Positive symptoms of schizophrenia are to ____, as negative symptoms of schizophrenia are to ____.

Schizophrenia is characterised by significant impairments in the way reality is perceived and changes in behaviour related to:

• persistent delusions: the person has fixed beliefs that something is true, despite evidence to the contrary;
• persistent hallucinations: the person may hear, smell, see, touch, or feel things that are not there;
• experiences of influence, control or passivity: the experience that one’s feelings, impulses, actions, or thoughts are not generated by oneself, are being placed in one’s mind or withdrawn from one’s mind by others, or that one’s thoughts are being broadcast to others;
• disorganized thinking, which is often observed as jumbled or irrelevant speech;
• highly disorganised behaviour e.g. the person does things that appear bizarre or purposeless, or the person has unpredictable or inappropriate emotional responses that interfere with their ability to organise their behaviour;
• “negative symptoms” such as very limited speech, restricted experience and expression of emotions, inability to experience interest or pleasure, and social withdrawal; and/or 
• extreme agitation or slowing of movements, maintenance of unusual postures.

People with schizophrenia often also experience persistent difficulties with their cognitive or thinking skills, such as memory, attention, and problem-solving.

At least one third of people with schizophrenia experiences complete remission of symptoms (1). Some people with schizophrenia experience worsening and remission of symptoms periodically throughout their lives, others a gradual worsening of symptoms over time.

Magnitude and impact

Schizophrenia affects approximately 24 million people or 1 in 300 people (0.32%) worldwide. This rate is 1 in 222 people (0.45%) among adults (2). It is not as common as many other mental disorders. Onset is most often during late adolescence and the twenties, and onset tends to happen earlier among men than among women.

Schizophrenia is frequently associated with significant distress and impairment in personal, family, social, educational, occupational, and other important areas of life.

People with schizophrenia are 2 to 3 times more likely to die early than the general population (3). This is often due to physical illnesses, such as cardiovascular, metabolic, and infectious diseases.

People with schizophrenia often experience human rights violations both inside mental health institutions and in community settings. Stigma against people with this condition is intense and widespread, causing social exclusion, and impacting their relationships with others, including family and friends. This contributes to discrimination, which in turn can limit access to general health care, education, housing, and employment. 

During humanitarian and public health emergencies, extreme stress and fear, breakdown of social supports, isolation and disruption of health-care services and supply of medication can occur. These changes can have an impact on the lives of people with schizophrenia, such as exacerbation of existing symptoms. During emergencies, people with schizophrenia are more vulnerable than others to various human rights violations, including neglect, abandonment, homelessness, abuse and exclusion.

Causes of schizophrenia

Research has not identified one single cause of schizophrenia. It is thought that an interaction between genes and a range of environmental factors may cause schizophrenia.  Psychosocial factors may also affect the onset and course of schizophrenia. Heavy use of cannabis is associated with an elevated risk of the disorder.

Services

Currently, the vast majority of people with schizophrenia around the world are not receiving mental health care. Approximately 50% of people in mental hospitals have a schizophrenia diagnosis (4). Only 31.3% of people with psychosis receive specialist mental health care (5). Most resources for mental health services are inefficiently spent on care within mental hospitals.

There is clear evidence that mental hospitals are not effective in providing the care that people with mental health conditions need and, regularly, violate the basic human rights of persons with schizophrenia. Efforts to transfer care from mental health institutions to the community need to be expanded and accelerated. Such efforts start with the development of a range of quality community-based mental health services. Options for community-based mental health care include integration in primary health and general hospital care, community mental health centres, day centres, supported housing, and outreach services for home-based support. The engagement of the person with schizophrenia, family members and the wider community in providing support is important.

Management and support

A range of effective care options for people with schizophrenia exist, and these include medication, psychoeducation, family interventions, cognitive-behavioural therapy and psychosocial rehabilitation (e.g., life skills  training). Facilitated assisted living, supported housing and supported employment are essential care options that should be available for people with schizophrenia.  A recovery-oriented approach – giving people agency in treatment decisions – is essential for people with schizophrenia and for their families and/or caregivers as well.

WHO response

WHO’s Comprehensive Mental Health Action Plan 2013-2030 highlights the steps required to provide appropriate services for people with mental disorders including schizophrenia. A key recommendation of the Action Plan is to shift services from institutions to the community. The WHO Special Initiative for Mental Health aims to further progress towards objectives of the Comprehensive Mental Health Action Plan 2013-2030 by ensuring 100 million more people have access to quality and affordable care for mental health conditions.

WHO's Mental Health Gap Action Programme (mhGAP) uses evidence-based technical guidance, tools and training packages to expand service in countries, especially in resource-poor settings. It focuses on a prioritized set of conditions, including psychosis, directing capacity building towards non-specialized health-care providers in an integrated approach that promotes mental health at all levels of care. Currently mhGAP is being implemented in more than 100 WHO Member States.

