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Chronic Care Programme
Treatment guidelines
Schizophrenia

Chronic condition
Alternative names
Consultations protocols
Preferred treating provider
Notes
 preferred as indicated by option
 referral protocols apply
Maximum consultations per annum
 Initial consultation
 Follow-up consultation
Tariff codes
Option/plan
Provider
GMHPP
Gold Options
G1000, G500 and
G200.
Blue Options
B300 and B200.
GMISHPP
General Practitioner
Physician
Paediatrician
Cardiologist
Neurologist
Neurosurgeon
New Patient
Existing patient
Stable
Unstable
Controlled
Uncontrolled
1
1
3
1
0183; 0142; 0187; 0108
1
5
Investigations protocols
Type
Electroencephalography: taking of
record
Electroencephalography:
interpretation
Serum urea
Serum creatinine
Serum potassium
Serum sodium
Leucocytes: total count
Platelet count
AST
ALT
Phenytoin and/or carbamazepine
levels
ICD 10 coding
Provider
General
practitioner
Pathologist
General
practitioner
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
Maximum investigations per annum
Tariff code
New
Existing patient
patient
Stable
Unstable
Controlled
Uncontrolled
2711
1
0
0
2712
1
0
0
4151
4032
4113
4114
3785
3797
4130
4131
4081; 4493
1
1
1
1
3
3
2
2
4
0
0
0
1
1
1
2
2
2
0
0
0
1
1
1
2
2
4
F20.
General
Schizophrenia (pronounced /ˌskɪtsəˈfriːniə/), from the Greek roots schizein (σχίζειν, "to split")
and phrēn, phren- (φρήν, φρεν-, "mind"), is a psychiatric diagnosis that describes a mental illness
characterized by impairments in the perception or expression of reality, most commonly
manifesting as auditory hallucinations, paranoid or bizarre delusions or disorganized speech and
thinking in the context of significant social or occupational dysfunction. Onset of symptoms
typically occurs in young adulthood,[1] with approximately 0.4–0.6%[2][3] of the population
affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No
laboratory test for schizophrenia currently exists.[4]
Studies suggest that genetics, early environment, neurobiology and psychological and social
processes are important contributory factors. Current psychiatric research is focused on the role of
neurobiology, but no single organic cause has been found. Due to the many possible
combinations of symptoms, there is debate about whether the diagnosis represents a single
disorder or a number of discrete syndromes. For this reason, Eugen Bleuler termed the disease the
schizophrenias (plural) when he coined the name. Despite its etymology, schizophrenia is not
synonymous with dissociative identity disorder, previously known as multiple personality
disorder or split personality; in popular culture the two are often confused.
Increased dopaminergic activity in the mesolimbic pathway of the brain is a consistent finding.
The mainstay of treatment is pharmacotherapy with antipsychotic medications; these primarily
work by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the
early decades of their use. Psychotherapy, vocational and social rehabilitation are also important.
In more serious cases—where there is risk to self and others—involuntary hospitalization may be
necessary, though hospital stays are less frequent and for shorter periods than they were in
previous years.[5]
The disorder is primarily thought to affect cognition, but it also usually contributes to chronic
problems with behavior and emotion. People diagnosed with schizophrenia are likely to be
diagnosed with comorbid conditions, including clinical depression and anxiety disorders;[6] the
lifetime prevalence of substance abuse is typically around 40%. Social problems, such as longterm unemployment, poverty and homelessness, are common and life expectancy is decreased;
the average life expectancy of people with the disorder is 10 to 12 years less than those without,
owing to increased physical health problems and a high suicide rate.[7]
Signs and symptoms
A person experiencing schizophrenia may demonstrate symptoms such as disorganized thinking,
auditory hallucinations, and delusions. In severe cases, the person may be largely mute, remain
motionless in bizarre postures, or exhibit purposeless agitation; these are signs of catatonia. The
current classification of psychoses holds that symptoms need to have been present for at least one
month in a period of at least six months of disturbed functioning. A schizophrenia-like psychosis
of shorter duration is termed a schizophreniform disorder.[4] No one sign is diagnostic of
schizophrenia, and all can occur in other medical and psychiatric conditions.[4]
Social isolation commonly occurs and may be due to a number of factors. Impairment in social
cognition is associated with schizophrenia, as are the active symptoms of paranoia from delusions
and hallucinations, and the negative symptoms of apathy and avolition. Many people diagnosed
with schizophrenia avoid potentially stressful social situations that may exacerbate mental
