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Schizophrenia, 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 Hallucination s, paranoid or bizarre Delusion s or Disorganized Speech And Thinking in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood,Castle E, Wessely S, Der G, Murray RM (1991). "The incidence of operationally defined schizophrenia in Camberwell 1965–84," British Journal of Psychiatry 159: 790–794. PMID 1790446 with approximately 0.4–0.6%Bhugra, D. (2005). The global prevalence of schizophrenia. PLoS Medicine, 2 (5), 372–373. PMID 15916460Goldner EM, Hsu L, Waraich P, Somers JM (2002). Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature. ''Canadian Journal of Psychiatry'', 47(9), 833–43. PMID 12500753 of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. 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 is focused on the role of neurobiology, but a clear organic cause has not 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. 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 ; the lifetime Prevalence of Substance Abuse is typically around 40%. Social problems, such as long-term 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.Brown S, Inskip H, Barraclough B. (2000) Causes of the excess mortality of schizophrenia. ''Br J Psychiatry'', 177, 212-7. PMID 11040880 SIGNS AND SYMPTOMS A person experiencing schizophrenia may demonstrate symptoms such as Disorganized Thinking , auditory Hallucination s, and Delusion s. In severe cases, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are Sign s 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 .American Psychiatric Association (2004) Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). American Psychiatric Association. ISBN 0890420246. DSM-IV & DSM-IV-TR Schizophrenia criteria No one sign is diagnostic of schizophrenia, and all can occur in other medical and psychiatric conditions. 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.Freeman D, Garety PA, Kuipers E, Fowler D, Bebbington PE, Dunn G. (2007) Acting on persecutory delusions: the importance of safety seeking. ''Behaviour Research and Therapy'', 45 (1), 89–99. PMID 16530161 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 impact of schizophrenia, much work has recently been done to identify and treat the in the prodromal period,Parnas J, Jorgensen A. (1989) Pre-morbid psychopathology in schizophrenia spectrum. ''British Journal of Psychiatry'', 155, 623–7. and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.Amminger GP, Leicester S, Yung AR, Phillips LJ, Berger GE, Francey SM, Yuen HP, McGorry PD. (2006) Early-onset of symptoms predicts conversion to non-affective psychosis in ultra-high risk individuals. ''Schizophrenia Research'', 84 (1), 67–76. PMID 16677803 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.Schneider, K. (1959) ''Clinical Psychopathology''. New York: Grune and Stratton. The reliability of first-rank symptoms has been questioned,Bertelsen, A. (2002). Schizophrenia and Related Disorders: Experience with Current Diagnostic Systems. ''Psychopathology'', 35, 89–93. PMID 12145490 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.Sims A (2002) Symptoms in the Mind: An Introduction to Descriptive Psychopathology (3rd edition). Edinburgh: Elsevier Science Ltd. ISBN 0-7020-2627-1 Positive symptoms include Delusion s, 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.Cohen & Docherty (2004). Affective reactivity of speech and emotional experience in patients with schizophrenia. ''Schizophr Res'', 1;69(1):7–14. PMID 15145465 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.Peralta V, Cuesta MJ. (2001) How many and which are the psychopathological dimensions in schizophrenia? Issues influencing their ascertainment. ''Schizophrenia Research'', 30, 49(3), 269-85. PMID 11356588 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. 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. These include blood tests measuring . Investigations are not generally repeated for relapse unless there is a specific ''medical'' indication. These may include serum BSL if Olanzapine has previously been prescribed, liver function tests if Chlorpromazine or 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.Jakobsen KD, Frederiksen JN, Hansen T, Jansson LB, Parnas J, Werge T (2005) Reliability of clinical ICD-10 schizophrenia diagnoses. ''Nordic Journal of Psychiatry'', 59 (3), 209-12. PMID 16195122 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:
