Schizophrenia and the Symptoms: When Can Treatment Begin?

By Samantha Broomfield

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Image by Anemone123 from Pixabay

We were walking down a busy sidewalk in Boston when a man's voice called out to my friend from behind us. "Stop following me!" the stranger exclaimed, "I swear to God I'll call the police." To be safe, we crossed to the other side of the street, but to our confusion, the man followed, continuing to yell expletives and threats at my friend if she were to follow him. She began to worry, and questioned if we should call the police, but I believed that ultimately, that would not be the optimal solution; I presumed this man, who appeared to be homeless, was experiencing paranoid delusions, a common symptom of schizophrenia ("Schizophrenia-Fact Sheet" 1). He didn't need a confrontation with the police; already, roughly ¼ of those in prison are severely mentally ill (Carroll 1). Rather, this man needed psychiatric care, which is something we could not provide. So, we ducked into a coffee shop and waited until he lost interest. We encountered several other homeless individuals who appeared to be mentally ill on the streets and on the train during that trip alone. Sadly, this is not surprising given the large number of schizophrenics in the homeless population. In fact, while only 1% of the United States' population is affected by schizophrenia, approximately ¼ of the U.S homeless population is made up of schizophrenics (Naeh, 1).

Considering that the percentage of schizophrenics in the homeless population is much higher than the percentage in the overall population, it seems as though we, as a society, are abandoning the mentally ill and leaving them to fend for themselves on the streets. Clearly, these individuals are not receiving proper treatment even though schizophrenia is very treatable ("Schizophrenia-Fact Sheet" 2). Yet, when a person develops schizophrenia, if they never begin taking medication or decide to stop taking medication, it can become very difficult to ensure they receive treatment, especially if they end up on the streets. It is known that the symptoms of schizophrenia usually appear in early adulthood, and there are many risk factors. Some of these risk factors include a family history of schizophrenia and the adolescent use of psychotropic drugs ("Schizophrenia" 3). The problem is, there is currently no straightforward test for schizophrenia—it can be diagnosed only based upon the appearance of outward symptoms ("Schizophrenia-Fact Sheet" 2).

Early treatment is critical in managing the symptoms of schizophrenia; without it, the disease could cause one's life to spiral out of control. Yet, studies have found that nearly 40% of people with early stage schizophrenia are not being treated properly (Robinson et al. 246). Evidently, treating schizophrenia based upon the outward symptoms alone often does not work; thus, we need another method of identifying schizophrenia as early as possible. Researchers from the University of Edinburgh were able to use MRI scans to identify a variety of abnormalities in the brains of schizophrenics. Not only that, they were able to link certain abnormalities to specific symptoms and their severity. Ultimately, they concluded that it is possible that these brain abnormalities begin to form before outward symptoms appear (Young, et al. 163).

My research seeks to examine the development of brain changes and symptoms of schizophrenia. I want to find out whether the brain abnormalities seen in schizophrenics appear well before the outward symptoms. With this information, primary care doctors could consider risk factors and potentially diagnose schizophrenia in children or adolescents before their symptoms begin to appear. Then, these individuals could begin receiving treatment for the disease before it truly starts to affect them. I will begin my discussion by analyzing the mechanisms of schizophrenia. I will describe how certain changes in the brain relate to and may exist prior to the outward symptoms which can take over an affected individual's life. Then, I will look at the manner in which schizophrenia is currently treated, and how improvements to that system could potentially be life-changing. Finally, I will show how making changes to the treatment process of schizophrenia, which is extremely prevalent in homeless and prison populations, could positively impact society as a whole.

The Mayo Clinic defines schizophrenia as "a serious mental disorder in which people interpret reality abnormally" ("Schizophrenia" 1). Schizophrenia affects both the brain and behavior, but each case of schizophrenia tends to be rather unique, which is why diagnosis and treatment can be so difficult. However, there are several common symptoms of schizophrenia that can be observed without examining the brain. The symptoms most commonly associated with schizophrenia are hallucinations and delusions. Hallucinations involve the perception of stimulus that does not actually exist, such as hearing voices that aren't really there. Delusions are false beliefs, such as delusions of grandeur: the belief that one is extremely talented, famous, exceptional, etc. Finally, the more common symptoms include disorganized thought, speech, and movement ("Schizophrenia" 1). These symptoms are classified as positive and negative symptoms. Positive symptoms are the addition of some phenomena that would not occur for a healthy individual, such as hearing voices. Negative symptoms cause a lack of "normal emotions and behaviors" like speaking less than normal or not at all ("Schizophrenia-Fact Sheet" 1). Typically, schizophrenia manifests somewhere in the late teens to mid-twenties. The onset usually starts with an episode of psychosis, which is a period of loss of touch with reality, like a hallucination ("What is Psychosis?" 1). A seemingly healthy young adult will suddenly lose touch with reality and be diagnosable as schizophrenic.

