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What is Schizophrenia? - Part 4

Suicide Risk
Suicide is a serious danger in people who have schizophrenia. If an individual tries to commit suicide or threatens to do so, professional help should be sought immediately. People with schizophrenia have a higher rate of suicide than the general population. Approximately 10 percent of people with schizophrenia (especially younger adult males) commit suicide. Unfortunately, the prediction of suicide in people with schizophrenia can be especially difficult.

What Causes Schizophrenia?
There is no known single cause of schizophrenia. Many diseases, such as heart disease, result from an interplay of genetic, environmental, and behavioral factors; and this may be the case for schizophrenia as well. Scientists do not yet understand all of the factors necessary to produce schizophrenia, but all the tools of modern biomedical research are being used to search for genes, critical moments in brain development, and environmental factors that may lead to the illness.

Is Schizophrenia Genetic?
It has long been known that schizophrenia runs in families. People who have a close relative with schizophrenia are more likely to develop the disorder than are people who have no relatives with the illness. For example, a monozygotic (identical) twin of a person with schizophrenia has the highest risk -- 40 to 50 percent -- of developing the illness. A child whose parent has schizophrenia has about a 10 percent chance. By comparison, the risk of schizophrenia in the general population is only about 1 percent.

Scientists are studying genetic factors in schizophrenia. It appears likely that multiple genes are involved in creating a predisposition to develop the disorder. In addition, factors such as prenatal difficulties like intrauterine starvation or viral infections, perinatal complications, and various nonspecific stressors, seem to influence the development of schizophrenia. However, it is not yet understood how the genetic predisposition is transmitted, and it cannot yet be accurately predicted whether a given person will or will not develop the disorder.

Is Schizophrenia Associated With a Chemical Imbalance in the Brain?
Basic knowledge about brain chemistry and its link to schizophrenia is expanding rapidly. Neurotransmitters, substances that allow communication between nerve cells, have long been thought to be involved in the development of schizophrenia. It is likely, although not yet certain, that the disorder is associated with some imbalance of the complex, interrelated chemical systems of the brain, perhaps involving the neurotransmitters dopamine and glutamate. This area of research is promising.

Is Schizophrenia Caused by a Physical Abnormality in the Brain?
Many studies of people with schizophrenia have found abnormalities in brain structure. It should be emphasized that these abnormalities are quite subtle and are not characteristic of all people with schizophrenia, nor do they occur only in individuals with this illness. Microscopic studies of brain tissue after death have also shown small changes in distribution or number of brain cells in people with schizophrenia. It appears that many (but probably not all) of these changes are present before an individual becomes ill, and schizophrenia may be, in part, a disorder in development of the brain.
Developmental neurobiologists funded by the National Institute of Mental Health (NIMH) have found that schizophrenia may be a developmental disorder resulting when neurons form inappropriate connections during fetal development. These errors may lie dormant until puberty, when changes in the brain that occur normally during this critical stage of maturation interact adversely with the faulty connections. This research has spurred efforts to identify prenatal factors that may have some bearing on the apparent developmental abnormality.

In other studies, investigators using brain imaging techniques have found evidence of early biochemical changes that may precede the onset of disease symptoms, prompting examination of the neural circuits that are most likely to be involved in producing those symptoms. Scientists working at the molecular level, meanwhile, are exploring the genetic basis for abnormalities in brain development and in the neurotransmitter systems regulating brain function.

Medications for Shizophrenia
Antipsychotic medications have been available since the mid-1950s. Medications reduce the psychotic symptoms of schizophrenia and usually allow the patient to function more effectively and appropriately. Antipsychotic drugs are the best treatment now available, but they do not “cure” schizophrenia or ensure that there will be no further psychotic episodes. The choice and dosage of medication can be made only by a qualified physician who is well trained in the medical treatment of mental disorders. The dosage of medication is individualized for each patient, since people may vary a great deal in the amount of drug needed to reduce symptoms without producing troublesome side effects.

The large majority of people with schizophrenia show substantial improvement when treated with antipsychotic drugs. Some patients, however, are not helped very much by the medications and a few do not seem to need them. It is difficult to predict which patients will fall into these two groups and to distinguish them from the large majority of patients who do benefit from treatment with antipsychotic drugs.

A number of new antipsychotic drugs (the so-called “atypical antipsychotics”) have been introduced since 1990. The newer antipsychotic drugs, such as risperidone (Risperdal®) and olanzapine (Zyprexa®), are safer than the older drugs, and they also may be better tolerated.

Antipsychotic drugs are often very effective in treating certain symptoms of schizophrenia, particularly hallucinations and delusions; unfortunately, the drugs may not be as helpful with other symptoms, such as reduced motivation and emotional expressiveness. Indeed, the older antipsychotics (which also went by the name of “neuroleptics”), medicines like haloperidol (Haldol®) or chlorpromazine (Thorazine®), may even produce side effects that resemble the more difficult to treat symptoms. Often, lowering the dose or switching to a different medicine may reduce these side effects; the newer medicines, including olanzapine (Zyprexa®), quetiapine (Seroquel®), and risperidone (Risperdal®), appear less likely to have this problem. Sometimes when people with schizophrenia become depressed, other symptoms can appear to worsen. The symptoms may improve with the addition of an antidepressant medication.

Patients and families sometimes become worried about the antipsychotic medications used to treat schizophrenia. In addition to concern about side effects, they may worry that such drugs could lead to addiction. However, antipsychotic medications do not produce a “high” (euphoria) or addictive behavior in people who take them.

Another misconception about antipsychotic drugs is that they act as a kind of mind control, or a “chemical straitjacket.” Anti-psychotic drugs used at the appropriate dosage do not “knock out” people or take away their free will. While these medications can be sedating, and while this effect can be useful when treatment is initiated particularly if an individual is quite agitated, the utility of the drugs is not due to sedation but to their ability to diminish the hallucinations, agitation, confusion, and delusions of a psychotic episode. Thus, antipsychotic medications should eventually help an individual with schizophrenia to deal with the world more rationally.

The Outlook for Those Living with Schizophrenia

The outlook for people with schizophrenia has improved over the last 25 years. Although no totally effective therapy has yet been devised, it is important to remember that many people with the illness improve enough to lead independent, satisfying lives. As we learn more about the causes and treatments of schizophrenia, we should be able to help more patients achieve successful outcomes.

Studies that have followed people with schizophrenia for long periods, from the first episode to old age, reveal that a wide range of outcomes is possible. When large groups of patients are studied, certain factors tend to be associated with a better outcome—for example, a pre-illness history of normal social, school, and work adjustment. However, the current state of knowledge does not allow for a sufficiently accurate prediction of long-term outcome.

Given the complexity of schizophrenia, the major questions about this disorder—its cause or causes, prevention, and treatment—must be addressed with research. The public should beware of those offering "the cure" for (or "the cause" of) schizophrenia. Such claims can provoke unrealistic expectations that, when unfulfilled, lead to further disappointment. Although progress has been made toward better understanding and treatment of schizophrenia, continued investigation is urgently needed. As the lead Federal agency for research on mental disorders, the National Institute on Mental Health (NIMH) conducts and supports a broad spectrum of mental illness research from molecular genetics to large-scale epidemiologic studies of populations. It is thought that this wide-ranging research effort, including basic studies on the brain, will continue to illuminate processes and principles important for understanding the causes of schizophrenia and for developing more effective treatments.

(Thanks are extended to the National Institute of Mental Health for the information provided here).

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