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Friday, July 31, 2026

Critical period

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Critical_period

In imprinting and developmental biology, a critical period is a maturational stage in the lifespan of an organism during which the nervous system is especially sensitive to certain environmental stimuli. If, for some reason, the organism does not receive the appropriate stimulus during this "critical period" to learn a given skill or trait, it may be difficult, ultimately less successful, or even impossible, to develop certain associated functions later in life.[citation needed] Functions that are indispensable to an organism's survival, such as vision, are particularly likely to develop during critical periods. "Critical period" also relates to the ability to acquire one's first language. Researchers found that people who passed the "critical period" without having developed communication skills would not acquire their first language fluently.

Some researchers differentiate between 'strong critical periods' and 'weak critical periods' (also known as 'sensitive' periods)—defining 'weak critical periods' / 'sensitive periods' as more extended periods, after which learning is still possible. Other researchers consider these the same phenomenon.

For example, the critical period for the development of a human child's binocular vision is thought to be between three and eight months, with sensitivity to damage extending up to at least three years of age. Further critical periods have been identified for the development of hearing and the vestibular system.

Strong versus weak critical periods

Examples of strong critical periods include monocular deprivation, filial imprinting, monaural occlusion, and Prefrontal Synthesis acquisition. These traits cannot be acquired after the end of the critical period.

Examples of weak critical periods include phoneme tuning, grammar processing, articulation control, vocabulary acquisition, music training, auditory processing, sport training, and many other traits that can be significantly improved by training at any age.

Critical period mechanisms

Critical period opening

Critical periods of plasticity occur in the prenatal brain and continue throughout childhood until adolescence and are very limited during adulthood. Two major factors influence the opening of critical periods: cellular events (i.e. changes in molecular landscape) and sensory experience (i.e. hearing sound, visual input, etc.). Both need to coincide for the critical period to open properly. At the cellular level, critical periods are characterized by maturation of the inhibitory circuits. More precisely, factors such as brain-derived neurotrophic factor (BDNF) and orthodenticle homeobox 2 (Otx2) contribute to the maturation of a major class of inhibitory neurons: parvalbumin-positive interneurons (PV cells). Prior to the onset of the critical period, modulation of this circuit is hampered by early factors such as polysialic acid (PSA). PSA acts, in part, by preventing Otx2 interaction with PV cells. Soon after the opening of the critical period, PSA levels decrease, allowing PV cell maturation by activating inhibitory GABAa receptors that facilitate inhibitory circuit remodeling. Artificially removing PSA, or experimentally manipulating inhibitory transmission can result in early opening of the critical period. While the timing of these molecular events seems to be partially explained by clock genes, experience is crucial as sensory deprivation experiments have been shown to interfere with the proper timing of critical periods.

Activity-dependent competition

Hebbian theory guides the idea of activity-dependent competition: if two neurons both have the potential to make a connection with a cell, the neuron that fires more will make the connection.

Ocular dominance

This phenomenon of activity-dependent competition is especially seen in the formation of ocular dominance columns within the visual system. Early in development, most of the visual cortex is binocular, meaning it receives roughly equal input from both eyes. Normally, as development progresses, the visual cortex will segregate into monocular columns that receive input from only one eye. However, if one eye is patched, or otherwise prevented from receiving sensory input, the visual cortex will shift to favor representation of the uncovered eye. This demonstrates activity-dependent competition and Hebbian theory because inputs from the uncovered eye make and retain more connections than the patched eye.

Axon growth

Axon formation and growth is another key part of plasticity and activity-dependent competition. Axon growth and branching has been shown to be inhibited when the neuron's electrical activity is suppressed below the level of an active neighbor. This shows that axonal growth dynamics are not independent but rather depend on the local circuits within which they are active (i.e. the activity of the other neurons competing for connections).

Microglia

Microglia inherently play a role in synaptic pruning during adolescence. As resident immune cells of the central nervous system, microglia's main role is phagocytosis and engulfment. Studies have found that during critical periods in the visual cortex, neural synapses become the target of microglial phagocytosis. Neurons who received less frequent input from retinal ganglion cells during early postnatal periods were more prone to be engulfed and pruned by microglia, as per monocular deprivation experiments. Similar results were found when manipulating G-coupled purinergic receptors on microglial processes. Blocking these receptors or performing a knockout experiment significantly lowered microglial interactions and synaptic pruning during the early visual cortex critical period. More recently, the expression of the complement component 4 gene has been found to significantly contribute to abnormally high levels of microglial synaptic pruning during early stages of development in the neurons and microglia of schizophrenics, suggesting a genomic connection between the immune system and critical periods.

