Schizophrenia is a debilitating mental illness that affects 1 percent of the population in all cultures. It affects equal numbers of men and women, but the onset is often later in women than in men.

Schizophrenia is characterized by positive and negative symptoms. Positive symptoms include hallucinations, voices that converse with or about the patient, and delusions that are often paranoid. Negative symptoms include flattened affect, loss of a sense of pleasure, loss of will or drive, and social withdrawal. Both types of symptoms affect patients’ families; therefore, it is important for physicians to provide guidance to all persons affected by the disease. Psychosocial and family interventions can improve outcomes.

Medications can control symptoms, but virtually all antipsychotics have neurologic or physical side effects (e.g., weight gain, hypercholesterolemia, diabetes). There is a 10 percent lifetime risk of suicide in patients with schizophrenia.

Schizophrenia is a devastating mental illness that impairs mental and social functioning and often leads to the development of comorbid diseases. These changes disrupt the lives of patients as well as their families and friends. Family physicians can play an important role in the effective treatment of schizophrenia; they are in a position to recognize the early signs of illness, make referrals to appropriate mental health professionals, help patients and their families cope with the devastating effects of schizophrenia, and encourage a multidisciplinary approach to address all dimensions of the illness.

Risk Factors, Etiology, and Pathophysiology

Schizophrenia has a prevalence of 1 percent in all cultures and is equally common in men and women.1 Men typically present with the disease in their late teenage years or early 20s, whereas women generally present in their late 20s or early 30s.

Diagnosis

Schizophrenia is characterized by positive and negative symptoms that can influence a patient’s thoughts, perceptions, speech, affect, and behaviors. Positive symptoms include hallucinations, voices that converse with or about the patient, and delusions that are often paranoid. Negative symptoms include flattened affect, loss of a sense of pleasure, loss of will or drive, and social withdrawal.

Schizophrenia is also characterized by disorganized thought, which is manifested in speech and behavior. Disorganized speech may range from loose associations and moving quickly through multiple topics to speech that is so muddled that it resembles schizophasia (commonly referred to as “word salad”). Schizophasia is speech that is confused and repetitive, and that uses words that have no apparent meaning or relationship to one another. Disorganized behavior may lead to difficulties in performing daily living activities, such as preparing a meal or maintaining hygiene. It also can manifest as childlike silliness or outbursts of unpredictable agitation.

No single sign or symptom is pathognomonic of schizophrenia. To make a definitive diagnosis, signs and symptoms must be present for a significant portion of one month (or a shorter period if successfully treated), and some must be present for at least six months. These symptoms also must be associated with marked social and occupational dysfunction.

There are five types of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual. Paranoid type is characterized by a preoccupation with one or more delusions or frequent auditory hallucinations; cognitive function and affect remain relatively well preserved. Disorganized type is characterized by disorganized speech and behavior, as well as flat or inappropriate affect. Catatonic type has at least two of the following features: immobility (as evidenced by stupor or catalepsy); excessive, purposeless motor activity; extreme negativism (e.g., resistance to all instructions, maintenance of rigid posture, mutism); or peculiarities of voluntary movement (e.g., posturing, prominent mannerisms, grimacing). A patient is said to have undifferentiated schizophrenia if none of the criteria for paranoid, disorganized, or catatonic types are met. Residual type is characterized by the continued presence of negative symptoms (e.g., flat affects, poverty of speech) and at least two attenuated positive symptoms (e.g., eccentric behavior, mildly disorganized speech, odd beliefs). A patient is diagnosed with residual type if he or she has no significant positive psychotic features.

Of note, this classic typing of schizophrenia can be limiting because patients often are difficult to classify. For that reason, an alternative three-factor dimensional model is given. The three factors are psychotic, disorganized, and negative (deficit). The symptoms are categorized as absent, mild, moderate, or severe.

STEPHEN H. SCHULTZ, MD, STEPHEN W. NORTH, MD, mph, and CLEVELAND G. SHIELDS, PhD, University of Rochester School of Medicine and Dentistry, Rochester, New York

STEPHEN H. SCHULTZ, MD, FAAFP, is an assistant professor of family medicine and the program director of the Family Medicine Residency Program at the University of Rochester (N.Y.) School of Medicine and Dentistry. Dr. Schultz received his medical degree from the Brown-Dartmouth Medical Program in Providence, R.I., and Hanover, N.H. He completed a family medicine residency at the University of Rochester School of Medicine and Dentistry and a fellowship at the National Institute for Program Director Development in Kansas City, Mo.

STEPHEN W. NORTH, MD, MPH, is a family physician and adolescent medicine specialist at the Bakersville (N.C.) Community Medical Clinic and an assistant clinical professor at the John C. Quillen School of Medicine at East Tennessee State University in Johnson City. At the time of writing this article, he was a clinical instructor and director of school-based services for the Department of Family Medicine at the University of Rochester School of Medicine and Dentistry. Dr. North received his medical degree from the University of North Carolina at Chapel Hill School of Medicine and a master’s degree in public health from the University of Rochester. He also completed a family medicine residency and a fellowship in adolescent medicine at the University of Rochester School of Medicine and Dentistry.

CLEVELAND G. SHIELDS, PhD, is an associate professor of marriage and family therapy in the Child Development and Family Studies Department at Purdue University in West Lafayette, Ind. At the time of writing this article, he was an associate professor of family medicine and psychiatry at the University of Rochester School of Medicine and Dentistry. He received his doctorate degree from Purdue University and completed his postgraduate training at the University of Rochester School of Medicine and Dentistry.

Address correspondence to Stephen H. Schultz, MD, FAAFP, Department of Family Medicine, Highland Family Medicine, 777 S. Clinton Ave., Rochester, NY 14620 (e-mail: .(JavaScript must be enabled to view this email address)). Reprints are not available from the authors.

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