distress.[8]
Late adolescence and early adulthood are peak years for the onset of schizophrenia. These are
critical periods in a young adult's social and vocational development, and they can be severely
disrupted by disease onset. To minimize the effect of schizophrenia, much work has recently been
done to identify and treat the prodromal (pre-onset) phase of the illness, which has been detected
up to 30 months before the onset of symptoms, but may be present longer.[9] Those who go on to
develop schizophrenia may experience the non-specific symptoms of social withdrawal,
irritability and dysphoria in the prodromal period,[10] and transient or self-limiting psychotic
symptoms in the prodromal phase before psychosis becomes apparent.[11]
Schneiderian classification
The psychiatrist Kurt Schneider (1887–1967) listed the forms of psychotic symptoms that he
thought distinguished schizophrenia from other psychotic disorders. These are called first-rank
symptoms or Schneider's first-rank symptoms, and they include delusions of being controlled by
an external force; the belief that thoughts are being inserted into or withdrawn from one's
conscious mind; the belief that one's thoughts are being broadcast to other people; and hearing
hallucinatory voices that comment on one's thoughts or actions or that have a conversation with
other hallucinated voices.[12] The reliability of first-rank symptoms has been questioned,[13]
although they have contributed to the current diagnostic criteria.
Positive and negative symptoms
Schizophrenia is often described in terms of positive (or productive) and negative (or deficit)
symptoms.[14] 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 or blunted affect and emotion, poverty of speech (alogia), anhedonia, and
lack of motivation (avolition). Despite the appearance of blunted affect, recent studies indicate
that there is often a normal or even heightened level of emotionality in schizophrenia, especially
in response to stressful or negative events.[15] A third symptom grouping, the disorganization
syndrome, is commonly described, and includes chaotic speech, thought, and behaviour. There is
evidence for a number of other symptom classifications.[16]
Diagnosis
Diagnosis is based on the self-reported experiences of the person as well as abnormalities in
behavior reported by family members, friends or co-workers, followed by secondary signs
observed by a psychiatrist, social worker, clinical psychologist or other clinician in a clinical
assessment. 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.[4]
An initial assessment includes a comprehensive history and physical examination by a physician.
Although there are no biological tests which confirm schizophrenia, tests are carried out to
exclude medical illnesses which may rarely present with psychotic schizophrenia-like
symptoms.[4] These include blood tests measuring TSH to exclude hypo- or hyperthyroidism,
basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count
including ESR to rule out a systemic infection or chronic disease, and serology to exclude
syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and
a CT scan of the head to exclude brain lesions. It is important to rule out a delirium which can be
distinguished by visual hallucinations, acute onset and fluctuating level of consciousness and
indicates an underlying medical illness. There are several psychiatric illnesses which may present
with psychotic symptoms other than schizophrenia. These include bipolar disorder,[17] borderline
personality disorder,[18] drug intoxication, brief drug-induced psychosis, and schizophreniform
disorder.
Investigations are not generally repeated for relapse unless there is a specific medical indication.
These may include serum blood sugar level (BSL) if olanzapine has been prescribed previously,
liver function tests if chlorpromazine, or creatine phosphokinase (CPK) to exclude neuroleptic
malignant syndrome. Assessment and treatment are usually done on an outpatient basis;
admission to an inpatient facility is considered if there is a risk to self or others.
The most widely used criteria for diagnosing schizophrenia are from the American Psychiatric
Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being
DSM-IV-TR, and the World Health Organization's International Statistical Classification of
Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used
in European countries while the DSM criteria are used in the USA or the rest of the world, as well
as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian first
rank symptoms although, in practice, agreement between the two systems is high.[19] The WHO
has developed the tool SCAN (Schedules for Clinical Assessment in Neuropsychiatry) which can
be used for diagnosing a number of psychiatric conditions, including schizophrenia.
DSM IV-TR Criteria
To be diagnosed with schizophrenia, a person must display:[4]