Spine motility

Dendritic spine motility is the altering of the dendritic morphology of a neuron, specifically the appearing and disappearing of the small protrusions known as spines. In early postnatal development, spine motility has been found to be at very high levels. Due to its most pronounced occurrence during postnatal days 11 through 15, spine motility is thought to have a role in neurogenesis. Motility levels significantly decrease before the start of the visual cortex critical period and monocular deprivation experiments show that motility levels steadily decrease until the critical period is over, hinting that motility might not be explicitly involved in this process. However, binocular deprivation before eye-opening resulted in a significant up-regulation of spine motility until the peak of the critical period, resulting in controversial findings regarding the role of dendritic spine motility.

Excitatory-inhibitory balance

Another critical component of neuronal plasticity is the balance of excitatory and inhibitory inputs. Early in development, GABA, the major inhibitory neurotransmitter in the adult brain, exhibits an excitatory effect on its target neurons. However, due to changes in internal chloride levels due to the up-regulation of potassium chloride pumps, GABA then switches to inhibitory synaptic transmission. The maturation of the GABAergic inhibitory system helps to trigger the onset of critical periods. Strengthened GABAergic systems can induce an early critical period, while weaker GABAergic inputs can delay or even prevent plasticity. Inhibition also guides plasticity once the critical period has begun. For example, lateral inhibition is especially important in guiding columnar formation in the visual cortex. Hebbian theory provides insight on the importance of inhibition within neural networks: without inhibition, there would be more synchronous firing and therefore more connections, but with inhibition, fewer excitatory signals get through, allowing only the more salient connections to mature.

Critical period closure

Perineuronal nets

Critical period closure has been shown to be modulated by the maturation of inhibitory circuits, mediated by the formation of perineuronal nets around inhibitory neurons. Perineuronal nets (PNNs) are structures in the extracellular matrix formed by chondroitin sulfate proteoglycans, hyaluronan, and link proteins. These structures envelop the soma of inhibitory neurons in the central nervous system, appearing with age to stabilize mature circuits. PNN development coincides with the closure of critical periods, and both PNN formation and critical period timing is delayed in dark-rearing. For example, PNN digestion by ABC chondroitinase in rats leads to a shift in ocular dominance upon monocular deprivation, which is normally restricted to its critical period much earlier in development.

Additionally, PNNs are negatively charged, which is theorized to create a cation-rich environment around cells, potentially leading to an increased firing rate of inhibitory neurons, thereby allowing for increased inhibition after the formation of PNNs and helping to close the critical period. The role of PNNs in critical period closure is further supported by the finding that fast-spiking parvalbulmin-positive interneurons are often surrounded by PNNs.

Perineuronal nets have also been found to contain chemorepulsive factors, such as semaphorin3A, which restrict axon growth necessary for plasticity during critical periods. In all, these data suggest a role for PNNs in the maturation of CNS inhibition, the prevention of plastic axonal growth, and subsequently, critical period closure.

Myelin

Another mechanism that closes the critical period is myelination. Myelin sheaths are formed by oligodendrocytes in the CNS that wrap around segments of axons to increase their firing speed. Myelin is formed in the early stages of development and progresses in waves, with brain areas of later phylogenetic development (i.e. those associated with "higher" brain functions like the frontal lobes) having later myelination. The maturation of myelination in intracortical layers coincides with critical period closure in mice, which has led to further research on the role of myelination on critical period duration.

Myelin is known to bind many different axonal growth inhibitors that prevent plasticity seen in critical periods. The Nogo receptor is expressed in myelin and binds to the axonal growth inhibitors Nogo and Myelin-associated glycoprotein (MAG) (among others), preventing axon growth in mature, myelinated neurons. Instead of affecting the timing of the critical period, mutations of the Nogo receptor prolong the critical period temporarily. A mutation of the Nogo receptor in mice was found to extend the critical period for monocular dominance from around 20–32 days to 45 or 120 days, suggesting a likely role of the myelin Nogo receptor in critical period closure.

