Schizophrenia

handbook
H. Lundbeck A/S
9 Ottiliavej
DK - 2500 Valby
Copenhagen, Denmark
Tel: +45 36 30 13 11
Fax: +45 36 43 89 00
www.lundbeck.com
September 2006
This booklet is sponsored by H. Lundbeck A/S – an international pharmaceutical company engaged
in the research and development, production, marketing and sale of drugs for the treatment of
psychiatric and neurological disorders.
 Contents

Page

Foreword 1

What is schizophrenia? 3

What is the frequency of schizophrenia? 9

What causes schizophrenia? 11

How is schizophrenia diagnosed? 15

What are the signs and symptoms of schizophrenia? 19

How is schizophrenia treated? 23

What are the co-morbidities of schizophrenia? 29

What is the social and economic

impact of schizophrenia? 31

Further information sources 35

Abbreviations and glossary 37

Index 41

Foreword
Even now in the 21st Century,
mental illnesses, such as
schizophrenia, remain
misunderstood, poorly diagnosed,
and under-treated. Despite the
advances in medical therapies
available for this disorder over
recent decades, there are still many
unmet needs in schizophrenia
therapy and we still do not
understand the disorder fully.
The first major advance for patients, families,
carers and physicians alike, would be treatments
with increased effectiveness against all
subtypes of symptoms, accompanied by fewer
side effects. These medications would also have
a rapid action with positive effects on the
conditions that frequently occur alongside
schizophrenia, such as those involving cognition
and mood. In addition, there is still a significant
group of patients who do not respond to
existing therapies, and we should not give up on
research to find new treatments which may be
effective for these patients.
But medication is not the only improvement
needed in the therapy for this disorder. Earlier
diagnosis would also be helpful, as would better
follow-up and more accessible and consistent
community care.
Foreword
Improved communication between the patient,
family and physician and the active
engagement of families and carers in the
treatment and care model are other issues
which need to be tackled.
Research is ongoing in all these areas, looking at
new treatments and healthcare approaches,
whilst maintaining the ultimate aims of
discovering a cause for the disorder and a cure.
In the meantime, education to raise awareness
and decrease stigma are other valuable ways to
improve the lives of those with schizophrenia.
This booklet has been designed as a short
synopsis of schizophrenia to provide you with
more information on the disorder.
Inger Nilsson,
President of EUFAMI
European Federation
of Associations of
Families of People with
Mental Illness
1
2
 What is schizophrenia?
Schizophrenia is the most common form of
severe mental illness,1 affecting approximately
24 million people worldwide.2 It is believed to
be caused by an imbalance of chemicals in the
brain (neurotransmitters), and is characterised
by psychotic episodes (delusions, hallucinations,
disorganised behaviour) interspersed with
periods of blunted emotions, apathy, and
withdrawal. However, although the condition is
highly treatable, it is complex and poorly
understood, and the word ‘schizophrenia’ is
associated with notable stigma and is often
misused.
A person with schizophrenia experiences a
condition where their thoughts (cognition),
emotion, and behaviour become disturbed and
they may find it difficult to judge reality. These
underlying processes produce symptoms that
are highly variable, but typically include
hallucinations, delusions, apathy, blunted
emotions, odd behaviour, poor personal care,
and social withdrawal. Consequently,
schizophrenia affects most aspects of the
human condition, and the resulting symptoms
can appear strange and frightening for both the
patient and those around them.
Images courtesy of Max Planck Institute and
www.corbis.com.
What is schizophrenia?
Although mental disorders have been
studied and described since medical records
began, it was the German psychiatrist, Emil
Kraepelin (1856–1926), who first classified
mental illness as an actual ‘disease’ with a
specific onset, course and outcome. As part
of this classification, Kraepelin described
the condition ‘dementia praecox’, meaning
early mental decline.
Dementia praecox was later renamed
‘schizophrenia’ following extensive study of
the symptoms of the disorder by the Swiss
psychiatrist, Eugen Bleuler (1857–1939).
The name schizophrenia (from the Greek:
‘schizo’=split, ‘phrenos’=mind) was chosen
to reflect the poor connection between the
thought processes (cognition) of a person
with the disorder, and other functions of
the mind such as emotion, behaviour, and
volition (self-will). It is a common
misconception that patients with
schizophrenia exhibit a ‘split’ or ‘multiple’
personality.
Emil Kraepelin Eugen Bleuler
(1856–1926) (1857–1939) 3
 The course of schizophrenia
The pattern of symptoms and psychotic
episodes in schizophrenia varies from person to
person (Figure 1). In addition, schizophrenia can
also change over time, with different types of
symptoms becoming predominant.3 In general,
the course of the disorder is long-term
(chronic), consisting of recurrent short-term
(acute) episodes characterised by high levels of
psychotic symptoms with longer periods with
less pronounced psychotic symptoms, or
sometimes recovery, in between. Other
symptoms, such as ‘negative’ and ‘cognitive’
symptoms, are often present in both stages of
the disorder.

Figure 1: Patterns in the development and course of schizophrenia

%
Onset Course Outcome with this
pattern

A acute episodic mild or recovered 25

B acute continuous moderate or severe 8

C gradual episodic mild or recovered 10

D gradual continuous mild or recovered 10

E gradual continuous moderate or severe 24

F other patterns 23

4
Adapted from: Target schizophrenia. The Association of the British Pharmaceutical Industry, London, 2003.1
The onset of symptoms can be sudden, or may
be preceded by weeks, months or years of
gradually increasing symptoms, known as the
prodromal phase. Prodromal signs tend to be
non-specific and can include patterns of social
isolation, neglected personal hygiene, loss of
interest in work/study, and development of odd
behaviour and ideas.
The psychotic episode is characterised by more
so-called ‘positive symptoms’, where an
individual may experience delusions,
hallucinations, fear/anxiety, and may lose the
perception of reality.
With treatment or, in some cases, left
untreated, the active phase diminishes, leaving
the person functional again (in remission), or
with varying severities of negative and/or
cognitive symptoms. These symptoms include
blunted emotions, lack of drive/interest,
problems with planning or abstract thinking,
and a tendency towards isolation. This period of
successful treatment is known as the
maintenance phase.
After the first psychotic episode, the course of
the disorder is unpredictable. As many as 15%
of people who experience an acute episode of
schizophrenia will never have another episode
and recover completely.4 However, more
commonly, the person will relapse into further
active phases interspersed with residual phases.4
Complete remission (recovery) is less likely once
a long-term pattern of episodes becomes
established. In addition, 50% of patients with
schizophrenia attempt suicide at some point
during the course of the disorder, leading to
fatality in 10% of cases.1 The overall mortality
rate is considerably higher in people with
schizophrenia than in the general population
(due to coexisting medical problems, as well as
suicide).

First visit to a doctor

Mrs Johnson requested an appointment with her general practitioner to speak about her son,
James, who was aged 18. James was a physically fit young man, but in recent months his
behaviour had started to become unusual. He had lost interest in socialising or contacting his
friends, and was unresponsive to any attempt at conversation – occasionally muttering
inaudible or cryptic phrases. He would spend most of his time withdrawn in his room, talking
as if he was conversing with some other ‘unseen’ person. Upon meeting James, the doctor was
unable to extract any coherent responses to his questions, and referred him to a psychiatrist
for further diagnosis.

