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Schizophrenia

2007 Schools Wikipedia Selection. Related subjects: Health and medicine

   CAPTION: Schizophrenia
   Classification & external resources

    ICD- 10   F 20.
     ICD- 9   295
      OMIM    181500
   DiseasesDB 11890
   eMedicine  med/2072  emerg/520
   MeSH       F03.700.750

   Schizophrenia (from the Greek word σχιζοφρένεια, or shjzofre'neja,
   meaning "split mind") is a psychiatric diagnosis that describes a
   mental disorder characterized by impairments in the perception or
   expression of reality and by significant social or occupational
   dysfunction. A person experiencing schizophrenia is typically
   characterized as demonstrating disorganized thinking, and as
   experiencing delusions or hallucinations, in particular auditory
   hallucinations.

   Although the disorder is primarily thought to affect cognition, it can
   also contribute to chronic problems with behaviour and emotion. Due to
   the many possible combinations of symptoms, heated debate is ongoing
   about whether the diagnosis necessarily or adequately describes a
   disorder, or alternatively whether it might represent a number of
   disorders. For this reason, Eugen Bleuler deliberately called the
   disease "the schizophrenias" plural, when he coined the present name.

   Diagnosis is based on the self-reported experiences of the patient, in
   combination with secondary signs observed by a psychiatrist, clinical
   psychologist or other clinician. No laboratory test for schizophrenia
   exists. Studies suggest that genetics, early environment, neurobiology
   and psychological and social processes are important contributory
   factors. Current psychiatric research into the development of the
   disorder often focuses on the role of neurobiology, although a reliable
   and identifiable organic cause has not been found. In the absence of a
   confirmed specific pathology underlying the diagnosis, some question
   the legitimacy of schizophrenia's status as a disease. Furthermore,
   some propose that the perceptions and feelings involved are meaningful
   and do not necessarily involve impairment.

   The term schizophrenia translates roughly as "splitting of the mind",
   and comes from the Greek σχίζω (or schizo, "to split" or "to divide")
   and φρήν (or phrēn, "mind"). Despite its etymology, schizophrenia is
   not synonymous with dissociative identity disorder, also known as
   multiple personality disorder or "split personality"; in popular
   culture the two are often confused. People with schizophrenia are
   generally not more violent or dangerous than other members of the
   population.

   Patients diagnosed with schizophrenia are highly likely to be diagnosed
   with other disorders. The lifetime prevalence of substance abuse is
   typically around 40%. Comorbidity is also high with clinical
   depression, anxiety disorders, and social problems, and a generally
   decreased life expectancy is also present. Patients diagnosed with
   schizophrenia typically live ten to twelve years less than those
   without the disorder, owing to increased physical health problems and a
   high suicide rate. Unemployment and poverty are common.

Overview

   Schizophrenia is often described in terms of "positive" and "negative"
   symptoms. Positive symptoms include delusions, 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, blunted or constricted affect and emotion,
   poverty of speech and lack of motivation. Additionally, a
   'disorganization syndrome' and neurocognitive deficits may be present.
   These may take the form of reduced or impaired psychological functions
   such as memory, attention, problem-solving, executive function or
   social cognition.

   Onset of schizophrenia typically occurs in late adolescence or early
   adulthood, with males tending to show symptoms earlier than females.

   In 1893 psychiatrist Emil Kraepelin was the first to draw a distinction
   between what he termed dementia praecox ("premature dementia") and
   other psychotic illnesses. In 1908, "dementia praecox" was renamed
   "schizophrenia" by psychiatrist Eugen Bleuler, who discovered that the
   disorder is not a form of dementia.

   The diagnostic category of schizophrenia has been widely criticised as
   lacking in scientific validity or reliability, consistent with evidence
   of poor levels of consistency in diagnostic practices and the use of
   criteria. One alternative suggests that the problems and issues making
   up the diagnosis of schizophrenia would be better addressed as
   individual dimensions along which everyone varies, such that there is a
   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 and delusional
   beliefs amongst the general public.

   Although no common cause of schizophrenia has been identified in all
   individuals diagnosed with the condition, currently most researchers
   and clinicians believe it results from a combination of both brain
   vulnerabilities (either inherited or acquired) and stressful
   life-events. This widely-adopted approach is known as the
   'stress-vulnerability' model, and much scientific debate now focuses on
   how much each of these factors contributes to the development and
   maintenance of schizophrenia.

   It is also thought that processes in early neurodevelopment are
   important, particularly prenatal processes. In adult life, particular
   importance has been placed upon the function (or malfunction) of
   dopamine in the mesolimbic pathway in the brain. This theory, known as
   the dopamine hypothesis of schizophrenia largely resulted from the
   accidental finding that a drug group which blocks dopamine function,
   known as the phenothiazines, reduced psychotic symptoms. However, this
   theory is now thought to be overly simplistic as a complete
   explanation. These drugs have now been developed further and
   antipsychotic medication is commonly used as a first-line treatment.
   Although effective in many cases, these medications are not well
   tolerated by some patients due to significant side-effects. The
   positive symptoms are more responsive to medications; negative symptoms
   being less so.

   Differences in brain structure have been found between people with
   schizophrenia and those without. However, these tend only to be
   reliable on the group level and, due to the significant variability
   between individuals, may not be reliably present in any particular
   individual. Significant brain atrophy and enlarged ventricles are the
   most conspicuous of such differences.

History

   Accounts that may relate to symptoms of schizophrenia date back as far
   as 2000 BC in the Book of Hearts, part of the ancient Ebers papyrus.
   However, a recent study into the ancient Greek and Roman literature
   showed that, while the general population probably had an awareness of
   psychotic disorders, there was no recorded condition that would meet
   the modern diagnostic criteria for schizophrenia in these societies.

   This nonspecific concept of " madness" has been around for many
   thousands of years, but schizophrenia was only classified as a distinct
   mental disorder by Kraepelin in 1893. He was the first to make a
   distinction in the psychotic disorders between what he called dementia
   praecox (a term first used by psychiatrist Benedict A. Morel) and manic
   depression. Kraepelin believed that dementia praecox was primarily a
   disease of the brain, and particularly a form of dementia. Kraepelin
   named the disorder 'dementia praecox' (early dementia) to distinguish
   it from other forms of dementia (such as Alzheimer's disease) which
   typically occur late in life. He used this term because his studies
   focused on young adults with dementia.