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)
o delusions
o hallucinations
o disorganized speech (e.g., frequent derailment or incoherence; speaking in abstracts).
See thought disorder.
o grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or
catatonic behavior
o 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).
o Note: Only one of these symptoms 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.

Social/occupational dysfunction: For a significant portion of the time since the onset of
the disturbance, one or more major areas of functioning such as work, interpersonal
relations, or self-care, are markedly below the level achieved prior to the onset.

Duration: Continuous signs of the disturbance persist for at least six months. This sixmonth period must include at least one month of symptoms (or less, if successfully
treated).
Additional criteria are also given that exclude the diagnosis; thus schizophrenia cannot be
diagnosed if symptoms of mood disorder or pervasive developmental disorder are present, or 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 (now
known as disorganized), and paranoid. The DSM contains five sub-classifications of
schizophrenia:

paranoid type: where delusions and hallucinations are present but thought disorder,
disorganized behavior, and affective flattening are absent (DSM code 295.3/ICD code F20.0)

disorganized type: named 'hebephrenic schizophrenia' in the ICD. Where thought disorder
and flat affect are present together (DSM code 295.1/ICD code F20.1)

catatonic type: prominent psychomotor disturbances are evident. Symptoms can include
catatonic stupor and waxy flexibility (DSM code 295.2/ICD code F20.2)

undifferentiated type: psychotic symptoms are present but the criteria for paranoid,
disorganized, or catatonic types have not been met (DSM code 295.9/ICD code F20.3)

residual type: where positive symptoms are present at a low intensity only (DSM code
295.6/ICD code F20.5)
The ICD-10 recognises a further two subtypes:

post-schizophrenic depression: a depressive episode arising in the aftermath of a
schizophrenic illness where some low-level schizophrenic symptoms may still be present
(ICD code F20.4)

simple schizophrenia: insidious but progressive development of prominent negative
symptoms with no history of psychotic episodes (ICD code F20.6)