Additionally, the effects of myelination are temporally limited, since myelination itself may have its own critical period and timing. Research has shown that social isolation of mice leads to reduced myelin thickness and poor working memory, but only during a juvenile critical period. In primates, isolation is correlated with abnormal changes in white matter potentially due to decreased myelination.

In all, myelin and its associated receptors bind several important axonal growth inhibitors which help close the critical period. The timing of this myelination, however, is dependent on the brain region and external factors such as the social environment.

Neuromodulation

While the presence or absence of sensory experiences most robustly shapes brain development during the critical period, the behavioral context (i.e. the amount of attention, arousal, fear and reward experienced) concurrent with the sensory inputs have been suggested to be important in regulating the brain remodeling mechanisms. In terms of brain connectivity, these behavioral and contextual inputs activate the neuromodulatory system, which have substantial connectivity to the cortex. The molecular effectors released by the neuromodulatory system are called neuromodulators, which include acetylcholine, dopamine, and noradrenaline among others. Investigating the effect of these molecules, as well as the neurons that release and bind them, has been one approach to elucidate the biology of neuromodulation. Research using this approach has highlighted the role of neuromodulation in sensory processing during the critical period. For example, in kittens, a shift in ocular dominance resulting from monocular deprivation during the critical period is reduced by combined destruction of noradrenergic and cholinergic neurons. In addition, prenatal exposure to selective serotonin reuptake inhibitors (SSRI) causes a shift in perceptual narrowing on language to earlier in development. On the other hand, neuromodulatory stimulation has been shown to induce brain plasticity in adult mice. While being subjected to cholinergic or dopaminergic stimulation, adult mice listening to a tone of specific frequency exhibited expansion of the tonotopic area in the auditory cortex that responds specifically to sounds of that frequency.

Mechanistically, neuromodulation is increasingly being recognized for its fine-tuning of the PV cell-mediated inhibition of excitatory pyramidal neurons' soma. Central to the neuromodulatory regulation of PV cell activity is the existence of distinct subsets of inhibitory neurons, which are responsive to activation by neuromodulators and which inhibit PV cells. Within these cells, some also inhibit specific pyramidal cell dendrites. By inhibiting PV cells activity, the neuromodulator-sensitive inhibitory cells such as those expressing vasoactive intestinal peptide (VIP) or somatostatin (SST) lift the inhibition of the pyramidal neurons; in other words, the activity of VIP and SST-expressing cells result in the disinhibition of pyramidal neurons. Then, by inhibiting only certain dendritic branches of these now dis-inhibited pyramidal neurons, the neuromodulation-activated cells allow select sensory inputs to excite the pyramidal neurons and be represented in the brain circuitry. Thus, in a landscape of global inhibition by maturing inhibitory signaling, neuromodulation allows windows of dis-inhibition, temporally and spatially, that allow behaviorally important sensory inputs the opportunity to influence the brain.

Linguistics

First language acquisition

The critical period hypothesis (CPH) states that the first few years of life constitute the time during which language develops readily and after which (sometime between age 5 and puberty) language acquisition is much more difficult and ultimately less successful. The hypothesis that language is acquired during a critical period was first proposed by neurologists Wilder Penfield and Lamar Roberts in 1959 and popularized by linguist Eric Lenneberg in 1967. Lenneberg argued for the hypothesis based on evidence that children who experience brain injury early in life develop far better language skills than adults with similar injuries.

Maria Montessori was one of the earlier educators who brought attention to this phenomenon and called it "sensitive periods", which is one of the pillars of her philosophy of education.

The two most famous cases of children who failed to acquire language after the critical period are the feral children Victor of Aveyron and Genie. However, the tragic circumstances of these cases and the moral and ethical impermissibility of replicating them make it difficult to draw conclusions about them. The children may have been cognitively disabled from infancy, or their inability to develop language may have resulted from the profound neglect and abuse they suffered.