The WHO QualityRights Project involves improving the quality of care and human rights conditions in mental health and social care facilities and to empower organizations to advocate for the health of people with mental health conditions and psychosocial disabilities. 

The WHO guidance on community mental health services and person-centred and rights-based approaches  provides information and support to all stakeholders who wish to develop or transform their mental health system and services to align with international human rights standards including the UN Convention on the Rights of Persons with Disabilities.

References

(1) Harrison G, Hopper K, Craig T, Laska E, Siegel C, Wanderling J. Recovery from psychotic illness: a 15- and 25-year international follow-up study. Br J Psychiatry 2001;178:506-17.

(2) Institute of health Metrics and Evaluation (IHME). Global Health Data Exchange (GHDx).  http://ghdx.healthdata.org/gbd-results-tool?params=gbd-api-2019-permalink/27a7644e8ad28e739382d31e77589dd7 (Accessed 25 September 2021)

(3) Laursen TM, Nordentoft M, Mortensen PB. Excess early mortality in schizophrenia. Annual Review of Clinical Psychology, 2014;10, 425-438.

(4) WHO. Mental health systems in selected low- and middle-income countries: a WHO-AIMS cross-national analysis. WHO: Geneva, 2009

 (5) Jaeschke K et al. Global estimates of service coverage for severe mental disorders: findings from the WHO Mental Health Atlas 2017 Glob Ment Health 2021;8:e27.

(January 2022) Schizophrenia is a chronic and severe brain disorder that interferes with a person’s ability to think clearly, manage emotions, make decisions and relate to others. Although it affects barely 1% of the population, it is one of the most disabling diseases affecting humankind.

Schizophrenia is a chronic and severe neurological brain disorder estimated in 2020 to affect 1.1 percent of the population or approximately 2.8 million adults in the United States aged 18 or older. An estimated 40 percent of individuals with the condition are untreated in any given year. Abnormalities that characterize schizophrenia include:

• delusions and hallucinations;

• alterations of the senses;

• an inability to sort and interpret incoming sensations, and an inability therefore to respond appropriately;

• an altered sense of self; and

• changes in emotions, movements and behavior. 

Psychotic disorders nearly always emerge in late adolescence or early adulthood, with onset peaking between the ages of 18 and 25. The reasons for its appearance in this age range have not been identified. Some consensus already has emerged around the concept that psychotic breaks are not, as they may seem, abrupt but rather are the climax of a long buildup. In this model, they are rooted in molecular changes in the brain that begin as much as a decade before symptoms occur and progress to an end-stage psychosis in which reality surrenders to delusion, paranoia, hallucinations or other forms of disordered thinking.  

For decades, research on the causes of schizophrenia has been dominated by theories related genetics and neurotransmitters. In the mid-2010s, a third theory–the infectious/inflammatory theory—became a major new addition to schizophrenia study. 

Symptoms of Schizophrenia

In healthy people, the brain functions in such a way that incoming stimuli are sorted and interpreted, followed by a logical response (e.g., saying "thank you" after a gift is given, realizing the potential outcome of arriving late to work, etc.). Conversely, the inability of patients with schizophrenia to sort and interpret stimuli and select appropriate responses is one of the hallmarks of the disease.

The symptoms of schizophrenia are generally divided into three categories: positive, negative and cognitive. The National Institute of Mental Illness (NIMH) publishes the following about the three categories of symptoms:  

Positive symptoms: “Positive” symptoms are psychotic behaviors not generally seen in healthy people. People with positive symptoms may “lose touch” with some aspects of reality. Symptoms include:

• Hallucinations
• Delusions
• Thought disorders
• Movement disorders (agitated body movements)

Negative symptoms: “Negative” symptoms are associated with disruptions to normal emotions and behaviors. Symptoms include:

• “Flat affect” (reduced expression of emotions via facial expression or voice tone)
• Reduced feelings of pleasure in everyday life
• Difficulty beginning and sustaining activities Reduced speaking

Cognitive symptoms: For some patients, the cognitive symptoms of schizophrenia are subtle, but for others, they are more severe and patients may notice changes in their memory or other aspects of thinking. Symptoms include:

• Poor “executive functioning” (the ability to understand information and use it to make decisions)
• Trouble focusing or paying attention
• Problems with “working memory” (the ability to use information immediately after learning it)

Diagnosing Schizophrenia

Although there are numerous abnormalities in the brain structure and function of individuals with schizophrenia, there is no single condition that can be tested or measured to produce a definitive diagnosis. Without such measures, the disease is diagnosed by its symptoms.

Prior to a medical diagnosis, it is critically important that a doctor rule out other problems that may mimic schizophrenia, such as psychotic symptoms caused by the use of drugs or other medical illnesses; major depressive episode or manic episode with psychotic features; delusional disorder (no hallucinations, disorganized speech or thought or "flattened" emotions) and autistic disorder or personality disorders (especially schizotypal, schizoid, or paranoid personality disorders). Schizoaffective disorder is a diagnosis used to indicate that the person has an illness with a mix of symptoms of both schizophrenia and bipolar disorder.