: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.
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:
The ICD-10 recognises a further two subtypes:
Diagnostic issues and controversies Schizophrenia as a diagnostic entity has been criticised as lacking in scientific validity or reliability,Bentall RP (1992) ''Reconstructing Schizophrenia''. London: Routledge. ISBN 0415075246Boyle M (2002) ''Schizophrenia: A Scientific Delusion?''. London: Routledge. ISBN 0415227186 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 experiencesVerdoux H, van Os J (2002). Psychotic symptoms in non-clinical populations and the continuum of psychosis. ''Schizophrenia Research'', 54(1–2), 59–65. PMID 11853979LC, van Os J. (2001). The continuity of psychotic experiences in the general population. ''Clinical Psychology Review'', 21 (8),1125–41. PMID 11702510 and often non-distressing delusional beliefsPeters ER, Day S, McKenna J, Orbach G(2005). Measuring delusional ideation: the 21-item Peters et al. Delusions Inventory (PDI). ''Schizophrenia Bulletin'', 30, 1005–22. PMID 15954204 amongst the general public.Johns LC, van Os J (2001) The continuity of psychotic experiences in the general population. ''Clinical Psychology Review'', 21 (8), 1125–41. PMID 11702510. Another criticism is that the definitions used for criteria lack consistency;David AS (1999) On the impossibility of defining delusions. ''Philosophy, Psychiatry and Psychology'', 6 (1), 17–20 this is particularly relevant to the evaluation of Delusion s 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".Tsuang MT, Stone WS, Faraone SV (2000). Toward reformulating the diagnosis of schizophrenia. ''American Journal of Psychiatry'', 157(7), 1041–1050. PMID 10873908 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.Rosenhan D (1973). On being sane in insane places. ''Science'', 179, 250-8. PMID 4683124 Full text as PDF More recent studies have found agreement between any two psychiatrists when diagnosing schizophrenia tends to reach about 65% at best.McGorry PD, Mihalopoulos C, Henry L, Dakis J, Jackson HJ, Flaum M, Harrigan S, McKenzie D, Kulkarni J, Karoly R (1995). Spurious precision: procedural validity of diagnostic assessment in psychotic disorders. ''American Journal of Psychiatry'', 152 (2), 220–3. PMID 7840355 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.Read J (2004) Does 'schizophrenia' exist? Reliability and validity. In Read J, Mosher LR, Bentall RP (eds) ''Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia''. ISBN 1-58391-906-6 In 2004 in Japan, Japanese term of schizophrenia was changed from ''Seishin-Bunretsu-Byo'' (mind-split-disease) to ''Tōgō-shitchō-shō'' ( 2006 ). Retrieved on 2007-05-16 . Alternatively, other proponents have put forward using the presence of specific Neurocognitive Deficit s 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.Green MF (2001) ''Schizophrenia Revealed: From Neurons to Social Interactions''. New York: W.W. Norton. ISBN 0393703347 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.Wilkinson G (1986) Political dissent and "sluggish" schizophrenia in the Soviet Union. ''Br Med J (Clin Res Ed)'', 293(6548), 641-2. PMID 3092963 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 .Lyons D (2001). Soviet-style psychiatry is alive and well in the People's Republic. ''British Journal of Psychiatry'', 178, 380–381. PMID 11282823 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. Much rarer are instances of childhood-onsetKumra S, Shaw M, Merka P, Nakayama E, Augustin R. (2001) Childhood-onset schizophrenia: research update. ''Canadian Journal of Psychiatry'', 46 (10), 923–30. and late- (middle age) or very-late-onset (old age) schizophrenia.Hassett A, Ames D, Chiu E (eds) (2005) Psychosis in the Elderly. London:Taylor and Francis. ISBN 18418439446 The environment and schizophrenia diagnosis, even after factors such as Drug Use , Ethnic Group and size of Social Group have been controlled for.Van Os J. (2004). Does the urban environment cause psychosis? ''British Journal of Psychiatry'', 184 (4), 287–288. PMID 15056569 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 .Ustun TB, Rehm J, Chatterji S, Saxena S, Trotter R, Room R, Bickenbach J, and the WHO/NIH Joint Project CAR Study Group (1999). Multiple-informant ranking of the disabling effects of different health conditions in 14 countries. '' The Lancet '', 354(9173), 111–115. PMID 10408486 CAUSES See Also: Causes of schizophrenia studyMeyer-Lindenberg A, Miletich RS, Kohn PD, ''et al'' (2002). Reduced prefrontal activity predicts exaggerated striatal dopaminergic function in schizophrenia. ''Nature Neuroscience'', 5, 267–71. PMID 11865311 suggests that the less the Frontal Lobe s 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 Deficit s in schizophrenia.]] While the reliability of the 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 and environmental factors can act in combination to result in schizophrenia.Harrison PJ, Owen MJ. (2003). Genes for schizophrenia? Recent findings and their pathophysiological implications. '' Lancet '', 361(9355), 417–9. PMID 12573388 Evidence suggests that the diagnosis of schizophrenia has a significant heritable component but that onset is significantly influenced by environmental factors or stressors.Day R, Nielsen JA, Korten A, Ernberg G, ''et al'' (1987). Stressful life events preceding the acute onset of schizophrenia: a cross-national study from the World Health Organization. ''Culture, Medicine and Psychiatry'', 11 (2), 123–205. PMID 3595169 The idea of an inherent vulnerability (or ''diathesis'') in some people, which can be unmasked by biological, psychological or environmental stressors, is known as the stress-diathesis model.Corcoran C, Walker E, Huot R, Mittal V, Tessner K, Kestler L, Malaspina D. (2003) The stress cascade and schizophrenia: etiology and onset. ''Schizophr Bull'', 29 (4), 671-92. PMID 14989406 The idea that biological, psychological and social factors are all important is known as the "biopsychosocial" model. Genetic Estimates of the .Craddock N, O'Donovan MC, Owen MJ. (2006) Genes for schizophrenia and bipolar disorder? Implications for psychiatric nosology. ''Schizophrenia Bulletin'', 32 (1), 9–16. PMID 16319375 Prenatal 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 ).Davies G, Welham J, Chant D, Torrey EF, McGrath J. (2003). A Systematic Review and meta-analysis of Northern Hemisphere season of birth studies in schizophrenia. ''Schizophrenia Bulletin'', 29 (3), 587–93. PMID 14609251 There is now 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.Brown, A.S. (2006). Prenatal infection as a risk factor for schizophrenia. ''Schizophrenia Bulletin'', 32 (2), 200–2. PMID 16469941 Social Living in an Urban environment has been consistently found to be a risk factor for schizophrenia.van Os J, Krabbendam L, Myin-Germeys I, Delespaul P (2005) The schizophrenia envirome. ''Current Opinion in Psychiatry'', 18 (2), 141-5. PMID 16639166 Social disadvantage has been found to be a risk factor, including povertyMueser KT & McGurk SR. (2004) Schizophrenia. ''Lancet.'' Jun 19;363(9426):2063-72. PMID 15207959 and migration related to social adversity, racial discrimination, family dysfunction, unemployment or poor housing conditions.Selten JP, Cantor-Graae E, Kahn RS. (2007) Migration and schizophrenia. ''Current Opininion in Psychiatry'', 20 (2), 111-5. PMID 17278906 Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life.Schenkel LS, Spaulding WD, Dilillo D, Silverstein SM (2005). Histories of childhood maltreatment in schizophrenia: Relationships with premorbid functioning, symptomatology, and cognitive deficits. ''Schizophrenia Research'', 76(2–3), 273–286. PMID 15949659Janssen I, Krabbendam L, Bak M, Hanssen M, ''et al'' (2004). Childhood abuse as a risk factor for psychotic experiences. ''Acta Psychiatrica Scandinavica'', 109, 38–45. PMID 14674957 Parenting is not held responsible for schizophrenia but unsupportive dysfunctional relationships may contribute to an increased risk. Subotnik, KL, Goldstein, MJ, Nuechterlein, KH, Woo, SM and Mintz, J. (2002) Are Communication Deviance and Expressed Emotion Related to Family History of Psychiatric Disorders in Schizophrenia? ''Schizophr Bull.'' 28(4):719-29 PMID 12795501 Substance 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, use can contribute to psychosis, though the researchers suspected cannabis use was only a small component in a broad range of factors that can cause psychosis.Arseneault L, Cannon M, Witton J, Murray RM (2004). Causal association between cannabis and psychosis: examination of the evidence. ''British Journal of