Many subsequent researchers have further developed the CPH, most notably Elissa Newport and Rachel Mayberry. Studies conducted by these researchers demonstrated that profoundly deaf individuals who are not exposed to a sign language as children never achieve full proficiency, even after 30 years of daily use. While the effect is most profound for individuals who receive no sign language input until after the age of 12, even those deaf people who began learning a sign language at age 5 were significantly less fluent than native deaf signers (whose exposure to a sign language began at birth). Early language exposure also affects the ability to learn a second language later in life: profoundly deaf individuals with early language exposure achieve comparable levels of proficiency in a second language to hearing individuals with early language exposure. In contrast, deaf individuals without early language exposure perform far worse.

Other evidence comes from neuropsychology where it is known that adults well beyond the critical period are more likely to suffer permanent language impairment from brain damage than are children, believed to be due to youthful resiliency of neural reorganization.

Steven Pinker discusses the CPH in his book, The Language Instinct. According to Pinker, language must be viewed as a concept rather than a specific language because the sounds, grammar, meaning, vocabulary, and social norms play an important role in the acquisition of language. Physiological changes in the brain are also conceivable causes for the terminus of the critical period for language acquisition. As language acquisition is crucial during this phase, similarly infant–parent attachment is crucial for social development of the infant. An infant learns to trust and feel safe with the parent, but there are cases in which the infant might be staying at an orphanage where it does not receive the same attachment with their caregiver. Research shows that infants who were unable to develop this attachment had major difficulty in keeping close relationships, and had maladaptive behaviors with adopted parents.

The discussion of language critical period suffers from the lack of a commonly accepted definition of language. Some aspects of language, such as phoneme tuning, grammar processing, articulation control, and vocabulary acquisition can be significantly improved by training at any age and therefore have weak critical periods. Other aspects of language, such as prefrontal synthesis, have strong critical periods and cannot be acquired after the end of the critical period. Consequently, when language is discussed in general, without dissection into components, arguments can be constructed both in favor and against the strong critical period of L1 acquisition.

Second language acquisition

The theory has often been extended to a critical period for second language acquisition (SLA), which has influenced researchers in the field on both sides of the spectrum, supportive and unsupportive of CPH, to explore. However, the nature of this phenomenon has been one of the most fiercely debated issues in psycholinguistics and cognitive science in general for decades.

Certainly, older learners of a second language rarely achieve the native-like fluency that younger learners display, despite often progressing faster than children in the initial stages. This is generally accepted as evidence supporting the CPH. Incorporating the idea, "younger equals better" by Penfield, David Singleton (1995) states that in learning a second language there are many exceptions, noting that five percent of adult bilinguals master a second language even though they begin learning it when they are well into adulthood—long after any critical period has presumably come to a close. The critical period hypothesis holds that first language acquisition must occur before cerebral lateralization completes, at about the age of puberty. One prediction of this hypothesis is that second language acquisition is relatively fast, successful, and qualitatively similar to first language only if it occurs before the age of puberty. To grasp a better understanding of SLA, it is essential to consider linguistic, cognitive, and social factors rather than age alone, as they are all essential to the learner's language acquisition.

Over the years, researchers have tried to find evidence in support of or against the critical periods for second language acquisition. Many have found evidence that young children acquire language more easily than adults, but there are also special cases of adults acquiring a second language with native-like proficiency. Thus it has been difficult for researchers to separate correlation from causation.

In 1989, Jacqueline S. Johnson and Elissa L. Newport found support for the claim that second languages are more easily acquired before puberty, or more specifically before the age of seven. They tested second language learners of English who arrived in the United States at various ages ranging from three to thirty-nine, and found that there was a decline in grammatical correctness after the age of seven. Johnson and Newport attributed this claim to a decline in language learning ability with age. Opponents of the critical period argue that the difference in language ability found by Johnson and Newport could be due to the different types of input that children and adults receive; children received reduced input while adults receive more complicated structures.

Additional evidence against a strict critical period is also found in the work of Pallier et al. (2003) who found that children adopted to France from Korea were able to become native-like in their performance of French even after the critical period for phonology. Their experiment may represent a special case where subjects must lose their first language in order to more perfectly acquire their second.

There is also some debate as to how one can judge the native-like quality of the speech participants produce and what exactly it means to be a near-native speaker of a second language. White et al. found that it is possible for non-native speakers of a language to become native-like in some aspects, but those aspects are influenced by their first language.