“Although there is no single symptom that is found only in schizophrenia, there are several that are found very uncommonly in diseases other than schizophrenia,” Dr. Torrey writes in Surviving Schizophrenia, now in its sixth edition as the authoritative book on the subject. “When they are present they should elevate the index of suspicion considerably….”

Precise diagnosis is of “utmost importance,” he writes. “It both determines the appropriate treatment for the patient and provides the patient and family with an informed prognosis. It also makes research on the disease easier because it allows researchers to be certain they are talking about the same thing.” It is important to diagnose and treat schizophrenia as early as possible to help people avoid or reduce frequent relapses and re-hospitalizations. Several promising, large-scale studies suggest early intervention may forestall the worst long-term outcomes of this devastating brain disorder.

Treatments and Therapies

While there is no cure for schizophrenia, it is a highly treatable disorder. In fact, according to the National Advisory Mental Health Council, the treatment success rate for schizophrenia is comparable to the treatment success rate for heart disease. People who experience acute symptoms of schizophrenia may require intensive treatment, sometimes including hospitalization, to treat severe delusions or hallucinations, serious suicidal inclinations, inability to care for oneself or severe problems with drugs or alcohol.

It is critical that people with schizophrenia stay in treatment even after recovering from an acute episode. About 80 percent of those who stop taking their medications after an acute episode will have a relapse within one year, whereas only 30 percent of those who continue their medications will experience a relapse in the same time period. Because the causes of schizophrenia are still unknown, treatments focus on eliminating the symptoms of the disease. Antipsychotic drugs typically are used in the treatment of schizophrenia because they help relieve the positive symptoms. No treatments exist for negative symptoms of the disease.

The NIMH publishes the following on treatments and therapies for schizophrenia:

• Antipsychotic medications: Antipsychotic medications are usually taken daily in pill or liquid form. Some antipsychotics are injections that are given once or twice a month. Some people have side effects when they start taking medications, but most side effects go away after a few days. Doctors and patients can work together to find the best medication or medication combination, and the right dose. Up-to-date information on medication use and side effects can be found on the U.S. Food and Drug Administration (FDA) website, including the latest information on warnings, patient medication guides, or newly approved medications.
• Psychosocial treatments: These treatments are helpful after patients and their doctor find a medication that works. Learning and using coping skills to address the everyday challenges of schizophrenia helps people to pursue their life goals, such as attending school or work. Individuals who participate in regular psychosocial treatment are less likely to have relapses or be hospitalized. For more information on psychosocial treatments, see the Psychotherapies webpage on the NIMH website.
• Coordinated specialty care (CSC): This treatment model integrates medication, psychosocial therapies, case management, family involvement and supported education and employment services, all aimed at reducing symptoms and improving quality of life. The NIMH Recovery After an Initial Schizophrenia Episode (RAISE) research project seeks to fundamentally change the trajectory and prognosis of schizophrenia through coordinated specialty care treatment in the earliest stages of the disorder. RAISE is designed to reduce the likelihood of long-term disability that people with schizophrenia often experience and help them lead productive, independent lives.

Schizophrenia and Mortality

Individuals with schizophrenia die at a younger age than do healthy people. Males have a 5.1 greater than expected early mortality rate than the general population, and females have a 5.6 greater risk of early death. Suicide is the single largest contributor to this excess mortality rate, which is 10 to 13 percent higher in schizophrenia than the general population.

Suicide is in fact the number one cause of premature death among people with schizophrenia, with an estimated 10 percent to 13 percent killing themselves. The extreme depression and psychoses that can result due to lack of treatment are the usual culprits in these sad cases. These suicides rates can be compared to the general population, which is somewhere around 0.01%. Other contributors to excess mortality include:

• Accidents: Although individuals with schizophrenia do not drive as much as other people, studies have shown that they have double the rate of motor vehicle accidents per mile driven. A significant but unknown number of individuals with schizophrenia also are killed as pedestrians by motor vehicles. 
• Diseases: There is some evidence that individuals with schizophrenia have more infections, heart disease, type II (adult onset) diabetes, and female breast cancer, all of which might increase their mortality rate. Individuals with schizophrenia who become sick are less able to explain their symptoms to medical personnel, and medical personnel are more likely to disregard their complaints and assume that they are simply part of the illness. There also is evidence that some persons with schizophrenia have an elevated pain threshold so they may not complain of symptoms until the disease has progressed too far to be treatable.
• Homelessness: Although it has not been well studied to date, it appears that homelessness increases the mortality rate of individuals with schizophrenia by making them even more susceptible to accidents and diseases.  

Additional information about schizophrenia is available from the following resources: