The gut contains < 200 mL of gas, whereas daily gas expulsion averages 600 to 700 mL after consuming a standard diet plus 200 g of baked beans. About 75% of flatus is derived from colonic bacterial fermentation of ingested nutrients and endogenous glycoproteins. Gases include hydrogen (H2), methane (CH4), and carbon dioxide (CO2). Flatus odor correlates with H2 sulphide concentrations. Swallowed air (aerophagia) and diffusion from the blood into the lumen also contribute to intestinal gas. Gas diffuses between the lumen and the blood in a direction that depends on the difference in partial pressures. Thus, most nitrogen (N2) in the lumen originates from the bloodstream, and most H2 in the bloodstream originates from the lumen.

Etiology

There are 3 main gas-related complaints: excessive belching, distention (bloating), and excessive flatus, each with a number of causes (see Table 11: Symptoms of GI Disorders: Some Causes of Gas-Related Complaints). Infants 2 to 4 mo of age with recurrent crying spells often appear to observers to be in pain, which in the past has been attributed to abdominal cramping or gas and termed colic. However, studies show no increase in H2 production or in mouth-to-cecum transit times in colicky infants. Hence, the cause of infantile colic remains unclear (see Approach to the Care of Normal Infants and Children: Colic).

Excessive belching: Belching (eructation) results from swallowed air or from gas generated by carbonated beverages. Aerophagia occurs normally in small amounts during eating and drinking, but some people unconsciously swallow air repeatedly while eating or smoking and at other times, especially when anxious or in an attempt to induce belching. Excessive salivation increases aerophagia and may be associated with various GI disorders (eg, gastroesophageal reflux disease), ill-fitting dentures, certain drugs, gum chewing, or nausea of any cause.

Most swallowed air is eructated. Only a small amount of swallowed air passes into the small bowel; the amount is apparently influenced by position. In an upright person, air is readily belched; in a supine person, air trapped above the stomach fluid tends to be propelled into the duodenum. Excessive eructation may also be voluntary; patients who belch after taking antacids may attribute the relief of symptoms to belching rather than to antacids and may intentionally belch to relieve distress.

Distention (bloating): Abdominal bloating may occur in isolation or along with other GI symptoms in patients with functional disorders (eg, aerophagia, nonulcer dyspepsia, gastroparesis, irritable bowel syndrome) or organic disorders (eg, ovarian cancer, colon cancer). Gastroparesis (and consequent bloating) also has many nonfunctional causes, the most important of which is autonomic visceral neuropathy due to diabetes; other causes include postviral infection, drugs with anticholinergic properties, and long-term opiate use. However, excessive intestinal gas is not clearly linked to these complaints. In most healthy people, 1 L/h of gas can be infused into the gut with minimal symptoms. It is likely that many symptoms are incorrectly attributed to “too much gas.”

On the other hand, some patients with recurrent GI symptoms often cannot tolerate small quantities of gas: Retrograde colonic distention by balloon inflation or air instillation during colonoscopy often elicits severe discomfort in some patients (eg, those with irritable bowel syndrome) but minimal symptoms in others. Similarly, patients with eating disorders (eg, anorexia nervosa, bulimia) often misperceive and are particularly stressed by symptoms such as bloating. Thus, the basic abnormality in patients with gas-related symptoms may be a hypersensitive intestine. Altered motility may contribute further to symptoms.

Excessive flatus: There is great variability in the quantity and frequency of rectal gas passage. As with stool frequency, people who complain of flatulence often have a misconception of what is normal. The average number of gas passages is about 13 to 21/day. Objectively recording flatus frequency (using a diary kept by the patient) is a first step in evaluation.
Sidebar 1

Essay on Flatulence


(First printed in the 14th Edition of The Merck Manual)


Flatulence, which can cause great psychosocial distress, is unofficially described according to its salient characteristics: (1) the “slider” (crowded elevator type), which is released slowly and noiselessly, sometimes with devastating effect; (2) the open sphincter, or “pooh” type, which is said to be of higher temperature and more aromatic; (3) the staccato or drumbeat type, pleasantly passed in privacy; and (4) the “bark” type (described in a personal communication) is characterized by a sharp exclamatory eruption that effectively interrupts (and often concludes) conversation. Aromaticity is not a prominent feature. Rarely, this usually distressing symptom has been turned to advantage, as with a Frenchman referred to as “Le Petomane,” who became affluent as an effluent performer who played tunes with the gas from his rectum on the Moulin Rouge stage.





Flatus is a metabolic byproduct of intestinal bacteria; almost none originates from swallowed air or back-diffusion of gases (primarily N2) from the bloodstream. Bacterial metabolism yields significant volumes of H2, CH4, and CO2.

H2 is produced in large quantities in patients with malabsorption syndromes and after ingestion of certain fruits and vegetables containing indigestible carbohydrates (eg, baked beans), sugars (eg, fructose), or sugar alcohols (eg, sorbitol). In patients with disaccharidase deficiencies (most commonly lactase deficiency), large amounts of disaccharides pass into the colon and are fermented to H2. Celiac disease, tropical sprue, pancreatic insufficiency, and other causes of carbohydrate malabsorption should also be considered in cases of excess colonic gas.

CH4 is also produced by colonic bacterial metabolism of the same foods (eg, dietary fiber). However, about 10% of people have bacteria that produce CH4 but not H2.

CO2 is also produced by bacterial metabolism and generated in the reaction of HCO3– and H+. H+ may come from gastric HCl or from fatty acids released during digestion of fats—the latter sometimes produces several hundred mEq of H+. The acid products released by bacterial fermentation of unabsorbed carbohydrates in the colon may also react with HCO3– to produce CO2. Although bloating may occasionally occur, the rapid diffusion of CO2 into the blood generally prevents distention.

Diet accounts for much of the variation in flatus production among individuals, but poorly understood factors (eg, differences in colonic flora and motility) may also play a role.

Despite the flammable nature of the H2 and CH4 in flatulence, working near open flames is not hazardous. However, gas explosion, even with fatal outcome, has been reported during jejunal and colonic surgery and colonoscopy, when diathermy was used during procedures in patients with incomplete bowel cleaning.

Table 11

Some Causes of Gas-Related Complaints

Cause
Suggestive Findings
Diagnostic Approach

Belching

Aerophagia (swallowing air)
With or without awareness of swallowing air

Sometimes in patients who smoke or chew gum excessively

Sometimes in patients who have esophageal reflux or ill-fitting dentures
Clinical evaluation

Gas from carbonated beverages
Beverage consumption usually obvious based on history
Clinical evaluation

Voluntary
Patient usually admits when questioned
Clinical evaluation

Distention or bloating

Aerophagia
See Belching
Clinical evaluation

Irritable bowel syndrome
Chronic, recurrent bloating or distention associated with a change in frequency of bowel movements or consistency of stool

No red flag findings

Typically beginning during the teens and 20s
Clinical evaluation

Examination of stool

Blood tests

Gastroparesis
Nausea, abdominal pain, sometimes vomiting

Early satiety

Sometimes in patients known to have a causative disorder
Upper endoscopy and/or nuclear scanning that evaluates stomach emptying

Eating disorders
Long-standing symptoms

In patients who are thin but still very concerned about excess body weight, particularly young women
Clinical evaluation

Constipation if chronic
A long history of hard, infrequent bowel movements
Clinical evaluation

Non-GI disorders (eg, ovarian or colon cancer)
New, persistent bloating in middle-aged or older patients

For colon cancer, sometimes blood in stool (blood may be visible or detected during a doctor's examination)
For ovarian cancer, pelvic ultrasonography

For colon cancer, colonoscopy

Flatus

Dietary substances, including beans, dairy products, vegetables, onions, celery, carrots, Brussels sprouts, fruits (eg, raisins, bananas, apricots, prune juice), and complex carbohydrates (eg, pretzels, bagels, wheat germ)
Symptoms that develop mainly after consuming food that can cause gas
Clinical evaluation

Trial of elimination

Disaccharidase deficiency
Bloating, cramps, and diarrhea after consuming milk products
Breath tests

Celiac disease (eg, celiac sprue, tropical sprue)
Symptoms of anemia, steatorrhea, loss of appetite, diarrhea

For celiac sprue,weakness, symptoms that often begin during childhood

For tropical sprue, nausea, abdominal cramps, weight loss
Blood tests

Biopsy of the small intestine

Pancreatic insufficiency
Diarrhea, steatorrhea

Usually a known history of pancreatic disease
Abdominal CT

Sometimes MRCP, endoscopic ultrasonography, or ERCP

MRCP = magnetic resonance cholangiopancreatography.




Evaluation

History: History of present illness in patients with belching should be directed at finding the cause of aerophagia, especially dietary causes.

In patients complaining of gas, bloating, or flatus, the relationship between symptoms and meals (both timing and type and amount of food), bowel movements, and exertion should be explored. Certain patients, particularly in the acute setting, may use the term "gas" to describe their symptoms of coronary ischemia. Changes in frequency and color and consistency of stool are sought. History of weight loss is noted.

Review of systems should seek symptoms of possible causes, including diarrhea and steatorrhea (malabsorption syndromes such as celiac sprue. tropical sprue, disaccharidase deficiency, and pancreatic insufficiency) and weight loss (cancer, chronic malabsorption).

Past medical history should review all components of the diet for possible causes (see Symptoms of GI Disorders: Some Causes of Gas-Related Complaints).

Physical examination: The examination is generally normal, but in patients with bloating or flatus, signs of an underlying organic disorder should be sought on abdominal, rectal, and (for women) pelvic examination.

Red flags: The following findings are of concern:

Weight loss

Blood in stool (occult or gross)

"Gas" sensation in chest

Interpretation of findings: Chronic, recurrent bloating or distention relieved by defecation and associated with change in frequency or consistency of stool but without red flag findings suggests irritable bowel syndrome.

Long-standing symptoms in an otherwise well young person who has not lost weight are unlikely to be caused by serious physiologic disease, although an eating disorder should be considered, particularly in young women. Bloating accompanied by diarrhea, weight loss, or both (or only after ingestion of certain foods) suggests a malabsorption syndrome.

Testing: Testing is not indicated for belching unless other symptoms suggest a particular disorder. Testing for carbohydrate intolerance (eg, lactose, fructose) with breath tests should be considered particularly when the history suggests significant consumption of these sugars. Testing for small-bowel bacterial overgrowth should also be considered, particularly in patients who also have diarrhea, weight loss, or both, preferably by aerobic and anaerobic culture of small-bowel aspirates obtained during upper GI endoscopy. Testing for bacterial overgrowth with H2 breath tests, generally glucose-H2 breath tests, is prone to false-positive (ie, with rapid transit) and false-negative (ie, when there are no H2-producing bacteria) results. New, persistent bloating in middle-aged or older women (or those with an abnormal pelvic examination) should prompt pelvic ultrasonography to rule out ovarian cancer.

Treatment

Belching and bloating are difficult to relieve because they are usually caused by unconscious aerophagia or increased sensitivity to normal amounts of gas. Aerophagia may be reduced by eliminating gum and carbonated beverages, cognitive behavioral techniques to prevent air swallowing, and management of associated upper GI diseases (eg, peptic ulcer). Foods containing unabsorbable carbohydrates should be avoided. Even lactose-intolerant patients generally tolerate up to 1 glass of milk drunk in small amounts throughout the day. The mechanism of repeated belching should be explained and demonstrated. When aerophagia is troublesome, behavioral therapy to encourage open-mouth, diaphragmatic breathing and minimize swallowing may be effective.

Drugs provide little benefit. Results with simethicone

, an agent that breaks up small gas
bubbles, and various anticholinergics are poor. Some patients with dyspepsia and postprandial upper abdominal fullness benefit from antacids, a low dose of tricyclic antidepressants (eg, nortriptyline

10 to 50 mg po once/day), or both to reduce visceral
hypersensitivity.

Complaints of excess flatus are treated with avoidance of triggering substances (see Table 11: Symptoms of GI Disorders: Some Causes of Gas-Related Complaints). Roughage (eg, bran, psyllium seed) may be added to the diet to try to increase colonic transit; however, in some patients, worsening of symptoms may result. Activated charcoal can sometimes help reduce gas and unpleasant odor; however, it stains clothing and the oral mucosa. Charcoal-lined undergarments are available. Probiotics (eg, VSL#3) may also reduce bloating and flatulence by modulating intestinal bacterial flora. Antibiotics are useful in patients with documented bacterial overgrowth.

Functional bloating, distention, and flatus may run an intermittent, chronic course that is only partially relieved by therapy. When appropriate, reassurance that these problems are not detrimental to health is important.

Key Points

Testing should be guided by the clinical features.

Be wary of new-onset, persistent symptoms in older patients.

Schizoaffective disorder is a mental illness. It includes a mix of the symptoms of schizophrenia, bipolar disorder, and depression.
What is the cause?

The cause of schizoaffective disorder is unknown. It seems to occur more in some families, and stress may trigger symptoms. About one person in 100 has schizoaffective disorder.
What are the symptoms?

Symptoms may include:
hallucinations (you may hear, see, or feel things that aren't there)
delusions (false beliefs)
not taking care of yourself (for example, not bathing or grooming)
speaking in a way that makes no sense to others
withdrawing or feeling isolated from other people
thoughts that race from one idea to the next
feelings of sadness, guilt, hopelessness, and anxiety
feelings of being very happy, powerful, energetic
feeling drained of energy
feeling very energetic
losing or gaining weight
being unable to concentrate
sleeping more or less than normal
How is it diagnosed?

You should tell your healthcare provider or a psychiatrist if you are having symptoms of this disorder. Sometimes it is hard for people with mental illness to recognize that they are not well. Take the advice of your friends or family members if they are encouraging you to seek help.

Your provider will ask about your symptoms, relationships, history of drug and alcohol use, medical problems, and family history of medical conditions and mental illnesses. He or she may do a physical exam or order tests to rule out medical conditions.
How is it treated?

Medicines are the most important part of the treatment of schizoaffective disorder. Many medicines are available. Take your medicine as prescribed, even when you are feeling and thinking well. Otherwise your symptoms are likely to worsen. Watch closely for any side effects of your medicine, and report them to your healthcare provider.

Schizoaffective disorder can change the way you relate to others and the way you think about everyday activities. You may need someone to assist you with your daily needs. You may need help managing your money or running errands, for example. You may live in a group setting with others who also have this illness.

If your symptoms are severe, you may need to go to the hospital until they improve. While you are in the hospital your medicine may be changed, and you may attend groups to learn skills such as how to deal with stress.
How long do the effects last?

Schizoaffective disorder is usually a lifelong illness. Symptoms may go away for awhile, and then come back. This can affect relationships, and make it hard to hold a job or go to school. While there is no cure for this disorder, symptoms may be controlled with proper treatment.
How can I take care of myself?
Get support. Talk with family and friends. Ask your provider or therapist if there are any support groups in your area for people with schizoaffective disorder.
Learn to manage stress. Ask for help at home and work when the load is too great to handle. Find ways to relax, for example take up a hobby, listen to music, watch movies, take walks. Try deep breathing exercises when you feel stressed.
Take care of your physical health. Try to get at least 7 to 9 hours of sleep each night. Eat a healthy diet. Limit caffeine. If you smoke, quit. Avoid alcohol and drugs, because they can make your symptoms worse. Exercise according to your healthcare provider's instructions.
Check your medicines. To help prevent problems, tell your healthcare provider and pharmacist about all the medicines, natural remedies, vitamins, and other supplements that you take. Tell your therapist or healthcare provider about any changes in your symptoms or in the effectiveness of your medicines.
Contact your healthcare provider or therapist if you have any questions or your symptoms seem to be getting worse.
Get emergency care if you or a loved one have serious thoughts of suicide or harming others.

