What is schizophrenia?
Schizophrenia is a severe and chronic mental disorder, characterised by a loss of contact with reality, affecting a person's thinking, perception, emotions and behaviour. It is defined as a psycho-organic disorder that affects the capacity to discern between the real and the imaginary, often involving hallucinations, delusional ideas and behavioural disturbances. In contrast with acute psychotic disorders, schizophrenia is a long-lasting condition that requires continuous treatment and careful monitoring.
The term “schizophrenia” comes from ancient Greek, where “schizo” means “to split” and “phren” refers to “mind”, suggesting the fragmentation of mental processes.
The history of the diagnosis of schizophrenia has evolved significantly over the centuries. The first descriptions of schizophrenia-like states date back to the writings of Emil Kraepelin, a pioneer of modern psychiatry, who described “dementia praecox” as a disorder distinct from the other psychotic disorders. Later, the Swiss psychiatrist Eugen Bleuler introduced the term “schizophrenia” in 1908, emphasising that not all patients present severe mental deterioration, but rather a “splitting” of the personality and a dissociation of mental functions. The diagnosis has been refined as research has advanced, and it now includes well-established criteria for its identification and for differentiating it from other mental disorders.
According to the DSM-5, the Diagnostic and Statistical Manual of Mental Disorders, schizophrenia is diagnosed on the basis of a set of rigorous criteria. Among these, the patient must present at least two symptoms out of five possible ones: hallucinations, delusional ideas, disorganised speech, catatonic or disorganised behaviour and negative symptoms (such as the absence of emotions). In addition, the symptoms must be present for a minimum period of six months and must significantly interfere with the person's social, professional or personal functioning. These criteria allow a clear identification of schizophrenia, establishing the diagnosis on the basis of persistent and specific signs and symptoms.
Although both schizophrenia and psychoses can involve a loss of contact with reality, there are essential differences between them. Schizophrenia is a chronic and far more complex psychotic disorder, characterised by negative symptoms and long-term cognitive disorganisation. Psychoses, on the other hand, are symptoms that can also appear in other mental disorders (such as psychotic depression) or can be caused by external factors, such as substance use or trauma. In this sense, schizophrenia is considered a “primary” form of psychosis, distinct through the persistence and diversity of its symptoms, as well as through its profound impact on the person's life.
Causes and risk or aggravating factors for schizophrenia
Genetic predisposition is one of the strongest risk factors for schizophrenia. Studies have shown that the risk of developing this disorder increases significantly if a family member suffers from schizophrenia, the risk being higher in the case of first-degree relatives. Genetic research suggests that several genes contribute to the vulnerability to schizophrenia, but there is no single gene responsible, rather a complex interaction between genes.
Neurobiological abnormalities are often observed in the brains of people with schizophrenia, and they may play a significant role in the onset of the illness. Brain imaging has shown that patients with schizophrenia frequently have altered brain structures and functions, especially in regions such as the prefrontal cortex and the temporal lobe. These changes can influence cognitive functions and behaviour, supporting the hypothesis according to which schizophrenia is a neurobiological disorder.
Environmental factors have also been correlated with the risk of developing schizophrenia. Traumatic experiences in childhood, parental neglect or abuse and exposure to intense stress over long periods can contribute to the onset of the disorder. Likewise, prenatal exposure to viral infections, maternal malnutrition and complications during birth are associated with an increased risk of schizophrenia.
Substance use is considered a major aggravating factor, especially among those who are genetically predisposed. Substances such as cannabis, amphetamines and cocaine can trigger psychotic symptoms and aggravate existing schizophrenic manifestations. Some research suggests that cannabis use in adolescence can significantly increase the risk of schizophrenia in those who are genetically predisposed, by affecting the normal development of the brain.
Socio-economic factors and social isolation can play a significant role in the course of schizophrenia. People who live in disadvantaged communities, who face discrimination or who suffer from social isolation are more vulnerable to severe stress and to psychotic symptoms. Likewise, the lack of stable social support and the absence of access to medical services can lead to the aggravation and chronicity of schizophrenic symptoms.