Because the cause of schizophrenia remains unknown, we do not really understand why or how schizophrenia appears when it does ("Schizophrenia-Fact Sheet" 1). It is clear, though, that schizophrenia and its associated symptoms have the potential to make living a normal life very difficult. The Mayo Clinic lists some of these complications as: "Inability to work or attend school, legal and financial problems and homelessness, social isolation, health and medical problems…" ("Schizophrenia" 3). This is why research to further understand the onset and mechanism of the disease is so critical. To gain more insight into schizophrenia, we can take MRI images of the brain to understand why certain symptoms exist.

Several different studies have concluded that, in general, some of the most common and consuming schizophrenic symptoms can be linked to specific abnormalities in the areas of the brain crucial to normal function. One study was able to identify a correlation between memory and the prefrontal cortex, a region of the brain linked to emotion, personality, and behavior ("Prefrontal Cortex" 1). Brain imaging of those with schizophrenia showed lower activity in the prefrontal cortex, as compared to healthy brain scans, when performing certain tasks relating to working memory schizophrenia (Perlstein et al. 1105). Researchers drew the conclusion that this deficit in prefrontal cortex activity is linked to cognitive disorganization, one of the defining characteristics of schizophrenia. They also concluded that this deficit impaired the schizophrenic patient's working memory, which is a type of short-term memory that allows for information to be retained long enough to use it (Perlstein et al. 1108-1111). In other words, it goes hand-in-hand with focus and concentration (Morin 1). Overall, it is evident that one of the symptoms which can be most detrimental to normal behavior, cognitive disorganization, is directly linked to a physical brain change. Obviously, decreased activity in the prefrontal cortex would have a strong impact on the life of a schizophrenic. Difficulty with memory, thinking, and behavior certainly could cause issues maintaining not only a stable job, but also healthy relationships.

Another study found further evidence that there is a correlation between brain abnormalities; in this case, brain volume was found to be associated with the negative and positive symptoms of schizophrenia. Here, researchers took brain scans of over 60 people, roughly half being schizophrenics. The scans showed a wide variety of differences in the sizes and ratios of different structures in the brain of a schizophrenic as compared to a normal brain (Young et al 158-162). The scans also showed one of the defining traits of schizophrenia: an increase in dopamine, which is a neurotransmitter involved in our behavior, moods, learning, and more (Brookshire 1). Researchers were then able to relate some of these changes to specific types of symptoms (Young et al 161-163). For example, they determined that negative symptoms can be associated with a larger ventricle (cavity) to overall brain size ratio. In other words, the schizophrenics whose scans showed more hollow parts in their brains exhibited more negative symptoms. Additionally, ventricles larger in size were found to be related to more intense positive symptoms. Lastly, they found several symptoms to be associated with increased dopamine in the amygdala, a region of the brain related to emotions (Young et al. 163). In sum, this study shows further evidence that the outward symptoms are a result of physical brain changes, specifically involving ventricles and dopamine. Again, it is evident that these brain changes have life-altering effects considering their correlation to positive and negative symptoms. These symptoms, like hallucinations, delusions, and a lack of speech or movement, as well as dopamine's affect on mood and behavior, certainly have the power to take over someone's life-- their ability to secure an income, take care of their family, and otherwise live a complete life could easily be impaired as a result of these abnormalities.

Furthermore, a similar study was able to relate brain tissue irregularities to positive symptoms. Researchers took MRI images of nearly 6o individuals, half of whom had schizophrenia. They analyzed the volume of three main types of tissue in the brain: gray matter, white matter, and cerebrospinal fluid (CSF) (Sigmundsson et al. 235). As a whole, the brain volume of schizophrenics was less than that of healthy individuals. The white and gray matter volumes were about 5% lower in schizophrenics, whereas the CSF volume was higher. While this study found no relation between decreased white/gray matter and negative symptoms, both were shown to have a significant effect on the intensity of positive symptoms (Sigmundsson et al. 236-241). Again, it is clear that there exist distinct anatomical abnormalities which show a significant correlation to specific types of symptoms. The more severe the abnormalities, the more intense the symptoms appear. Of course, experiencing intense positive symptoms like hallucinations and delusions would be devastating. The obsessions, anxiety, and fear that come with hallucinations and delusions could prevent a schizophrenic from having a healthy social life or being able to function sufficiently at work.