Psychiatry'', 184, 110-7. PMID 14754822 Full text Psychological A number of psychological mechanisms have been implicated in the development and maintenance of schizophrenia. .Bell V, Halligan PW, Ellis HD. (2006) Explaining delusions: a cognitive perspective. ''Trends Cogn Sci.'' May;10(5):219-26. PMID 16600666 Further evidence for the role of psychological mechanisms comes from the effects of therapies on symptoms of schizophrenia.Kuipers E, Garety P, Fowler D, Freeman D, Dunn G, Bebbington P. (2006) Cognitive, emotional, and social processes in psychosis: refining cognitive behavioral therapy for persistent positive symptoms. ''Schizophr Bull.'' Oct;32 Suppl 1:S24-31. PMID 16885206 Neural and other Brain Imaging technologies allow for the study of differences in brain activity among people diagnosed with schizophrenia.]] Studies using s often associated with schizophrenia.Green MF. (2006) Cognitive impairment and functional outcome in schizophrenia and bipolar disorder. ''Journal of Clinical Psychiatry'', 67, Suppl 9, 3–8. PMID 16965182 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 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.Jones HM, Pilowsky LS (2002) Dopamine and antipsychotic drug action revisited. ''British Journal of Psychiatry'', 181, 271–275. PMID 12356650 Interest has also focused on the neurotransmitter and Ketamine can mimic the symptoms and cognitive problems associated with the condition.Lahti AC, Weiler MA, Tamara Michaelidis BA, Parwani A, Tamminga CA. (2001). Effects of ketamine in normal and schizophrenic volunteers. ''Neuropsychopharmacology'', 25(4), 455–67. PMID 11557159 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.Coyle JT, Tsai G, Goff D. (2003). Converging evidence of NMDA receptor hypofunction in the pathophysiology of schizophrenia. ''Annals of the New York Academy of Sciences'', 1003, 318–27. PMID 14684455 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.Tuominen HJ, Tiihonen J, Wahlbeck K. (2005). Glutamatergic drugs for schizophrenia: a systematic review and meta-analysis. ''Schizophr Res'', 72:225–34. PMID 15560967 There have also been findings of differences in the size and structure of certain brain areas in Schizohrenia, starting with the discovery of Ventricular enlargement in those for whom negative symptoms were most prominent.Johnstone EC, Crow TJ, Frith CD, Husband J, Kreel L. (1976). Cerebral ventricular size and cognitive impairment in chronic schizophrenia. ''Lancet'', 30;2 (7992), 924–6. PMID 62160 However, this has not proven particularly reliable on the level of the individual person, with considerable variation between patients. More recent studies have shown various differences in brain structure between people with and without diagnoses of schizophrenia.Flashman LA, Green MF (2004). Review of cognition and brain structure in schizophrenia: profiles, longitudinal course, and effects of treatment. ''Psychiatric Clinics of North America'', 27 (1), 1–18, vii. PMID 15062627 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. TREATMENT AND SERVICES See Also: Treatment of schizophrenia , which revolutionized treatment of schizophrenia in the 1950s.]] 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.van Os J, Burns T, Cavallaro R, ''et al'' (2006). Standardized remission criteria in schizophrenia. ''Acta Psychiatrica Scandinavica'', 113(2), 91–5. PMID 16423159 The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the most common being the Positive And Negative Syndrome Scale (PANSS).Kay SR, Fiszbein A, Opler LA (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. ''Schizophrenia Bulletin'', 13(2), 261–76. PMID 3616518 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 .1 A Recovery Model is increasingly adopted, emphasizing hope, empowerment and social inclusion.Bellack AS. (2006) Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. ''Schizophr Bull.'' Jul;32(3):432-42. PMID 16461575 Hospitalization may occur with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or team, supported employmentMcGurk, SR, Mueser KT, Feldman K, Wolfe R, Pascaris A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. ''Am J Psychiatry.'' Mar;164(3):437–41. PMID 17329468 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.Kulhara P (1994). Outcome of schizophrenia: some transcultural observations with particular reference to developing countries. ''European Archives of Psychiatry and Clinical Neuroscience'', 244(5), 227–35. PMID 7893767 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 . These can reduce the "positive" symptoms of psychosis. Most antipsychotics take around 7–14 days to have their main effect. (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 Antipsychotic s; 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.Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK, Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. '' The New England Journal Of Medicine '', 353 (12), 1209–23. PMID 16172203 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.Ananth J, Parameswaran S, Gunatilake S, Burgoyne K, Sidhom T. (2004) Neuroleptic malignant syndrome and atypical antipsychotic drugs. ''Journal of Clinical Psychiatry'', 65 (4), 464-70. PMID 15119907 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.Leucht S, Wahlbeck K, Hamann J, Kissling W (2003). New generation antipsychotics versus low-potency conventional antipsychotics: a Systematic Review and meta-analysis. '' The Lancet '', 361(9369), 1581–9. PMID 12747876 Response of symptoms to mediation is variable; "Treatment-resistant schizophrenia" is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics.2 Patients in this category may be prescribed Clozapine ,3 a medication of superior effectiveness but several potentially lethal side effects including Agranulocytosis and Myocarditis .4 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. 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. Nevertheless, some findings indicate that in the longer-term many individuals do better without taking antipsychotics.Harrow M, Jobe TH. (2007) Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. ''J Nerv Ment Dis.'' May;195(5):406-14. PMID 17502806 Psychological and social interventions 2005 , Volume 40, Number 22, page 24. Retrieved on 2007-05-17 . s 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 .Wykes T, Brammer M, Mellers J, ''et al'' (2002). Effects on the brain of a psychological treatment: cognitive remediation therapy: functional magnetic resonance imaging in schizophrenia. ''British Journal of Psychiatry'', 181, 144–52. PMID 12151286 A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy.Hogarty GE, Flesher S, Ulrich R, Carter M, ''et al'' (2004). Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior. ''Arch Gen Psychiatry.'' Sep;61(9):866–76.PMID 15351765 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.McFarlane WR, Dixon L, Lukens E, Lucksted A (2003). Family psychoeducation and schizophrenia: a review of the literature. ''J Marital Fam Ther.'' Apr;29(2):223–45. PMID 12728780 Glynn SM, Cohen AN, Niv N (2007). New challenges in family interventions for schizophrenia. '' Expert Rev Neurother.'' Jan;7(1):33–43. PMID 17187495Pharoah F, Mari J, Rathbone J, Wong W. (2006) Family intervention for schizophrenia Cochrane Database of Systematic Reviews, Issue 4 Aside from therapy, the impact of schizophrenia on families and the burden on carers has been recognized, with the increasing availability of self-help books on the subject.56 There is also some evidence for benefits from social skills training, although there have also been significant negative findings.Kopelowicz A, Liberman RP, Zarate R (2006). Recent advances in social skills training for schizophrenia. ''Schizophr Bull.'' 2006 Oct;32 Suppl 1:S12–23. PMID 16885207 American Psychiatric Association (2004) Practice Guideline for the Treatment of Patients With Schizophrenia. Second Edition. Some studies have explored the possible benefits of music therapy and other creative therapies.Talwar N, Crawford MJ, Maratos A, Nur U, McDermott O, Procter S (2006). Music therapy for in-patients with schizophrenia: Exploratory randomised controlled trial. ''The British Journal of Psychiatry.'' Nov;189:405–9. PMID 17077429 Full text available. Ruddy R, Milnes D. (2005) Art therapy for schizophrenia or schizophrenia-like illnesses. Cochrane Database of Systematic Reviews, Issue 4Ruddy RA, Dent-Brown K. (2007) Drama therapy for schizophrenia or schizophrenia-like illnesses. Cochrane Database of Systematic Reviews, Issue 1. 