Types of schizophrenia
Schizophrenia was previously classified into several types, such as paranoid, catatonic, disorganised, undifferentiated and residual. Although these categories are no longer officially used in the DSM-5, they remain useful for understanding the variety of symptoms and manifestations of schizophrenia. Here is a description of each type, based on the predominant symptoms:
- Paranoid schizophrenia
It is characterised by the predominant presence of delusional ideas and auditory hallucinations. People with this type of schizophrenia may have persistent false beliefs, such as ideas of persecution or of grandeur, believing, for example, that they are the target of conspiracies or that they have a special importance. The hallucinations are often auditory in nature (voices commenting on the person's actions), and cognitive and emotional functioning remains relatively intact. People with paranoid schizophrenia are often tense, suspicious and withdrawn, but they may have a greater degree of control over their behaviour and thinking compared with other types of schizophrenia.
- Catatonic schizophrenia
This type of schizophrenia is characterised by severe movement disturbances, which can range from a state of complete immobility (catatonia) to excessive, agitated and purposeless activity. People with catatonic schizophrenia may adopt rigid postures for long periods of time or may imitate the movements and words of others, a feature called echolalia and echopraxia. These symptoms are often associated with a significant impairment of the capacity to interact with the environment. Catatonic schizophrenia is relatively rare, and treatment may include specific medical interventions for managing the motor symptoms.
- Disorganised (or hebephrenic) schizophrenia
It is characterised by disorganised thinking, incoherent speech and chaotic behaviour. People with disorganised schizophrenia have difficulties in expressing coherent ideas and may present inappropriate emotions or emotional flatness. For example, they may burst out laughing in serious situations or may seem completely detached emotionally. Social and personal functioning is severely affected, and the capacity to carry out simple daily activities is compromised. This type is considered one of the most severe and involves an increased need for support and care.
- Undifferentiated schizophrenia
This type of schizophrenia includes symptoms that do not clearly fit into a particular category, but rather represent a mixture of features from other types of schizophrenia. People with undifferentiated schizophrenia may present hallucinations, delusional ideas, disorganised behaviour and catatonic symptoms without a clear predominance of any one of these aspects. This diagnosis was used in the past for people with complex and varied symptoms that did not fit specifically into other types.
- Residual schizophrenia
Residual schizophrenia is characterised by the absence of acute psychotic symptoms, while the person still presents negative or cognitive symptoms. People with residual schizophrenia may have a significant reduction of motivation, of emotional expression and of the capacity to interact socially, even if the hallucinations and delusional ideas have disappeared or are reduced. This type often appears after the acute phases of schizophrenia and reflects a state of “partial remission”, in which the person continues to have difficulties in functioning and needs constant psychosocial support.
The symptoms of schizophrenia
1. Hallucinations are false sensory perceptions that appear in the absence of a real stimulus, most frequently auditory hallucinations. People with schizophrenia often hear voices that command them, criticise them or comment on their actions, causing discomfort and confusion. Although rarer, visual, olfactory or tactile hallucinations can appear, contributing to a constant state of anxiety and stress.
2. Delusional ideas are false, firmly held beliefs that are not influenced by reality or reason. Among these are often ideas of persecution (the conviction that someone wants to do harm), ideas of grandeur (the person believes that they have special powers or that they are important) and ideas of control (the belief that their thoughts or actions are being manipulated). Delusional ideas lead to social isolation and to a distorted perception of reality.
3. Disorganised thinking and speech manifests through difficulties in expressing ideas and in following a logical line of thought. Speech can become incoherent, and sentences can be meaningless or confusing for the listener. These people move from one subject to another without a clear connection between them, making communication and relating difficult.