All of this research, combined with many more studies, provides strong evidence which supports the theory that both positive and negative symptoms correlate to abnormalities in the brain. But, unfortunately, correlation does not prove causation. Thus far, it has not been determined which comes first- -the internal abnormalities in the brain or the outward symptoms. However, because research has not determined a relationship between the onset of the disease and the appearance of brain abnormalities in MRI scans, a study in the British Journal of Psychiatry claimed that "brain changes may precede the onset of clinical symptoms" (Young et al. 163). This means that it is theoretically possible to scan the brain of a seemingly healthy individual and see the early markers of a schizophrenic brain. If the brain starts to show notable changes in volume, dopamine production, and more before symptoms occur, schizophrenia could be diagnosed before the life-altering symptoms set in. Having this information could potentially change the way schizophrenia is treated.

Due to the lack of understanding regarding the causes of schizophrenia, there currently exists no method of treatment which really gets to the root of the problem. The main treatment for schizophrenia, antipsychotic drugs, focuses solely on relieving the positive symptoms of the disease; unfortunately, there is no method for treating the negative symptoms ("Schizophrenia-Fact Sheet" 2). Because there is no way to fix the physical brain abnormalities shown to be present in schizophrenia, such as an unusual brain volume, the only variation antipsychotic drugs can really target is the dopamine levels. Even though this treatment exists, nearly half of schizophrenics go untreated ("Schizophrenia-Fact Sheet" 1). Of those who do receive treatment, the many side effects that come with attempting to fix dopamine levels often make them reluctant to keep taking their medication ("Schizophrenia" 4). Because dopamine is involved in critical brain functions, attempts to decrease dopamine levels can have the severe, potentially permanent effects of the inability to move, a lack of emotions, and more ("Schizophrenia" 4). Of course, while this may help to eliminate delusion, hallucinations, etc. it seems that the effects of the treatment also have the ability to impede a normal lifestyle. In fact, even schizophrenics receiving treatment often "require some form of daily living support" ("Schizophrenia" 4). Thus, any improvements to the current treatment method could be quite beneficial.

One potential improvement of the treatment of schizophrenia is beginning treatment as soon as possible after the first schizophrenic/psychotic episode. Studies have recently emerged involving a potential new treatment strategy called RAISE: recovery after an initial schizophrenic episode. RAISE involves using therapy and lower volumes of medication either during or as soon as possible after the first schizophrenic episode an individual experiences (Naeh 1). One study examined roughly 400 patients being treated for their first episode of schizophrenia and found that a significant number of them could benefit from a different type of medication and/or a lower dosage. This lower dosage would reduce the side effects of the medicine while still lessening the positive symptoms, resulting in a more successful, long-lasting treatment experience. According to researchers, "better medication treatment of the initial illness episode raises the possibility of better acute and long-term outcomes" (Robinson et al. 246). Researchers suggested that initial treatment involve the earliest and lowest needed dose of antipsychotics (Robinson et al. 246). However, it can be difficult for community or primary care physicians to identify schizophrenia early enough for this information to be significant, considering that so many schizophrenics fail to seek treatment or may not realize they need treatment until it is too late ("Schizophrenia" 4). One way to address this issue is educating primary care physicians on the signs, symptoms, and risk factors implicated in schizophrenia so that they can be prepared to treat schizophrenia as early as possible.