5
 Who is affected?
Schizophrenia is most common in young adults,
with the majority of individuals developing the
disorder between the ages of 15 and 25 years.5
Onset is rare beyond age 40, but it is possible
for schizophrenia to develop at any time of life.
Schizophrenia affects men and women in
approximately equal numbers. However, men
tend to develop the disorder 3–5 years earlier
than women (Figure 2). There is also evidence
to suggest that, in general, men experience
more severe symptoms than women, although
women appear to have a worsening of
symptoms during the menopause.
Schizophrenia affects all cultures.5
6
Well-known individuals with schizophrenia
have included Vaclav Nijinsky (ballet
dancer/choreographer), Syd Barrett
(musician, Pink Floyd), Peter Green
(musician, Fleetwood Mac), and Eduard
Einstein (son of physicist, Albert).
Schizophrenia has also been portrayed on
film, in the life stories of John Nash
(mathematician/Nobel prize winner – ‘A
beautiful mind’) and David Helpffgott
(pianist – ‘Shine’), and in the fictional
account of ‘One flew over the cuckoo’s
nest’.
Figure 2: Relative risk of the onset of schizophrenia versus age
Incidence of schizophrenia

Female

Male

Median Median
25 years 28 years

20 25 30 35 40 45
Age (years)

Adapted from: Target schizophrenia. The Association of the British Pharmaceutical Industry, London, 2003.1

7
 The consequences of
schizophrenia
As a diverse and serious condition, schizo-
phrenia produces complex consequences.
The obvious major consequence is to the
patients themselves, who typically experience
severe anxiety and fear during psychotic
episodes, prompted by hallucinations, delusions
and general loss of reality. While it is distressing
for the patient to cope with situations that
they genuinely perceive as ‘real’, it is also
extremely disturbing for family and friends to
deal with this often alarming change in
behaviour. For every person with schizophrenia,
around 10 others are affected by its
consequences.1 This can put a strain on
relationships, leading to inevitably difficult
decisions about care provision, and adding to
the general stress of the situation.
Aside from emotional concerns, schizophrenia
can also impact on an individual’s future in
terms of education, employment and resulting
financial security. The intermittent and
unpredictable nature of symptoms makes
steady work and independent living difficult for
most individuals. Therefore, information and
support are necessary for patients and their
families to provide adequate patient care and
avoid potential decline into problems such as
family breakdown, drug and alcohol abuse, and
homelessness. As a result, healthcare costs for
8
support to patients with schizophrenia are high
and wide ranging, with only 1% of the cost of
care due to drug treatment. Community follow-
up of hospital treatment is essential for many
reasons, not least because one of the highest
risk periods for patient suicide is in the first 6
weeks after discharge from hospital following
the initial psychotic episode.
All these difficulties, combined with the social
stigma of this often misunderstood condition
can compound the issues facing people with
schizophrenia and further impair their chances
of regaining their quality of life.
References
1. ABPI. Target schizophrenia. May, 2003.
2. World Health Organization (WHO).
Schizophrenia. www.who.int/mental_health/
management/schizophrenia, accessed
March 2006.
3. Marneros A, Deister A, Rohde A. Validity of the
negative/positive dichotomy for schizophrenic
disorders under long-term conditions.
Schizophr Res 1992; 7 (2): 117–123.
4. Watt DC, Katz K, Shepherd M. The natural
history of schizophrenia: a 5-year prospective
follow-up of a representative sample of
schizophrenics by means of a standardized
clinical and social assessment. Psychol Med
1983; 13 (3): 663–670.
5. NHS National electronic Library for Health.
www.nelmh.org/home_schizophrenic.asp?c=10,
accessed March 2006.
 What is the frequency of
schizophrenia?
Schizophrenia most frequently appears in young
adults (generally between 15 and 25). Although
men and women are affected equally,
symptoms may appear later in women than
men (see Figure 2, page 7).1 Schizophrenia is a
fairly common illness, although estimates of its
frequency are variable due to worldwide
differences in diagnosis, methods of estimation,
and healthcare provision.
Data from various studies give a prevalence rate
(total number of cases in the population) of
about 0.5%. That is, schizophrenia affects 1 in
every 200 people worldwide.2 However, the
prevalence varies with age, increasing until age
40, and then declining. The estimate of lifetime
risk is 1% (or 1 in 100 people). This measure is
thought to be a more representative value as it
takes into account that the most high-risk age
group is between 20 and 39 years.2
Studies of the number of new cases of
schizophrenia gave an incidence of 21.8 per
100,000 people.2 This gives an incidence rate of
0.02%. The incidence rate is lower than the
prevalence rate because schizophrenia is a
predominantly chronic disorder, and so its
presence in the population is cumulative.3
Where in the world?
The prevalence of schizophrenia does not follow
a geographical pattern, appearing to be
generally constant across all areas of the world.2
However, there are some variations within
individual countries, with a higher number of
cases generally found in larger cities.
Unfortunately, although the prevalence of
schizophrenia shows a relatively constant
Frequency
worldwide distribution, treatment levels do not.
The World Health Organization (WHO)
estimates that 90% of people with untreated
schizophrenia are in developing countries.3
References
1. ABPI. Target schizophrenia. May, 2003.
2. Tsuang MT, Faraone SV. Schizophrenia, the
facts. Second edition. Oxford University Press,
1997.
3. World Health Organization (WHO).
Schizophrenia. www.who.int/mental_health/
management/schizophrenia, accessed
March 2006.
9
10
 What causes schizophrenia?

The exact cause of schizophrenia is not yet Figure 3: Altered brain activity in patients
known, although studies point towards a with schizophrenia
combination of genetic and environmental
factors that influence the function of the brain.

The disorder process

The symptoms of schizophrenia are associated

with changes in brain activity, which can be
seen using medical imaging techniques that
measure electrical activity, as shown in Figure 3.
The specific processes of the disorder that
cause these changes remain unclear, but one Coloured positron emission tomography (PET) scans of
accepted theory is that people with axial sections through a healthy brain (left) and a
schizophrenia have an imbalance in the schizophrenic brain (right). The colours show different
chemicals that send signals in the brain levels of activity within the brain during an attention
test. Red shows high activity, through yellow and green
(neurotransmitters). For example, visual to black (very low activity). The schizophrenic brain
hallucinations may be due to over-stimulation shows much lower activity in the frontal lobes.
of certain brain areas by the neurotransmitter,
Image from the Science Photo Library.
dopamine,1 while the negative symptoms may
be correlated with lowered dopamine activity in
other brain regions.

Causes
In addition, brain scans of people with
schizophrenia have shown that fluid-filled areas
of the brain called the ventricles may be
enlarged in some types of schizophrenia, with
the amygdala and hippocampus reduced in size
(Figure 4).2 How these alterations are connected
to the symptoms of schizophrenia is unknown.

11
 Figure 4: Areas of the brain – in some types of schizophrenia, the ventricles may be enlarged,
whilst the amygdala and hippocampus may be reduced in size

a) Brain ventricles and the central canal

Lateral ventricles

Third ventricle

Fourth ventricle

Central canal

b) The limbic system

Anterior nucleus
of thalmus

Area of thalamus Corpus callosum

(dotted)
Mammillary body
of hypothalamus
Hippocampus

Amygdala

12
Is the condition inherited? Figure 5: Family patterns of schizophrenia
development
The parents or siblings of a person with
schizophrenia have a 10-fold higher risk of Affected relative
developing the disorder than a person in the
general population, and this rises to a 15-fold None
higher risk for the children of people with
schizophrenia (Figure 5).3 However, studies in
identical and non-identical twins have shown Cousin
that development of the condition is not
entirely explained by genetic inheritance. In
those cases where one identical twin developed Aunt or uncle
schizophrenia, the second identical twin (who
would have inherited exactly the same genes)
developed schizophrenia in only around 50% of
Grandparent
cases.3

The conclusion is that genes (probably a

Brother or sister
complex interaction of several) do play an
important part in whether or not an individual
will develop schizophrenia, but that other
Parent
factors must also play a significant role.

Non-identical
twin

Identical twin

0 10 20 30 40 50
Risk of developing
schizophrenia (%)

Adapted from: Target schizophrenia. The Association of

the British Pharmaceutical Industry, London, 2003.4 13
 Can the environment be a risk
factor?

In the ‘nature versus nurture’ argument, if genes

(‘nature’) do not cause schizophrenia every References
time (as shown by the twin studies), then the 1. Kandel ER, Schwartz JH, Jessell TM. Principles
of neural science. Fourth edition. McGraw Hill,
environment (‘nurture’), must also be involved
2000.
in some way – perhaps acting as a trigger for
the genetic factors. 2. Frith C, Johnstone E. Schizophrenia. A very short
introduction. Oxford University Press, 2003.
Male gender and winter birth are known to be 3. Tsuang MT, Faraone SV. Schizophrenia, the facts.
connected with earlier development of, and Second edition. Oxford University Press, 1997.
higher rates of schizophrenia, respectively. But 4. ABPI. Target schizophrenia. May, 2003.
the mechanism underlying these links is
5. NHS National electronic Library for Health.
unknown.2 Long-term use of drugs (in
www.nelmh.org/home_schizophrenic.asp?c=10,
particular, use of cannabis and stimulants) is accessed March 2006.
thought to carry increased risk, alcohol may
also alter the brain chemistry to produce
schizophrenia.5 Other proposed environmental
triggers include stress, viral infection, exposure
to toxins, physical injury (prenatal or in
childhood), or difficult family dynamics, but the
connection between these factors and
schizophrenia is less well established.

14
 How is schizophrenia diagnosed?
Schizophrenia is a complex disorder to diagnose
due to the variation in symptoms and the lack
of a defect measurable by a laboratory or
clinical method. Therefore, schizophrenia is
generally diagnosed by a psychiatrist, speaking
to the patient about their experiences of the
condition. The specialist will also aim to
establish how long the symptoms have been
present, how they are affecting everyday life,
and will try to speak to the patient’s family and
friends. It may not be possible to diagnose
schizophrenia at an early stage if the symptoms
are mild and non-specific, and some physicians
may be unwilling to offer a definite early
diagnosis due to the immediate social and
personal consequences of being labelled with
schizophrenia.
Diagnosis
There are two main sets of clinical guidelines
that provide standard rules for the diagnosis of
schizophrenia. These are:
• International Classification of Diseases, 10th
edition (ICD-10), which is issued by the
World Health Organization and is frequently
used in Europe1
• Diagnostic and Statistical Manual, 4th edition
(DSM-IV), which is issued by the American
Psychiatric Association and is more
frequently used as a guide in the US.2
These classification systems outline the
requirements for diagnosis. The first of these is
a combination of core symptoms, such as
hallucinations, delusions, and disruption in
thought processes, along with evidence of
functional decline (work, social, self-care). In
addition, these symptoms must have been
present for a particular duration, which ranges
from 1–6 months, depending on the scale used.
Finally, the patient must display no exclusion
criteria, that is, the physician must ensure that
the symptoms are not being caused by another
condition, e.g., drug-use, brain tumour, epilepsy,
or mood disorder. In this way, the physician can
make a differential diagnosis of schizophrenia.
Diagnosis
15
 Differentiating schizophrenia
from other disorders
Several other conditions may produce
symptoms that are very similar to those
observed in schizophrenia. For effective
management, it is extremely important that
schizophrenia is differentiated from these other
conditions, some of which are described in the
table opposite.
Schizoaffective disorder
Some patients show equal measures of
symptoms of both mood-based (affective)
disorders and schizophrenia. In such cases, a
schizoaffective disorder may be diagnosed,
although it has not yet been established
whether these are entirely separate conditions,
or different extremes of the same disorder.3

References
1. World Health Organization. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria
for research. Geneva, Switzerland. © World Health Organization, 1992.

2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fourth edition.
Washington, USA © American Psychiatric Association, 1994.

3. Tsuang MT, Faraone SV. Schizophrenia, the facts. Second edition. Oxford University Press, 1997.

16
Table 1: Disorders producing similar symptoms to schizophrenia

Condition type Examples Differentiating factors

Drug-induced Known use of drugs such as LSD, Symptoms subside upon withdrawal
cannabis, amphetamines, cocaine, of the drug/alcohol.
ecstasy.
Note that, long-term abuse of these
Alcohol abuse. substances can lead to permanent
brain changes that may induce
schizophrenia.

Physical Viral infection of the brain Brain scans or analysis of cerebro-

(encephalitis), epilepsy, brain injury, spinal fluid (CSF) show evidence of a
loss of brain cells in old age, brain distinct physical cause.
tumour.

Non-brain related impairments Similarly, physical analysis of the blood

in thyroid, liver or kidney function, and organ function (kidney, liver, etc.),
or diabetes. will highlight any other causes.

Mood-based Manic depression (bipolar disorder), Like schizophrenia, they have no known
(affective) social anxiety disorder, obsessive– defect that can be confirmed by
compulsive disorder, personality and physical examination. Instead, careful
delusional disorders. observation of symptoms is required.

In contrast to schizophrenia in which

mood is blunted or disjointed, mood
disorders show high levels of emotion.
For example, patients with bipolar
disorder cycle from ‘high’ cheerfulness
and excitability to ‘low’ depression.