4. Disorganised or catatonic behaviour can include a wide range of abnormal behaviours, from a lack of reaction and repetitive movements, to excessive agitation or a total lack of movement (catatonia). People with disorganised behaviour may display bizarre gestures and socially inappropriate behaviour and may adopt rigid body postures for long periods of time, reflecting the serious impairment of the capacity to control and express behaviour.
5. Negative symptoms include the absence of emotions (flat affect), the loss of motivation (avolition), difficulties in speech (alogia) and social withdrawal. These symptoms lead to a reduction of interest in activities, relationships and life in general, contributing to a low quality of life. Negative symptoms are often harder to observe, but they have a major impact on the person's functioning and recovery.
Signs and symptoms of schizophrenia in childhood
Identifying schizophrenia in childhood is complex, because the symptoms are often more subtle and harder to interpret. Nevertheless, there are early signs that may suggest a predisposition to schizophrenia or a risk of developing this disorder in adult life.
1. Problems of social and behavioural development: Children predisposed to schizophrenia may have difficulties in relating to others and may present withdrawn behaviour. They often avoid eye contact, do not respond to emotional stimuli and may seem uninterested in social activities or in relating to their peers. Likewise, learning difficulties and attention problems can appear as early as childhood.
2. Hallucinations and bizarre ideas: Children at risk of schizophrenia may report unusual perceptions, such as auditory hallucinations (imaginary voices), even if these are not always obvious. They may also express strange beliefs or intense fantasies about themselves, the world or imaginary roles, which intensify as time passes.
3. Delays in motor and cognitive development: Some children present delays in the development of fine motor skills or in language acquisition, compared with other children of the same age. They may have difficulties with coordination and may display repetitive, stereotyped behaviours, which become more evident in situations of stress.
4. Early negative symptoms: Some children may show a lack of emotional expressiveness, apathy and a decrease of motivation even from an early age. The lack of facial expression and difficulties in experiencing pleasure (anhedonia) can be warning signs for a predisposition to schizophrenia.
It is important that early signs and symptoms are carefully monitored by parents and professionals, because early intervention can contribute to reducing the severity of the symptoms and to improving the child's quality of life.
Diagnosing schizophrenia
Schizophrenia is a complex disorder whose diagnosis involves a detailed assessment of the symptoms and of the patient's history. Schizophrenia is usually diagnosed from late adolescence until around the age of 30, because the symptoms become more evident as the brain and the central nervous system mature. Typically, the initial symptoms appear around the age of 18-25 in men and slightly later in women, between 25 and 35 years. This time window is significant because the brain continues to develop until late adolescence, and the characteristic manifestations of schizophrenia can be clearer and more persistent once brain maturation is complete.
Identifying the predisposition to schizophrenia
Although the formal diagnosis of schizophrenia cannot be made in children, there is research suggesting that certain behaviours and symptoms at younger ages may indicate a predisposition. This predisposition is often determined by genetic factors, developmental problems and neurological abnormalities that can appear in childhood. Psychological and psychiatric assessments can detect signs of risk, and neuroimaging techniques and cognitive tests can help identify patterns of brain functioning that indicate vulnerability to schizophrenia. Nevertheless, these early signs are not sufficient for an official diagnosis and are used only to monitor the risk.
The standard methods of diagnosis
In order to diagnose schizophrenia, professionals rely on the criteria established by the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders). These criteria require the presence of at least two main symptoms, such as hallucinations, delusional ideas, disorganised thinking, catatonic behaviour or negative symptoms. In addition, these symptoms must be present for at least six months and must significantly affect social and professional functioning. The diagnosis is usually made by a psychiatrist, who assesses the symptoms, the family history and the patient's general mental state.
The role of brain imaging techniques in diagnosis
In addition to the clinical assessment, brain imaging techniques, such as MRI (magnetic resonance imaging) and positron emission tomography (PET), offer a perspective on the structure and functioning of the brain in patients with schizophrenia. In these patients, imaging has shown structural abnormalities, including a reduction of volume in brain areas such as the prefrontal cortex and the temporal lobes, regions associated with critical thinking and memory. These structural and functional changes are correlated with the cognitive and behavioural symptoms of schizophrenia and can help confirm the diagnosis in complex cases.
