = Canadian Journal of Psychiatry |volume = 43 |pages = 855–856 |date = 1998 }}</ref> For other patients who are unwilling or unable to take medication regularly, long-acting [[Typical antipsychotic#Depot injections|depot]] preparations of antipsychotics may be given every two weeks to achieve control. The United States of America and Australia are two countries with [[Outpatient commitment|laws]] allowing the forced administration of this type of medication on those who refuse but are otherwise stable and living in the community. Some findings have found that in the longer-term some individuals may do better not taking antipsychotics.<ref>{{cite journal |author=Harrow M, Jobe TH |title=Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study |journal=[[Journal of Nervous and Mental Disease]] |volume=195 |issue=5 |pages=406–414 |year=2007 |month=May |pmid=17502806}}</ref> Despite the promising results of early pilot trials,<ref name="pmid11356585">{{cite journal |author=Peet M, Brind J, Ramchand CN, Shah S, Vankar GK |title=Two double-blind placebo-controlled pilot studies of eicosapentaenoic acid in the treatment of schizophrenia |journal=Schizophr. Res. |volume=49 |issue=3 |pages=243–51 |year=2001 |pmid=11356585| doi = 10.1016/S0920-9964(00)00083-9}}</ref> [[omega-3 fatty acids]] failed to improve schizophrenic symptoms, according to the most recent [[meta-analysis]].<ref name="pmid17194275">{{cite journal |author=Freeman MP, Hibbeln JR, Wisner KL, Davis JM, Mischoulon D, Peet M, Keck PE, Marangell LB, Richardson AJ, Lake J, Stoll AL |title=Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry |journal=The Journal of clinical psychiatry |volume=67 |issue=12 |pages=1954–67 |year=2006 |pmid=17194275 |doi=}}</ref> ===Psychological and social interventions=== [[Psychotherapy]] is also widely recommended and used in the treatment of schizophrenia, although services may often be confined to pharmacotherapy because of reimbursement problems or lack of training.<ref>Moran, M (2005). [http://pn.psychiatryonline.org/cgi/content/full/40/22/24-b Psychosocial Treatment Often Missing From Schizophrenia Regimens.] ''Psychiatr News'' [[November 18]] [[2005]], Volume 40, Number 22, page 24. Retrieved on [[2007-05-17]].</ref> [[Cognitive behavioral therapy]] (CBT) is used to reduce symptoms and improve related issues such as [[self-esteem]], social functioning, and insight. Although the results of early trials were inconclusive,<ref name="fn_38">{{cite journal |author=Cormac I, Jones C, Campbell C |title=Cognitive behaviour therapy for schizophrenia |journal=Cochrane Database of [[systematic review]]s |volume= |issue=1 |pages=CD000524 |year=2002 |pmid=11869579 |doi=10.1002/14651858.CD000524|accessdate=2008-07-03}}</ref> more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia.<ref name="fn_39">{{cite journal |author=Zimmermann G, Favrod J, Trieu VH, Pomini V |title=The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis |journal=Schizophrenia Research |volume=77 |issue=1 |pages=1–9 |year=2005 |month=September |pmid=16005380 |doi=10.1016/j.schres.2005.02.018 |url=http://linkinghub.elsevier.com/retrieve/pii/S0920-9964(05)00084-8|accessdate=2008-07-03}}</ref> Another approach is cognitive remediation therapy, a technique aimed at remediating the [[neurocognitive deficit]]s sometimes present in schizophrenia. Based on techniques of [[neuropsychological rehabilitation]], early evidence has shown it to be cognitively effective, with some improvements related to measurable changes in brain activation as measured by [[fMRI]].<ref name="fn_40">{{cite journal |author=Wykes T, Brammer M, Mellers J, ''et al'' |title=Effects on the brain of a psychological treatment: cognitive remediation therapy: functional magnetic resonance imaging in schizophrenia |journal=[[British Journal of Psychiatry]] |volume=181 |issue= |pages=144–52 |year=2002 |month=August |pmid=12151286 |url=http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=12151286 |accessdate=2008-07-03 |doi=10.1192/bjp.181.2.144 |doi_brokendate=2008-07-08}}</ref> A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy.<ref>{{cite journal |author=Hogarty GE, Flesher S, Ulrich R, ''et al'' |title=Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior |journal=Arch. Gen. Psychiatry |volume=61 |issue=9 |pages=866–76 |year=2004 |month=September |pmid=15351765 |doi=10.1001/archpsyc.61.9.866 |url=http://archpsyc.ama-assn.org/cgi/pmidlookup?view=long&pmid=15351765|accessdate=2008-07-03}}</ref> [[Family Therapy]] or Education, which addresses the whole family system of an individual with a diagnosis of schizophrenia, has been consistently found to be beneficial, at least if the duration of intervention is longer-term.<ref>{{cite journal |author=McFarlane WR, Dixon L, Lukens E, Lucksted A |title=Family psychoeducation and schizophrenia: a review of the literature |journal=J Marital Fam Ther |volume=29 |issue=2 |pages=223–45 |year=2003 |month=April |pmid=12728780 |doi=10.1111/j.1752-0606.2003.tb01202.x }}</ref><ref>{{cite journal |author=Glynn SM, Cohen AN, Niv N |title=New challenges in family interventions for schizophrenia |journal=Expert Review of Neurotherapeutics |volume=7 |issue=1 |pages=33–43 |year=2007 |month=January |pmid=17187495 |doi=10.1586/14737175.7.1.33 |url=http://www.future-drugs.com/doi/abs/10.1586/14737175.7.1.33?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dncbi.nlm.nih.gov|accessdate=2008-07-03}}</ref><ref>Pharoah F, Mari J, Rathbone J, Wong W. (2006) [http://www.cochrane.org/reviews/en/ab000088.html Family intervention for schizophrenia] Cochrane Database of Systematic Reviews, Issue 4</ref> Aside from therapy, the impact of schizophrenia on families and the burden on carers has been recognized, with the increasing availability of self-help books on the subject.<ref>{{cite book |author=Jones S, Hayward P |title=Coping with Schizophrenia: A Guide for Patients, Families and Caregivers | publisher = Oneworld Pub. | date = 2004 | location = Oxford, England |isbn=1-85168-344-5}}</ref><ref>{{cite book |author=[[E. Fuller Torrey|Torrey EF]] |title=Surviving Schizophrenia: A Manual for Families, Consumers, and Providers |edition=5th Edition |publisher=HarperCollins |year=2006 | isbn=0-06-084259-8}}</ref> There is also some evidence for benefits from social skills training, although there have also been significant negative findings.<ref>{{cite journal |author=Kopelowicz A, Liberman RP, Zarate R |title=Recent advances in social skills training for schizophrenia |journal=[[Schizophrenia Bulletin]] |volume=32 Suppl 1 |issue= |pages=S12–23 |year=2006 |month=October |pmid=16885207 |doi=10.1093/schbul/sbl023 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16885207|accessdate=2008-07-03}}</ref><ref>American Psychiatric Association (2004) Practice Guideline for the Treatment of Patients With Schizophrenia. Second Edition.</ref> Some studies have explored the possible benefits of music therapy and other creative therapies.<ref>{{cite journal |author=Talwar N, Crawford MJ, Maratos A, Nur U, McDermott O, Procter S |title=Music therapy for in-patients with schizophrenia: exploratory randomised controlled trial |journal=The British Journal of Psychiatry |volume=189 |issue= |pages=405–9 |year=2006 |month=November |pmid=17077429 |doi=10.1192/bjp.bp.105.015073 |url=http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=17077429|accessdate=2008-07-03}}</ref><ref>Ruddy R, Milnes D. (2005) [http://www.cochrane.org/reviews/en/ab000088.html Art therapy for schizophrenia or schizophrenia-like illnesses.] Cochrane Database of Systematic Reviews, Issue 4</ref><ref>Ruddy RA, Dent-Brown K. (2007) [http://www.cochrane.org/reviews/en/ab005378.html Drama therapy for schizophrenia or schizophrenia-like illnesses.] Cochrane Database of Systematic Reviews, Issue 1.