17
 Lundbeck Belgium Art Collection

18

What are the signs and symptoms
of schizophrenia?
The symptoms of schizophrenia are usually
divided into ‘positive’ and ‘negative’ groups, as
described below.
Positive symptoms
The positive symptoms of schizophrenia mainly
occur in the active periods of psychosis. They
are called ‘positive’ because they are added
effects created by the process of the disorder,
and therefore tend to be the most outwardly
noticeable symptoms.
Hallucinations
The most common type of hallucination in
schizophrenia is auditory (heard). This often
involves the person hearing voices ‘in their
head’ having conversations, arguing or
commenting on/criticising their actions. These
voices may be regular characters to which the
person attributes identities. Other less common
types of hallucination (that are more often seen
in other types of mental disorder) involve
tasting, smelling, feeling or seeing things that
are not really there.
Recordings of brain activity have shown that,
during visual or auditory hallucinations, the
brain activity of the patient with schizophrenia
appears to be the same as that of a real
stimulus. In other words, in terms of their brain
activity, the patient is experiencing the
hallucination as if they were real
sensations/experiences (see Figure 6).
Signs & symptoms
Figure 6: Hallucinations in schizophrenia
MRI/PET image showing areas of visual and auditory
brain activity (orange) during hallucination.
Image from the Science Photo Library.
Delusions
Delusions are basically false or unrealistic
beliefs. Some delusions are called ‘secondary’,
which refers to them being interpretations of
illusions of hallucinations. For example, if a
patient has auditory hallucinations and is
hearing voices or ‘hearing’ thoughts then a
secondary interpretation may be that the voices
are coming from a transmitter in the fan, in the
television set, or even in the persons head.
Furthermore, the patient can make the
interpretation that an organisation, the CIA for
example, is sending the thoughts or voices. In
this way the delusion of being under
surveillance by the CIA is created. Delusions can
also be ‘primary’. These are often unrealistic
beliefs that seem to arise from nowhere. For 19
 example, ‘I am god’, or ‘My brain is made of
gold’. These kinds of primary delusions are seen
as ‘bizarre’, meaning that they are completely
unrealistic. Delusions occur at some stage in
more than 90% of patients with schizophrenia.1
Disorganised speech, behaviour and thought
Another class of positive symptoms involves
changes in the pattern of speech, behaviour,
and thought. There is a loosening of association
between thought and speech, making speech
muddled, with illogical jumps between ideas,
and producing a disjointed mix of words.
Behaviour is also disorganised, with increased
agitation and childlike silliness.
Positive symptoms
Sarah – a 30 year-old single woman with
schizophrenia, living with her parents – had
been repeatedly admitted to hospital
following experiences of delusions and
hallucinations. Most recently, she had been
found wandering the streets in a distressed
state as she believed that her every move
was being ‘watched’ through the walls in
her own house. However, she was also
hearing voices, and these continued outside
the house, criticising her behaviour and
encouraging her to harm herself. These
types of symptoms had been present
intermittently for many years, but were
now becoming increasingly frequent and
more severe.
20
Negative symptoms
This class of symptoms is known as ‘negative’,
because they represent the absence of a usual
trait. Negative symptoms occur with varying
duration and severity in the periods between
active psychotic phases.
Negative symptoms include:
• emotional blunting (affective flattening) –
impairment of all expression of emotion, e.g.,
facial expression, body language, vocal tone
• poverty of speech (alogia) – speech that is
brief, rarely initiated, or containing little
meaningful content
• avolition – general apathy and lack of drive
to perform any actions
• anhedonia – inability to experience pleasure
• social withdrawal – avoidance of the
company of others, extending to include
avoidance of romantic attachments or sexual
interest
• catatonic behaviour – unusual postures,
mannerisms and rigidity. Interestingly,
catatonia was once a characteristic feature of
schizophrenia worldwide, but is now
predominantly seen in patients from
developing countries.2 This class of symptom
also includes negativism, which is a refusal to
comply with reasonable requests.

Negative symptoms
Christopher was hospitalised one year ago,
aged 21, in a state of anxiety, and
agitation, with persecutory delusions, and
auditory hallucinations. He was discharged
after two months of successful treatment
with an antipsychotic drug. He has since
lived with his parents. He was recently
persuaded to visit the doctor by his sister,
who was concerned about the apparently
severe change in his personality. He has
given up his regular job for no logical
reason, and has become a virtual recluse,
spending most of the day in bed. His
appearance is unkempt, and he has
obviously not washed or shaved for some
time. He had previously been close to his
family, but in recent months he has mainly
stayed in his room and he has often
refused to even speak with his sister or
parents. As far as his family can say, he has
continued his antipsychotic treatment.
Types of schizophrenia
Due to the large variety of symptoms seen in
different patients with schizophrenia,
sometimes the disorder is divided into distinct
subtypes according to the symptoms that
predominate. The three most commonly
described subtypes are:
• paranoid schizophrenia – mainly involving
thoughts of persecution and being plotted
against. Occurs more frequently in men than
in women
• disorganised (hebephrenic) schizophrenia –
consisting of inappropriate/disturbed
emotions, and a profound deterioration of
personality. This type of schizophrenia has an
early onset
• catatonic schizophrenia – involving extreme
withdrawal, lack of speech, and abnormal
body positions that can remain fixed for long
periods of time.3 The state is sometimes
described as a ‘waking coma’.
21
 Cognitive impairment
Cognitive impairment can be considered to be a
separate condition from schizophrenia, or is
sometimes classed as a third category of
symptom, alongside the positive and negative
signs. Cognition refers to the thought processes
that allow functions such as learning, memory,
attention, speed of thought, problem solving,
planning, and situation assessment. Cognitive
impairment reduces the ability to use logical
thought, and markedly diminishes quality of
life. Cognitive problems are common in patients
with schizophrenia, with one study showing
that 85% of patients who were almost fully
recovered from schizophrenia, still experienced
cognitive difficulties.4
Patients with schizophrenia tend to perform
badly on a variety of different ‘intellectual’
tests. Whilst routine, well-learned tasks such as
reading and mental arithmetic are often
unimpaired, other cognitive tasks, especially
those which require a flexible approach to
problem solving, are often severely impaired.
There is general agreement that patients with
schizophrenia exhibit impairment in three main
cognitive areas – memory, attention, and
executive function.5
22
Assessing symptoms in
schizophrenia
In addition to the classification systems used in
diagnosis, clinical scales may be used by
physicians to follow the progress of a patient’s
symptoms over time. These include the Brief
Psychiatric Rating Scale (BPRS), the Positive and
Negative Syndrome Scale (PANSS), and the
Calgary Depression Scale (CDS).6,7,8
References
1. Hirsch SR, Weinberger DR. Schizophrenia.
Second edition. Blackwell Publishing, 2005.
2. Concise Medical Dictionary. Sixth edition.
Oxford University Press, 2003.
3. Kandel ER, Schwartz JH, Jessell TM. Principles of
neural science. Fourth edition. McGraw Hill,
2000.
4. ABPI. Target schizophrenia. May, 2003.
5. Frith C, Johnstone E. Schizophrenia. A very short
introduction. First edition. Oxford University
Press, 2003.
6. Overall JE, Gorham DR. The Brief Psychiatric
Rating Scale. Psychological Reports 1962; 10:
799–812.
7. Kay SR, Fiszbein A, Opler LA. The positive and
negative syndrome scale (PANSS) for
schizophrenia. Schizophr Bull 1987; 13 (2):
261–276.
8. Addington D, Addington J, Maticka-Tyndale E.
Specificity of the Calgary Depression Scale for
schizophrenics. Schizophr Res 1994; 11 (3):
239–244.
 How is schizophrenia treated?
Currently, there is no cure for schizophrenia, but
there are many treatments available to help
control symptoms of the disorder and to
prevent relapse into psychotic episodes. This
control is extremely valuable, and can help a
person with schizophrenia to restore elements
of normal life. Treatment usually consists of a
combination of medication and psychosocial
therapy, with a period in hospital often
necessary for care and monitoring during
psychotic episodes.
Treatment for schizophrenia is long-term over a
period of years, and appears to be most
effective when started early in the course of the
disorder.1 However, despite the treatable nature
of the disorder, approximately one third of
patients are not improved following standard
treatment.2
Drug therapy
Treatment
Drug treatment for schizophrenia pre-
dominantly involves the use of antipsychotic
medications, which help to restore the balance
of neurotransmitters in the brain.
Antipsychotic medication for schizophrenia was
first used in the 1950s, and was shown to be
effective in controlling the positive symptoms
of the disorder (hallucinations, delusions, etc.).
Research has since shown that these ‘typical’
antipsychotic drugs block the action of the
neurotransmitter, dopamine, in the brain (see
Figure 7).
Figure 7: Dopamine in neurotransmission
Dopamine
terminal
Dopamine
Dopamine (D2) receptor
Chlorpromazine
(typical antipsychotic) –
blocks dopamine binding
to dopamine (D2) receptor,
preventing signal transmission 23
 Newer antipsychotics block both dopamine and Table 2: Examples of antipsychotic drugs*
serotonin pathways, although the additional
effects on the serotonin pathway are, as yet, Typical (conventional) Atypical (new)
antipsychotics antipsychotics
not so well understood. The serotonin block is
believed to contribute to the lower levels of Largactil®/Thorazine® Solian®
extrapyramidal symptom (EPS) side effects. (chlorpromazine) (amisulpride)
Increased dopamine in the meso-cortical Modecate®/Moditen® Abilify®
pathway is thought to be the main reason for (fluphenazine) (aripiprazole)
positive symptoms. Amphetamines, which Depixol® Clozaril®
stimulate the dopamine pathway, cause similar (flupentixol) (clozapine)
symptoms which may be indistinguishable from Haldol® Zyprexa®
schizophrenia.2 However, the action of (haloperidol) (olanzapine)
antipsychotics to block this pathway can lead
Loxapac®/Loxitane® Seroquel®
to EPS (see ‘Side effects with antipsychotic (loxapine) (quetiapine)
treatment’).
Fentazin® Risperdal®
(perphenazine) (risperidone)
In recent years, new ‘atypical’ antipsychotics
have been developed. These are at least as Navane® Serdolect®
(thiothixene) (sertindole)
effective on the positive symptoms of
schizophrenia as the typical antipsychotics, as Mellaril® Geodon®/Zeldox®
well as indicating a possibility of being more (thioridazine) (ziprasidone)
effective on the negative symptoms. Atypical
antipsychotics also work by altering *Antipsychotic drugs are marketed under a variety of
brand names – the names given in brackets are the
neurotransmitter (dopamine, serotonin)
generic (non-proprietary) names. Some may also be
function in the brain. Their mechanisms of known under other proprietary names.
action tend to be different from the typical
agents, and this may be related to the atypical
antipsychotics’ tendency to cause fewer severe Side effects with antipsychotic treatment
EPS side effects (see opposite), although they Side effects occur when the antipsychotic drug
are not free of side effects in general. influences systems other than those involved in
schizophrenia. The occurrence of side effects
Drug selection must, therefore, not only take varies from drug to drug, as well as between the
into account the symptoms and needs of the general drug classes. A description of some side
patient, but also balance the risk–benefit in effects associated with antipsychotic drug use
24 terms of effectiveness and side effects. is given in the table opposite.
Table 3: Side effects of antipsychotic drugs