Recently, a connectionist model has been developed to explain the changes that take place in second language learning assuming that sensitive period affects lexical learning and syntactic learning parts of the system differently, which sheds further light on how first and second language acquisition changes over the course of learners development.

Vision

In mammals, neurons in the brain that process vision actually develop after birth based on signals from the eyes. A landmark experiment by David H. Hubel and Torsten Wiesel (1963) showed that cats that had one eye sewn shut from birth to three months of age (monocular deprivation) only fully developed vision in the open eye. They showed that columns in the primary visual cortex receiving inputs from the other eye took over the areas that would normally receive input from the deprived eye. In general electrophysiological analyses of axons and neurons in the lateral geniculate nucleus showed that the visual receptive field properties was comparable to adult cats. However, the layers of cortex that were deprived had less activity and fewer responses were isolated. The kittens had abnormally small ocular dominance columns (part of the brain that processes sight) connected to the closed eye, and abnormally large, wide columns connected to the open eye. Because the critical period time had elapsed, it would be impossible for the kittens to alter and develop vision in the closed eye. This did not happen to adult cats even when one eye was sewn shut for a year because they had fully developed their vision during their critical period. Later experiments in monkeys found similar results consistent with the strong critical period.

In a follow-up experiment, Hubel and Wiesel (1963) explored the cortical responses present in kittens after binocular deprivation; they found it difficult to find any active cells in the cortex, and the responses they did get were either slow-moving or fast-fatiguing. Furthermore, the cells that did respond selected for edges and bars with distinct orientation preferences. Nevertheless, these kittens developed normal binocularity. Hubel and Wiesel first explained the mechanism, known as orientation selectivity, in the mammalian visual cortex. Orientation tuning, a model that originated with their model, is a concept in which receptive fields of neurons in the LGN excite a cortical simple cell and are arranged in rows. This model was important because it was able to describe a strong critical period for the proper development of normal ocular dominance columns in the lateral geniculate nucleus, and thus able to explain the effects of monocular deprivation during this critical period. The critical period for cats is about three months and for monkeys, about six months.

In a similar experiment, Antonini and Stryker (1993) examined the anatomical changes that can be observed after monocular deprivation. They compared geniculocortical axonal arbors in monocularly deprived animals in the long term (4 weeks) to short term (6–7 days) during the critical period established by Hubel and Wiesel (1993). They found that in the long term, monocular deprivation causes reduced branching at the end of neurons, while the amount of afferents allocated to the nondeprived eye increased. Even in the short term, Antonini and Stryker (1993) found that geniculocortical neurons were similarly affected. This supports the aforementioned concept of a critical period for proper neural development for vision in the cortex.

Studies of people whose sight has been restored after a long blindness (whether from birth or a later point in life) reveal that they cannot necessarily recognize objects and faces (as opposed to color, motion, and simple geometric shapes). Some hypothesize that being blind during childhood prevents some part of the visual system necessary for these higher-level tasks from developing properly. The general belief that a critical period lasts until age 5 or 6 was challenged by a 2007 study that found that older patients could improve these abilities with years of exposure.

Expression of the protein Lynx1 has been associated with the normal end of the critical period for synaptic plasticity in the visual system.

Imprinting

Konrad Lorenz

In psychology, imprinting is any type of rapid learning that occurs in a particular life stage. While this rapid learning is independent of the behavioral outcome, it also establishes it and can affect behavioral responses to different stimuli. Konrad Lorenz is well known for his classic studies of filial imprinting in graylag geese. From 1935 to 1938, he presented himself to a group of newly hatched gosling and took note of how he was instantly accepted, followed, and called to as if he were the one who laid them himself. As the first moving object they encountered, Lorenz studied the phenomenon in how quickly the geese were able to form such an irreversible bond. Through his work he demonstrated that this only developed during a brief "critical period", which was about a few hours after hatching, suggesting a strong critical period.

Lorenz also discovered a long-lasting effect of his studies, and that was a shift in the species' sexual imprinting as a result from imprinting upon a foster mother of a second species. For certain species, when raised by a second one, they develop and retain imprinted preferences and approach the second species they were raised by rather than choose their own, if given a choice.