   The term schizophrenia is derived from the Greek words σχίζειν (split)
   and φρήν (mind) and was coined by Eugene Bleuler in 1908 to refer to
   the lack of interaction between thought processes and perception. He
   was also the first to describe the symptoms as "positive" or
   "negative." Bleuler described the main symptoms as 4 "A"'s: flattened
   Affect, Autism, impaired Association of ideas and Ambivalence. Bleuler
   suggested the name schizophrenia, as it was obvious that Kraepelin's
   name was misleading. The word "praecox" implied precocious or early
   onset, hence premature dementia, as opposed to senile dementia from old
   age. Bleuler realized the illness was not a dementia as some of his
   patients improved rather than following a deteriorating course.

   With the name 'schizophrenia' Bleuler intended to capture the
   separation of function between personality, thinking, memory, and
   perception, however it is commonly misunderstood to mean that affected
   persons have a 'split personality' (something akin to the character in
   Robert Louis Stevenson's The Strange Case of Dr Jekyll and Mr Hyde).
   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 perhaps arises in part due to the meaning of Bleuler's
   term 'schizophrenia' (literally 'split' or 'shattered mind').
   Interestingly, the first known misuse of this word schizophrenia to
   mean 'split personality' (in the Jekyll and Hyde sense) was in an
   article by the poet T. S. Eliot in 1933.

   In the first half of the twentieth century schizophrenia was considered
   by many to be a "hereditary defect", and individuals affected by
   schizophrenia became subject to eugenics in many countries. Hundreds of
   thousands were sterilized, with or without consent, the majority in
   Nazi Germany, the United States, and Scandinavian countries, Many
   people diagnosed with schizophrenia, together with other people labeled
   "mentally unfit", were murdered in the Nazi " Operation T-4" program.

Diagnosis

Criteria (signs and symptoms)

   Like many mental illnesses, the diagnosis of schizophrenia is based
   upon the behaviour of the person being assessed. There is a list of
   criteria that must be met for someone to be so diagnosed. These depend
   on both the presence and duration of certain signs and symptoms.

   The most commonly used criteria for diagnosing schizophrenia are from
   the American Psychiatric Association's Diagnostic and Statistical
   Manual of Mental Disorders (DSM) and the World Health Organization's
   International Statistical Classification of Diseases and Related Health
   Problems (ICD). The most recent versions are ICD-10 and DSM-IV-TR.

   Below is an abbreviated version of the diagnostic criteria from the
   DSM-IV-TR; the full version is available here.

   To be diagnosed as having schizophrenia, a person must display:
     * A) Characteristic symptoms: Two or more of the following, each
       present for a significant portion of time during a one-month period
       (or less, if successfully treated)
          + delusions
          + hallucinations
          + disorganized speech (e.g., frequent derailment or incoherence;
            speaking in abstracts). See thought disorder.
          + grossly disorganized behaviour (e.g. dressing inappropriately,
            crying frequently) or catatonic behaviour
          + 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: Only one Criterion A symptom is required if delusions are
          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.

     * B) 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.

     * C) 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 successfully treated) that meet
       Criterion A.

   Additional criteria (D, E and F) are also given that exclude a
   diagnosis of schizophrenia if symptoms of mood disorder or pervasive
   developmental disorder are present. Additionally a diagnosis of
   schizophrenia is excluded if the symptoms are the direct result of a
   substance (e.g., abuse of a drug, medication) or a general medical
   condition.

Subtypes

   Historically, schizophrenia in the West was classified into simple,
   catatonic, hebephrenic, and paranoid. The DSM now contains five
   sub-classifications of schizophrenia, the ICD-10 identifies 7:
     * (295.2/F20.2) catatonic type (prominent psychomotor disturbances
       are evident. Symptoms can include catatonic stupor and waxy
       flexibility).
     * (295.1/F20.1) disorganized type (where thought disorder and flat
       affect are present together),
     * (295.3/F20.0) paranoid type (where delusions and hallucinations are
       present but thought disorder, disorganized behaviour, and affective
       flattening are absent),
     * (295.6/F20.5) residual type (where positive symptoms are present at
       a low intensity only) and
     * (295.9/F20.3) undifferentiated type (psychotic symptoms are present
       but the criteria for paranoid, disorganized, or catatonic types has
       not been met).

   NB: Brackets indicate codes for DSM and ICD-10 diagnostic manuals,
   respectively. Some older classifications still use "Hebephrenic
   schizophrenia" instead of "Disorganized schizophrenia".

Deficit Syndrome

   Currently, there is debate in the field about a new subtype known as
   the deficit syndrome. It is not currently included in the DSM-IV-TR,
   however it has been receiving a great deal of attention in the last 20
   years. This subtype is more expansive than the other subtypes as a
   person can be diagnosed with both paranoid schizophrenia and the
   deficit syndrome. It is characterized by primary negative symptoms
   (which means that they cannot be caused by such things as the
   side-effects of medication or depression). People with the deficit
   syndrome tend to have extremely flat affect (do not appear to be very
   emotional), do not have good eye contact, do not enjoy normally
   pleasurable activities (see dysphoria), and seem to be uninterested in
   social interaction. (There is, however, conflict in the research on
   this last point. While people who have been diagnosed with the deficit
   syndrome report being uninterested in social interaction, in the
   laboratory, they often report normal reactions to the situations.)
   Patients who have been diagnosed with the deficit syndrome tend to have
   a worse prognosis as these symptoms tend to be resistant to medication.
   This fact has brought much needed attention to negative symptoms (which
   have traditionally not been viewed as important as the positive
   symptoms).

Presentation

   Symptoms may also be described as 'positive symptoms' (those additional
   to normal experience and behavior) and 'negative symptoms' (the lack or
   decline in normal experience or behaviour). 'Positive symptoms'
   describe psychosis and typically include delusions, hallucinations and
   thought disorder. 'Negative symptoms' describe inappropriate or
   nonpresent emotion, poverty of speech, and lack of motivation. In
   three-factor models of schizophrenia, a third symptom grouping, the
   so-called 'disorganization syndrome', is also given. This considers
   thought disorder and related disorganized behaviour to be in a separate
   symptom cluster from delusions and hallucinations.