Side effect Description

Extrapyramidal symptoms (EPS) Set of movement-related side effects (e.g., tremor,

stiffness, cramps, involuntary movements, restlessness),
that are caused primarily by typical antipsychotic drugs
influencing pathways in the brain that control movement,
in addition to the psychosis-related pathways.

Long-term use of antipsychotic drugs can produce an

often irreversible side effect called ‘tardive dyskinesia’,
which involves uncontrollable muscle movements, usually
of the face.

Anticholinergic effects, e.g., dry Effects caused by the antipsychotic acting non-specifically,
mouth, blurred vision, constipation, and blocking the action of the neurotransmitter,
dizziness acetylcholine.

Sedation Common effect of many antipsychotics.

Seizures Antipsychotic drugs can lower the threshold for seizures.

Patients with a history of seizures may have an
increased risk.

Weight gain Common effect of many antipsychotics.

Raised prolactin levels Elevated levels of the hormone, prolactin, may promote
milk production, suppress ovulation, and reduce sexual
drive in women. In men, higher prolactin levels can lower
sexual drive and may induce impotence.

Neuroleptic malignant syndrome Very rare, but potentially fatal effect that produces
(NMS) problems with breathing and heart rate.

25
 The most common side effects of antipsychotic
drugs are EPS side effects: caused by the effect
of the antipsychotic on the part of the brain
that helps to control movement. There are three
basic types of EPS effect: dystonia, akasthisia,
and pseudo-parkinsonism. These effects may
occur in up to 40–60% of patients.2
Other less common side effects include
sedation, weight gain, and raised prolactin levels
(leading to disruption of sexual function) (see
Table 3), although not all of the side effects
listed here occur with every drug. There is
evidence that some antipsychotics may impair
cognitive function, and this has potentially
confused the classification of this type of
schizophrenia symptom.
Shortcomings of antipsychotic
treatments
Recent evidence suggests that the majority of
patients with schizophrenia (74%) will
discontinue their medication before 18 months
of treatment.3 Patients stop taking their
medication for a number of reasons, including
inefficacy and intolerable side effects. Each
patient has a different profile of symptoms, and
each antipsychotic a different profile of side
effects, thus it might be expected that there is
no simple answer to drug therapy. A good
relationship between clinician and patient will
prevent the patient from ceasing medication
before an alternative can be offered, and
switching medication is common before the
best balance between symptoms control and
side effects is met.

Side effects of drug treatment

At age 28, Charlotte had been diagnosed with schizophrenia. Now, aged 50, she has received
drug treatment for many years, which has provided reasonable control of symptoms. However,
lapses in taking her medication have led to regular admissions to hospital. The reason for her
risking stopping the treatment was a feeling of emotional ‘numbness’, like being constantly
‘blue’. This is a side effect of her medication, interpreted as a very painful mental component
of the EPS-syndrome. This has caused social withdrawal and severe lack of motivation, which
has often been seen as depression. Her doctor has tried to reduce the dose of her medication
to avoid this effect, but this increased her schizophrenia symptoms, leading to the return of
disturbing hallucinations.

26
Psychosocial and cognitive/
behavioural therapies
Psychological, including behavioural therapies,
form a key part of schizophrenia treatment and
rehabilitation. These therapies cannot generally
help in dealing with acute psychotic phases of
illness, but have been shown to reduce the rate
of relapse.4 Used in combination with
medication, they can help a person with
schizophrenia to rebuild their social, functional,
and communication skills. Psychosocial support
and psychoeducation can be very helpful for
the families of people with schizophrenia.
Psychotherapy involves regular meetings
between the patient and a therapist to talk
about their problems and concerns in general,
which may or may not be related directly to
the schizophrenia. The types of psychotherapy
differ, and range from dealing with specific day-
to-day problems, to the recall of previous
events to guide the patient to insights in their
life.2 Behavioural therapy seeks exclusively to
change the behaviour of the patient, with the
primary aim of addressing the patient’s ability
to deal with social situations.2 Cognitive
behavioural psychotherapy focuses on helping
the patient to find ways of changing core
beliefs and/or thought patterns that cause
discomfort, anxiety, depression, or in some way
interfere with their life situation.
The supportive nature of these therapies can
also encourage patients to comply with their
drug treatment – a significant concern in this
patient population, where approximately 50%
of patients fail to take their medication once
discharged from hospital.2
Future therapies
Despite innumerable advances in drug
treatments over recent decades, there are still
many unmet needs in schizophrenia therapy.
Obvious improvements would be treatments
with increased effectiveness against all types of
symptoms, fewer side effects, and rapid action.
In addition, treatments are required for patients
with symptoms that do not respond to existing
therapies (i.e., are refractory). Earlier diagnosis
would also be helpful, along with therapies that
offered positive effects on conditions that
frequently occur alongside schizophrenia such
as those involving cognition and mood (see
next section – ‘ What are the co-morbidities of
schizophrenia?’).
Research is ongoing in all of these areas, looking
at new approaches to treatment, and
maintaining the ultimate aims of discovering a
cause and a cure. In the meantime, education
to raise awareness and decrease stigma are
other valuable ways to improve the lives of
those with schizophrenia.
27
 References
1. National Alliance for Research on Schizophrenia
and Depression (NARSAD). Understanding
schizophrenia. © NARSAD, 2003. Accessed
online, March 2006.