Schizophrenia is a mental disorder characterized by loss of contact with reality (psychosis), hallucinations (usually, hearing voices), firmly held false beliefs (delusions), abnormal thinking, a restricted range of emotions (flattened affect), diminished motivation, and disturbed work and social functioning.

Schizophrenia is probably caused by hereditary and environmental factors.

People may have a variety of symptoms, ranging from bizarre behavior and rambling, disorganized speech to loss of emotions and little or no speech to inability to concentrate and remember.

Doctors diagnose schizophrenia based on symptoms after they do tests to rule out other possible causes.

How well people do depends largely on whether they take the prescribed drugs as directed.

Treatment involves antipsychotic drugs, rehabilitation and community support activities, and psychotherapy.

Schizophrenia is a major health problem throughout the world. The disorder typically strikes young people at the very time they are establishing their independence and can result in lifelong disability and stigma. In terms of personal and economic costs, schizophrenia has been described as among the worst disorders afflicting humankind.

Schizophrenia is the 9th leading cause of disability worldwide. It affects about 1% of the population. Schizophrenia affects men and women equally. In the United States, schizophrenia accounts for about 1 of every 5 Social Security disability days and 2.5% of all health care expenditures. Schizophrenia is more common than Alzheimer's disease and multiple sclerosis.

Determining when schizophrenia begins (onset) is often difficult because unfamiliarity with symptoms may delay medical care for several years. The average age at onset is 18 for men and 25 for women. Onset during childhood or early adolescence is uncommon (see Mental Health Disorders in Children: Childhood Schizophrenia). Onset is also uncommon late in life.

Deterioration in social functioning can lead to substance abuse, poverty, and homelessness. People with untreated schizophrenia may lose contact with their families and friends and often find themselves living on the streets of large cities.


Did You Know...


Schizophrenia is more common than Alzheimer's disease and multiple sclerosis.

Various disorders, including thyroid disorders, brain tumors, seizure disorders, and other mental health disorders, can cause symptoms similar to those of schizophrenia.



Causes

What precisely causes schizophrenia is not known, but current research suggests a combination of hereditary and environmental factors. Fundamentally, however, it is a biologic problem (involving changes in the brain), not one caused by poor parenting or a mentally unhealthy environment. People who have a parent or sibling with schizophrenia have about a 10% risk of developing the disorder, compared with a 1% risk among the general population. An identical twin whose co-twin has schizophrenia has about a 50% risk of developing schizophrenia. These statistics suggest that heredity is involved.

Other causes may include problems that occurred before, during, or after birth, such as influenza in the mother during the 2nd trimester of pregnancy, oxygen deprivation at birth, a low birth weight, and incompatibility of the mother's and infant's blood type.

Symptoms

The onset of schizophrenia may be sudden, over a period of days or weeks, or slow and insidious, over a period of years. Although the severity and types of symptoms vary among different people with schizophrenia, the symptoms are usually sufficiently severe as to interfere with the ability to work, interact with people, and care for oneself. In some people with schizophrenia, mental function declines, leading to an impaired ability to pay attention, think in the abstract, and solve problems. The severity of mental impairment largely determines overall disability in people with schizophrenia.

Symptoms may be triggered or worsened by environmental stresses, such as stressful life events. Drug use, including use of marijuana, may trigger or worsen symptoms as well.

Categories: Overall, the symptoms of schizophrenia fall into four major categories:

Positive symptoms

Negative symptoms

Disorganization

Cognitive impairment

People may have symptoms from one, two, or all categories.