</ref> The [[Soteria]] model is alternative to inpatient hospital treatment using a minimal medication approach. It is described as a [[Social environment|milieu]]-therapeutic [[psychosocial recovery|recovery]] method, characterized by its founder as "the 24 hour a day application of interpersonal phenomenologic interventions by a nonprofessional staff, usually without neuroleptic drug treatment, in the context of a small, homelike, quiet, supportive, protective, and tolerant social environment."<ref name="mosh99">{{cite journal |author=Mosher LR |title=Soteria and other alternatives to acute psychiatric hospitalization: a personal and professional review |journal=[[Journal of Nervous and Mental Disease]] |volume=187 |issue=3 |pages=142–9 |year=1999 |month=March |pmid=10086470 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0022-3018&volume=187&issue=3&spage=142 |issn= |accessdate=2008-07-03 |doi=10.1097/00005053-199903000-00003}}</ref> Although research evidence is limited, a 2008 systematic review found the programme equally as effective as treatment with medication in people diagnosed with first and second episode schizophrenia.<ref name="Calton_et_al_2008">{{cite journal |author=Calton T, Ferriter M, Huband N, Spandler H |title=A systematic review of the Soteria paradigm for the treatment of people diagnosed with schizophrenia |journal=[[Schizophrenia Bulletin]] |volume=34 |issue=1 |pages=181–92 |year=2008 |month=January |pmid=17573357 |doi=10.1093/schbul/sbm047 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17573357|accessdate=2008-07-03}}</ref> ===Other=== [[Electroconvulsive therapy]] is not considered a [[first line treatment]] but may be prescribed in cases where other treatments have failed. It is more effective where symptoms of catatonia are present,<ref>{{cite journal |author=Greenhalgh J, Knight C, Hind D, Beverley C, Walters S |year=2005 |month=March |title= Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies|journal= Health Technol Assess.|volume= 9|issue=9 |pages=1–156 |url=http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15774232 (abstract) |accessdate= 2007-06-17}}</ref> and is recommended for use under [[National Institute for Health and Clinical Excellence|NICE]] guidelines in the UK for catatonia if previously effective, though there is no recommendation for use for schizophrenia otherwise.<ref>{{cite web |url=http://www.nice.org.uk/page.aspx?o=TA059 |title= The clinical effectiveness and cost effectiveness of electroconvulsive Therapy (ECT) for depressive illness, schizophrenia, catatonia and mania.|accessdate=2007-06-17 |author= National Institute for Health and Clinical Excellence|year= 2003|month=April |publisher= National Institute for Health and Clinical Excellence|language= English}}</ref> [[Psychosurgery]] has now become a rare procedure and is not a recommended treatment for schizophrenia.<ref name="Mashour_et_al_2005">{{cite journal |author=Mashour GA, Walker EE, Martuza RL |title=Psychosurgery: past, present, and future |journal=Brain Res. Brain Res. Rev. |volume=48 |issue=3 |pages=409–19 |year=2005 |month=June |pmid=15914249 |doi=10.1016/j.brainresrev.2004.09.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S0165-0173(04)00129-8 |accessdate=2008-07-04}}</ref> Service-user led movements have become integral to the recovery process in [[Europe]] and [[United States|America]]; groups such as the [[Hearing Voices Network]] and the [[Paranoia Network]] have developed a self-help approach that aims to provide support and assistance outside the traditional medical model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of criteria for [[mental illness]] or [[mental health]], they aim to destigmatize the experience and encourage individual responsibility and a positive self-image. Partnerships between hospitals and consumer-run groups are becoming more common, with services working toward remediating social withdrawal, building social skills and reducing rehospitalization.<ref name="Goering_et_al_2006">{{cite journal |author=Goering P, Durbin J, Sheldon CT, Ochocka J, Nelson G, Krupa T |title=Who uses consumer-run self-help organizations? |journal=Am J Orthopsychiatry |volume=76 |issue=3 |pages=367–73 |year=2006 |month=July |pmid=16981815 |doi=10.1037/0002-9432.76.3.367 |url=http://content.apa.org/journals/ort/76/3/367 |accessdate=2008-07-04}}</ref> ==Prognosis== [[Image:John f nash 20061102 3.jpg|200px|thumb|right|[[John Forbes Nash|John Nash]], an [[United States|American]] [[mathematician]], began showing signs of paranoid schizophrenia during his college years. Despite having stopped taking his prescribed medication, Nash continued his studies and was awarded the [[Nobel Prize]] in 1994. His life was the source of the biography ''[[A Beautiful Mind]]'' and the subsequent [[A Beautiful Mind (film)|film adaptation]].]] ===Course=== The International Study of Schizophrenia (ISoS), coordinated by the [[World Health Organization]], carried out a long-term follow-up study of 1633 individuals diagnosed with schizophrenia around the world. Outcome after 10 and 15 years varied substantially between individuals and countries. Overall over half of those available for follow-up had recovered in terms of symptomology ([[Bleuler Scale]] of 4) and over a third on combined symptomology and good functioning ([[GAF]] greater than 60). Around one sixth of those were "judged as having achieved complete recovery, in the sense of no longer requiring any form of treatment", although some still had some level of symptomology or disability. There was significant "late recovery" even after continued problems and treatment failures. It was concluded that: "the ISoS findings join others in relieving patients, carers and clinicians of the chronicity paradigm which dominated thinking throughout much of the 20th century."<Ref>{{cite journal |author=Harrison G, Hopper K, Craig T, ''et al'' |title=Recovery from psychotic illness: a 15- and 25-year international follow-up study |journal=Br J Psychiatry |volume=178 |issue= |pages=506–17 |year=2001 |month=June |pmid=11388966 |url=http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=11388966 |accessdate=2008-07-04 |doi=10.1192/bjp.178.6.506}}</ref> A review of major longitudinal studies in North America also found large variation in outcomes, and that the course could be mild, moderate, or severe. Outcome was on average worse than for other psychotic and psychiatric disorders, but between 21% and 57% showed good outcome, depending on the strictness of the criteria used. "Very few" showed a deteriorating course, although the danger of suicide and early death was indicated. It was noted that: "Of central importance, there is now evidence that a moderate number of schizophrenia patients do have complete symptomatic remissions without further relapses, at least for a good period of time, and that some of these patients may not require maintenance medication."