Imprinting serves as the distinguishing factor between one's own mother and other mother figures. The mother and the infant both identify with each other, this is a strong bonding moment for humans. It provides a sort of model or guide to adult behaviors in addition to other factors such as nurture, protection in infancy, guidance, and nourishment. The imprinting process, Lorenz also found, brought about a sense of familiarity for the young animals. When such a strong bond is formed at such an early stage, it creates a sense of security and comfort for the subject and actually encourages the imprinting behavior.

Pheromones play a key role in the imprinting process, they trigger a biochemical response in the recipient, leading to a confirmed identification in the other individual. If direct contact between mother and infant is not maintained during the critical imprinting period, then the mother goose may reject the infant because she is unfamiliar with her newborn's scent. If that does happen, then the infant's life would be in jeopardy unless it were claimed by a substitute mother, possibly leading to awkward social behavior in later life. In relation to humans, a newborn during the critical period identifies with its mother's and other peoples' scents since its scent is one of the most developed senses at that stage in life. The newborn uses this pheromone identification to seek the people it identifies with, when in times of distress, hunger, and discomfort as a survival skill. Inferences could be made for newborns based upon Lorenz's studies. When imprinting on their mothers, newborns look to them for nourishment, a sense of security, and comfort. Human newborns are among the most helpless known with orangutan newborns ranking second. Newborns of these species have a very limited array of innate survival abilities. Their most important and functional ability is to form bonds with close individuals who are able to keep them alive. Imprinting is a crucial factor of the critical period because it facilitates the newborn's abilities to form bonds with other individuals, from infancy to adulthood.

Auditory processing

Many studies have supported a correlation between the type of auditory stimuli present in the early postnatal environment and the development on the topographical and structural development of the auditory system.

First reports on critical periods came from deaf children and animals that received a cochlear implant to restore hearing. Approximately at the same time, both an electroencephalographic study by Sharma, Dorman and Spahr and an in-vivo investigation of the cortical plasticity in deaf cats by Kral and colleagues demonstrated that the adaptation to the cochlear implant is subject to an early, developmental sensitive period. The closure of sensitive periods likely involves a multitude of processes that in their combination make it difficult to reopen these behaviorally. The understanding of the mechanisms behind critical periods has consequences for medical therapy of hearing loss. M. Merzenich and colleagues showed that during an early critical period, noise exposure can affect the frequency organization of the auditory cortex.

Recent studies have examined the possibility of a critical period for thalamocortical connectivity in the auditory system. For example, Zhou and Merzenich (2008) studied the effects of noise on development in the primary auditory cortex in rats. In their study, rats were exposed to pulsed noise during the critical period and the effect on cortical processing was measured. Rats that were exposed to pulsed noise during the critical period had cortical neurons that were less able to respond to repeated stimuli; the early auditory environment interrupted normal structural organization during development.

In a related study, Barkat, Polley and Hensch (2011) looked at how exposure to different sound frequencies influences the development of the tonotopic map in the primary auditory cortex and the ventral medical geniculate body. In this experiment, mice were reared either in normal environments or in the presence of 7 kHz tones during early postnatal days. They found that mice that were exposed to an abnormal auditory environment during a critical period P11-P15 had an atypical tonotopic map in the primary auditory cortex. These studies support the notion that exposure to certain sounds within the critical period can influence the development of tonotopic maps and the response properties of neurons. Critical periods are important for the development of the brain for the function from a pattern of connectivity. In general, the early auditory environment influences the structural development and response specificity of the primary auditory cortex.

Absolute pitch

Absolute pitch manifests itself almost always before adolescence and rarely if ever among individuals who are first exposed to music after mid-childhood, suggesting that exposure to music or similar phenomena (e.g., tonal languages) in early to mid-childhood is a necessary condition for its development or refinement. Studies that ask musicians and non-musicians to sing or hum well-known popular songs that have definitive recordings (and hence are sung in standardized keys) show that—on average—participants sing within a semitone of the standardized key but that outside the small subset of participants with absolute pitch there is broad variation (the "bell curve" that reflects the degree of approximation to the standard key is broad and flat). These results suggest that almost all humans have some innate aptitude for absolute pitch recognition—though other factors may enhance or limit the level of that aptitude. Also, the results' conjunction with the aforementioned chronological observations suggests that early to mid-childhood exposure to environments whose interpretation depends on pitch is a developmental "trigger" for whatever aptitude an individual possesses.