   Some symptoms, such as social isolation, may be caused by a number of
   factors. One possible factor is impairment in social cognition, which
   is associated with schizophrenia, but isolation may also result from an
   individual reacting to psychotic symptoms (such as paranoia) or
   avoiding potentially stressful social situations which may exacerbate
   mental distress in some people.

   It is worth noting that many of the positive or psychotic symptoms may
   occur in a variety of disorders and not only in schizophrenia. The
   psychiatrist Kurt Schneider tried to list the particular forms of
   psychotic symptoms that he thought were particularly useful in
   distinguishing between schizophrenia and other disorders that could
   produce psychosis. These are called first rank symptoms or Schneiderian
   first rank symptoms and 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 hallucinated voices which
   comment on one's thoughts or actions, or may have a conversation with
   other hallucinated voices. As with other diagnostic methods, the
   reliability of 'first rank symptoms' has been questioned, although they
   remain in use as diagnostic criteria in many countries.

Diagnostic issues and controversies

   It has been argued that the diagnostic approach to schizophrenia is
   flawed, as it relies on an assumption of a clear dividing line between
   what is considered to be mental illness (fulfilling the diagnostic
   criteria) and mental health (not fulfilling the criteria). Recently it
   has been argued, notably by psychiatrist Jim van Os and psychologist
   Richard Bentall, that this makes little sense, as studies have shown
   that many people have psychotic experiences and have delusion-like
   ideas without becoming distressed, disabled or diagnosable by the
   categorical system (potentially because they interpret their
   experiences in more positive ways, or hold more pragmatic and commonly
   accepted beliefs).

   Of particular concern is that the decision as to whether a symptom is
   present is a subjective decision by the person making the diagnosis or
   relies on an incoherent definition (for example, see the entries on
   delusions and thought disorder for a discussion of this issue). 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".

   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's 1972
   study, published as On being sane in insane places, demonstrated that
   the diagnosis of schizophrenia was (at least at the time) often
   subjective and unreliable. More recent studies have found agreement
   between any two psychiatrists when diagnosing schizophrenia tends to
   reach about 65% at best. 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.

   In 2004 in Japan, the category of schizophrenia was abandoned and
   replaced with integration disorder. 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.

   Alternatively, other proponents have argued for a new approach that
   would use the presence of specific neurocognitive deficits to make a
   diagnosis. These often accompany schizophrenia and 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.

   The diagnostic approach to schizophrenia has also been opposed by the
   proponents of the anti-psychiatry movement, who argue that classifying
   specific thoughts and behaviors as an illness allows social control of
   people that society finds undesirable but who have committed no crime.
   They argue that this is a way of unjustly classifying a social problem
   as a medical one to allow the forcible detention and treatment of
   people displaying these behaviors, which is something which can be done
   under mental health legislation in most Western countries.

   An example of this can be seen in the Soviet Union, where an additional
   sub-classification of sluggishly progressing schizophrenia was created.
   Particularly in the 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. In 2000 similar concerns about
   the abuse of psychiatry to unjustly silence and detain practitioners of
   the Falun Gong movement by the Chinese government led the 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 China.

   Western psychiatric medicine tends to favour a definition of symptoms
   that depends on form rather than content (an innovation first argued
   for by psychiatrists Karl Jaspers and Kurt Schneider). Therefore, a
   subject should be able to believe anything, however unusual or socially
   unacceptable, without being diagnosed delusional, unless their belief
   is held in a particular way. In principle, this would stop people being
   forcibly detained or treated simply for what they believe. However, the
   distinction between form and content is not easy, or always possible,
   to make in practice (see delusion). This had led to accusations by
   anti-psychiatry, surrealist and mental health system survivor groups
   that psychiatric abuses exist in the West as well.

Causes

   While the reliability of the schizophrenia diagnosis introduces
   difficulties in measuring the relative effect of genes and environment
   (for example, symptoms overlap to some extent with severe bipolar
   disorder or major depression), evidence suggests that genetic
   vulnerability and environmental stressors can act in combination to
   result in diagnosis of schizophrenia.

   The extent to which these factors influence the likelihood of being
   diagnosed with schizophrenia is debated widely, and currently,
   controversial. Schizophrenia is likely to be a diagnosis of complex
   inheritance. Thus, it is likely that several genes interact to generate
   risk for schizophrenia or for the separate components that can co-occur
   to lead to a diagnosis. This, combined with disagreements over which
   research methods are best, or how data from genetic research should be
   interpreted, has led to differing estimates over genetic contribution.

Genetic

   Substantial evidence suggests that the diagnosis of schizophrenia has a
   heritable component (some estimates are as high as 80%). Current
   research suggests that environmental factors play a significant role in
   the expression of any genetic disposition towards schizophrenia (i.e.
   if someone has the genes that increase risk, this will not
   automatically result in a diagnosis of schizophrenia later in life). A
   recent review of the genetic evidence has suggested a more than 28%
   chance of one identical twin obtaining the diagnosis if the other
   already has it (see twin studies), but such studies are not noted for
   pondering the likelihood of similarities of social class and/or other
   socio-psychological factors between the twins. The estimates of
   heritability of schizophrenia from twin studies varies a great deal,
   with some notable studies showing rates as low as 11.0%–13.8% among
   monozygotic twins, and 1.8%–4.1% among dizygotic twins. However, some
   scientists criticise the methodology of the twin studies, and have
   argued that the genetic basis of schizophrenia is still largely unknown
   or open to different interpretations.

   There is currently a great deal of effort being put into molecular
   genetic studies of schizophrenia, which attempt to identify specific
   genes which may increase risk. Because of this, the genes that are
   thought to be most involved can change as new evidence is gathered. A
   2003 review of linkage studies listed seven genes as likely to increase
   risk for a later diagnosis of the disorder. Two more recent reviews
   have suggested that the evidence is currently strongest for two genes
   known as dysbindin (DTNBP1) and neuregulin (NRG1), with a number of
   other genes (such as COMT, RGS4, PPP3CC, ZDHHC8, DISC1, and AKT1)
   showing some early promising results that have not yet been fully
   replicated.