2. Tsuang MT, Faraone SV. Schizophrenia, the facts.

Second edition. Oxford University Press, 1997.

3. Lieberman JA, Stroup TS, McEvoy JP, et al.

Effectiveness of antipsychotic drugs in patients
with chronic schizophrenia. NEJM 2005; 353
(12): 1209–1223.

4. Tarrier N. Cognitive behaviour therapy for

schizophrenia – a review of development,
evidence and implementation. Psychother
Psychosom 2005; 74 (3): 136–144.

Lundbeck Belgium Art Collection

28
 What are the co-morbidities of
schizophrenia?

In addition to the symptoms of schizophrenia,

some patients will experience co-morbidity –
that is, additional illness alongside their
schizophrenia. The most frequent conditions
associated with schizophrenia are mood
disorders, such as depression and anxiety. The
co-morbidity of substance abuse among
individuals with schizophrenia is also high, and
around 50–70% abuse one or more
substances.1
Co-morbidity with depression
During his teenage years, Michael had
experienced mood disorders, and had a
problem with obesity. Early in his twenties,
he had also been diagnosed with
schizophrenia, mainly characterised by the
negative signs of isolation and avolition.
At this time, Michael received treatment
for schizophrenia, along with an

People with schizophrenia and manic
depression (bipolar disorder) have higher risks
of certain physical conditions than average:2
• 2–4 times the rate of cardiovascular diseases
• 2–4 times the rate of respiratory disease
• 5 times the rate of diabetes
• 8 times the rate of Hepatitis C
• 15 times the rate of HIV.
Mood disorders
Co-morbidities
antidepressant. Unfortunately, while
addressing certain of his symptoms, this
therapy increased his weight further,
potentiating some of his original problems
and impacting upon his health and quality
of life.

Mood disorders such as anxiety and depression

show a high co-morbidity with schizophrenia.
Approximately 75% of patients with
schizophrenia will experience depression during
their lifetime, and this is thought to contribute
to an increased risk of suicide.3

29
 Lundbeck Belgium Art Collection

References
1. Kosten T, Ziedonis D. Substance abuse and schizophrenia: editor’s introduction. Schizophrenia Bulletin 1997;
23: 181–185.

2. www.rethink.org

3. ABPI. Target schizophrenia. May, 2003.

30
 What is the social and economic
impact of schizophrenia?
Social and economic effects form an important
part of living with, and treating, schizophrenia.
Schizophrenia is often a difficult disorder for
society to accept and deal with, as it influences
behaviour, emotion, communication and
functional capacity. To live with these
symptoms, a person with schizophrenia requires
attentive care, which understandably entails
extensive costs – both personal and financial.
Social factors
Social interaction
A person with schizophrenia often finds it
difficult to integrate socially. This may be
because of fear, anxiety or distressing beliefs, or
because of symptoms such as poverty of
speech and withdrawal, which are not
conducive with social activity. In addition, many
positive symptoms can be worsened by being
exposed to arguments, emotional discussions or
large crowds.
Poor communication can be a particular
hindrance when trying to converse with a
physician, making it more difficult for patients
to express their needs, and for physicians to
assess the disorder severity.
Employment
The severity and intermittent nature of positive
symptoms can make employment practically
difficult for a person with schizophrenia. In
addition, negative symptoms such as apathy,
poor articulation, and withdrawal, do not often
fit in with a work environment. Further to this,
the stress of having to attend work, as well as
any stress associated with the work itself, can
make symptoms worse. For these reasons,
schizophrenia frequently generates a barrier to
employment.
Education
It is under some debate whether patients with
schizophrenia suffer a decline in IQ as a
consequence of their disorder since, in most
cases, an IQ test for the patient prior to
diagnosis is not available for comparison.
However, a lower IQ is known to be associated
with a poorer prognosis.1
Homelessness
Social & economic impact
Approximately 40% of homeless people are
thought to suffer from mental illnesses,
including schizophrenia.1 Homelessness can be a
result of many factors affecting people with
schizophrenia, including difficulty fitting into a
shared home, broken relationships, loss of
employment, desire for isolation, paranoid
thoughts and delusions, and a lack of financial
support.
Drugs, alcohol and violence
Abuse of drugs and/or alcohol can be a
consequence of the withdrawal from society,
loss of employment and homelessness that
may affect a person with schizophrenia.
31
 Estimates indicate that up to 50% of people
with schizophrenia are periodic drug or alcohol
abusers.
Further consequences of this abuse may be an
increased likelihood of violence, accidents,
financial poverty, and deterioration in
appearance. However, patients with
schizophrenia are not inherently violent, with
anxiety or the side effects of medication often
misread as aggression.
Suicide and mortality
Suicidal behaviour is a common complication of
schizophrenia. Some 50% of individuals with
schizophrenia will attempt suicide at some
time, and it is the cause of death for 6–13% of
patients.2 Along with natural causes,
predominantly affecting the heart/blood
system, this distressing statistic contributes to
the 2.4-fold raised mortality risk in people with
schizophrenia.
32
Social impact
At age 24, Carola felt the significant social
impact of her recent diagnosis with
schizophrenia. She was finding it
increasingly difficult to hide her symptoms
(changes in behaviour, hallucinations) from
her work colleagues in the office where she
was employed. The symptoms occurred
intermittently, and it was almost
impossible for her to predict when her
behaviour would change. She was unwilling
to speak to her employer about her
situation in case she lost her job. Outside
work, she felt similarly isolated and less
inclined to socialise. Although her friends
had noticed some changes in her, she
didn’t want to tell them about her
diagnosis, because of the stigma that is
associated with the condition, and the
potential change in attitude towards her
that this might bring about.
Economic factors

The estimated cost of treating a person with

schizophrenia for a year is over €100,000. References
Overall, this is likely to account for 1. Tsuang MT, Faraone SV. Schizophrenia, the facts.
Second edition. Oxford University Press, 1997.
approximately 2% of total hospital costs. This
includes both pharmacological and non- 2. ABPI. Target schizophrenia. May, 2003.
pharmacological costs. Only 1% of this total
cost of care per patient is attributable to the
cost of medications, and demonstrates the huge
level of non-pharmacological support required
by patients with schizophrenia. Although
individuals with schizophrenia usually require a
period of hospitalisation during their psychotic
episodes, there is a rising trend to treat more
patients outside the hospital environment – a
trend that is driven by the increased
effectiveness of antipsychotic drugs, as well as
changing political priorities. Consequently, the
number of hospital beds allocated to patients
with schizophrenia in Western Europe has fallen
by 30–50% over the past 10 years.

In addition to direct expenses of care, economic

evaluation also takes into account the indirect
cost of lost productivity – for both the person
with schizophrenia, and any friend or family
member who has had to limit work in order to
act as a carer. These factors all contribute to a
considerable association of schizophrenia with
poverty.