Vestibular system

In our vestibular system, neurons are undeveloped at neuronal birth and mature during the critical period of the first 2–3 postnatal weeks. Hence, disruption of maturation during this period can cause changes in normal balance and movement through space. Animals with abnormal vestibular development tend to have irregular motor skills. Studies have consistently shown that animals with genetic vestibular deficiencies during this critical period have altered vestibular phenotypes, most likely as a result of insufficient input from the semicircular canals and dopaminergic abnormalities. Moreover, exposure to abnormal vestibular stimuli during the critical period is associated with irregular motor development. Children with hypofunctioning vestibular receptors frequently have delayed motor development. The results of the studies done on ferrets and rats reinforced the idea that the vestibular system is very important to motor development during the initial neonatal period. If the vestibular receptors are present during the initial six months to a year when the infant is learning to sit and stand, then the child may develop motor control and balance normally.

The vestibulo-ocular reflex (VOR) is a reflex eye movement that stabilizes images on the retina during head movement. It produces an eye movement in the direction opposite to head movement, thus preserving the image on the center of the visual field. Studies in fish and amphibians revealed a sensitivity in their VOR. They launched into space flight for 9–10, some with developing VORs and others with already developed reflexes. The fish with developing reflexes developed an upward bend in their tails. The altered gravity resulted in a shift of orientation. Those who were already matured with the reflex were insensitive to the microgravity exposure.

Memory

Recent studies also support the possibility of a critical period for the development of neurons that mediate memory processing. Experimental evidence supports the notion that young neurons in the adult dentate gyrus have a critical period (about 1–3 weeks after neuronal birth) during which they are integral to memory formation. Although the exact reasoning behind this observation is uncertain, studies suggest that the functional properties of neurons at this age make them most appropriate for this purpose; these neurons: (1) Remain hyperactive during the formation of memories; (2) are more excitable; and (3) More easily depolarizable due to GABAergic effects. It is also possible that hyperplasticity makes the neurons more useful in memory formation. If these young neurons had more plasticity than adult neurons in the same context, they could be more influential in smaller numbers. The role of these neurons in the adult dentate gyrus in memory processing is further supported by the fact that behavioral experiments have shown that an intact dentate gyrus is integral to hippocampal memory formation. It is speculated that the dentate gyrus acts as a relay station for information relating to memory storage. The likelihood of a critical period could change the way we view memory processing because it would ultimately mean that the collection of neurons present is constantly being replenished as new neurons replace old ones. If a critical period does indeed exist, this could possibly mean that: (1) Diverse populations of neurons that represent events occurring soon after one another may connect those events temporally in the memory formation and processing; or (2) these different populations of neurons may distinguish between similar events, independent of temporal position; or (3) separate populations may mediate the formation of new memories when the same events occur frequently.

Malleability of intelligence

From Wikipedia, the free encyclopedia

Malleability of intelligence describes the processes by which intelligence can increase or decrease over time and is not static. These changes may come as a result of genetics, pharmacological factors, psychological factors, behavior, or environmental conditions. Malleable intelligence may refer to changes in cognitive skills, memory, reasoning, or muscle memory related motor skills. In general, the majority of changes in human intelligence occur at either the onset of development, during the critical period, or during old age (see neuroplasticity).

Charles Spearman, who coined the general intelligence factor "g", described intelligence as one's ability to adapt to his environment with a set of useful skills including reasoning and understanding patterns and relationships. He believed individuals highly developed in one intellectual ability tended to be highly developed at other intellectual abilities. A more intelligent individual was thought to be able to more easily "accommodate" experiences into existing cognitive structures to develop structures more compatible with environmental stimuli.

In general, intelligence is thought to be attributed to both genetic and environmental factors, but the extent to which each plays a key role is highly disputed. Studies of identical and non-identical twins raised separately and together show a strong correlation between child IQ and socio-economic level of the parents. Children raised in lower-class families tend to score lower on intelligence tests when compared to children raised in both middle and upper-class families. However, there is no difference in intelligence scores between children raised in middle versus upper-class families.