Incorporating the monitoring and managing of potential and early schizophrenia in primary care would be a major improvement in the treatment of schizophrenia. Research has shown that the earlier the treatment begins, the more effective it is. We also know that it is theoretically possible to scan the brain of a seemingly healthy individual and see the brain markers for schizophrenia before symptoms have developed. Research has also proven a correlation between the development of schizophrenia and certain risk factors. One study took over a hundred individuals considered to be at high risk for developing schizophrenia and compared images of their brains to those of both confirmed schizophrenics and healthy individuals. Here, high risk was defined as a younger (early-mid teens) individual who had two or more direct relatives who have schizophrenia (Lawrie et al. 812-814). The study found that a significant number of these otherwise healthy high-risk individuals showed signs of brain abnormalities similar to those of schizophrenia, including a lower brain volume. With this information, researchers concluded that some of the brain changes could be passed down genetically, while others have environmental causes, and others yet, many of which cause the severest symptoms, still have unknown origins (Lawrie et al. 815-819). So, while these early indications of brain abnormalities do not always result in schizophrenia, they do indicate the possibility that schizophrenia may manifest in a few years, provided that the other abnormalities also exist. This means that a primary care physician could look at an adolescent's family history, and, if schizophrenia was prevalent, scan this individual's brain. If the early signs of brain abnormalities were present, the physician, individual, and their family could keep a close eye on potential signs of schizophrenia, allowing for the earliest possible treatment.

Another study came to a similar conclusion regarding the ability to monitor potential schizophrenia in children. In this study, which spanned 15 years, nearly 800 eleven-year-old children (~15% of whom described early schizophrenia-like symptoms prior to the study but were not diagnosable as schizophrenic) were monitored and interviewed until age 26. The interview contained five simple questions: "(1) 'Some people believe in mind reading or being psychic. Have other people ever read your mind?'; (2) 'Have you ever had messages sent just to you through television or radio?'; (3) 'Have you ever thought that people are following you or spying on you?'; (4) 'Have you heard voices other people can't hear?'; and (5) 'Has something ever gotten inside your body or has your body changed in some strange way?'" (Poulton et al. 1054). The responses to these questions were assigned a numerical value, and each individual's score helped to determine the presence of early signs of schizophrenia. The results of the study revealed that almost half of those from the group of roughly 800 who developed schizophrenia by age 26 had been in the 15% of children presenting early signs (Poulton et al. 1055-1057). Therefore, incorporating the monitoring and managing of potential and early schizophrenia in primary care would be very possible, and could, in theory, help to predict future schizophrenia with five simple questions. Keeping known risk factors in mind, physicians could ask at-risk children/adolescents these five questions at annual check-ups to identify possible signs of schizophrenia. If necessary, if family history and/or the answers to these questions caused any worry, brain images could be taken and, if these scans revealed the markers for schizophrenia, the earliest possible treatment could commence.

Some experts fear that this approach could lead to the over-prescription of antipsychotics in a preventative manner. However, if an individual presents with both the risk factors as well as physical brain changes indicating schizophrenia, it is clear that they are at very high risk for developing it. Of course, there is currently no way to guarantee that schizophrenia will occur. This is why closely monitoring the patient for signs of psychosis may be the best option. However, if a physician determines the risk of developing schizophrenia to be quite high, they may decide it is best to begin prescribing antipsychotics. British psychologists who specialize in psychosis state that, "We have no real objection to preventative psychopharmacology between consenting adults…They should be told that they may be receiving treatment unnecessarily and that [there will be] side effects…" (Read et al. 103). It seems reasonable that someone who may develop schizophrenia have the opportunity to start treatment as early as possible, as long as the individual or their guardian is aware of the risks of treatment, and that physicians can't guarantee schizophrenia will develop. Thus, the only way this style of early/preventative treatment of schizophrenia would be unethical is if physicians were prescribing antipsychotics completely unnecessarily (without any indication of risk of schizophrenia) and/or not explaining the risk associated with treatment. In the end, though, I think that the benefits of treating schizophrenia as early as possible generally outweigh the risks of treatment.

Treating schizophrenia as early as possible is not only important because it results in the best treatment outcome, but also because improving the treatment of schizophrenics could have a major impact on homeless populations as well as society as a whole. Because such a significant percentage of the homeless population is composed of schizophrenics, incorporating the monitoring of schizophrenia for children's primary care check-ups could potentially reduce the overall homeless populations in the United States. In total, about 1/3 of the U.S homeless population is facing untreated severe mental illness (Mondics 1). Considering that ¼ of the homeless population in the U.S. is schizophrenic, it is safe to say that most of these schizophrenics are not being treated. If any of these individuals had received treatment before becoming homeless, it is possible that they could have avoided homelessness altogether. As explained, the symptoms of schizophrenia, when not properly treated, greatly impair the ability to live a normal life, hold a job, support a family, and more. This is why many schizophrenics end up homeless; often, they remain homeless because a refusal to seek treatment is a common occurrence with schizophrenics ("Schizophrenia" 4). Treating any of these individuals as early as possible, before their lives are taken over by the symptoms of schizophrenia, could certainly improve their ability to function as normal adults. Early, or even preemptive, treatment would not just reduce homeless populations, increase the number of functioning members in society, and prevent families from getting split up by the disease, it would also have a positive monetary impact on society. A study from the University of Pennsylvania concluded that homeless people with mental illness cost taxpayers over $40,000 a year. So, treating schizophrenics before they end up on the streets will actually save all taxpaying Americans some money. Overall, it is clear that both the homeless population and the average American could benefit from incorporating schizophrenia screening in primary care.