Environmental

   Considerable evidence indicates that stressful life events cause or
   trigger schizophrenia. Childhood experiences of abuse or trauma have
   also been implicated as risk factors for a diagnosis of schizophrenia
   later in life.

   Evidence is also consistent that negative attitudes towards individuals
   with (or with a risk of developing) schizophrenia can have a
   significant adverse impact. In particular, critical comments,
   hostility, authoritarian and intrusive or controlling attitudes (termed
   'high expressed emotion' by researchers) from family members have been
   found to correlate with a higher risk of relapse in schizophrenia
   across cultures. It is not clear whether such attitudes play a causal
   role in the onset of schizophrenia, although those diagnosed in this
   way may claim it to be the primary causal factor. The research has
   focused on family members but also appears to relate to professional
   staff in regular contact with clients. While initial work addressed
   those diagnosed as schizophrenic, these attitudes have also been found
   to play a significant role in other mental health problems. This
   approach does not blame 'bad parenting' or staffing, but addresses the
   attitudes, behaviors and interactions of all parties. Some go as far as
   to criticise the whole approach of seeking to localise 'mental illness'
   within one individual - the patient - rather than his/her group and its
   functionality, citing a scapegoat effect.

   Factors such as poverty and discrimination also appear to be involved
   in increasing the risk of schizophrenia or schizophrenia relapse,
   perhaps due to the high levels of stress they engender, or faults in
   diagnostic procedure/assumptions. Racism in society, including in
   diagnostic practices, and/or the stress of living in a different
   culture, may explain why minority communities have shown higher rates
   of schizophrenia than members of the same ethnic groups resident in
   their home country. The "social drift hypothesis" suggests that the
   functional problems related to schizophrenia, or the stigma and
   prejudice attached to them, can result in more limited employment and
   financial opportunities, so that the causal pathway goes from mental
   health problems to poverty, rather than, or in addition to, the other
   direction. Some argue that unemployment and the long-term unemployed
   and homeless are simply being stigmatised.

   One particularly stable and replicable finding has been the association
   between living in an urban environment and schizophrenia diagnosis,
   even after factors such as drug use, ethnic group and size of social
   group have been controlled for. A recent study of 4.4 million men and
   women in Sweden found an alleged 68%–77% increased risk of diagnosed
   psychosis for people living in the most urbanized environments, a
   significant proportion of which is likely to be described as
   schizophrenia.

Perinatal brain development

   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). However, the
   effect is not large. Some researchers postulate that the correlation is
   due to viral infections during the third trimester (4-6 months) of
   pregnancy. There is now significant 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.

   A study by Sweden's Karolinska Institute and Bristol University in the
   UK, looked at the medical records of over 700,000 people and calculated
   that 15.5% of cases of schizophrenia seen in the group may have been
   due to the patient having a father who was aged over 30 years at their
   birth, the researchers argue this is due to build up of mutations in
   the sperm of elder fathers.

   Women who were pregnant during the Dutch famine of 1944, where many
   people were close to starvation, had a higher chance of having a child
   who would later develop schizophrenia. Similarly, studies of Finnish
   mothers who were pregnant when they found out that their husbands had
   been killed during the Winter War of 1939–1940 have shown that their
   children were much more likely to develop schizophrenia when compared
   with mothers who found out about their husbands' death after pregnancy,
   suggesting that even psychological trauma in the mother may have an
   effect.

Childhood and adolescent development

   Schizophrenia is most commonly first diagnosed during late adolescence
   or early adulthood suggesting it is often the end process of childhood
   and adolescent development. Studies have indicated that genetic
   dispositions can interact with early environment to increase the risk
   of developing schizophrenia, including through global neurobehavioral
   deficits, a poorer family environment and disruptive school behaviour,
   poor peer engagement, immaturity or unpopularity or poorer social
   competence and increasing schizophrenic symptomology emerging during
   adolescence These developmental problems have also been linked to
   socioeconomic disadvantage or early experiences of traumatic events.

   There is on average a somewhat earlier onset for men than women, with
   the possible protective influence of the female hormone oestrogen being
   one hypothesis made and sociocultural influences another.
   Data from a PET study suggests that the less the frontal lobes are
   activated (red) during a working memory task, the greater the increase
   in abnormal dopamine activity in the striatum (green), thought to be
   related to the neurocognitive deficits in schizophrenia.
   Data from a PET study suggests that the less the frontal lobes are
   activated (red) during a working memory task, the greater the increase
   in abnormal dopamine activity in the striatum (green), thought to be
   related to the neurocognitive deficits in schizophrenia.

Adult brain structure

   Differences in the size and structure of certain brain areas have been
   found in some adults diagnosed with schizophrenia. Early findings came
   from the discovery of ventricular enlargement in people diagnosed with
   schizophrenia with negative symptoms most prominent. However, this
   finding has not proved particularly reliable on the level of the
   individual person, with considerable variation between patients. The
   role of antipsychotic medication, which nearly all those studied had
   taken, in causing such abnormalities is also unclear.

   More recent studies have shown a large number of differences in brain
   structure between people with and without diagnoses of schizophrenia.
   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.

Neuropsychology and brain function

   Studies using neuropsychological tests and brain imaging technologies
   such as fMRI and PET to examine functional differences in brain
   activity have shown that differences seem to most commonly occur in the
   frontal lobes, hippocampus, and temporal lobes. These differences are
   heavily linked to the neurocognitive deficits which often occur with
   schizophrenia, particularly in areas of memory, attention, problem
   solving, executive function and social cognition.

   Electroencephalograph (EEG) recordings of persons with schizophrenia
   performing perception oriented tasks showed an absence of gamma band
   activity in the brain, indicating weak integration of critical neural
   networks in the brain. Those who experienced intense hallucinations,
   delusions and disorganized thinking showed the lowest frequency
   synchronization. None of the drugs taken by the persons scanned had
   moved neural synchrony back into the gamma frequency range. Gamma band
   and working memory alterations may be related to alterations in
   interneurons that produced the neurotransmitter GABA.