Positive symptoms involve an excess or a distortion of normal functions. They include the following:

Delusions are false beliefs that usually involve a misinterpretation of perceptions or experiences. For example, people with schizophrenia may have persecutory delusions, believing that they are being tormented, followed, tricked, or spied on. They may have delusions of reference, believing that passages from books, newspapers, or song lyrics are directed specifically at them. They may have delusions of thought withdrawal or thought insertion, believing that others can read their mind, that their thoughts are being transmitted to others, or that thoughts and impulses are being imposed on them by outside forces.

Hallucinations of sound, sight, smell, taste, or touch may occur, although hallucinations of sound (auditory hallucinations) are by far the most common. People may hear voices in their head commenting on their behavior, conversing with one another, or making critical and abusive comments.

Negative symptoms involve a decrease in or loss of normal functions. They include the following:

Blunted affect refers to a flattening of emotions. The face may appear immobile. People make little or no eye contact and lack emotional expressiveness. Events that would normally make them laugh or cry produce no response.

Poverty of speech refers to a decreased amount of speech. Answers to questions may be terse, perhaps one or two words, creating the impression of an inner emptiness.

Anhedonia refers to a diminished capacity to experience pleasure. People may take little interest in previous activities and spend more time in purposeless ones.

Asociality refers to a lack of interest in relationships with other people. These negative symptoms are often associated with a general loss of motivation, sense of purpose, and goals.

Disorganization involves thought disorders and bizarre behavior:

Thought disorder refers to disorganized thinking, which becomes apparent when speech is rambling or shifts from one topic to another. Speech may be mildly disorganized or completely incoherent and incomprehensible.

Bizarre behavior may take the form of childlike silliness, agitation, or inappropriate appearance, hygiene, or conduct. Catatonia is an extreme form of bizarre behavior in which people maintain a rigid posture and resist efforts to be moved or, in contrast, display purposeless and unstimulated motor activity.

Cognitive impairment refers to difficulty concentrating, remembering, organizing, planning, and problem solving. Some people are unable to concentrate sufficiently to read, follow the story line of a movie or television show, or follow directions. Others are unable to ignore distractions or remain focused on a task. Consequently, work that involves attention to detail, involvement in complicated procedures, and decision making may be impossible.










Disorders That Resemble Schizophrenia


General medical and neurologic conditions such as thyroid disorders, brain tumors, seizure disorders, kidney failure, toxic reactions to drugs, and vitamin deficiencies can sometimes cause symptoms similar to those of schizophrenia. In addition, a number of mental disorders share features of schizophrenia.

Brief psychotic disorder: Symptoms of this disorder resemble those of schizophrenia but last only for 1 day to 1 month. This time-limited disorder often occurs in people with a preexisting personality disorder or in people who have experienced a severe stress, such as loss of a loved one.

Schizophreniform disorder: The schizophrenia-like symptoms characteristic of this disorder last for 1 to 6 months. This disorder may resolve or may progress to manic-depressive illness or schizophrenia.

Schizoaffective disorder: This disorder is characterized by the presence of mood symptoms, such as depression or mania, plus more typical symptoms of schizophrenia.

Schizotypal personality disorder: This personality disorder (see Personality Disorders: Schizotypal personality disorder) may share symptoms of schizophrenia, but they are generally not severe enough to meet the criteria for psychosis. People with this disorder tend to be shy and to isolate themselves and may be mildly suspicious and have other disturbances in thinking. Genetic studies indicate that schizotypal personality disorder may be a mild form of schizophrenia.



Subtypes of Schizophrenia: Some researchers believe schizophrenia is a single disorder, but others believe it is a syndrome (a collection of symptoms) based on numerous underlying disorders. Subtypes of schizophrenia have been proposed in an effort to classify people into more distinct groups. However, the subtype in a particular person may change over time. Subtypes include the following:

Paranoid: People are preoccupied with delusions or auditory hallucinations. Disorganized speech and inappropriate emotions are less prominent.

Disorganized: Speech and behavior are disorganized, and people do not express emotions or have inappropriate emotions.

Catatonic: Symptoms are mainly physical. They include immobility, excessive motor activity, and assumption of bizarre postures.

Undifferentiated: People have a mixture of symptoms from the other subtypes: delusions and hallucinations, thought disorder and bizarre behavior, and negative symptoms.

Residual: People have had a clear history of prominent schizophrenia symptoms that are followed by a long period of mild negative symptoms.

Diagnosis

No definitive test exists to diagnose schizophrenia. A doctor makes the diagnosis based on a comprehensive assessment of a person's history and symptoms. Schizophrenia is diagnosed when symptoms persist for at least 6 months and cause significant deterioration in work, school, or social functioning. Information from family members, friends, or teachers is often important in establishing when the disorder began.

Laboratory tests are often done to rule out substance abuse or an underlying medical, neurologic, or hormonal disorder that can have features of psychosis. Examples of such disorders include brain tumors, temporal lobe epilepsy, thyroid disorders, autoimmune disorders, Huntington's disease, liver disorders, and side effects of drugs. Testing for drug abuse is sometimes done.

People with schizophrenia have brain abnormalities that may be seen on a computed tomography (CT) or magnetic resonance imaging (MRI) scan. However, the abnormalities are not specific enough to help in diagnosing schizophrenia.


Did You Know...


About 10% of people with schizophrenia commit suicide.



Prognosis

For people with schizophrenia, the prognosis depends largely on adherence to drug treatment. Without drug treatment, 70 to 80% of people have another episode within the first year after diagnosis. Drugs taken continuously can reduce this percentage to about 20 to 30% and can lessen the severity of symptoms significantly in most people. After discharge from a hospital, people who do not take prescribed drugs are very likely to be readmitted within the year. Taking drugs as directed dramatically reduces the likelihood of being readmitted.

Despite the proven benefit of drug therapy, half of people with schizophrenia do not take their prescribed drugs. Some do not recognize their illness and resist taking drugs. Others stop taking their drugs because of unpleasant side effects. Memory problems, disorganization, or simply a lack of money prevents others from taking their drugs.

Adherence is most likely to improve when specific barriers are addressed. If side effects of drugs are a major problem, a change to a different drug may help. A consistent, trusting relationship with a doctor or other therapist helps some people with schizophrenia to accept their illness more readily and recognize the need for adhering to prescribed treatment.

Over longer periods, the prognosis varies. In general, one third of people achieve significant and lasting improvement, one third achieve some improvement with intermittent relapses and residual disabilities, and one third experience severe and permanent incapacity. Factors associated with a better prognosis include the following:

Sudden onset of the disorder

Older age at onset

A good level of skills and accomplishments before becoming ill

Presence of positive rather than negative symptoms

Factors associated with a poor prognosis include the following:

Younger age at onset

Poor social and vocational functioning before becoming ill

A family history of schizophrenia

Presence of negative rather than positive symptoms

About 10% of people with schizophrenia commit suicide.










What Is Neuroleptic Malignant Syndrome?


Neuroleptic malignant syndrome is unresponsiveness caused by use of certain antipsychotic drugs. It develops in up to 3% of people who are treated with antipsychotic drugs, usually within the first few weeks of treatment. The syndrome is most common among men who, because they are agitated, are given rapidly increased doses of the drugs or high doses initially.

Symptoms include muscle rigidity, a dangerously high temperature, a fast heart rate, a fast breathing rate, high blood pressure, and coma. Damaged muscles release the protein myoglobin, which is excreted in the urine. Myoglobin turns the urine brown. This condition (myoglobinuria) can result in kidney damage or even kidney failure.