33
 Lundbeck Belgium Art Collection
34
 Further information
Index sources
This section includes a selection of websites
and books that provide further information
about schizophrenia.
Websites
General information on
schizophrenia
EUFAMI
www.eufami.org
EUFAMI is a European network of family and
carer associations with the mission to achieve a
continuous improvement throughout Europe in
mental health, and in the quality of care and
welfare, for people affected by mental illnesses;
to campaign continuously for the rights of
families and carers of people with mental
illnesses across the whole of Europe; and to
support and strengthen member organisations
– 48 national and regional voluntary
associations in 27 countries – in their fight for
better health care for those affected by mental
illnesses.
National Institute of Mental Health (NIMH)
www.nimh.nih.gov
The National Institute of Mental Health (NIMH)
is one of 27 components of the National
Institutes of Health (NIH) – the United States
Federal government’s principal biomedical and
behavioural research agency. NIH is part of the
US Department of Health and Human Services.
The NIMH mission is to reduce the burden of
mental illness and behavioural disorders through
research on mind, brain, and behaviour. NIMH
funds research by scientists across the US as
well as in NIMH studies in the internal research
programme. Through its extramural programme,
NIMH supports more than 2,000 research grants
and contracts at universities and other
institutions across the country and overseas.
Schizophrenia.com
www.schizophrenia.com
Schizophrenia.com is a US-based non-profit-
making web community that provides
information, support and education to the
family members, caregivers and individuals
whose lives have been affected by schizophrenia.
The site contains articles on all aspects of life
with schizophrenia, as well as related news
items. The site also has discussion and chat
boards on various topics, as well as national
discussion groups from across the world.
Rethink
www.rethink.org
Rethink is the largest severe mental illness
charity in the UK, and aims to improve the lives
Further information
of all those affected by severe mental illness,
whether as a patient, carer, or healthcare
worker/professional. Rethink provides a range of
community services including employment
projects, supported housing, day services,
helplines, residential care, and respite centres. 31
35
 National Alliance for Research on
Schizophrenia and Depression (NARSAD)
www.narsad.org
NARSAD is a charity organisation that raises
funds for scientific research into the causes,
cures, treatments and prevention of severe
psychiatric brain disorders, such as
schizophrenia and depression. The site contains
a brochure on schizophrenia, as well as advice
and case stories from people suffering with the
illness.
Lundbeck Institute
www.cnsforum.com
The Lundbeck Institute aims to improve the
quality of life of people affected by central
nervous system disorders, through education.
The site contains a section on schizophrenia
and a ‘brain explorer’ animation, which is a
visual aid describing disorders of the brain.
Schizophrenia Treatment and Evaluation
Programme (STEP)
www.ncartsforhealth.org/STEP.htm
The STEP art gallery displays artwork and
poetry by inpatients and clinic outpatients from
the University of North Carolina STEP
programme. They hope to decrease the stigma
associated with mental illness and demonstrate
that people with serious mental illnesses
(particularly schizophrenia and bipolar disorder)
36 can be creative and productive.
Corporate information
H. Lundbeck A/S
www.lundbeck.com
This comprehensive site gives a complete
overview of Lundbeck, including company
history, vision, mission, and product pipeline.
Corporate information such as share prices,
sales figures and other financial tools are also
available.
Books
Birchwood M, Jackson C. Schizophrenia.
Psychology Press, 2001.
Frith C, Johnstone E. Schizophrenia. A very short
introduction. Oxford University Press, 2003.
Hirsch SR, Weinberger DR (eds). Schizophrenia.
Second edition. Blackwell Science (UK), 2003.
McKenna PJ. Schizophrenia and related
syndromes. Taylor Francis Group, 1997.
Schiller L, Bennett A. The quiet room: journey
out of the torment of madness. Little, Brown
and Company, 1996.
Tsuang MT, Faraone SV. Schizophrenia, the facts.
Second edition. Oxford University Press, 1997.
Williamson P. Mind, brain, and schizophrenia.
Oxford University Press, 2005.
 Abbreviations & glossary
Abbreviations and glossary

ABPI Association of the British Amygdala

Pharmaceutical Industry A roughly almond-shaped mass of grey matter
APA American Psychiatric Association deep in each cerebral hemisphere. The
BPRS Brief Psychiatric Rating Scale amygdala have extensive connections with the
CDS Calgary Depression Scale olfactory system, and also the hypothalamus.
CIA Central Intelligence Agency (US The functions of the amygdala are apparently
agency) concerned with mood, feeling, instinct, and
CSF cerebrospinal fluid possibly memory for recent events.
DSM-IV Diagnostic and Statistical Manual, 4th
edition Anhedonia
EPS extrapyramidal symptoms A negative symptom of schizophrenia which
manifests as an inability to experience pleasure.
EUFAMI European Federation of Associations
of Families of people with Mental
Illness Avolition
HIV Human Immunodeficiency Virus A general lack of drive to perform activity of
ICD-10 International Classification of any kind, including those which might
Diseases, 10th edition constitute ‘daily living’.
IQ intelligence quotient
Brief Psychiatric Rating Scale (BPRS)
MRI magnetic resonance imaging
BPRS is a 16-item scale with nine general
NARSAD National Alliance for Research on
Schizophrenia and Depression
symptom items, five positive-symptom items,
and two negative-symptom items. Completed
NHS National Health Service (of the
United Kingdom) by the physician, each item is scored on a
seven-point severity scale (the higher the
NIH National Institutes of Health (US
medical agency) number, the more severe the symptom),
NIMH National Institutes of Mental Health
resulting in a range of possible scores from 16
(US) to 112. For example, the average patient with
NMS neuroleptic malignant syndrome schizophrenia entering a clinical trial might
typically score 33.
PANSS Positive and Negative Syndrome Scale
PET positron emission tomography
Catatonic behaviour
STEP Schizophrenia Treatment and
A negative symptom of schizophrenia involving
Evaluation Programme
unusual postures, mannerisms or rigidity.
WHO World Health Organization

37
 Co-morbidity
A term used to refer to a disease or disorder
that is not directly caused by another disorder
but occurs at the same time.
Delusion
False or unrealistic belief.
Dopamine
One of many chemicals (neurotransmitters)
that send messages between nerve cells.
Dystonia
A dysfunction of the muscles, characterised by
spasms or abnormal muscle contraction.
Extrapyramidal symptoms (EPS)
A set of movement-related side effects
common with antipsychotics, e.g., tremor,
stiffness, cramps, involuntary movements, and
restlessness.
Hallucination
Symptom that can be produced by a disease or
medications, which makes a person believe they
are seeing, hearing, or feeling things that are
not really there.
Hippocampus
An area of the floor of the lateral ventricle of
the brain. It contains complex foldings of
cortical tissue and is involved in the limbic
system.
38
Hypothalamus
A region of the forebrain, linked with the
thalamus and pituitary gland. It contains
centres controlling body temperature, thirst,
hunger, water balance, and sexual function. It is
also closely connected with emotional activity.
Limbic system
A complex system of nerve pathways and
networks in the brain that is involved in the
expression of instinct and mood. It includes the
activities of the amygdala, hippocampus and
hypothalamus.
MRI scan
Magnetic resonance imaging (MRI) is a type of
scan that uses radio waves to generate an
image of body tissues. It is especially useful for
examining the nervous system, muscles, and
bones.
Negative symptoms
Symptoms which represent the absence of
some usual trait, such as blunted emotions,
apathy, or social withdrawal.
Neuroleptic malignant syndrome (NMS)
A very rare, but potentially fatal side effect of
some antipsychotics.
Neurological
Describing any condition or symptom that
affects the nervous system.
Neurotransmitter
Type of chemical that is present in the nervous
system to carry messages between different
nerve cells. Examples of neurotransmitters
include dopamine, acetylcholine, and
noradrenaline.
PET scan
Positron emission tomography (PET) is a type of
scan that can detect chemicals in the brain. It is
sometimes used to produce pictures (scans)
showing the arrangement of dopamine-
producing nerve cells.
Positive symptoms
Symptoms considered to be added effects of
the disorder, such as hallucinations, delusions,
and disorganised speech.
Prolactin
A hormone that stimulates milk production
after childbirth and also stimulates production
of the ‘male’ hormone progesterone. Excessive
secretion of prolactin can give rise to abnormal
production of milk in both sexes.
Substantia nigra
Area of the brain where dopamine is produced.