<ref name="Jobe2005">{{cite journal |author=Jobe TH, Harrow M |title=Long-term outcome of patients with schizophrenia: a review |journal=Canadian Journal of Psychiatry |volume=50 |issue=14 |pages=892–900 |year=2005 |month=December |pmid=16494258 |url=http://ww1.cpa-apc.org:8080/Publications/Archives/CJP/2005/december/cjp-dec-05-Harrow-IR.pdf|format=PDF |accessdate=2008-07-05}}</ref> A clinical study using strict recovery criteria (concurrent remission of positive and negative symptoms and adequate social and vocational functioning continuously for two years) found a recovery rate of 14% within the first five years.<ref name="fn_43">{{cite journal |author=Robinson DG, Woerner MG, McMeniman M, Mendelowitz A, Bilder RM |title=Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder |journal=Am J Psychiatry |volume=161 |issue=3 |pages=473–9 |year=2004 |month=March |pmid=14992973 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=14992973 |accessdate=2008-07-04 |doi=10.1176/appi.ajp.161.3.473}}</ref> A 5-year community study found that 62% showed overall improvement on a composite measure of symptomatic, clinical and functional outcomes.<ref>{{cite journal |author=Harvey CA, Jeffreys SE, McNaught AS, Blizard RA, King MB |year=2007 |month= |title=The Camden Schizophrenia Surveys III: Five-Year Outcome of a Sample of Individuals From a Prevalence Survey and the Importance of Social Relationships |journal=International Journal of Social Psychiatry |volume=53 |issue=4 |pages=340–356 |url=http://isp.sagepub.com/cgi/content/abstract/53/4/340 |accessdate=2008-07-04 |doi=10.1177/0020764006074529 }}</ref> An important additional finding from the [[World Health Organization]] studies was that individuals diagnosed with schizophrenia have much better long-term outcomes in "[[developing countries]]" ([[India]], [[Colombia]] and [[Nigeria]]) than in "[[developed countries]]" ([[United States|USA]], [[United Kingdom|UK]], [[Republic of Ireland|Ireland]], [[Denmark]], [[Czech Republic]], [[Slovakia]], [[Japan]], and [[Russia]]),<ref name="fn_44">{{cite journal |author=Hopper K, Wanderling J |title=Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia |journal=Schizophr Bull |volume=26 |issue=4 |pages=835–46 |year=2000 |pmid=11087016 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=11087016 |accessdate=2008-07-04}}</ref> despite the fact antipsychotic drugs are typically not widely available in poorer countries. ===Defining recovery=== Rates are not always comparable across studies because exact definitions of remission and recovery have not been widely established. A "Remission in Schizophrenia Working Group" has proposed standardized ''remission'' criteria involving "improvements in core signs and symptoms to the extent that any remaining symptoms are of such low intensity that they no longer interfere significantly with behavior and are below the threshold typically utilized in justifying an initial diagnosis of schizophrenia."<ref>{{cite journal |author=Andreasen NC, Carpenter WT, Kane JM, Lasser RA, Marder SR, Weinberger DR |title=Remission in schizophrenia: proposed criteria and rationale for consensus |journal=The American Journal of Psychiatry |volume=162 |issue=3 |pages=441–9 |year=2005 |month=March |pmid=15741458 |doi=10.1176/appi.ajp.162.3.441 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=15741458 |accessdate=2008-07-07}}</ref> Standardized ''recovery'' criteria have also been proposed by a number of different researchers, with the stated DSM definitions of a "complete return to premorbid levels of functioning” or "complete return to full functioning" seen as inadequate, impossible to measure, incompatible with the variability in how society defines normal psychosocial functioning, and contributing to self-fullfilling pessimism and stigma.<ref>{{cite journal |author=Liberman RP, Kopelowicz A|year=2005 |month=June |title=Recovery From Schizophrenia: A Concept in Search of Research |journal=Psychiatric Services |volume=56 |issue=6 |pages=735–742 |url=http://psychservices.psychiatryonline.org/cgi/content/full/56/6/735 |accessdate=2008-07-07 |doi=10.1176/appi.ps.56.6.735 |pmid=15939952}}</ref> Some [[mental health professionals]] may have quite different basic perceptions and concepts of recovery than individuals with the diagnosis, including those in the [[consumer/survivor movement]].<ref>{{cite journal |author=Davidson L, Schmutte T, Dinzeo T, Andres-Hyman R |title=Remission and recovery in schizophrenia: practitioner and patient perspectives |journal=Schizophrenia Bulletin |volume=34 |issue=1 |pages=5–8 |year=2008 |month=January |pmid=17984297 |doi=10.1093/schbul/sbm122 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17984297 |accessdate=2008-07-07}}</ref> One notable limitation of nearly all the research criteria is failure to address the person's own evaluations and feelings about their life. Schizophrenia and recovery often involve a continuing loss of self-esteem, alienation from friends and family, interruption of school and career, and social stigma, "experiences that cannot just be reversed or forgotten."<ref name="Bellack06"/> An increasingly influential [[Recovery model|model]] defines recovery as a process, similar to being "in recovery" from drug and alcohol problems, and emphasizes a personal journey involving factors such as hope, choice, empowerment, social inclusion and achievement.<ref name="Bellack06"/> ===Predictors=== Several factors have been associated with a better overall prognosis: Being female, acute (vs. insidious) onset of symptoms, older age of first episode, predominantly positive (rather than negative) symptoms, presence of mood symptoms, and good pre-illness functioning.<ref name="Davidson_Glashan_1997">{{cite journal |author=Davidson L, McGlashan TH |title=The varied outcomes of schizophrenia |journal=Canadian Journal of Psychiatry |volume=42 |issue=1 |pages=34–43 |year=1997 |month=February |pmid=9040921 }}</ref><ref name="Lieberman_et_al_1996">{{cite journal |author=Lieberman JA, Koreen AR, Chakos M, ''et al'' |title=Factors influencing treatment response and outcome of first-episode schizophrenia: implications for understanding the pathophysiology of schizophrenia |journal=J Clin Psychiatry |volume=57 Suppl 9 |issue= |pages=5–9 |year=1996 |pmid=8823344}}</ref> The strengths and internal resources of the individual concerned, such as determination or "[[psychological resilience]]", have also been associated with better prognosis.<ref name="Jobe2005"/> The attitude and level of support from people in the individual's life can have a significant impact; research framed in terms of the negative aspects of this - the level of critical comments, hostility, and intrusive or controlling attitudes (termed high '[[Expressed emotion]]' by researchers) - has consistently indicated links to relapse.<ref name="fn_70">{{cite journal |author=Bebbington P, Kuipers L |title=The predictive utility of expressed emotion in schizophrenia: an aggregate analysis |journal=Psychol Med |volume=24 |issue=3 |pages=707–18 |year=1994 |month=August |pmid=7991753}}</ref> Most research on predictive factors is correlational in nature, however, and a clear cause-and-effect relationship is often difficult to establish. ===Mortality=== In a study of over 168,000 Swedish citizens undergoing psychiatric treatment, schizophrenia was associated with an average life expectancy of approximately 80–85% of that of the general population. Women with a diagnosis of schizophrenia were found to have a slightly better life expectancy than that of men, and as a whole, a diagnosis of schizophrenia was associated with a better life expectancy than [[substance abuse]], [[personality disorder]], [[myocardial infarction|heart attack]] and [[stroke]].