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,7 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.8 Psychosurgery has now become a rare procedure and is not a recommended treatment for schizophrenia.Mashour GA, Walker EE, Martuza RL. (2005) Psychosurgery: past, present, and future. ''Brain Research: Brain Research Reviews'', 48 (3), 409-19. PMID 15914249 An unconventional approach is the use of omega-3 fatty acids, with one study finding some benefits from their use as a dietary supplement.Peet M, Stokes C (2005). Omega-3 fatty acids in the treatment of psychiatric disorders. Drugs, 65(8), 1051–9. PMID 15907142 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 consumer-run groups are becoming more common, with services working toward remediating social withdrawal, building social skills and reducing rehospitalization.Goering P, Durbin J, Sheldon CT, Ochocka J, Nelson G, Krupa T. Who uses consumer-run self-help organizations? ''American Journal of Orthopsychiatry'', 76 (3), 367-73. PMID 16981815 PROGNOSIS Numerous international studies have demonstrated favorable long-term outcomes for around half of those diagnosed with schizophrenia, with substantial variation between individuals and regions.Harrison G, Hopper K, Craig T, Laska E, Siegel C, Wanderling J, Dube KC, Ganev K, Giel R, an der Heiden W, Holmberg SK, Janca A, Lee PW, León CA, Malhotra S, Marsella AJ, Nakane Y, Sartorius N, Shen Y, Skoda C, Thara R, Tsirkin SJ, Varma VK, Walsh D, Wiersma D. (2001) Recovery from psychotic illness: a 15- and 25-year international follow-up study. ''Br J Psychiatry.'' Jun;178:506-17. PMID 11388966 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.Harding CM, Brooks GW, Ashikaga T, Strauss JS, Breier A (1987). The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. ''American Journal of Psychiatry'', 144(6), 727–35. PMID 3591992 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.Robinson DG, Woerner MG, McMeniman M, Mendelowitz A, Bilder RM (2004). Symptomatic and functional recovery from a first episode of schizophrenia or Schizoaffective Disorder . ''American Journal of Psychiatry'', 161, 473–479. PMID 14992973 A 5-year community study found that 62% showed overall improvement on a composite measure of symptomatic, clinical and functional outcomes.Harvey, C.A., Jeffreys, S.E., McNaught, A.S., Blizard, R.A., King, M.B.(2007) The Camden Schizophrenia Surveys III: Five-Year Outcome of a Sample of Individuals From a Prevalence Survey and the Importance of Social Relationships. ''International Journal of Social Psychiatry,'' Vol. 53, No. 4, 340-356 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. 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 ),Hopper K, Wanderling J (2000). Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. ''Schizophrenia Bulletin'', 26 (4), 835–46. PMID 11087016 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.Davidson L, McGlashan TH. (1997) The varied outcomes of schizophrenia. ''Canadian Journal of Psychiatry'', 42 (1), 34–43. PMID 9040921Lieberman JA, Koreen AR, Chakos M, Sheitman B, Woerner M, Alvir JM, Bilder R. (1996) Factors influencing treatment response and outcome of first-episode schizophrenia: implications for understanding the pathophysiology of schizophrenia. ''Journal of Clinical Psychiatry'', 57 Suppl 9, 5–9. PMID 8823344 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.Bebbington PE, Kuipers E (1994). The predictive utility of expressed emotion in schizophrenia: an aggregate analysis. ''Psychological Medicine'', 24, 707–718. PMID 7991753 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 .Hannerz H, Borga P, Borritz M (2001). Life expectancies for individuals with psychiatric diagnoses. ''Public Health'', 115 (5), 328–37. PMID 11593442 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.Radomsky ED, Haas GL, Mann JJ, Sweeney JA (1999). Suicidal behavior in patients with schizophrenia and other psychotic disorders. ''American Journal of Psychiatry'', 156(10), 1590–5. PMID 10518171 Another study suggested that 10% of persons with schizophrenia die by suicide.Caldwell CB, Gottesman II. (1990). Schizophrenics kill themselves too: a review of risk factors for suicide. ''Schizophrenia Bulletin'', 16(4), 571–89. PMID 2077636 Other identified factors include smoking, poor diet, little exercise and the negative health effects of psychiatric drugs. 