Positive and Negative Syndrome Scale

(PANSS)
PANSS is a 30-item scale with 16 general
psychopathology symptom items, 7 positive-
symptom items, and 7 negative-symptom
items. Completed by a physician, each item is
scored on a 7-point severity scale, resulting in a
range of possible scores from 30 to 210. The
positive- and negative-symptom item groups
are often reported separately, with a possible
range of 7 to 49. For example, a patient with
schizophrenia entering a clinical trial might
typically score 91.

39
40
 Index

Abilify® (aripiprazole) 24 Chloropromazine 24

Active period 19 Chronic 4, 9

Index
Acute 4, 5, 27 Clinical scales 22
Age of onset 6, 7, 9 Clozapine 24
Alcohol abuse 8, 14, 31, 32 Clozaril® (clozapine) 24
Alogia 20 Cognitive impairment 3, 22, 26
American Psychiatric Association (APA) 15 Cognitive symptoms 4, 5, 22
Amisulpride 24 Co-morbidities 5, 27, 29
Amygdala 11, 12, 37, 38 - cardiovascular disease 29
- respiratory disease 29
Anhedonia 20, 37
- diabetes 29
Antidepressant 29 - hepatitis C 29
Antipsychotic drugs 21, 23 - HIV 29
- atypical 24 Core symptoms 15
- discontinuation 26, 27
Course 4, 5
- side effects 24, 25, 26
- switching 26 Definitions 37–39
- typical 23 Delusions 3, 5, 15, 17, 19–20, 21, 23, 38
Anxiety 5, 8, 21, 29 Dementia praecox 3
Apathy 3, 20, 31, 38 Depixal® (flupentixol) 24
Aripiprazole 24 Depression 17, 26, 27, 29
Avolition 20, 29, 37 Development 4, 5, 6, 13
Bipolar disorder 17, 29 Diagnosis 9, 15
Bleuler, Eugen 3 Disease course 4
Blunted emotions 3, 5, 20 Disease development 4, 5, 6, 13
Brain tumour 15, 17 Disorganised (hebephrenic) schizophrenia 21
Brief Psychiatric Rating Scale (BPRS) 22, 37 Dopamine 11, 23, 24, 38
Calgary Depression Scale (CDS) 22 Drug abuse 8, 14, 15, 29, 31, 32
Catatonic 20, 21, 37 DSM-IV 15
Cause(s) 11–14 Dystonia 38
- genetic 11, 13 Economic factors 8, 32, 33
- environmental 11, 14 - hospitalisation 33

41
 Epilepsy 15, 17 Magnetic resonance imaging (MRI) 19, 38
European Federation of Associations of Families of Maintenance phase 5
People with Mental Illness (EUFAMI) 35 Medication 23
Exclusion criteria 15 Mellaril® (thioridazine) 24
Extrapyramidal symptom side (EPS) effects 24, 25, 38 Meso-cortical pathway 24
- dystonia 26
Modecate® (fluphenazine) 24
- akasthisia 26
- pseudo-parkinsonism 26 Moditen® (fluphenazine) 24
Fentazin® (perphenazine) 24 Mood disorder 15, 29
Flupentixol 24 Mortality 5, 32
Fluphenazine 24 MRI See Magnetic resonance imaging
Frequency 3, 9 National Alliance for Research on Schizophrenia and
Depression (NARSAD) 36
Gender 6, 7, 9, 14
National Institute of Mental Health (NIMH) 35
Genetic 11, 13
National Institutes of Health (NIH) 35
Geodon® (ziprasidone) 24
Navane® (thiothixene) 24
H. Lundbeck A/S 36
Negative symptoms 4, 5, 11, 19, 20, 24, 38
Haldol® (haloperidol) 24
Neuroleptic malignant syndrome (NMS) 25, 38
Hallucinations 3, 5, 11, 15, 19, 21, 23, 38
Neurotransmitters 3, 11, 23, 24, 39
Haloperidol 24
Obsessive–compulsive disorder 17
Hebephrenic see Disorganised (hebephrenic)
schizophrenia 21 Olanzapine 24
Hippocampus 11, 12, 38 Paranoid 21, 31
Hypothalamus 38 Perphenazine 24
ICD-10 15 Personality disorder 17
Imaging 11, 17 PET See Positron Emission Tomography
Incidence 7, 9 Positive and Negative Syndrome Scale (PANSS) 22, 39
Kraepelin, Emil 3 Positive symptoms 5, 19–20, 23, 24, 39
Largactil® (chlorpromazine) 24 Positron Emission Tomography (PET) 11, 19, 39
Loxapac® (loxapine) 24 Prevalence 9
- geographical 9
Loxapine 24
Prodomal phase 5
Loxitane® (loxapine) 24
Psychiatrist 3, 5, 15
Lundbeck Institute 36
Psychosocial therapy 23, 27

42
Psychotic episode 3, 4, 5, 8, 23, 33 Stigma 3, 8, 27, 32
Quality of life 8, 29 Suicide 5, 8, 29, 32
Quetiapine 24 Symptoms 3, 4
Relative risk 7 - core 15
- cognitive 4, 5, 22
Remission 5
- negative 4, 5, 11, 19, 20, 21, 23, 24, 37, 38, 39
Risperidol® (risperidone) 24 - positive 5, 19–20, 22, 23, 24, 31, 37, 39
Risperidone 24 Thioridazine 24
Schizoaffective disorder 16 Thiothixene 24
schizophrenia.com 35 Thorazine® (chloropromazine) 24
Schizophrenia Treatment and Evaluation Programme Treatment 23 See antipsychotic drugs; psychosocial
(STEP) 36 therapy
Self-care 3, 5, 15, 21 - costs 8, 31, 33
Serdolect® (sertindole) 24 Unmet needs 27
Seroquel® (quetiapine) 24 Ventricles 11, 12
Serotonin 24 Viral infection 14, 17
Sertindole 24 Winter birth 14
Side effects 24, 25, 26 World Health Organization (WHO) 9, 15
- anticholinergic effects 25 Zeldox® (ziprasidone) 24
- extrapyramidal symptoms (EPS) 24, 25, 38
Ziprasidone 24
- sedation 25
- seizures 25 Zyprexa® (olanzapine) 24
- weight gain 25, 29
- prolactin 25, 26, 39
- neuroleptic malignant syndrome 25, 38
- sexual 20, 25, 26, 38
Social anxiety disorder 17
Social factors 8, 31
- social interaction 31
- employment 8, 31
- education 8, 31
- homelessness 8, 31
- drugs, alcohol and violence 31–32
- suicide and mortality 32
Social withdrawal 3, 20
Solian® (amisulpride) 24