Schizophrenia: Many questions remain

Schizophrenia affects about 1 percent of the population. It’s found in greater numbers in families who share the disorder. On average, the illness can strike in the prime of a young person’s life: the late teens, early 20s, causing thought and memory problems, hallucinations,
inappropriate emotions and apathy. Women tend to be affected a little later than their male counterparts.

The time of onset is one of the most distressing aspects of the disease. Just as people are on the verge of major transitions in their lives—pursuing an education, beginning a career or establishing adult relationships—the rug is swept out from under them and their lives are put on hold. Some experts theorize that the stresses of puberty account for the timing of its onset in susceptible individuals, but when it comes to causes, we have much to learn.

Genetic component
We do know there is a strong genetic component of schizophrenia. Schizophrenia tends to run in families, and children with a schizophrenic parent have a 10 percent chance of getting the disease—10 times higher than the rest of the population—but the statistics are tricky. The identical twin of a person with schizophrenia has only a 40 percent chance of being affected, despite having identical genes.

So it now appears that schizophrenia, like other chronic diseases such as heart disease and diabetes, results from a complex interaction of multiple genes and environmental triggers. Geneticists are searching for those genes in order to perhaps someday create genetic tests or tailored treatments. But it’s a huge task.

One of the paradoxes of the disease is that men with schizophrenia seldom marry and have children, so one might think the disease would gradually diminish without a replenishing of the gene pool, but it does not. In fact, some data indicate that the incidence of the disease is increasing in parts of the world where recreational drugs such as marijuana are readily accessible.

In the last few decades, the use of increasingly powerful brain-imaging technologies has made it possible for scientists to see that the disease affects both brain structure and function, but we still do not know what is causing these changes.

Early signs
What are some of the signs that indicate a young person may need to be assessed for schizophrenia? Some early signs include:

• an unexplainable decline in school performance
• social withdrawal
• a deterioration in personal hygiene
• magical thinking
• disturbing behavior that is uncharacteristic of the individual
• speech confusion

The PRIME study researchers have developed some new scales to help identify those most at risk, and their assessment tool is proving to be relatively effective. About one-third of the patients meeting the prodromal or early symptom criteria became psychotic. Of the 31 patients who were taking the medication, five became psychotic compared to 10 patients in the placebo group, which statistically suggests the drug is helpful but not conclusively so. When treatment is discontinued, symptoms return.

Dr. McGlashan’s hypothesis is that the longer a patient with schizophrenia is not treated, the worse his or her outcome. It’s unclear if that hypothesis is correct since scientists have known for some time that patients whose disease emerges slowly have a poorer prognosis than patients who have an acute onset of schizophrenia.

There are, in fact, different forms of psychosis, which complicates this whole issue. In any case, it is a good idea to identify young people who are at high risk of becoming ill and getting them into treatment quickly. This is not as controversial now as it was before the discovery of newer kinds of antipsychotic drugs with fewer side effects. Any parent who notices the emergence of some of the behavioral signs listed above should seek help from a mental health professional, particularly if there is any family history of schizophrenia.

Treatment
Decades ago, people with schizophrenia were often confined to large state hospitals. Those hospitals have closed, and today most patients live in the community. Treatment with a new generation of antipsychotic medications has been very effective for what we call the “positive” symptoms of schizophrenia such as delusions and hallucinations. Medication and supportive therapy that focuses on positive reinforcement and skill learning have resulted in better outcomes for schizophrenia patients. Many patients participate in community programs that provide social interaction and training opportunities.

We have been less successful in treating the “negative” symptoms of schizophrenia such as lack of motivation, problems with focus, emotional flatness, disorganized speech and the inability to experience pleasure. These symptoms can be debilitating since they interfere with the ability to do critical things such as getting jobs, going to school and establishing relationships. These negative symptoms are the focus of much of the current research. We are trying to determine if they respond to rehabilitation or if there are different kinds of medication that may help.

We do know that patients often plateau or even improve in the fifth decade of life. Many people recover to the extent that they are able to manage their illness with medication and therapy. One of the stumbling blocks to effective treatment is that schizophrenic patients often lack insight into their disease. They often deny their condition and fail to take medication or participate in rehabilitation. Success rates are often tied to the degree this lack of awareness is present in an individual.

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Dr. Bowers is an attending psychiatrist at Yale-New Haven Psychiatric Hospital and a professor emeritus of psychiatry at Yale University School of Medicine.