Diagnostic issues and controversies
Schizophrenia as a diagnostic entity has been criticised as lacking in scientific validity or
reliability,[20][21] part of a larger criticism of the validity of psychiatric diagnoses in general. One
alternative suggests that the issues with the diagnosis would be better addressed as individual
dimensions along which everyone varies, such that there is a spectrum 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[22][23] and often non-distressing delusional
beliefs[24] amongst the general public.[23]
Another criticism is that the definitions used for criteria lack consistency;[25] this is particularly
relevant to the evaluation of delusions and thought disorder. More recently, it has been argued
that psychotic symptoms are not a good basis for making a diagnosis of schizophrenia as
"psychosis is the 'fever' of mental illness — a serious but nonspecific indicator".[26]
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.[27] More
recent studies have found agreement between any two psychiatrists when diagnosing
schizophrenia tends to reach about 65% at best.[28] 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.[29]
In 2004 in Japan, the Japanese term for schizophrenia was changed from Seishin-Bunretsu-Byo
(mind-split-disease) to Tōgō-shitchō-shō (integration disorder).[30] 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.[31]
Alternatively, other proponents have put forward using the presence of specific neurocognitive
deficits to make a diagnosis. These take the form of a reduction or impairment in basic
psychological functions such as memory, attention, executive function and problem solving. It is
these sorts of difficulties, rather than the psychotic symptoms (which can in many cases be
controlled by antipsychotic medication), which seem to be the cause of most disability in
schizophrenia. However, this argument is relatively new and it is unlikely that the method of
diagnosing schizophrenia will change radically in the near future.[32]
The diagnosis of schizophrenia has been used for political rather than therapeutic purposes; in the
Soviet Union an additional sub-classification of sluggishly progressing schizophrenia was
created. Particularly in the 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.[33] In 2000 there were similar concerns regarding
detention and 'treatment' of practitioners of the Falun Gong movement by the Chinese
government. This 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.[34]
Treatment
The concept of a cure as such remains controversial, as there is no consensus on the definition,
although some criteria for the remission of symptoms have recently been suggested.[89] The
effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the
most common being the Positive and Negative Syndrome Scale (PANSS).[90] Management of
symptoms and improving function is thought to be more achievable than a cure. Treatment was
revolutionized in the mid 1950s with the development and introduction of chlorpromazine.[91] A
recovery model is increasingly adopted, emphasizing hope, empowerment and social inclusion.[92]
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). Longterm inpatient stays are now less common due to deinstitutionalization, although can still occur.[5]
Following (or in lieu of) a hospital admission, support services available can include drop-in
centers, visits from members of a community mental health team or Assertive Community
Treatment team, supported employment[93] and patient-led support groups.
In many non-Western societies, schizophrenia may only be treated with more informal,
community-led methods. The outcome for people diagnosed with schizophrenia in non-Western
countries may actually be better than for people in the West.[94] The reasons for this effect are not
clear, although cross-cultural studies are being conducted.
Medication
The mainstay of psychiatric treatment for schizophrenia is an antipsychotic (aka "neuroleptic")
medication.[95] These can reduce the "positive" symptoms of psychosis. Most antipsychotics take
around 7–14 days to have their main effect.
Risperidone (trade name Risperdal) is a common atypical antipsychotic medication.
Though expensive, the newer atypical antipsychotic drugs are usually preferred for initial
treatment over the older typical antipsychotics; they are often better tolerated and associated with
lower rates of tardive dyskinesia, although they are more likely to induce weight gain and
obesity-related diseases.[96] Prolactin elevations have been reported in women with schizophrenia
taking atypical antipsychotics.[97]It remains unclear whether the newer antipsychotics reduce the
chances of developing neuroleptic malignant syndrome, a rare but serious and potentially fatal
neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic
drugs.[98]
The two classes of antipsychotics are generally thought equally effective for the treatment of the
positive symptoms. Some researchers have suggested that the atypicals offer additional benefit for
the negative symptoms and cognitive deficits associated with schizophrenia, although the clinical
significance of these effects has yet to be established. Recent reviews have refuted the claim that
atypical antipsychotics have fewer extrapyramidal side effects than typical antipsychotics,
especially when the latter are used in low doses or when low potency antipsychotics are
chosen.[99]
Response of symptoms to medication is variable; "Treatment-resistant schizophrenia" is a term
used for the failure of symptoms to respond satisfactorily to at least two different