<ref name="fn_45">{{cite journal |author=Hannerz H, Borgå P, Borritz M |title=Life expectancies for individuals with psychiatric diagnoses |journal=Public Health |volume=115 |issue=5 |pages=328–37 |year=2001 |month=September |pmid=11593442 |doi=10.1038/sj.ph.1900785 }}</ref> There is a high [[suicide]] rate associated with schizophrenia; a recent study showed that 30% of patients diagnosed with this condition had attempted suicide at least once during their lifetime.<ref name="fn_46">{{cite journal |author=Radomsky ED, Haas GL, Mann JJ, Sweeney JA |title=Suicidal behavior in patients with schizophrenia and other psychotic disorders |journal=Am J Psychiatry |volume=156 |issue=10 |pages=1590–5 |year=1999 |month=October |pmid=10518171 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=10518171 |accessdate=2008-07-04}}</ref><ref name="fn_128">{{cite book |author=Dalby JT, Williams RJ |title=Depression in schizophrenics |publisher=Plenum Press |location=New York |year=1989 |isbn=0-306-43240-4}}</ref>Another study suggested that 10% of persons with schizophrenia die by suicide.<ref name="fn_47">{{cite journal |author=Caldwell CB, Gottesman II |title=Schizophrenics kill themselves too: a review of risk factors for suicide |journal=Schizophr Bull |volume=16 |issue=4 |pages=571–89 |year=1990 |pmid=2077636}}</ref> Other identified factors include smoking, poor diet, little exercise and the negative health effects of psychiatric drugs.<ref name="Brown_Barraclough_2000" /> ===Violence=== The relationship between violent acts and schizophrenia is a contentious topic. Current research indicates that the percentage of people with schizophrenia who commit violent acts is higher than the percentage of people without any disorder, but lower than is found for disorders such as [[alcoholism]], and the difference is reduced or not found in same-neighbourhood comparisons when related factors are taken into account, notably sociodemographic variables and [[substance misuse]].<ref name="Walsh02">{{cite journal |author=Walsh E, Buchanan A, Fahy T |title=Violence and schizophrenia: examining the evidence |journal=Br J Psychiatry |volume=180 |issue= |pages=490–5 |year=2002 |month=June |pmid=12042226 |url=http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=12042226 |accessdate=2008-07-04 |doi=10.1192/bjp.180.6.490}}</ref><ref name="Stuart 03">{{cite journal |author=Stuart H |title=Violence and mental illness: an overview |journal=World Psychiatry |volume=2 |issue=2 |pages=121–124 |year=2003 |month=June |pmid=16946914 |pmc=1525086 |doi= |url= |accessdate=2008-07-04}}</ref><ref>{{cite journal |author=Steadman HJ, Mulvey EP, Monahan J, ''et al'' |title=Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods |journal=Arch. Gen. Psychiatry |volume=55 |issue=5 |pages=393–401 |year=1998 |month=May |pmid=9596041 |url=http://archpsyc.ama-assn.org/cgi/pmidlookup?view=long&pmid=9596041 |accessdate=2008-07-04 |doi=10.1001/archpsyc.55.5.393}}</ref><ref>{{cite journal |author=Swanson JW, Swartz MS, Van Dorn RA, ''et al'' |title=A national study of violent behavior in persons with schizophrenia |journal=Arch. Gen. Psychiatry |volume=63 |issue=5 |pages=490–9 |year=2006 |month=May |pmid=16651506 |doi=10.1001/archpsyc.63.5.490 |url=http://archpsyc.ama-assn.org/cgi/pmidlookup?view=long&pmid=16651506 |accessdate=2008-07-04}}</ref><ref>{{cite journal |author=Swanson JW, Holzer CE, Ganju VK, Jono RT |title=Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys |journal=Hosp Community Psychiatry |volume=41 |issue=7 |pages=761–70 |year=1990 |month=July |pmid=2142118 |url=http://ps.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=2142118 |accessdate=2008-07-04}}</ref> Studies have indicated that 5% to 10% of those charged with murder in Western countries have a schizophrenia spectrum disorder.<ref name="Mullen 06">{{cite journal |author=Mullen PE |year=2006 |title=Schizophrenia and violence: from correlations to preventive strategies |journal=Advances in Psychiatric Treatment |volume=12 |pages=239–248 |url=http://apt.rcpsych.org/cgi/content/abstract/12/4/239 |accessdate=2008-07-04 |doi=10.1192/apt.12.4.239}}</ref><ref name="fn_52">{{cite journal |author=Simpson AI, McKenna B, Moskowitz A, Skipworth J, Barry-Walsh J |title=Homicide and mental illness in New Zealand, 1970-2000 |journal=Br J Psychiatry |volume=185 |issue= |pages=394–8 |year=2004 |month=November |pmid=15516547 |doi=10.1192/bjp.185.5.394 |url=http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=15516547 |accessdate=2008-07-04}}</ref><ref name="fn_53">{{cite journal |author=Fazel S, Grann M |title=Psychiatric morbidity among homicide offenders: a Swedish population study |journal=Am J Psychiatry |volume=161 |issue=11 |pages=2129–31 |year=2004 |month=November |pmid=15514419 |doi=10.1176/appi.ajp.161.11.2129 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=15514419 |accessdate=2008-07-04}}</ref> The occurrence of [[psychosis]] in schizophrenia has sometimes been linked to a higher risk of violent acts. Findings on the specific role of delusions or hallucinations have been inconsistent, but have focused on delusional jealousy, perception of threat and command hallucinations. It has been proposed that a certain type of individual with schizophrenia may be most likely to offend, characterized by a history of educational difficulties, low [[IQ]], conduct disorder, early-onset substance misuse and offending prior to diagnosis.<ref name= "Mullen 06"/> A consistent finding is that individuals with a diagnosis of schizophrenia are often the [[victim of a crime|victims]] of violent crime—at least 14 times more often than they are perpetrators.<ref>{{cite journal |author=Brekke JS, Prindle C, Bae SW, Long JD |title=Risks for individuals with schizophrenia who are living in the community |journal=Psychiatr Serv |volume=52 |issue=10 |pages=1358–66 |year=2001 |month=October |pmid=11585953 |doi= |url=http://ps.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=11585953 |accessdate=2008-07-04}}</ref><ref name="fn_55">{{cite journal |author=Fitzgerald PB, de Castella AR, Filia KM, Filia SL, Benitez J, Kulkarni J |title=Victimization of patients with schizophrenia and related disorders |journal=Aust N Z J Psychiatry |volume=39 |issue=3 |pages=169–74 |year=2005 |month=March |pmid=15701066 |doi=10.1111/j.1440-1614.2005.01539.x |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0004-8674&date=2005&volume=39&issue=3&spage=169 |accessdate=2008-07-04}}</ref> Another consistent finding is a link to substance misuse, particularly alcohol,<ref name="fn_51">{{cite journal |author=Walsh E, Gilvarry C, Samele C, ''et al'' |title=Predicting violence in schizophrenia: a prospective study |journal=Schizophr. Res. |volume=67 |issue=2-3 |pages=247–52 |year=2004 |month=April |pmid=14984884 |doi=10.1016/S0920-9964(03)00091-4 |url=http://linkinghub.elsevier.com/retrieve/pii/S0920996403000914 |accessdate=2008-07-04}}</ref> among the minority who commit violent acts. Violence by or against individuals with schizophrenia typically occurs in the context of complex social interactions within a family setting,<ref>{{cite journal |author=Solomon PL, Cavanaugh MM, Gelles RJ |title=Family violence among adults with severe mental illness: a neglected area of research |journal=Trauma Violence Abuse |volume=6 |issue=1 |pages=40–54 |year=2005 |month=January |pmid=15574672 |doi=10.1177/1524838004272464 |url=http://tva.sagepub.com/cgi/pmidlookup?view=long&pmid=15574672 |accessdate=2008-07-04}}</ref> and is also an issue in clinical services<ref>{{cite journal |author=Chou KR, Lu RB, Chang M |title=Assaultive behavior by psychiatric in-patients and its related factors |journal=J Nurs Res |volume=9 |issue=5 |pages=139–51 |year=2001 |month=December |pmid=11779087}}</ref> and in the wider community.<ref>{{cite journal |author=Lögdberg B, Nilsson LL, Levander MT, Levander S |title=Schizophrenia, neighbourhood, and crime |journal=Acta Psychiatr Scand |volume=110 |issue=2 |pages=92–7 |year=2004 |month=August |pmid=15233709 |doi=10.1111/j.1600-0047.2004.00322.x |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0001-690X&date=2004&volume=110&issue=2&spage=92 |accessdate=2008-07-04}}</ref> ==Screening and prevention== There are no reliable markers for the later development of schizophrenia although research is being conducted into how well a combination of genetic risk plus non-disabling psychosis-like experience predicts later diagnosis.<ref name="Cannon_et_al_2007">{{cite journal |author=Cannon TD, Cornblatt B, McGorry P |title=The empirical status of the ultra high-risk (prodromal) research paradigm |journal=Schizophrenia Bulletin |volume=33 |issue=3 |pages=661–4 |year=2007 |month=May |pmid=17470445 |doi=10.1093/schbul/sbm031 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17470445 |accessdate=2008-07-06}}</ref> People who fulfill the 'ultra high-risk mental state' criteria, that include a family history of schizophrenia plus the presence of transient or self-limiting psychotic experiences, have a 20–40% chance of being diagnosed with the condition after one year.<ref name="Drake_Lewis_2005">{{cite journal |author=Drake RJ, Lewis SW |title=Early detection of schizophrenia |journal=Current Opinion in Psychiatry |volume=18 |issue=2 |pages=147–50 |year=2005 |month=March |pmid=16639167|url=http://www.co-psychiatry.com/pt/re/copsych/abstract.00001504-200503000-00007.htm |accessdate=2008-07-06 |doi=10.1097/00001504-200503000-00007}}</ref> The use of psychological treatments and medication has been found effective in reducing the chances of people who fulfill the 'high-risk' criteria from developing full-blown schizophrenia.<ref name="vanOs_Delespaul_2005">{{cite journal |author=Van Os J, Delespaul P |title=Toward a world consensus on prevention of schizophrenia |journal=Dialogues Clin Neurosci |volume=7 |issue=1 |pages=53–67 |year=2005 |pmid=16060596}}</ref> However, the treatment of people who may never develop schizophrenia is controversial, in light of the side-effects of antipsychotic medication; particularly with respect to the potentially disfiguring [[tardive dyskinesia]] and the rare but potentially lethal [[neuroleptic malignant syndrome]].<ref name="Haroun_et_al_2006">{{cite journal |author=Haroun N, Dunn L, Haroun A, Cadenhead KS |title=Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research |journal=Schizophrenia Bulletin |volume=32 |issue=1 |pages=166–78 |year=2006 |month=January |pmid=16207892 |doi=10.1093/schbul/sbj007 |url=http://schizophreniabulletin.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16207892 |accessdate=2008-07-06}}</ref> The most widely used form of preventative health care for schizophrenia takes the form of public education campaigns that provide information on risk factors, early detection and treatment options.<ref name="Hafner_et_al_2004">{{cite journal |author=Häfner H, Maurer K, Ruhrmann S, ''et al'' |title=Early detection and secondary prevention of psychosis: facts and visions |journal=European Archives of Psychiatry and Clinical Neuroscience |volume=254 |issue=2 |pages=117–28 |year=2004 |month=April |pmid=15146341 |doi=10.1007/s00406-004-0508-z |accessdate=2008-07-06}}</ref> ==Alternative approaches== An approach broadly known as the [[anti-psychiatry]] movement, most active in the 1960s, opposes the orthodox medical view of schizophrenia as an illness.<ref name="Cooper1969">{{cite book |author=Cooper, David A. |title=The Dialectics of Liberation (Pelican) |publisher=Penguin Books Ltd |location=London, England |year=1969 |isbn=0-14-021029-6}}</ref> Psychiatrist [[Thomas Szasz]] argued that psychiatric patients are not ill, but rather individuals with unconventional thoughts and behavior that make society uncomfortable.<ref name="Szasz1984">{{cite book |author=Szasz, Thomas Stephen |title=The myth of mental illness: foundations of a theory of personal conduct |publisher=Harper & Row |location=San Francisco |year=1974|isbn=0-06-091151-4}}</ref> He argues that society unjustly seeks to control them by classifying their behavior as an illness and forcibly treating them as a method of [[social control]]. According to this view, "schizophrenia" does not actually exist but is merely a form of [[Social constructionism|social construction]], created by society's concept of what constitutes normality and abnormality. Szasz has never considered himself to be "anti-psychiatry" in the sense of being against psychiatric treatment, but simply believes that treatment should be conducted between consenting adults, rather than imposed upon anyone against his or her will. Similarly, psychiatrists [[R. D. Laing]], [[Silvano Arieti]], [[Theodore Lidz]] and [[Colin A. Ross|Colin Ross]]<ref>{{cite book |author=Colin R|title=Schizophrenia: Innovations in Diagnosis and Treatment |publisher=Haworth Press |year=2004 |isbn=0789022699}}</ref> have argued that the symptoms of what is called mental illness are comprehensible reactions to impossible demands that society and particularly family life places on some sensitive individuals. Laing, Arieti, Lidz and Ross were notable in valuing the ''content'' of [[psychosis|psychotic]] experience as worthy of interpretation, rather than considering it simply as a secondary but essentially meaningless marker of underlying psychological or neurological distress. Laing described eleven case studies of people diagnosed with schizophrenia and argued that the content of their actions and statements was meaningful and logical in the context of their family and life situations.<ref>R.D. Laing's and Aaron Esterson. ''Sanity, Madness and the Family'' (1964)</ref> In 1956, [[Palo Alto]], [[Gregory Bateson]] and his colleagues [[Paul Watzlawick]], [[Donald deAvila Jackson|Donald Jackson]], and [[Jay Haley]]<ref>{{cite journal |author=Bateson G, Jackson DD, Haley J, Weakland JH|year=1956 |title=Toward a theory of schizophrenia |journal=Behavioral Science |volume=1 |pages=251–264}}</ref> articulated a theory of schizophrenia, related to Laing's work, as stemming from [[double bind]] situations where a person receives different or contradictory messages. Madness was therefore an expression of this distress and should be valued as a [[catharsis|cathartic]] and trans-formative experience. In the books ''Schizophrenia and the Family'' and ''The Origin and Treatment of Schizophrenic Disorders'' Lidz and his colleagues explain their belief that parental behaviour can result in mental illness in children. Arieti's ''[[Interpretation of Schizophrenia]]'' won the 1975 scientific [[National Book Award]] in the United States. The concept of schizophrenia as a result of civilization has been developed further by psychologist [[Julian Jaynes]] in his 1976 book ''[[The Origin of Consciousness in the Breakdown of the Bicameral Mind]]''; he proposed that until the beginning of historic times, schizophrenia or a similar condition was the normal state of human consciousness.