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.Cannon TD, Cornblatt B, McGorry P. (2007) Editor's Introduction: The Empirical Status of the Ultra High-Risk (Prodromal) Research Paradigm. ''Schizophrenia Bulletin'', 33 (3), 661–4. PMID 17470445 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.Drake RJ, Lewis SW. (2005) Early detection of schizophrenia. ''Current Opinion in Psychiatry'', 18 (2), 147–50. PMID 16639167 The use of psychological treatments and medication has been found effective in reducing the chances of people who fulfil the 'high-risk' criteria from developing full-blown schizophrenia.Van Os J, Delespaul P. (2005) Toward a world consensus on prevention of schizophrenia. ''Dialogues in Clinical Neuroscience'', 7 (1), 53–67. 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.Haroun N, Dunn L, Haroun A, Cadenhead KS. (2006) Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research. ''Schizophrenia Bulletin'', 32 (1), 166–78. PMID 16207892. Full text 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.Hafner H, Maurer K, Ruhrmann S, ''et al''. (2004) "Early detection and secondary prevention of psychosis: facts and visions". ''European Archives of Psychiatry and Clinical Neuroscience'', 254 (2), 117–28. PMID 15146341 POPULAR VIEWS AND MISCONCEPTIONS Views held by the public about mental disorders, including schizophrenia, may not coincide with available evidence or with the views held by some mental health professionals. Treatment Some psychiatrists believe patients can be discouraged by friends or family members from taking prescribed medication because of the latters' non-biological views of mental disorders.American Psychiatric Association. Americans Still Cling to Myths About Mental Illness, Survey Finds. ''Psychiatric News.'' December 7, 2001 Volume 36 Number 23 Full text There is scientific difference of opinion about the use of medication in schizophrenia.Gould, JE. (2006) Ethical Considerations in Medication-Free Research with Schizophrenia Patients: An Expert Interview with William T. Carpenter, Jr., M.D. ''Medscape Psychiatry & Mental Health'' 2006:11(2) Full text available Consumers' views on treatment and recovery may differ from those of mental health professionals. Violence The relationship between violent acts and schizophrenia is a contentious topic. One survey found that 61% of Americans judged individuals with schizophrenia as likely to commit an act of interpersonal violence, while only 17% thought such an act likely to be committed by a person described as "troubled".Pescosolido BA, Monahan J, Link BG, Stueve A, Kikuzawa S (1999). The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. '' American Journal Of Public Health .'' Sep;89(9):1339–45. PMID 10474550 Research on violence indicates that the percentage of people with schizophrenia who commit violent acts is several times 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.Walsh E, Buchanan A, Fahy T (2002). Violence and schizophrenia: examining the evidence. ''British Journal of Psychiatry.'' 2002 Jun;180:490–5. PMID 12042226Stuart, H (2003). Violence and mental illness: an overview. ''World Psychiatry.'' June; 2(2): 121–124. PMID 16946914 Full text, Retrieved on .Simpson AI, McKenna B, Moskowitz A, Skipworth J, Barry-Walsh J (2004). Homicide and mental illness in New Zealand, 1970–2000. ''British Journal of Psychiatry'', 185, 394–8. PMID 15516547Fazel S, Grann M (2004). Psychiatric morbidity among homicide offenders: a Swedish population study. ''American Journal of Psychiatry'', 161(11), 2129–31. PMID 15514419 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. 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.Brekke JS, Prindle C, Bae SW, Long JD (2001). Risks for individuals with schizophrenia who are living in the community. ''Psychiatric Services.'' Oct;52(10):1358–66. PMID 11585953Fitzgerald PB, de Castella AR, Filia KM, Filia SL, Benitez J, Kulkarni J (2005). Victimization of patients with schizophrenia and related disorders. ''Australia and New Zealand Journal of Psychiatry'', 39(3), 169-74. (1), 187–9. PMID 15701066 Another consistent finding is a link to substance misuse, particularly alcohol,Walsh E, Gilvarry C, Samele C, ''et al'' (2004). Predicting violence in schizophrenia: a prospective study. ''Schizophrenia Research'', 67(2–3), 247-52. PMID 14984884 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, Solomon PL, Cavanaugh MM, Gelles RJ (2005). Family Violence among Adults with Severe Mental Illness. ''Trauma, Violence, & Abuse'', Vol. 6, No. 1, 40–54. PMID 15574672 Full text available. and is also an issue in clinical servicesChou KR, Lu RB, Chang M (2001). Assaultive behavior by psychiatric in-patients and its related factors. ''Journal of Nursing Research.'' Dec;9(5):139–51. PMID 11779087 and in the wider community.Logdberg B, Nilsson LL, Levander MT, Levander S (2004). Schizophrenia, neighbourhood, and crime. ''Acta Psychiatrica Scandinavica,'' 110(2) Page 92. PMID 15233709 Full text available, Retrieved on 2007-05-16 ALTERNATIVE APPROACHES An approach broadly known as the . 