antipsychotics.[100] Patients in this category may be prescribed clozapine,[101] a medication of
superior effectiveness but several potentially lethal side effects including agranulocytosis and
myocarditis.[102] Clozapine may have the additional benefit of reducing propensity for substance
abuse in schizophrenic patients. [103] For other patients who are unwilling or unable to take
medication regularly, long-acting depot preparations of antipsychotics may be given every two
weeks to achieve control. The United States of America and Australia are two countries with laws
allowing the forced administration of this type of medication on those who refuse but are
otherwise stable and living in the community. Some findings have found that in the longer-term
some individuals may do better not taking antipsychotics.[104] Despite the promising results of
early pilot trials,[105] omega-3 fatty acids failed to improve schizophrenic symptoms, according to
the most recent meta-analysis.[106]
Psychological and social interventions
Psychotherapy is also widely recommended and used in the treatment of schizophrenia, although
services may often be confined to pharmacotherapy because of reimbursement problems or lack
of training.[107]
Cognitive behavioral therapy (CBT) is used to reduce symptoms and improve related issues such
as self-esteem, social functioning, and insight. Although the results of early trials were
inconclusive,[108] more recent reviews suggest that CBT can be an effective treatment for the
psychotic symptoms of schizophrenia.[109] 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.[110] A similar approach known as cognitive enhancement therapy, which
focuses on social cognition as well as neurocognition, has shown efficacy.[111]
Family Therapy or Education, which addresses the whole family system of an individual with a
diagnosis of schizophrenia, has been consistently found to be beneficial, at least if the duration of
intervention is longer-term.[112][113][114] Aside from therapy, the impact of schizophrenia on
families and the burden on carers has been recognized, with the increasing availability of selfhelp books on the subject.[115][116] There is also some evidence for benefits from social skills
training, although there have also been significant negative findings.[117][118] Some studies have
explored the possible benefits of music therapy and other creative therapies.[119][120][121]
The Soteria model is alternative to inpatient hospital treatment using a minimal medication
approach. It is described as a milieu-therapeutic recovery method, characterized by its founder as
"the 24 hour a day application of interpersonal phenomenologic interventions by a
nonprofessional staff, usually without neuroleptic drug treatment, in the context of a small,
homelike, quiet, supportive, protective, and tolerant social environment."[122] Although research
evidence is limited, a 2008 systematic review found the programme equally as effective as
treatment with medication in people diagnosed with first and second episode schizophrenia.[123]
Other
Electroconvulsive therapy is not considered a first line treatment but may be prescribed in cases
where other treatments have failed. It is more effective where symptoms of catatonia are
present,[124] and is recommended for use under NICE guidelines in the UK for catatonia if
previously effective, though there is no recommendation for use for schizophrenia otherwise.[125]
Psychosurgery has now become a rare procedure and is not a recommended treatment for
schizophrenia.[126]
Service-user led movements have become integral to the recovery process in Europe and
America; groups such as the Hearing Voices Network and the Paranoia Network have developed
a self-help approach that aims to provide support and assistance outside the traditional medical
model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of
criteria for mental illness or mental health, they aim to destigmatize the experience and encourage
individual responsibility and a positive self-image. Partnerships between hospitals and consumerrun groups are becoming more common, with services working toward remediating social
withdrawal, building social skills and reducing rehospitalization.[127]
Medicine formularies
Plan or option
GMHPP
Gold Options
G1000, G500 and
G200
Blue Options
B300 and B200
GMISHPP
Link to appropriate Mediscor formulary
[Core]
Blue Option B100
n/a
Epidemiology
Schizophrenia occurs equally in males and females although typically appears earlier in men with
the peak ages of onset being 20–28 years for males and 26–32 years for females.[1] Much rarer are
instances of childhood-onset[35] and late- (middle age) or very-late-onset (old age)
schizophrenia.[36] The lifetime prevalence of schizophrenia, that is, the proportion of individuals
expected to experience the disease at any time in their lives, is commonly given at 1%. A 2002
systematic review of many studies, however, found a lifetime prevalence of 0.55%.[3] Despite the
received wisdom that schizophrenia occurs at similar rates throughout the world, its prevalence
varies across the world,[37] within countries,[38] and at the local and neighbourhood level.[39] 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.[40] Schizophrenia is known to be a major cause of
disability. In a 1999 study of 14 countries, active psychosis was ranked the third-most-disabling
condition, after quadriplegia and dementia and before paraplegia and blindness.[41]
Prognosis
John Nash, an American mathematician, began showing signs of paranoid schizophrenia during