<ref name="Jaynes1976">{{cite book |author =Jaynes J |title=The origin of consciousness in the breakdown of the bicameral mind |publisher=Houghton Mifflin |location=Boston |year=1976 |isbn=0-395-20729-0}}</ref> This would take the form of a "[[bicameral mind]]" where a normal state of low affect, suitable for routine activities, would be interrupted in moments of crisis by "mysterious voices" giving instructions, which early people characterized as interventions from the gods. Researchers into [[shaman]]ism have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman;<ref name="fn_57">{{cite journal |author=Polimeni J, Reiss JP |title=How shamanism and group selection may reveal the origins of schizophrenia |journal=Med. Hypotheses |volume=58 |issue=3 |pages=244–8 |year=2002 |month=March |pmid=12018978 |doi=10.1054/mehy.2001.1504 |url=http://linkinghub.elsevier.com/retrieve/pii/S030698770191504X |accessdate=2008-07-07}}</ref> the experience of having access to multiple realities is not uncommon in schizophrenia, and is a core experience in many shamanic traditions. Equally, the shaman may have the skill to bring on and direct some of the [[altered state of consciousness|altered states of consciousness]] psychiatrists label as illness. [[Psychohistory|Psychohistorians]], on the other hand, accept the psychiatric diagnoses. However, unlike the current [[Biological psychiatry|medical model of mental disorders]] they argue that [[Trauma model of mental disorders#Psychohistory Table|poor parenting in tribal societies]] causes the shaman's schizoid personalities.<ref>{{cite book |author=[[Lloyd deMause|DeMause L]]|title=Emotional Life of Nations |publisher=Other Press (NY) |location= |year=2002 |isbn=1-892746-98-0 |chapter=The seven stages of historical personality |chapterurl=http://primal-page.com/ps2.htm |accessdate=2008-07-07}}</ref> Speculation regarding primary and important religious figures as having schizophrenia abound. Commentators such as [[Paul Kurtz#Critique of the paranormal|Paul Kurtz]] and others have endorsed the idea that major religious figures experienced psychosis, heard voices and displayed delusions of grandeur.<ref>{{cite book |author=[[Paul Kurtz|Kurtz P]] |title=The transcendental temptation: a critique of religion and the paranormal |publisher=Prometheus Books |location=Buffalo, N.Y |year=1991 |isbn=0-87975-645-4}}</ref> Psychiatrist [[Tim Crow]] has argued that schizophrenia may be the evolutionary price we pay for a left brain hemisphere specialization for [[language]].<ref name="fn_56">{{cite journal |author=Crow TJ |title=Schizophrenia as failure of hemispheric dominance for language |journal=Trends Neurosci. |volume=20 |issue=8 |pages=339–43 |year=1997 |month=August |pmid=9246721 |url=http://linkinghub.elsevier.com/retrieve/pii/S0166223697010710 |accessdate=2008-07-07 |doi=10.1016/S0166-2236(97)01071-0}}</ref> Since psychosis is associated with greater levels of right brain hemisphere activation and a reduction in the usual left brain hemisphere dominance, our language abilities may have evolved at the cost of causing schizophrenia when this system breaks down. ===Alternative medical treatments=== A branch of [[alternative medicine]] that deals with schizophrenia is known as [[orthomolecular psychiatry]]. Orthomolecular psychiatry considers the schizophrenias to be a group of disorders; management entails performing the appropriate diagnostic tests and then providing the appropriate therapy.<ref name = Pfeiffer>{{cite book |author=Pfeiffer, Carl C. |title=Nutrition and Mental Illness: An Orthomolecular Approach to Balancing Body Chemistry |publisher=Healing Art Press |isbn=0-89281-226-5}}</ref> Vitamin B-3 ([[Niacin]]) has been proposed as an effective treatment in some cases.<ref>{{cite book |author=Walker M, Hoffer A |title=Orthomolecular nutrition: new lifestyle for super good health |publisher=Keats Publishing |location=Los Angeles |year=1978 |isbn=0-87983-154-5 }}</ref> The body's adverse reactions to [[gluten]] are [[gluten-free, casein-free diet|implicated in some alternative theories]]; proponents of orthomolecular psychiatric thought claim that an adverse reaction to gluten is involved in the etiology of some cases. This theory—discussed by one author in three British journals in the 1970s<ref>Three studies by Dohan: *{{cite journal |author=Dohan FC |title=Coeliac disease and schizophrenia |journal=[[Lancet]] |volume=1 |issue=7652 |pages=897–8 |year=1970 |month=April |pmid=4191543 |doi= |url= |accessdate=2008-07-03}} *{{cite journal |author=Dohan FC |title=Coeliac disease and schizophrenia |journal=Br Med J |volume=3 |issue=5870 |pages=51–2 |year=1973 |month=July |pmid=4740433 |pmc=1587927 |doi= |url= |accessdate=2008-07-03}} *{{cite journal |author=Dohan FC |title=Celiac-type diets in schizophrenia |journal=Am J Psychiatry |volume=136 |issue=5 |pages=732–3 |year=1979 |month=May |pmid=434265}}</ref>—is unproven. A 2006 literature review suggests that gluten may be a factor for patients with celiac disease and for a subset of patients afflicted with schizophrenia, but that further study is needed to conclusively confirm such a link.<ref name="Kalaydjian_AE">{{cite journal |author=Kalaydjian AE, Eaton W, Cascella N, Fasano A |title=The gluten connection: the association between schizophrenia and celiac disease |journal=Acta Psychiatr Scand |volume=113 |issue=2 |pages=82–90 |year=2006 |month=February |pmid=16423158 |doi=10.1111/j.1600-0447.2005.00687.x |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0001-690X&date=2006&volume=113&issue=2&spage=82 |accessdate=2008-07-03}}</ref> In a 2004 Israeli study, anti-gluten antibodies were measured in 50 schizophrenic patients and a matched control group. All antibody tests in both groups were negative leading to the conclusion that "it is unlikely that there is an association between gluten sensitivity and schizophrenia."<ref>{{cite journal |author=Peleg R, Ben-Zion ZI, Peleg A, ''et al'' |title="Bread madness" revisited: screening for specific celiac antibodies among schizophrenia patients |journal=European Psychiatry |volume=19 |issue=5 |pages=311–4 |year=2004 |month=August |pmid=15276666 |doi=10.1016/j.eurpsy.2004.06.003 |url=http://linkinghub.elsevier.com/retrieve/pii/S0924933804001348 |accessdate=2008-07-03}}</ref> Some researchers suggest that dietary and nutritional treatments may hold promise in the treatment of schizophrenia.<ref name="pmid18208598">{{cite journal |author=Lakhan SE, Vieira KF |title=Nutritional therapies for mental disorders |journal=Nutr J |volume=7 |pages=2 |year=2008 |pmid=18208598 |doi=10.1186/1475-2891-7-2}}</ref> ==History== Descriptions of schizophrenia-like symptoms date back to ''circa'' 2000 BC in the ''Book of Hearts''—part of the [[Ancient Egyptian medicine|ancient Egyptian]] [[Ebers Papyrus]].<ref name=Okasha1999>{{cite journal | author = Okasha, A. | year = 1999 | title = Mental health in the middle east an egyptian perspective | journal = Clinical Psychology Review | volume = 19 | issue = 8 | pages = 917–933 | doi = 10.1016/S0272-7358(99)00003-3 | url = http://linkinghub.elsevier.com/retrieve/pii/S0272735899000033}}</ref> Study of the [[Ancient Greece|ancient Greek]] and [[Ancient Rome|Roman]] literature shows that although the general population probably had an awareness of psychotic disorders, there was no recorded condition that would meet the modern criteria for schizophrenia.