Neurochemical pathways

   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 therefore 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. In addition dopamine pathway dysfunction has not been reliably
   shown to correlate with symptom onset or severity.

   Interest has also focused on the neurotransmitter glutamate and the
   reduced function of the NMDA glutamate receptor in schizophrenia. This
   has largely been suggested by abnormally low levels of glutamate
   receptors found in postmortem brains of people previously diagnosed
   with schizophrenia and the discovery that the glutamate blocking drugs
   such as phencyclidine and ketamine can mimic the symptoms and cognitive
   problems associated with the condition. The fact that reduced glutamate
   function is linked to poor performance on tests requiring frontal lobe
   and 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. 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.

   Calcium channel abnormalities are currently being explored as a factor
   in schizophrenia. Related to this, three small studies have found some
   improvements on some measures, in schizophrenia with tardive
   dyskinesia, with the calcium channel blocking agent nilvadipine added
   to an existing antipsychotic regimen

Psychosocial factors

   A number of cognitive biases or deficits have been found in people
   diagnosed with schizophrenia. These include jumping to conclusions when
   faced with limited or contradictory information; specific biases in
   reasoning about social situations, for example assuming other people
   cause things that go wrong (external attribution); difficulty
   distinguishing inner speech from speech from an external source (source
   monitoring); difficulty in adjusting speech to the needs of the hearer,
   related to theory of mind difficulties; difficulties in the very
   earliest stages of processing visual information (including reduced
   latent inhibition); difficulty with attention e.g. being more easily
   distracted, attentional bias towards threat. Some of these tendencies
   have been shown to worsen or appear when under emotional stress or in
   confusing situations. As with the related neurological findings, they
   are not shown by all individuals with a diagnosis of schizophrenia and
   it is not clear how specific they are to schizophrenia or to particular
   symptoms. However, the findings regarding cognitive difficulties in
   schizophrenia are reliable and consistent enough for some researchers
   to argue that they are diagnostic Similar cognitive features have been
   identified in close relatives of people diagnosed with schizophrenia.

   A number of emotional factors have been implicated in schizophrenia,
   with some models putting them at the core of the disorder. It was
   thought that the appearance of blunted affect meant that sufferers did
   not experience strong emotions, but more recent studies indicate there
   is often a normal or even heightened level of emotionality,
   particularly in response to negative events or stressful social
   situations. Some theories suggest positive symptoms of schizophrenia
   can result from or be worsened by negative emotions, including
   depressed feelings and low self-esteem and feelings of vulnerability,
   inferiority or loneliness. Chronic negative feelings and maladaptive
   coping skills may explain some of the association between psychosocial
   stressors and symptomology. Critical and controlling behaviour by
   significant others (high expressed emotion) causes increased emotional
   arousal and lowered self-esteem and a subsequent increase in positive
   symptoms such as unusual thoughts. Countries or cultures where
   schizotypal personalities or schizophrenia symptoms are more accepted
   or valued appear to be associated with reduced onset of, or increased
   recovery from, schizophrenia.

   Related studies suggest that the content of delusional and psychotic
   beliefs in schizophrenia can be meaningful and play a causal or
   mediating role in reflecting the life history or social circumstances
   of the individual. Holding minority or poorly understood sociocultural
   beliefs, for example due to ethnic background, has been linked to
   increased diagnosis of schizophrenia. The way an individual personally
   understands and attributes their delusions or hallucinations (e.g. as
   threatening or as potentially positive) has also been found to
   influence functioning and recovery.

Autoimmune theory

   Currently, there is growing evidence of the crucial role of
   autoimmunity in the etiology and pathogenesis of schizophrenia. This
   can be seen as a study of the statistical correlation schizophrenia
   with other autoimmune diseases and the recent work on the direct
   detailed study immune status of patients with schizophrenia.

Incidence and prevalence

   In the western world, schizophrenia is typically diagnosed in late
   adolescence or early adulthood. In the western world, it is found
   approximately equally in men and women, though the onset tends to be
   later in women, who also tend to have a better course and outcome.
   Although rare, there are also instances of childhood onset
   schizophrenia and late-onset schizophrenia that occurs in the elderly.

   The lifetime prevalence of schizophrenia is commonly given at 1%;
   however, a recent review of studies from around the world estimated it
   to be 0.55%. The same study also found that prevalence may vary greatly
   from country to country, despite the received wisdom that schizophrenia
   occurs at the same rate throughout the world. It is worth noting
   however, that this may be in part due to differences in the way
   schizophrenia is diagnosed. The incidence of schizophrenia was given as
   a range of between 7.5 and 16.3 cases per year per 100,000 population.

   Schizophrenia is also a major cause of disability. In a recent
   14-country study, active psychosis was ranked the third most disabling
   condition after quadriplegia and dementia and before paraplegia and
   blindness.

Findings on violence and schizophrenia

   Violent acts by individuals with a diagnosis of schizophrenia, and the
   public fear of such acts, are a contentious topic. A US national survey
   indicated that 61% of Americans judge individuals with schizophrenia to
   be likely to do something violent to other people, while only 17%
   thought a "troubled person" would be equally likely.

   Scientific research on actual acts of violence is generally accepted
   as, on balance, indicating a moderately increased number of violent
   acts by a minority of individuals with a diagnosis of schizophrenia. An
   assessment of violent acts verified by multiple sources, indicated that
   15% of individuals with schizophrenia had committed violent acts during
   the course of a year, which was statistically related to the relatively
   poor and violent neighbourhoods in which they resided and to substance
   misuse. An assessment of individuals enrolled in a trial of
   antipsychotics indicated a figure of 19% having committed violent acts
   in the preceding six months, with 15.5% being of a "minor" nature.

   Population-attributable figures indicate that a small percentage (e.g.
   3% in the ECA study in America) of the overall violence of a given
   population is attributable to people with schizophrenia, and that the
   majority of this risk is attributable to substance misuse, young age,
   other correlated variables, and social and economic contexts, rather
   than schizophrenia per se. Studies suggest that 5-10% of those awaiting
   trial for murder in Western countries have a schizophrenia spectrum
   disorder, with lower figures for convictions, representing a tiny
   probability for a given individual with a diagnosis of schizophrenia.