his college years. Despite refusing to take his prescribed medication, Nash continued his studies
and was awarded the Nobel Prize in 1994. His life was the source of the biography A Beautiful
Mind and the subsequent film adaptation.
Numerous international studies have demonstrated favorable long-term outcomes for around half
of those diagnosed with schizophrenia, with substantial variation between individuals and
regions.[128] One retrospective study found that about a third of people made a full recovery, about
a third showed improvement but not a full recovery, and a third remained ill.[129] A clinical study
using strict recovery criteria (concurrent remission of positive and negative symptoms and
adequate social and vocational functioning continuously for two years) found a recovery rate of
14% within the first five years.[130] A 5-year community study found that 62% showed overall
improvement on a composite measure of symptomatic, clinical and functional outcomes.[131]
Rates are not always comparable across studies because an exact definition of what constitutes
recovery has not been widely accepted, although standardized criteria have been suggested.[89]
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 found 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),[132] despite the fact antipsychotic drugs are typically not widely available in poorer
countries, raising questions about the effectiveness of such drug-based treatments.
Several factors are associated with a better prognosis: Being female, acute (vs. insidious) onset of
symptoms, older age of first episode, predominantly positive (rather than negative) symptoms,
presence of mood symptoms and good premorbid functioning.[133][134] Most studies done on this
subject, however, are correlational in nature, and a clear cause-and-effect relationship is difficult
to establish. Evidence is also consistent that negative attitudes towards individuals with
schizophrenia can have a significant adverse impact. In particular, critical comments, hostility,
authoritarian and intrusive or controlling attitudes (termed high 'Expressed emotion' or 'EE' by
researchers) from family members have been found to correlate with a higher risk of relapse in
schizophrenia across cultures.[135]
Mortality
In a study of over 168,000 Swedish citizens undergoing psychiatric treatment, schizophrenia was
associated with an average life expectancy of approximately 80–85% of that of the general
population. Women with a diagnosis of schizophrenia were found to have a slightly better life
expectancy than that of men, and as a whole, a diagnosis of schizophrenia was associated with a
better life expectancy than substance abuse, personality disorder, heart attack and stroke.[136]
There is a high suicide rate associated with schizophrenia; a recent study showed that 30% of
patients diagnosed with this condition had attempted suicide at least once during their
lifetime.[137] [138]Another study suggested that 10% of persons with schizophrenia die by
suicide.[139] Other identified factors include smoking, poor diet, little exercise and the negative
health effects of psychiatric drugs.[7]
Violence
The relationship between violent acts and schizophrenia is a contentious topic. Current research
indicates that the percentage of people with schizophrenia who commit violent acts is higher than
the percentage of people without any disorder, but lower than is found for disorders such as
alcoholism, and the difference is reduced or not found in same-neighbourhood comparisons when
related factors are taken into account, notably sociodemographic variables and substance
misuse.[140][141][142][143][144] Studies have indicated that 5% to 10% of those charged with murder in
Western countries have a schizophrenia spectrum disorder.[145][146][147]
The occurrence of psychosis in schizophrenia has sometimes been linked to a higher risk of
violent acts. Findings on the specific role of delusions or hallucinations have been inconsistent,
but have focused on delusional jealousy, perception of threat and command hallucinations. It has
been proposed that a certain type of individual with schizophrenia may be most likely to offend,
characterized by a history of educational difficulties, low IQ, conduct disorder, early-onset
substance misuse and offending prior to diagnosis.[145]
A consistent finding 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.[148][149] Another consistent
finding is a link to substance misuse, particularly alcohol,[150] among the minority who commit
violent acts. Violence by or against individuals with schizophrenia typically occurs in the context
of complex social interactions within a family setting,[151] and is also an issue in clinical
services[152] and in the wider community.[153]
Screening and prevention
There are no reliable markers for the later development of schizophrenia although research is
being conducted into how well a combination of genetic risk plus non-disabling psychosis-like
experience predicts later diagnosis.[154] People who fulfil the 'ultra high-risk mental state' criteria,
that include a family history of schizophrenia plus the presence of transient or self-limiting
psychotic experiences, have a 20–40% chance of being diagnosed with the condition after one
year.[155] The use of psychological treatments and medication has been found effective in
reducing the chances of people who fulfill the 'high-risk' criteria from developing full-blown
schizophrenia.[156] However, the treatment of people who may never develop schizophrenia is