<ref name="fn_1>{{cite journal |author=Evans K, McGrath J, Milns R |title=Searching for schizophrenia in ancient Greek and Roman literature: a systematic review |journal=[[Acta Psychiatrica Scandinavica]] |volume=107 |issue=5 |pages=323–30 |year=2003 |month=May |pmid=12752027 |doi= |url=http://www3.interscience.wiley.com/journal/118826875/abstract |accessdate=2008-07-03}}</ref> Symptoms resembling schizophrenia were, however, reported in [[Islamic medicine|Arabic medical]] and [[Islamic psychology|psychological literature]] during the [[Middle Ages]]. In ''[[The Canon of Medicine]]'', for example, [[Avicenna]] described a condition somewhat resembling schizophrenia which he called ''Junun Mufrit'' (severe madness), which he distinguished from other forms of madness (''Junun'') such as [[mania]], [[rabies]] and [[Bipolar disorder|manic depressive]] [[psychosis]].<ref name=Dening-57>{{cite journal |author=Youssef HA, Youssef FA, Dening TR |title=Evidence for the existence of schizophrenia in medieval Islamic society |journal=History of Psychiatry |volume=7 |issue=25 |pages=55–62 |year=1996 |month=March |pmid=11609215 |doi= |url=http://hpy.sagepub.com/cgi/content/abstract/7/25/055 |accessdate=2008-07-04}}</ref> [[Image:Emil Kraepelin.png|left|thumb|[[Emil Kraepelin]] (1856–1926) refined the concept of [[psychosis]].]] Although a broad concept of [[Insanity|madness]] has existed for thousands of years, schizophrenia was only classified as a distinct mental disorder by [[Emil Kraepelin]] in 1893. He was the first to make a distinction in the psychotic disorders between what he called ''[[dementia praecox]]'' (literally 'early dementia'—developed from a syndrome first outlined by psychiatrist [[Bénédict Morel]] in 1853 and labelled ''démence précoce'') and [[bipolar disorder|manic depression]]. Kraepelin believed that ''dementia praecox'' was primarily a disease of the brain,<ref name="fn_2">Kraepelin E. (1907) ''Text book of psychiatry (7th ed)'' (trans. A.R. Diefendorf). London: Macmillan.</ref> and particularly a form of [[dementia]], distinguished from other forms of dementia, such as [[Alzheimer's disease]], which typically occur later in life.<ref name="fn_49">{{cite book |author=Hansen RA, Atchison B |title=Conditions in occupational therapy: effect on occupational performance |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2000 |isbn=0-683-30417-8}}</ref> The word ''schizophrenia''—which translates roughly as "splitting of the mind" and comes from the [[Ancient Greek|Greek]] roots ''schizein'' (σχίζειν, "to split") and ''phrēn'', ''phren-'' (φρήν, φρεν-, "[[mind]]")<ref>{{cite journal |author=Kuhn R; tr. Cahn CH |title=Eugen Bleuler's concepts of psychopathology |journal=Hist Psychiatry |volume=15 |issue=3 |date=2004 |pages=361–6 |doi=10.1177/0957154X04044603 |pmid=15386868}}</ref>—was coined by [[Eugen Bleuler]] in 1908 and was intended to describe the separation of function between [[personality psychology|personality]], [[thought|thinking]], [[memory]], and [[perception]]. Bleuler described the main symptoms as 4 ''A'''s: flattened ''Affect'', ''Autism'', impaired ''Association'' of ideas and ''Ambivalence''.<ref name="fn_78">{{cite journal |author=Stotz-Ingenlath G |title=Epistemological aspects of Eugen Bleuler's conception of schizophrenia in 1911 |journal=Medicine, Health Care and Philosophy |volume=3 |issue=2 |pages=153–9 |year=2000 |pmid=11079343|url=http://www.kluweronline.com/art.pdf?issn=1386-7423&volume=3&page=153|format=PDF |accessdate=2008-07-03 |doi=10.1023/A:1009919309015}}</ref> 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.<ref name="fn_3">{{cite book |author=Porter, Roy; Berrios, G. E. |title=A history of clinical psychiatry: the origin and history of psychiatric disorders |publisher=Athlone Press |location=London |year=1995 |pages= |isbn=0-485-24211-7}}</ref> 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 [[Sterilization (surgical procedure)|sterilized]], with or without consent—the majority in [[Nazi Germany]], the [[United States]], and [[Scandinavia]]n countries.<ref name="fn_76">{{cite journal |author=Allen GE |title=The social and economic origins of genetic determinism: a case history of the American Eugenics Movement, 1900-1940 and its lessons for today |journal=Genetica |volume=99 |issue=2-3 |pages=77–88 |year=1997 |pmid=9463076 |url=http://www.kluweronline.com/art.pdf?issn=0016-6707&volume=99&page=77 |format=PDF|accessdate=2008-07-03 |doi=10.1007/BF02259511}}</ref><ref name="fn_77">{{cite book |author=Bentall RP, Read JE, Mosher LR |title=Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia |publisher=Brunner-Routledge |location=Philadelphia |year=2004 |isbn=1-58391-906-6}}</ref> Along with other people labeled "mentally unfit", many diagnosed with schizophrenia were murdered in the Nazi "[[Action T4]]" program.<ref name="Lifton_2000">{{cite book |author=Lifton, Robert Jay |title=The Nazi doctors: medical killing and the psychology of genocide |publisher=Basic Books |location=New York |year=1986 |isbn=0-465-04905-2}}</ref> The diagnostic description of schizophrenia has changed over time. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe.<ref name="Wing1971">{{cite journal |author=Wing JK |title=International comparisons in the study of the functional psychoses |journal=British Medical Bulletin |volume=27 |issue=1 |pages=77–81 |year=1971 |month=January |pmid=4926366}}</ref> This was partly due to looser diagnostic criteria in the US, which used the [[DSM-II]] manual, contrasting with Europe and its [[ICD-9]]. This was one 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]].<ref name="Wilson1993">{{cite journal |author=Wilson M |title=DSM-III and the transformation of American psychiatry: a history |journal=[[American Journal of Psychiatry]] |volume=150 |issue=3 |pages=399–410 |year=1993 |month=March |pmid=8434655 |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=8434655 |accessdate=2008-07-03}}</ref> ==Society and culture== [[Stigma]] has been identified as a major obstacle in the recovery of patients with schizophrenia.<ref>McGorry, Patrick (2003). "The Influence of Stigma on Preventive Efforts in Psychotic Disorders," in ''Schizophrenia (WPA Series in Evidence & Experience in Psychiatry)'', p. 292.</ref> 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.<ref>{{cite journal |author=Pescosolido BA, Monahan J, Link BG, Stueve A, Kikuzawa S |title=The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems |journal=Am J Public Health |volume=89 |issue=9 |pages=1339–45 |year=1999 |month=September |pmid=10474550 |pmc=1508769 |doi= |url=http://www.ajph.org/cgi/pmidlookup?view=long&pmid=10474550 |accessdate=2008-07-03}}</ref> The perception of individuals with psychosis as violent has more than doubled in prevalence since the 1950s, according to one meta-analysis.<ref>{{cite journal |author=Phelan JC, Link BG, Stueve A, Pescosolido BA|year=2000 |month=June |title=Public Conceptions of Mental Illness in 1950 and 1996: What Is Mental Illness and Is It to be Feared? |journal=Journal of Health and Social Behavior |volume=41 |issue=2 |pages=188–207 |doi=10.2307/2676305}}</ref> The book and film ''[[A Beautiful Mind (film)|A Beautiful Mind]]'' chronicled the life of [[John Forbes Nash]], a [[Nobel-Prize]]-winning mathematician who was diagnosed with schizophrenia. The [[Marathi language|Marathi]] film ''Devrai'' (Featuring [[Atul Kulkarni]]) is a presentation of a patient with schizophrenia. The film, set in the [[Konkan]] region of [[Maharashtra]] in Western [[India]], shows the behavior, mentality, and struggle of the patient as well as his loved-ones. It also portrays the treatment of this mental illness using medication, dedication and plenty of patience by the close relatives of the patient. Other factual books have been written by relatives on family members; Australian journalist [[Anne Deveson]] told the story of her son's battle with schizophrenia in ''Tell me I'm Here'',<ref>{{cite book |author=[[Anne Deveson|Deveson A]] |title=Tell Me I'm Here |publisher=Penguin |year=1991 |pages= |isbn=0-14-027257-7}}</ref> later made into a movie. In [[Mikhail Bulgakov|Bulgakov's]] ''[[Master and Margarita]]'' the poet Ivan Bezdomnyj is institutionalized and diagnosed with schizophrenia after witnessing the devil (Woland) predict Berlioz's death. The book ''[[The Eden Express]]'' by [[Mark Vonnegut]] recounts his struggle with schizophrenia and his recovering journey. ==References== {{reflist|2}} ==Further reading== <!-- Please only include material which addresses schizophrenia in general, rather than specific aspects, or related topics --> <div class="references-small"> *{{cite book |author=[[Richard Bentall|Bentall, Richard]] |title=Madness explained: psychosis and human nature |publisher=Allen Lane |location=London |year=2003 |isbn=0-7139-9249-2}} *{{cite book |last=Dalby |first=J. Thomas |title=Mental disease in history: a selection of translated readings |publisher=Peter Lang |location=Bern |year=1996 |pages= |isbn=0-8204-3056-0 }} *{{cite journal |last=Fallon |first=James H. |authorlink=James Fallon |year=2003 |title=The Neuroanatomy of Schizophrenia: Circuitry and Neurotransmitter Systems |journal=Clinical Neuroscience Research |volume=3 |pages=77–107 |doi=10.1016/S1566-2772(03)00022-7 |accessdate=2008-07-07}} *{{cite book |last=Green |first=Michael |title=Schizophrenia revealed: from neurons to social interactions |publisher=W.W. Norton |location=New York |year=2001 |isbn=0-393-70334-7}} *{{cite journal |author=Keen TM |title=Schizophrenia: orthodoxy and heresies. A review of alternative possibilities |journal=Journal of Psychiatric and Mental Health Nursing |volume=6 |issue=6 |pages=415–24 |year=1999 |month=December |pmid=10818864 |doi= |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=1351-0126&date=1999&volume=6&issue=6&spage=415 |accessdate=2008-07-07}} *{{cite book |last=Laing |first=Ronald D. |authorlink=Ronald David Laing |title=The divided self: an existential study in sanity and madness |publisher=Penguin Books |location=New York |year=1990 |pages= |isbn=0-14-013537-5 }} *{{cite book |last=Fleck |first=Stephen |authorlink=Theodore Lidz |coauthors=[[Theodore Lidz]] and Alice Cornelison |title=Schizophrenia and the family |publisher=International Universities Press |location=New York |year=1985 |pages= |isbn=0-8236-6001-X}} *{{cite book |author=Noll, Richard |title=The Encyclopedia of Schizophrenia And Other Psychotic Disorders (Facts on File Library of Health and Living) |publisher=Facts on File |location=New York |year=2006 |pages= |isbn=0-8160-6405-9}} * [http://www.openthedoors.com/english/index.html Open The Doors - information on global programme to fight stigma and discrimination because of Schizophrenia. The World Psychiatric Association (WPA)] *{{cite book |author=Bentall, Richard P.; Read, John E; Mosher, Loren R. |title=Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia |publisher=Brunner-Routledge |location=Philadelphia |year=2004 |pages= |isbn=1-58391-906-6}} A critical approach to biological and genetic theories, and a review of social influences on schizophrenia. * [http://www.sciam.com/article.cfm?chanID=sa006&articleID=000EE239-6805-1FD5-A23683414B7F0000 Scientific American Magazine (January 2004 Issue) Decoding Schizophrenia] *{{cite journal |author=Shaner A, Miller G, Mintz J |title=Schizophrenia as one extreme of a sexually selected fitness indicator |journal=Schizophr. Res. |volume=70 |issue=1 |pages=101–9 |year=2004 |month=September |pmid=15246469 |doi=10.1016/j.schres.2003.09.014 |url=http://www.unm.edu/~gfmiller/new_papers/shaner%20miller%202004%20schizo.pdf|format=PDF|accessdate=2008-07-07}} *{{cite book |last=Szasz |first=Thomas Stephen |authorlink=Thomas Szasz |title=Schizophrenia: the sacred symbol of psychiatry |publisher=Basic Books |location=New York |year=1976 |pages= |isbn=0-465-07222-4 |oclc= |doi= |accessdate=}} *{{cite book |last=Roazen |first=Paul |authorlink=Paul Roazen |coauthors=[[Victor Tausk]] |title=Sexuality, war, and schizophrenia: collected psychoanalytic papers |publisher=Transaction Publishers |location=New Brunswick, N.J., U.S.A |year=1991 |pages= |isbn=0-88738-365-3}} (On the Origin of the 'Influencing Machine' in Schizophrenia.) * Wiencke, Markus (2006) ''Schizophrenie als Ergebnis von Wechselwirkungen: Georg Simmels Individualitätskonzept in der Klinischen Psychologie''. In David Kim (ed.), ''Georg Simmel in Translation: Interdisciplinary Border-Crossings in Culture and Modernity'' (pp. 123–155). Cambridge Scholars Press, Cambridge, ISBN 1-84718-060-5 </div> ==External links== * {{dmoz|Health/Mental_Health/Disorders/Schizophrenia/}} ;News, information and further description * [http://www.npr.org/programs/atc/features/2002/aug/schizophrenia/ NPR: the sight and sounds of schizophrenia] * [http://www.who.int/mental_health/management/schizophrenia/en/ The current World Health Organisation definition of Schizophrenia] * [http://www.archive.org/details/Symptoms1940 Symptoms in Schizophrenia] Film made in 1940 showing some of the symptoms of Schizophrenia. * [http://www.wcr.ab.ca/news/2006/1127/mental112706.shtml Schizophrenics call to Church for understanding, Western Catholic Reporter] * [http://www.world-schizophrenia.org World Fellowship for Schizophrenia and Allied Disorders] - 'Information for families caring for people with mental illness' ;Critical approaches to schizophrenia * Leo, Jonathan Ph.D., & Jay Joseph, Psy. D. [http://www.icspp.org/index.php?option=com_content&task=view&id=128&Itemid=72 Schizophrenia: Medical students are taught it's all in the genes, but are they hearing the whole story?] {{featured article}} {{Mental and behavioural disorders}} [[Category:Schizophrenia|*]] [[Category:Disability]] [[Category:Mental illness diagnosis by DSM and ICD]] [[Category:Greek loanwords]] {{Link FA|pt}} {{Link FA|ro}} [[ar:فصام]] [[bs:Shizofrenija]] [[bg:Шизофрения]] [[ca:Esquizofrènia]] [[cs:Schizofrenie]] [[da:Skizofreni]] [[de:Schizophrenie]] [[et:Skisofreenia]] [[el:Σχιζοφρένεια]] [[es:Esquizofrenia]] [[eo:Skizofrenio]] [[fa:روان‌گسیختگی]] [[fr:Schizophrénie]] [[gl:Esquizofrenia]] [[ko:정신분열증]] [[hr:Shizofrenija]] [[io:Skizofrenio]] [[id:Skizofrenia]] [[ia:Schizophrenia]] [[is:Geðklofi]] [[it:Schizofrenia]] [[he:סכיזופרניה]] [[kl:Skizofrenii]] [[ku:Şîzofrenî]] [[la:Morbus dissidentiae phreneticae]] [[lt:Šizofrenija]] [[hu:Skizofrénia]] [[ms:Skizofrenia]] [[nl:Schizofrenie]] [[ja:統合失調症]] [[no:Schizofreni]] [[pl:Schizofrenia]] [[pt:Esquizofrenia]] [[ro:Schizofrenie]] [[qu:Waq'akay]] [[ru:Шизофрения]] [[simple:Schizophrenia]] [[sk:Schizofrénia]] [[sl:Shizofrenija]] [[sr:Схизофренија]] [[sh:Shizofrenija]] [[fi:Skitsofrenia]] [[sv:Schizofreni]] [[tr:Şizofreni]] [[uk:Шизофренія]] [[ur:انفصام]] [[zh:精神分裂症]]