   A consistent finding from the research is that individuals with a
   diagnosis of schizophrenia are often the victims of violent crime - at
   least 14 times more often than they are perpetrators, with 4.3% being
   victims in a one month period and this ongoing "victimization" has been
   linked to committing violent acts and an increased perception of
   threat.

   Another consistent finding is a link to substance misuse, particularly
   alcohol, among the minority who commit violent acts.

   The occurrence of psychosis in schizophrenia has been linked to a
   higher risk of violent acts. Findings on the specific role of delusions
   or hallucinations are inconsistent, but have included a focus on
   delusional jealousy and perception of threat or command hallucinations.
   It has also been proposed that there is a type of individual with
   schizophrenia characterized by a history of educational difficulties,
   low IQ, conduct disorder, early-onset substance misuse and offending
   prior to diagnosis.

   Violence by or against individuals with schizophrenia typically occurs
   in the context of complex social interactions (including in atmosphere
   of mutually high " expressed emotion") within a family setting, as well
   as being an issue in healthcare settings and the wider community.

Treatment and Services

   The concept of 'curing' schizophrenia is controversial, partly because
   there are no clear criteria for what might constitute a cure. Some
   criteria for the remission of symptoms have recently been suggested.
   The efficacy of schizophrenia treatment is often assessed by using
   standardized assessment methods, one of the most common being the
   positive and negative syndrome scale ( PANSS).

Medication

   The first line pharmacological therapy for schizophrenia is usually
   antipsychotic medication. Antipsychotic drugs are thought to mainly
   provide symptomatic relief from the positive symptoms of psychosis. The
   newer atypical antipsychotic medications are now usually preferred over
   the older typical antipsychotic medications. Compared to the typical
   antipsychotics, the atypicals are associated with a lower incident rate
   of extrapyramidal adverse effects (EPS) and tardive dyskinesia (TD)
   although they are more likely to induce weight gain and obesity-related
   diseases. It is still unclear whether the newer antipsychotics reduce
   the chances of developing the rare but potentially life-threatening
   neuroleptic malignant syndrome (NMS).

   Atypical and typical antipsychotics are generally thought to be
   equivalent in efficacy for the treatment of the positive symptoms of
   schizophrenia. It has been suggested by some researchers that the
   atypicals have some additional beneficial effects on negative symptoms
   and cognitive deficits associated with schizophrenia, although the
   clinical significance of these effects has yet to be established.
   However, recent reviews have suggested that typical antipsychotics,
   when dosed conservatively, may have similar effects to atypicals. The
   atypical antipsychotics are much more costly to purchase and profitable
   to market, as they are still within patent, whereas the older drugs are
   now available in inexpensive generic forms. Aripiprazole is a drug from
   a new class of antipsychotic drugs (variously named 'dopamine system
   stabilizers' or 'partial dopamine agonists') that has also recently
   been developed and is now widely licensed for the treatment of
   schizophrenia.

Dietary supplements

   Omega-3 fatty acids (found naturally in foods such as oily fish, flax
   seeds, hemp seeds, walnuts and canola oil) have recently been studied
   as a treatment for schizophrenia. Although the number of research
   trials has been limited, the majority of randomized controlled trials
   have found omega-3 supplements to be effective when used as a dietary
   supplement.

   Supplements which lower homocysteine levels (d-sarcosine, folate),
   increase antioxidant levels (vitamins A, C, E and alpha lipoic acid)
   and agonize the NMDA receptor (glycine) are also being explored as
   possible methods to reduce symptomology in schizophrenia.

Neurological procedures

   Electroconvulsive therapy (also known as 'electroshock') may be used in
   countries where it is legal. It is not considered a first line
   treatment but may be prescribed in cases where other treatments have
   failed. Psychosurgery has now become a rare procedure and is not a
   recommended treatment for schizophrenia.

Psychological and Social Interventions

   Psychotherapy may be used in the treatment of schizophrenia. It has
   been reported that, despite evidence and recommendations, treatment is
   often confined to pharmacotherapy alone because of reimbursement
   problems or lack of training

   Cognitive behavioural therapy may focus on the direct reduction of the
   symptoms, or on related aspects, such as issues of self-esteem, social
   functioning, and insight. Although the results of early trials with
   cognitive behavioural therapy (CBT) were inconclusive, more recent
   reviews suggest that CBT can be an effective treatment for the
   psychotic symptoms of schizophrenia. There have also been advances in
   social skills training

   Another approach is cognitive remediation therapy, a technique aimed at
   remediating the neurocognitive deficits 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. A similar approach known as
   cognitive enhancement therapy, which focuses on social cognition as
   well as neurocognition, has shown efficacy

   A recent randomised controlled trial found that music therapy
   significantly improved symptom scores in a group of patients diagnosed
   with schizophrenia. A notable early mention of the beneficial effect of
   music on mental illness was in 1621 by Robert Burton in The Anatomy of
   Melancholy.

   Therapy which addresses the whole family system of an individual with a
   diagnosis of schizophrenia, including through psychological education,
   has also been found to have significant benefits

Community Services

   Support services available can include drop-in centers, visits from
   members of a 'community mental health team' or Assertive Community
   Treatment team, supported employment and patient-led support groups.

   In recent years the importance of service-user led recovery based
   movements has grown substantially throughout Europe and America. Groups
   such as the Hearing Voices Network and more recently, the Paranoia
   Network, have developed a self-help approach that aims to provide
   support and assistance outside of 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. Peer-to-peer suppport is also developing a
   professional footing with partnerships between hospitals and consumer
   run groups becoming more common. These services work towards
   remediating social withdrawal, building social skills and reducing
   rehospitalization.

   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. The reasons for this effect are not clear,
   although cross-cultural studies are being conducted.

Inpatient services

   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.

Prognosis

   Prognosis for any particular individual affected by schizophrenia is
   particularly hard to judge as treatment and access to treatment is
   continually changing, as new methods become available and medical
   recommendations change.

   One retrospective study has shown that about a third of people make a
   full recovery, about a third show improvement but not a full recovery,
   and a third remain ill. A more recent study using stricter recovery
   criteria (i.e. concurrent remission of positive and negative symptoms
   and specific instances of adequate social / vocational functioning)
   reported a recovery rate of 13.7%.

