Expert Q&A

The Controversies in the Risk Factors of Schizophrenia

The exact cause of schizophrenia is unknown, but a combination of genetics, environment and altered brain chemistry, and structure may play a role.

W. Clay Jackson, MD, DipTh, discusses schizophrenia and the controversies surrounding the risk factors of the disorder. Dr Jackson is an assistant professor of clinical psychiatry and family medicine at the University of Tennessee College of Medicine in Memphis, Tennessee.

Consultant360: What is the prevalence of schizophrenia?

Clay Jackson, MD, DipTh: Well, in the United States and worldwide, the easiest way to remember it is it's under 1%. It's depending on the epidemiologic survey that one examines, but somewhere between 1 in 200 to 1 in 400 persons suffers from schizophrenia. So, 0.5 to 0.25%, if you wanted to put it that way. 1 in 200 to 1 in 400 is about the prevalence that most researchers have found.

C360: What are the symptoms of schizophrenia?

Dr Jackson: Well, classically in terms of schizophrenia, we've talked about positive symptoms and negative symptoms, and positive there doesn't mean that it's a good thing, of course. It means that these are symptoms that are easily seen or recognized from say 25 feet. The post person or the policewoman might recognize these symptoms. It doesn't take a clinician to see them. Whereas the negative symptoms tend to be sort of decreased motivation or other symptoms that might take a clinical eye to spot.

So, on the positive side of things, we're talking about disruptions in thought processes, disruptions in thought perceptions, emotional responsiveness, and social interactions. The five classic symptoms, we're talking about delusions or fixed false belief, hallucinations, again, altered perception, disorganized or incoherent speaking, not being able to carry on a usual conversation, and disorganized movements. Those are the four sort of positive symptoms. The negative symptoms are a decrease in emotion in terms of facial expressions, sort of a flat affect or a flat facies in terms of responsiveness and then fewer gestures with our hands or other parts of our bodies that we use for nonverbal communication.

So 4 positive symptoms, delusions, hallucinations, disorganized speaking, and disorganized movements. And then the negative symptoms that we talked about, sort of a flattening or a dulling of human responses in both terms of internal motivations, but also personal expressions.

C360: Let's jump to risk factors now. What are the risk factors of schizophrenia?

Dr Jackson: Oh, well, that's a whole podcast or a whole series of CME in itself. Schizophrenia is fascinating. It is an illness that's been with us for so long in human history. And it's been commented on by historians and artists. You'll recall Ophelia in Hamlet suffers from mental illness. A modern psychiatrist looking at that play sees schizophrenia large in Shakespeare's earth.

We have a lot of studies now about where schizophrenia arises. There are sociological and epidemiological factors that may pertain, such as growing up in a neighborhood that's below the economic standard deviation, a poor area, an urban area, and often those go together. This is controversial because historically in America, for instance, African Americans have been diagnosed with schizophrenia in larger percentages than non-African American patients or Caucasian patients. And so there's controversy as to whether this is systemic racism or whether this is truly socioeconomic factors that are driving a greater incidence of schizophrenia.

So those risk factors, it's the same old thing. It's genetics, it's environment, but that interplay with schizophrenia is rich. It is robust and it is controversial. So there are Nobel prizes to be won for any of our listeners who want to get out there and tease out some of these contributing factors. And obviously that would be personally satisfying, but more importantly, it would offer us some pathways forward in terms of prevention of this devastating illness.

C360: When are people typically diagnosed with schizophrenia?

Dr Jackson: Adolescent years, late teens, early 20s. Unlike bipolar disorder, which sometimes has a sort of a decade gap in terms of diagnosis, schizophrenia typically declares itself and schizophrenia speaks with a loud voice. People typically do and say things with schizophrenia that draw the attention of the surrounding community, including first responders. People typically call someone with a badge, a professional help degree, when schizophrenia is involved because people's behaviors and speech and thought is clearly out of norm with societal or community expectations. People are frightened when they're around someone who has schizophrenia often.

And so this typically involves engagement with law enforcement or the first responder community, and then patients receive psychiatric evaluation, which then leads to proper and rapid diagnosis of schizophrenia. So 18 to 22, that sort of age span, is typically when schizophrenia presents and is diagnosed.

C360: Is there anything else that you'd like to add today, Dr Jackson?

Dr Jackson: As we said, schizophrenia is a devastating illness. There's a reason why art and literature offer us examples of these patients and their suffering because it invokes tremendous compassion, or it should, from us, not only as clinicians, but in general for society. To have a patient in the flower of youth to absolutely be denuded of personality, of thought, of behavior, of affect, and to have all of those things which make us most human to be threatened by a neuropsychiatric disease at this time of life is a tragedy.

And so to properly diagnose, to properly have compassion and to institute proper treatment for these patients is absolutely critical. And we can do that. We do have wonderful tools at our disposal. We have tools that are in the pipeline, so to speak, to mix metaphors there, and it's a time of hope for patients with schizophrenia because societal understanding is increasing and our capacity for treatment is increasing. And so for both clinicians and patients, I think it's a good time to look to the future in the present in terms of what can be done to arrest the progress of the devastation and deterioration that can occur with this awful illness.

C360: Thank you for your compassion, the work that you're doing with these patients, and for being on the podcast today.

Dr Jackson: Thank you so much for having me.