Schizophrenia: Antipsychotics

by Food and Drug Administration (FDA)

"The visions are extremely vivid. Paving stones transform into demonic faces, shattering in front of my petrified eyes. When I am in contact with people, they can become grotesquely deformed, their skin peeling away to reveal decomposing inner muscles and organs. Buildings and rooms spin and weave and their walls close in as I look on, paralyzed by fear. ... The voices either ramble in alien tongues or scream orders to carry out violent acts. They also persecute me by way of unwavering commentary and ridicule to deceive, derange, and force me into a world of crippling paranoia."

— Robert Bayley, a schizophrenia sufferer, in Schizophrenia Bulletin, No. 4, 1996, published by the National Institute of Mental Health (NIMH).

More than 300,000 adults in this country are like Bayley, unable to distinguish their imaginations from reality. These people have schizophrenia, a mental illness whose hallmarks are visual and auditory hallucinations. Fortunately the living hell Bayley describes can often be alleviated with a number of antipsychotic drugs, including the relatively new drugs clozapine (Clozaril) and risperidone (Risperdal), which don't seem to have some of the limiting side effects of more traditional drugs, as well as the newcomer known as olanzapine (Zyprexa), which came on the market in the fall of 1996. The Food and Drug Administration is responsible for ensuring the safety and effectiveness of the drugs used to treat schizophrenia.

About one out of a hundred people in this country develops schizophrenia during his or her lifetime, according to NIMH. Usually, it first surfaces in the teens or 20s in men and in the 20s or early 30s for women. Schizophrenia rarely develops in children, and many schizophrenics appeared perfectly normal during childhood.

Although research has turned up some intriguing clues, the puzzle of what causes schizophrenia has yet to be solved. Some people may inherit susceptibility to the condition. A person with a parent or sibling who is schizophrenic has about a 10 percent risk of developing the condition, and half of all identical twins of schizophrenics also succumb to the mental illness.

Anatomy studies suggest the condition is not caused by damage to the brain, but rather due to faulty brain development. Studies show that exposure to viral infections during the second trimester and birth complications can boost the risk of developing schizophrenia, because the normal development of the brain may be altered, according to Stephen Marder, M.D., of the University of California in Los Angeles.

Because the drugs that effectively treat schizophrenia affect the functioning of the chemical messengers in the brain known as neurotransmitters, some experts hypothesize that the disorder stems from an inappropriate balance of these messengers in brain cells.

In some patients, schizophrenia is persistent, while others have remissions and exacerbations. Full recovery rarely occurs. Suicide rates among paranoid schizophrenics can be as high as 10 percent, according to study by Thomas McGlashan, M.D., of the Yale Psychiatric Institute, published in the February 1997 American Journal of Psychiatry.

Voices No One Else Can Hear

Schizophrenia is one of the most complex, puzzling and disabling of the major mental illnesses. People who suffer from this condition can have a number of different symptoms, the most prominent being hallucinations, delusions, disordered thinking and behavior, and abnormal expression of emotions. Hearing voices that other people don't is the most common type of hallucination in schizophrenia. Such voices may describe the patient's activities, carry on a conversation, warn of impending dangers, or tell the person what to do.

Another common symptom of schizophrenia is delusions of persecution or grandeur. As cited in an issue of Schizophrenia Bulletin, one schizophrenic, who was a computer programmer, imagined that the end of the world was coming and he determined which of his colleagues would survive in the afterlife by the keys he punched on the computer. Another patient, cited in an NIMH brochure, thought a neighbor was controlling his behavior with magnetic waves.

Schizophrenics often are not able complete a line of thought. Their thoughts come and go so rapidly it is not possible to "catch them." Fragmented thinking and conversing results. Contributing to this hampered logic is an inability to sort out relevant from peripheral information in a situation.

Another frequent symptom of schizophrenia is deadened emotional expression, indicated by a monotonous tone of voice and flat facial expressions. "Her face was a solemn mask, and she could neither give nor receive affection," wrote Evelyn Smith of her schizophrenic daughter in Schizophrenia Bulletin, No. 4, 1991.

Schizophrenics also may show inappropriate emotions — a laugh in response to a tragic situation, for example. Some schizophrenics exhibit bizarre behavior, such as excessive activity that is apparently purposeless and not influenced by what is happening around them. In contrast, some schizophrenics may lapse into a catatonic state in which they are immobile and unresponsive.

To be diagnosed as schizophrenic, a patient needs to have two or more of any of these symptoms during a one-month period. However, some symptoms are more characteristic of schizophrenia and aid in more definitive diagnosis. For example, it is rare for people with other disorders to hear a voice commenting on their behavior or to hear two or more voices conversing with each other. Also key to the diagnosis of schizophrenia, is a significantly hampered ability to work or socialize for at least six months.

Before providing a firm diagnosis of schizophrenia, doctors need to rule out drugs as the cause. A number of illegal drugs, such as PCP (phencyclidine hydrochloride), or chronic use of high doses of amphetamines can cause some of the disorder's symptoms.

Antipsychotics Revolutionized Treatment

A dismal outlook for schizophrenia was dramatically changed in the 1950s with the development of the first antipsychotic drug, chlorpromazine (Thorazine). Since then, more than a dozen other similar-acting antipsychotic medications have been developed, including haloperidol (Haldol), thioridazine (Mellaril), loxapine (Loxatane), and molindone (Moban). These drugs work by blocking binding sites of the neurotransmitter dopamine. They are equally effective at stemming the delusions and hallucinations and bizarre behavior and speech experienced by schizophrenics, according to NIMH. What effects these older antipsychotic medications have on other symptoms of schizophrenia, such as flattened emotions and apathy, is not as well documented. They also foster significant side effects that can limit their use.

When patients first start taking these antipsychotic drugs, they may be troubled by such side effects as drowsiness, restlessness, cramps, muscle spasms, dizziness, stiffness of the limbs, tremors, dry mouth, impotence, menstrual irregularities, or blurring of vision. Most of these can be corrected by lowering the dosage or can be controlled by other medications.

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