   The exact definition of what constitutes a recovery has not been widely
   defined, however, although criteria have recently been suggested to
   define a remission in symptoms. Therefore, this makes it difficult to
   give an exact estimate as recovery and remission rates are not always
   comparable across studies.

   The World Health Organization conducted two long-term follow-up studies
   involving more than 2,000 people suffering from schizophrenia in
   different countries. These studies' findings were that these patients
   have much better long-term outcomes in developing countries (India,
   Colombia and Nigeria) than in developed countries (USA, UK, Ireland,
   Denmark, Czech Republic, Slovakia, Japan, and Russia), despite the fact
   antipsychotic drugs are typically not widely available in poorer
   countries, thus raising questions about the effectiveness of such
   drug-based treatments.

   Prognosis also depends on some other factors. Females tend to show
   recovery rates higher than males, and acute and sudden onset of
   schizophrenia is associated with higher rates of recovery, while
   gradual onset is associated with lower rates. Most studies done on this
   subject, however, are correlational in nature, and a clear
   cause-and-effect relationship is difficult to establish. Pre-morbid
   functioning and positive prognosis also seem to be correlated.

   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, heart attack and stroke.

   There is an extremely 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.
   Another study suggested that 10% of persons with schizophrenia die by
   suicide.

Recovery and Rehabilitation

   Just as the clarity of the diagnosis itself attacts controversy and
   criticism, it is difficult to establish a clear picture of recovery and
   rehabilitation. Both long ago and in the recent past, patients in
   developed countries were told that chances of recovery were limited,
   with statistics being quoted to support this negative prognosis. Today,
   with the advent of a vocal "Recovery Movement" in mental health, and
   longitudinal studies indicating better rates of recovery than
   previously assumed, attention is drawn to cultural and local factors in
   impeding or accelerating recovery and different models of
   rehabilitation and recovery

Schizophrenia and drug use

   The relationship between schizophrenia and drug use is complex, meaning
   that a clear causal connection between drug use and schizophrenia has
   been difficult to tease apart. 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.

   The rate of substance use is known to be particularly high in this
   group. In a recent study, 60% of people with schizophrenia were found
   to use substances and 37% would be diagnosable with a substance use
   disorder.

Amphetamines

   As amphetamines trigger the release of dopamine and excessive dopamine
   function is believed to be responsible for many symptoms of
   schizophrenia (known as the dopamine hypothesis of schizophrenia),
   amphetamines may worsen schizophrenia symptoms.

Hallucinogens

   Schizophrenia can sometimes be triggered by heavy use of hallucinogenic
   drugs , although some claim that a predisposition towards developing
   schizophrenia is needed for this to occur. There is also some evidence
   suggesting that people suffering schizophrenia but responding to
   treatment can have relapse because of subsequent drug use. Some widely
   known cases where hallucinogens have been suspected of precipitating
   schizophrenia are Pink Floyd founder-member Syd Barrett and The Beach
   Boys producer, arranger and songwriter Brian Wilson.

   Drugs such as ketamine, PCP, and LSD have been used to mimic
   schizophrenia for research purposes, although this has now fallen out
   of favour with the scientific research community, as the differences
   between the drug induced states and the typical presentation of
   schizophrenia have become clear.

   Hallucinogenic drugs were also briefly tested as possible treatments
   for schizophrenia by psychiatrists such as Humphry Osmond and Abram
   Hoffer in the 1950s. It was mainly for this experimental treatment of
   schizophrenia that LSD administration was legal, briefly before its use
   as a recreational drug led to its criminalization.

Cannabis

   There is evidence that cannabis use can contribute to schizophrenia.
   Some studies suggest that cannabis is neither a sufficient nor
   necessary factor in developing schizophrenia, but that cannabis may
   significantly increase the risk of developing schizophrenia and may be,
   among other things, a significant causal factor. Nevertheless, some
   previous research in this area has been criticised as it has often not
   been clear whether cannabis use is a cause or effect of schizophrenia.
   To address this issue, a recent review of studies from which a causal
   contribution to schizophrenia can be assessed has suggested that
   cannabis statistically doubles the risk of developing schizophrenia on
   the individual level, and may, assuming a causal relationship, be
   responsible for up to 8% of cases in the population.

Tobacco

   People with schizophrenia tend to smoke significantly more tobacco than
   the general population. The rates are exceptionally high amongst
   institutionalized patients and homeless people. In a UK census from
   1993, 74% of people with schizophrenia living in institutions were
   found to be smokers. A 1999 study that covered all people with
   schizophrenia in Nithsdale, Scotland found a 58% prevalence rate of
   cigarette smoking, to compare with 28% in the general population. An
   older study found that as much as 88% of outpatients with schizophrenia
   were smokers.

   Despite the higher prevalence of tobacco smoking, people diagnosed with
   schizophrenia have a much lower than average chance of developing and
   dying from lung cancer. While the reason for this is unknown, it may be
   because of a genetic resistance to the cancer, a side-effect of drugs
   being taken, or a statistical effect of increased likelihood of dying
   from causes other than lung cancer.

   A recent study of over 50,000 Swedish conscripts found that there was a
   small but significant protective effect of smoking cigarettes on the
   risk of developing schizophrenia later in life. While the authors of
   the study stressed that the risks of smoking far outweigh these minor
   benefits, this study provides further evidence for the
   'self-medication' theory of smoking in schizophrenia and may give clues
   as to how schizophrenia might develop at the molecular level.
   Furthermore, many people with schizophrenia have smoked tobacco
   products long before they are diagnosed with the illness, and some
   groups advocate that the chemicals in tobacco have actually contributed
   to the onset of the illness and have no benefit of any kind.

   It is of interest that cigarette smoking affects liver function such
   that the antipsychotic drugs used to treat schizophrenia are broken
   down in the blood stream more quickly. This means that smokers with
   schizophrenia need slightly higher doses of antipsychotic drugs in
   order for them to be effective than do their non-smoking counterparts.