The homeless population isn't the only population that could benefit from earlier treatment of schizophrenia; it could also help to reduce prison populations. Prisons suffer from subpar mental health treatment, so sending the mentally ill to prison is not the way to help them turn their lives around. Though a significant portion of prison populations are composed of mentally ill inmates (roughly ¼), "…most prisons in the country do not have adequate funding to provide appropriate treatment for inmates with mental illness. Thus, individuals with schizophrenia are placed in an adverse environment that does not meet their mental health needs and can make their mental health worse" (Meskill 2). So, as with the homeless population, mentally ill inmates are not properly treated, and, as a result, are likely unable to function normally. Upon release from prison, the mentally ill often no longer have access to any treatment at all (Meskill 7). Of course, this lack of treatment prohibits them from rejoining society in a healthy manner. As a result, they may simply end up homeless or back in prison; in fact, the mentally ill are reincarcerated at notably higher rates than healthy criminals (Meskill 6). The best way to avoid these issues would be to treat schizophrenia before the problematic symptoms appear. The earliest treatment possible could help those affected by schizophrenia to stay out of prison by making it easier for them to maintain a job, relationships, and an otherwise healthy lifestyle. Again, not only would we have more contributing members of society, but reducing prison populations would result in a monetary benefit, too. Studies have shown that "the average prisoner costs the state about $22,000 a year, but prisoners with mental illness range from $30,000 to $50,000 a year" (Carroll 2). Clearly, reducing the number of mentally ill in prisons would save American taxpayers a lot of money. Combined with the amount of money saved from reducing the homeless population, this is an issue worth caring about even for those whose lives have not been impacted by schizophrenia.

Considering the research and statistics, it is clear that treating schizophrenia as early as possible could greatly benefit those diagnosed with schizophrenia as well as society. Schizophrenia is clearly a life-altering disease; it has the power to essentially take over someone's mind; to break apart families; to cause homelessness and/or incarceration. As a result, schizophrenics impose a great cost on our society. However, there is a potential way to lessen its effects. Studies have shown that the physical brain abnormalities associated with schizophrenia are related to the outward symptoms. It is possible that these brain abnormalities could show up on an MRI before symptoms are present. Because the most effective way to treat schizophrenia includes starting treatment as early as possible, incorporating the screening for and treatment of schizophrenia in primary care could, at the very least, be a good way to start tackling this problem. The presence of certain known risk factors, as well as a simple psychological interview, could indicate a strong risk for developing schizophrenia. This would allow doctors to closely monitor the situation, if needed, take brain scans to look for abnormalities, and ultimately, begin treatment as early as possible; theoretically, before outward symptoms even fully develop. Ideally, future research would be done to show how accurately this system could predict the onset of schizophrenia to persuade those opposed to this method. In the end, early treatment would help affected individuals maintain a more normal, healthy lifestyle, allowing them to be contributing members of society. Also, considering the financial cost of the mentally ill being homeless or in prison, treating schizophrenics before they are at risk of becoming homeless or ending up in jail could provide significant savings to taxpayers. However, there is more to the issues than just money, of course. It is easy to see a mentally ill homeless person on the street and just turn your head, or even call the police. But that is not a productive or long-term solution to this issue. Schizophrenics do not belong in jail or on the streets; it is not their fault that they cannot hold jobs or stay on the straight and narrow. One in 100 may not sound like a big number, but considering all the people we know and interact with, odds are we each know someone who has been impacted in some way by this disease. Schizophrenics are unable to help themselves, so if we, as their friends, their family members, or even just their fellow human beings, have the power to help improve their treatment and life in any way, we certainly should do so.