Brain Mapping
An innovative method used in the diagnosis of schizophrenia is brain mapping, which offers a detailed map of brain activity and of the connectivity between the various areas of the brain. Brain mapping uses advanced techniques, such as quantitative electroencephalography (qEEG), in order to monitor the electrical activity of the brain and to detect possible abnormalities specific to schizophrenia. Studies show that patients with schizophrenia present abnormal electrical activity in the regions associated with information processing and perception, such as the auditory and visual cortex. This method can offer additional data for diagnosis, complementing the traditional clinical assessment.
Structural and functional differences in patients with schizophrenia
Imaging and brain mapping have demonstrated that, at a structural level, patients with schizophrenia have larger cerebral ventricles and a reduction of grey matter in certain regions. These changes indicate an impairment of neuronal connectivity and of cognitive functions. From a functional point of view, neuronal activity in areas such as the prefrontal cortex is often reduced, affecting the capacities for critical thinking and decision-making. These findings suggest that schizophrenia involves not only a chemical imbalance, but also a complex change of brain structures and functions.
Treatment options for schizophrenia
- Antipsychotic medication
The basic treatment for schizophrenia includes antipsychotic medication, which helps reduce the intensity and frequency of symptoms such as hallucinations, delusional ideas and disorganised thinking. The role of these medicines is to stabilise the chemical activity in the brain, facilitating an improvement of daily functioning. Although they can be effective, they may have side effects, which is why it is important that their administration is monitored by a specialist. The medicines are usually used over the long term, and the dose is adjusted according to the individual needs of each patient.
- Individual and group psychotherapy
Psychotherapy, especially cognitive behavioural therapy (CBT), is an effective and complementary option for treating schizophrenia. It helps patients learn to recognise and manage the distorted thoughts and behaviours associated with the disorder. Group psychotherapy can also be beneficial, offering a supportive and educational setting where patients can discuss their specific experiences and difficulties. These forms of therapy contribute to reducing stress and negative symptoms and to improving quality of life.
- Neurofeedback therapy
Neurofeedback is a non-invasive and innovative method that helps patients regulate their brain activity by monitoring and modifying brain waves in real time. Through controlled sessions, patients receive immediate feedback on the activity of their brain, so that the brain learns to improve its self-control and to reduce the symptoms of schizophrenia, especially those associated with anxiety and cognitive dysfunctions. Neurofeedback is a promising method because it does not involve medication and can be combined with other forms of treatment.
- Psychosocial rehabilitation
Psychosocial rehabilitation is essential for the integration of patients into society and for improving their life skills. This type of therapy includes counselling, social skills training and vocational training, allowing patients to develop their communication capacities and to acquire the skills needed for an independent life. The benefits of psychosocial rehabilitation are particularly important for patients with chronic schizophrenia, because they contribute to preventing social isolation and to increasing self-esteem.
- Occupational therapy
Occupational therapy is a practical method through which patients with schizophrenia are supported in developing life skills and in taking part in everyday activities in a structured and safe way. It can involve training for carrying out daily activities, such as cooking, managing finances and personal care. Occupational therapy helps patients become more independent and develop healthy routines, contributing to better general functioning.
- Transcranial magnetic stimulation (TMS)
Transcranial magnetic stimulation is a non-invasive option that uses magnetic fields in order to stimulate certain brain regions associated with the negative and cognitive symptoms of schizophrenia. TMS is generally applied for reducing depressive and anxiety symptoms, but recent research shows that it can also contribute to improving cognitive functioning in schizophrenia. Being a non-invasive method, TMS does not require anaesthesia and does not involve the risks associated with more aggressive treatments.