   The increased rate of smoking in schizophrenia may be due to a desire
   to self-medicate with nicotine. One possible reason is that smoking
   produces a short term effect to improve alertness and cognitive
   functioning in persons who suffer this illness. It has been postulated
   that the mechanism of this effect is that people with schizophrenia
   have a disturbance of nicotinic receptor functioning which is
   temporarily abated by tobacco use.

Alternative approaches to schizophrenia

   An approach broadly known as the anti-psychiatry movement, notably most
   active in the 1960s, has opposed the orthodox medical view of
   schizophrenia as an illness.

   Psychiatrist Thomas Szasz argues that psychiatric patients are not ill
   but are just individuals with unconventional thoughts and behavior that
   make society uncomfortable. He argues that society unjustly seeks to
   control such individuals by classifying their behaviour 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, created by society's concept of what
   constitutes normality and abnormality. It is worth noting that Szasz
   has never considered himself to be "anti-psychiatry" in the sense of
   being against psychiatric treatment, but simply believes that it 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
   presently Colin Ross have argued that the symptoms of what is normally
   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 revolutionary
   in valuing the content of 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's work, co-authored with Aaron Esterson,
   Sanity, Madness and the Family (1964) 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. Arieti's Interpretation of
   Schizophrenia won the 1975 scientific National Book Award in the United
   States. 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.

   In the 1976 book The Origin of Consciousness in the Breakdown of the
   Bicameral Mind, psychologist Julian Jaynes proposed that until the
   beginning of historic times, schizophrenia or a similar condition was
   the normal state of human consciousness. 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. This theory was briefly
   controversial. Continuing research has failed to either further confirm
   or refute the thesis.

   Psychiatrist Tim Crow has argued that schizophrenia may be the
   evolutionary price we pay for a left brain hemisphere specialization
   for language. 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.

   Researchers into shamanism have speculated that in some cultures
   schizophrenia or related conditions may predispose an individual to
   becoming a shaman. Certainly, 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 states of
   consciousness psychiatrists label as illness. Psychohistorians, on the
   other hand, accept the psychiatric diagnoses. However, unlike the
   current medical model of mental disorders they argue that poor
   parenting in tribal societies causes the shaman’s schizoid
   personalities. Speculations regarding primary and important religious
   figures as having schizophrenia abound. Commentators such as Paul Kurtz
   and others have endorsed the idea that major religious figures
   experienced psychosis, heard voices and displayed delusions of
   grandeur.

   Alternative medicine tends to hold the view that schizophrenia is
   primarily caused by imbalances in the body's reserves and absorption of
   dietary minerals, vitamins, fats, and/or the presence of excessive
   levels of toxic heavy metals. The body's adverse reactions to gluten
   are also strongly implicated in some alternative theories (see
   gluten-free, casein-free diet). Although this theory is generally
   deemed to be unproven, it is worth noting that it was positively
   discussed in the Lancet in 1970, the British Medical Journal in 1973,
   and other publications. A recent literature by scientists at Johns
   Hopkins University confirms some of these findings. The branch of
   alternative medicine that deals with these views regarding the cause of
   schizophrenia, is known as orthomolecular psychiatry.

   One theory put forward by psychiatrists E. Fuller Torrey and R.H.
   Yolken is that the parasite Toxoplasma gondii leads to some, if not
   many, cases of schizophrenia. This is supported by evidence that
   significantly higher levels of Toxoplasma antibodies in schizophrenia
   patients compared to the general population.

   An additional approach is suggested by the work of Richard Bandler who
   argues that "The usual difference between someone who hallucinates and
   someone who visualizes normally, is that the person who hallucinates
   doesn't know he's doing it or doesn't have any choice about it." ( Time
   for a Change, p107). He suggests that because visualization is a
   sophisticated mental capability, schizophrenia is a skill, albeit an
   involuntary and dysfunctional one that is being used but not
   controlled. He therefore suggests that a significant route to treating
   schizophrenia might be to teach the missing skill - how to distinguish
   created reality from consensus external reality, to reduce its
   maladaptive impact, and ultimately how to exercise appropriate control
   over the vizualization or auditory process. Hypnotic approaches have
   been explored by the physician Milton H. Erickson as a means of
   facilitating this.

   Regarding schizophrenia as a waking dreamer syndrome, Jie Zhang
   hypothesizes that the hallucinations of schizophrenia are caused by the
   activation of the continual-activation mechanism during waking, a
   mechanism that induces dreaming while asleep, due to the malfunction of
   the continual-activation thresholds in the conscious part of brain.

Popular Culture

     * The Marathi (India) film "DEVRAI" (Featuring Atul Kulkarni) is one
       of the best presentations of patients with schizophrenia. The film,
       set in the Konkan region of Maharashtra in Western India, shows the
       behaviour, 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 lots of patience of the close
       relatives of the patient.

     * The book and film A Beautiful Mind chronicled the life of John
       Forbes Nash, a Nobel-Prize-winning mathematician who was diagnosed
       with schizophrenia.

     * In 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 accounts his struggle
       into schizophrenia and his journey back to sanity.

     * In the book Misery by Stephen King, the antagonist Annie Wilkes is
       thought to suffer from a form of schizophrenia, in addition to
       other psychological disorders that makes her very argumentative and
       not able to easily distinguish between fiction and reality.

     * EastEnders featured a very successful storyline in 1996 that
       involved a character suffering from schizophrenia, triggered by the
       loss of a relative.

     * Paul C. Elliot's stage play Perspective follows three
       institutionalized patients with schizophrenia through visiting day
       with family members. The play is written from a patients'
       perspective to give the viewer a feeling as to what those suffering
       from schizophrenia experience.

     * The effects of untreated schizophrenia on the family are documented
       in Virginia Holman's autobiography, Rescuing Patty Hearst (Simon &
       Schuster 2003). The book also discusses the legal impediments to
       treatment that face many people with schizophrenia and their
       families.

     * The PC Video Game Max Payne and Max Payne 2 portrays schizophrenia

     * Nicole Diver, from F. Scott Fitzgerald's " Tender Is the Night" is
       diagnosed with schizophrenia.

     * Also see Lobotomy in Popular Culture

     * In the television show Dirt photographer Don Konkey is a
       schizophrenic.

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