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 9 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.R.D. Laing's and Aaron Esterson. ''Sanity, Madness and the Family'' (1964) 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 ) ISBN 0-87975-645-4 Psychiatrist Tim Crow has argued that schizophrenia may be the evolutionary price we pay for a left brain hemisphere specialization for Language .Crow TJ (1997). Schizophrenia as failure of hemispheric dominance for language. ''Trends in Neurosciences'', 20(8), 339–343. PMID 9246721 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. The Soteria model is an alternative treatment to institutionalization and early use of antipsychotics.10 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."Mosher LR (1999). "Soteria and Other Alternatives to Acute Psychiatric Hospitalization: A Personal and Professional Review." Journal of Nervous and Mental Disease, 187, 142–149.
HISTORY Descriptions of schizophrenia-like symptoms date to 2000 BC in the ''Book of Hearts''—part of the ancient . ''Acta Psychiatrica Scandanavica'', 107(5), 323–330. PMID 12752027 (1856–1926) refined the concept of Psychosis .]] Although a broad concept of , distinguished from other forms of dementia, such as Alzheimer's Disease , which typically occur later in life."''Conditions in Occupational Therapy: effect on occupational performance.''" ed. Ruth A. Hansen and Ben Atchison (Baltimore: Lippincott, Williams & Williams, 2000), 54–74. ISBN 0-683-30417-8 The word ''schizophrenia''—which translates roughly as "splitting of the mind" and comes from the as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead. The term ''schizophrenia'' is commonly misunderstood to mean that affected persons have a "split personality". 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 arises in part due to the meaning of Bleuler's term "schizophrenia" (literally 'split' or 'shattered mind'). The first known misuse of the term to mean "split personality" was in an article by the poet T. S. Eliot in 1933.Turner T. (1999) 'Schizophrenia'. In G.E. Berrios and R. Porter (eds) ''A History of Clinical Psychiatry''. London: Athlone Press. ISBN 0-485-24211-7 In the first half of the twentieth century schizophrenia was considered to be a hereditary defect, and sufferers were subject to " program.Lifton RJ. (2000) ''The Nazi Doctors: Medical Killing and the Psychology of Genocide''. Basic Books. ISBN 0465049052 The diagnostic description of schizophrenia has changed over time. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe.Wing JK (1971) International comparisons in the study of the functional psychoses. ''British Medical Bulletin'', 27 (1), 77–81. PMID 4926366 This was partly due to looser diagnostic criteria in the US, which used the DSM-II manual, contrasting with Europe and its ICD-9 . This was one of the factors in leading to the revision not only of the diagnosis of schizophrenia, but the revision of the whole DSM manual, resulting in the publication of the DSM-III .Wilson M. (1993) DSM-III and the transformation of American psychiatry: a history. ''American Journal of Psychiatry'', 150 (3), 399–410. PMID 8434655 Cultural references The book and film '' A Beautiful Mind '' chronicled the life of John Forbes Nash , a Nobel-Prize -winning mathematician who was diagnosed with schizophrenia. The Marathi film ''Devrai'' (Featuring Atul Kulkarni ) is a presentation of a patient with schizophrenia. The film, set in the Konkan region of Maharashtra in Western India , shows the behavior, 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. Other factual books have been written by relatives on family members; Australian journalist Anne Deveson told the story of her son's battle with schizophrenia in ''Tell me I'm Here'',12 later made into a movie. 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. NOTES FURTHER READING
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