- Family support and family counselling
The family plays an essential role in the treatment and recovery of patients with schizophrenia. Family counselling helps family members understand the illness better, develop effective methods of communication and offer emotional support to the patient. This type of support is crucial, because a solid support network reduces stress for the patient, contributes to improving their general state and can reduce the risk of relapse. Family support is considered an important complementary component in long-term treatment.
Complications associated with schizophrenia
Psychological complications: depression and anxiety
People with schizophrenia frequently face depression and anxiety, because of social isolation, difficulties of adaptation and awareness of the symptoms. These psychological problems can aggravate the symptoms of schizophrenia and increase the risk of relapse and of suicide. Effectively managing depression and anxiety is crucial for improving patients' quality of life and can involve both medication treatments and complementary therapies.
Cognitive disturbances
Cognitive disturbances, such as difficulties with concentration, impaired memory and disorganised thinking, are common in schizophrenia. They affect the patient's capacity to work, to manage daily life and to interact socially, thus limiting independence. Recovering and maintaining cognitive abilities represents a major challenge and requires effective therapeutic methods.
Social isolation and stigmatisation
Because of the symptoms, people with schizophrenia can be stigmatised and can feel socially isolated, which aggravates the negative symptoms and leads to an even deeper withdrawal from society. Isolation affects mental and physical health, amplifying vulnerability to depression and anxiety and making the recovery process more difficult.
Physiological complications: cardiovascular problems and diabetes
Patients with schizophrenia have an increased risk of developing cardiovascular conditions and diabetes, often because of a sedentary lifestyle, unhealthy eating and certain side effects of medication treatments. These physical health problems can reduce life expectancy and require medical interventions and lifestyle changes.
Immune system dysfunctions
Recent studies suggest that people with schizophrenia have a more vulnerable immune system and a higher risk of infections and inflammation. These vulnerabilities may be correlated with the neurological and chemical changes in the body, affecting general health and the body's capacity to cope with infections and illnesses.
Substance abuse
Substance abuse, such as alcohol and drugs, is a common problem among patients with schizophrenia, because they often try to self-manage their symptoms by these means. Substance abuse aggravates the symptoms, interferes with treatment and increases the risk of severe mental and physical complications.
The risk of suicide
Suicidal risk is significantly increased in people with schizophrenia, especially during moments of severe depression or during psychotic episodes. Understanding and monitoring this risk is essential for reducing suicide incidents, and family support and therapeutic interventions are extremely important for diminishing this risk.
Economic problems and problems of professional integration
People with schizophrenia often face economic problems and difficulties of professional integration because of persistent symptoms and stigmatisation. These economic difficulties lead to a low quality of life and can contribute to stress and to an accentuation of the symptoms. Vocational rehabilitation programmes are important in order to help patients maintain economic independence and take an active part in society.
Schizophrenia involves multiple complications, both physiological and psychological, and effectively managing the symptoms can make a significant difference in patients' lives. Neurofeedback therapy offers an innovative and non-invasive solution, supporting patients through brain wave training. Neurofeedback is a treatment that brings real benefits in this condition, helping also with the management of stress, anxiety and other symptoms and complications associated with schizophrenia, thus contributing to a more complete recovery. Take the first step towards your mental health by booking a BrainMap now.
References
- Khashayar Pazooki, Leibetseder, M., Renner, W., Gougleris, G. and Efsevia Kapsali (2018). Neurofeedback Treatment of Negative Symptoms in Schizophrenia: Two Case Reports. Applied Psychophysiology and Biofeedback, [online] 44(1), pp.31–39. doi:https://doi.org/10.1007/s10484-018-9417-1.
- S. McCarthy-Jones (2012). Taking Back the Brain: Could Neurofeedback Training Be Effective for Relieving Distressing Auditory Verbal Hallucinations in Patients With Schizophrenia? Schizophrenia Bulletin, [online] 38(4), pp.678–682. doi:https://doi.org/10.1093/schbul/sbs006.
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