controversial, in light of the side-effects of antipsychotic medication; particularly with respect to
the potentially disfiguring tardive dyskinesia and the rare but potentially lethal neuroleptic
malignant syndrome.[157] The most widely used form of preventative health care for schizophrenia
takes the form of public education campaigns that provide information on risk factors, early
detection and treatment options.[158]
Alternative approaches
An approach broadly known as the anti-psychiatry movement, most active in the 1960s, opposes
the orthodox medical view of schizophrenia as an illness.[159] Psychiatrist Thomas Szasz argued
that psychiatric patients are not ill, but rather individuals with unconventional thoughts and
behavior that make society uncomfortable.[160] He argues that society unjustly seeks to control
them by classifying their behavior as an illness and forcibly treating them as a method of social
control. According to this view, "schizophrenia" does not actually exist but is merely a form of
social construction, created by society's concept of what constitutes normality and abnormality.
Szasz has never considered himself to be "anti-psychiatry" in the sense of being against
psychiatric treatment, but simply believes that treatment should be conducted between consenting
adults, rather than imposed upon anyone against his or her will. Similarly, psychiatrists R. D.
Laing, Silvano Arieti, Theodore Lidz and Colin Ross[161] have argued that the symptoms of what
is called mental illness are comprehensible reactions to impossible demands that society and
particularly family life places on some sensitive individuals. Laing, Arieti, Lidz and Ross were
notable in valuing the content of psychotic experience as worthy of interpretation, rather than
considering it simply as a secondary but essentially meaningless marker of underlying
psychological or neurological distress. Laing described eleven case studies of people diagnosed
with schizophrenia and argued that the content of their actions and statements was meaningful
and logical in the context of their family and life situations.[162] In 1956, Palo Alto, Gregory
Bateson and his colleagues Paul Watzlawick, Donald Jackson, and Jay Haley[163] articulated a
theory of schizophrenia, related to Laing's work, as stemming from double bind situations where
a person receives different or contradictory messages. Madness was therefore an expression of
this distress and should be valued as a cathartic and trans-formative experience. In the books
Schizophrenia and the Family and The Origin and Treatment of Schizophrenic Disorders Lidz
and his colleagues explain their belief that parental behaviour can result in mental illness in
children. Arieti's Interpretation of Schizophrenia won the 1975 scientific National Book Award in
the United States.
The concept of schizophrenia as a result of civilization has been developed further by
psychologist Julian Jaynes in his 1976 book The Origin of Consciousness in the Breakdown of the
Bicameral Mind; he proposed that until the beginning of historic times, schizophrenia or a similar
condition was the normal state of human consciousness.[164] This would take the form of a
"bicameral mind" where a normal state of low affect, suitable for routine activities, would be
interrupted in moments of crisis by "mysterious voices" giving instructions, which early people
characterized as interventions from the gods. Researchers into shamanism have speculated that in
some cultures schizophrenia or related conditions may predispose an individual to becoming a
shaman;[165] 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.[166] Speculation 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.[167]
Psychiatrist Tim Crow has argued that schizophrenia may be the evolutionary price we pay for a
left brain hemisphere specialization for language.[168] Since psychosis is associated with greater
levels of right brain hemisphere activation and a reduction in the usual left brain hemisphere
dominance, our language abilities may have evolved at the cost of causing schizophrenia when
this system breaks down.
Alternative medical treatments
A branch of alternative medicine that deals with schizophrenia is known as orthomolecular
psychiatry. Orthomolecular psychiatry considers the schizophrenias to be a group of disorders;
management entails performing the appropriate diagnostic tests and then providing the
appropriate therapy.[169] Vitamin B-3 (Niacin) has been proposed as an effective treatment in
some cases.[170] The body's adverse reactions to gluten are implicated in some alternative theories;
proponents of orthomolecular psychiatric thought claim that an adverse reaction to gluten is
involved in the etiology of some cases. This theory—discussed by one author in three British
journals in the 1970s[171]—is unproven. A 2006 literature review suggests that gluten may be a
factor for patients with celiac disease and for a subset of patients afflicted with schizophrenia, but
that further study is needed to conclusively confirm such a link.[172] In a 2004 Israeli study, antigluten antibodies were measured in 50 schizophrenic patients and a matched control group. All
antibody tests in both groups were negative leading to the conclusion that "it is unlikely that there
is an association between gluten sensitivity and schizophrenia."[173] Some researchers suggest that
dietary and nutritional treatments may hold promise in the treatment of schizophrenia.[174]
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Further reading