People with this syndrome are usually treated in an intensive care unit. The antipsychotic drug is stopped, fever is controlled (usually by wetting people and blowing air on them and by placing special cooling blankets on them). People are also given a muscle relaxant (such as bromocriptine

or dantrolene
). Giving sodium bicarbonate
intravenously helps prevent myoglobulinuria by making the urine alkaline.

Almost 30% of people with this syndrome die, but most of the rest recover completely. After recovery, up to 30% of people develop the syndrome again if they are given the same antipsychotic drug.



Treatment

Generally, treatment aims

To reduce the severity of psychotic symptoms

To prevent the recurrence of symptomatic episodes and the associated deterioration in functioning

To provide support and thus enable people to function at the highest level possible

Antipsychotic drugs, rehabilitation and community support activities, and psychotherapy are the major components of treatment.

Antipsychotic Drugs: Drugs can be effective in reducing or eliminating symptoms, such as delusions, hallucinations, and disorganized thinking. After the immediate symptoms have cleared, the continued use of antipsychotic drugs substantially reduces the probability of future episodes. However, antipsychotic drugs have significant side effects, which can include drowsiness, muscle stiffness, tremors, weight gain, and motor restlessness. Antipsychotic drugs may also cause tardive dyskinesia, an involuntary movement disorder most often characterized by puckering of the lips and tongue or writhing of the arms or legs. Tardive dyskinesia may not go away even after the drug is stopped. For tardive dyskinesia that persists, there is no effective treatment. A rare but potentially fatal side effect of antipsychotic drugs is neuroleptic malignant syndrome. It is characterized by muscle rigidity, fever, high blood pressure, and changes in mental function (such as confusion and lethargy).

Some newer antipsychotic drugs, termed second-generation antipsychotic drugs, have fewer side effects. However, these drugs seem to cause significant weight gain. They also increase the risk of the metabolic syndrome (see Obesity and the Metabolic Syndrome: Metabolic Syndrome). In this syndrome, fat accumulates in the abdomen, blood levels of triglycerides (a fat) are elevated, levels of high density cholesterol (HDL, the “good” cholesterol) are low, and blood pressure is high. Also, insulin is less effective (called insulin resistance), increasing the risk of diabetes. These drugs may relieve positive symptoms (such as hallucinations), negative symptoms (such as lack of emotion), and cognitive impairment (such as reduced mental functioning and attention span) to a greater extent than the older antipsychotic drugs, although some doctors question these differences.

Clozapine
, the first of the second-generation antipsychotic drugs, is effective in up to half of
people who do not respond to other antipsychotic drugs. However, clozapine
can have
serious side effects, such as seizures or potentially fatal suppression of bone marrow activity (which includes making blood cells). Thus, it is usually used only for people who have not responded to other antipsychotic drugs. People who take clozapine
must have their white
blood cell count measured weekly, at least for the first 6 months, so that clozapine
can be
stopped at the first indication that the number of white blood cells is decreasing.

Rehabilitation and Community Support Activities: Community support activities, such as on-the-job coaching, are directed at teaching the skills needed to survive in the community. These skills enable people with schizophrenia to work, shop, care for themselves, manage a household, and get along with others. Hospitalization may be needed during severe relapses, and involuntary hospitalization may be needed if people pose a danger to themselves or others. However, the general goal is to have people live in the community. To achieve this goal, some people need to live in a supervised apartment or group home where someone can ensure that drugs are taken as prescribed.

A few people with schizophrenia are unable to live independently, either because they have severe, persistent symptoms or because they lack the skills necessary to live in the community. They usually require full-time care in a safe and supportive setting.

Psychotherapy: Generally, psychotherapy aims to establish a collaborative relationship between people, their family members, and doctor. That way people may learn to understand and manage their disorder, to take antipsychotic drugs as prescribed, and to manage stresses that can aggravate the disorder. A good doctor-patient relationship is often a major determinant of whether treatment is successful. Psychotherapy reduces the severity of symptoms in some people and helps prevent relapse in others.