Bentall, R. (2003) Madness explained: Psychosis and Human Nature. London: Penguin
Books Ltd. ISBN 0-7139-9249-2

Dalby, J.T. (1997) Mental Disease in History: A selection of translated readings. New
York: Peter Lang Publishing. ISBN 0-8204-3056-0

Fallon, James H. et al. (2003) The Neuroanatomy of Schizophrenia: Circuitry and
Neurotransmitter Systems. Clinical Neuroscience Research 3:77–107. Available at
Elsevier article locater.

Green, M.F. (2001) Schizophrenia Revealed: From Neurons to Social Interactions. New
York: W.W. Norton. ISBN 0-393-70334-7

Keen, T. M. (1999) Schizophrenia: orthodoxy and heresies. A review of alternative
possibilities. Journal of Psychiatric and Mental Health Nursing, 1999, 6, 415–424. PMID
10818864

Laing, R.D. (1999) The Divided Self: An Existential Study in Sanity and Madness.
London: Penguin Books Ltd. ISBN 0-140-13537-5

Lidz, Theodore, Stephen Fleck & Alice Cornelison, Schizophrenia and the Family.
International Universities Press, 1965. ISBN 978-0823660018

Noll, Richard (2007) The Encyclopedia of Schizophrenia and Other Psychotic Disorders,
Third Edition ISBN 0-8160-6405-9

Open The Doors - information on global programme to fight stigma and discrimination
because of Schizophrenia. The World Psychiatric Association (WPA)

Read, J., Mosher, L.R., Bentall, R. (2004) Models of Madness: Psychological, Social and
Biological Approaches to Schizophrenia. ISBN 1-58391-906-6. A critical approach to
biological and genetic theories, and a review of social influences on schizophrenia.

Scientific American Magazine (January 2004 Issue) Decoding Schizophrenia

Shaner, A., Miller, G. F., & Mintz, J. (2004). Schizophrenia as one extreme of a sexually
selected fitness indicator. Schizophrenia Research, 70(1), 101–109. PMID 15246469Full
text (PDF), Retrieved on 2007-05-17.

Szasz, T. (1976) Schizophrenia: The Sacred Symbol of Psychiatry. New York: Basic
Books. ISBN 0-465-07222-4

Tausk, V. : "Sexuality, War, and Schizophrenia: Collected Psychoanalytic Papers",
Publisher: Transaction Publishers 1991, ISBN 0-88738-365-3 (On the Origin of the
'Influencing Machine' in Schizophrenia.)

Wiencke, Markus (2006) Schizophrenie als Ergebnis von Wechselwirkungen: Georg
Simmels Individualitätskonzept in der Klinischen Psychologie. In David Kim (ed.), Georg
Simmel in Translation: Interdisciplinary Border-Crossings in Culture and Modernity (pp.
123–155). Cambridge Scholars Press, Cambridge, ISBN 1-84718-060-5