Definitions

  • Intelligence: a very general capability that, among other things, involves the ability to reason, plan, solve problems, think abstractly, comprehend complex ideas, learn quickly and learn from experience.
  • Critical period: a restricted developmental period during which the nervous system is particularly sensitive to the effects of experience.

Neuroscience basis

The biological basis of intelligence is founded in the degree of connectivity of neurons in the brain and the varying amounts of white and grey matter. Studies show that intelligence is positively correlated with total cerebral volume. While it is true that the number of neurons in the brain actually decreases throughout development, as neural connections grow and the pathways become more efficient, the supporting structures in the brain increase. This increase in supporting tissues, which include myelination, blood vessels, and glial cells, leads to an increase in overall brain size. When brain circumference and IQ were compared in 9 year olds, a positive correlation was found between the two. An increase of 2.87 IQ points occurred for each standard deviation increase in brain circumference.

Importance of critical period

The brain grows rapidly for the first five years of human development. At age five, the human brain is 90% of its total size. Then the brain finishes growing gradually until mid to late twenties. From start to finish, the brain increases in size by over 300% from birth. The critical period, defined as the beginning years of brain development, is essential to intellectual development, as the brain optimizes the overproduction of synapses present at birth. During the critical period, the neuronal pathways are refined based on which synapses are active and receiving transmission. It is a "use it or lose it" phenomenon.

Neural plasticity

Neural plasticity refers to any change in the structure of the neural network that forms the central nervous system. Neural plasticity is the neuronal basis for changes in how the mind works, including learning, the formation of memory, and changes in intelligence. One well-studied form of plasticity is Long-Term Potentiation (LTP). It refers to a change in neural connectivity as a result of high activation on both sides of a synaptic cleft. This change in neural connectivity allows information to be more easily processed, as the neural connection associated with that information becomes stronger through LTP. Other forms of plasticity involve the growth of new neurons, the growth of new connections between neurons, and the selective elimination of such connection, called "dendritic pruning".

Genetic factors of intelligence

Humans have varying degrees of neuroplasticity due to their genetic makeups, which affects their ability to adapt to conditions in their environments and effectively learn from experiences. The degree to which intelligence test scores can be linked to genetic heritability increases with age. There is presently no explanation for this puzzling result, but flaws in the testing methods are suspected. A study of Dutch twins concludes that intelligence of 5 year olds is 26% heritable, while the test scores of 12-year-olds is 64% heritable. Structurally, genetic influences explain 77–88% of the variance in the thickness of the mid-sagittal area of the corpus callosum, the volume of the caudate nucleus, and the volumes of the parietal and temporal lobes.

Pharmacological influence

Numerous pharmacological developments have been made to help organize neural circuitry for patients with learning disorders. The cholinergic and glutamatergic systems in the brain serve an important role in learning, memory, and the developmental organization of neuronal circuitry. These systems help to capitalize on the critical period and organize synaptic transmission. Autism and other learning disabilities have been targeted with drugs focusing on cholinergic and glutamatergic transmission. These drugs increase the amount of acetylcholine present in the brain by increasing the production of acetylcholine precursors, as well as inhibiting acetylcholine degradation by cholinesterases. By focusing on heightening the activity of this system, the brain's responsiveness to activity-dependent plasticity is improved. Specifically, glutamatergic drugs may reduce the threshold for LTP, promote more normal dendritic spine morphology, and retain a greater number of useful synaptic connections. Cholinergic drugs may reconnect the basal forebrain with the cortex and hippocampus, connections that are often disrupted in patients with learning disorders.

Psychological factors

Psychological factors and preconceived notions about intelligence can be as influential on intelligence as genetic makeup. Children with early chronic stress show impaired corticolimbic connectivity in development. Early chronic stress is defined as inconsistent or inadequate care-giving and disruption to early rearing environment. These children showed decreased cognitive function, especially in fluid cognition, or the ability to effectively utilize working memory. The lack of connectivity between the limbic system and the prefrontal cortex can be blamed for this deficiency.

Behavioral factors

In the study of malleable intelligence, behavioral factors are often the most intriguing because these are factors humans can seek to control. There are numerous behavioral factors that affect intellectual development and neural plasticity. The key is plasticity, which is caused by experience-driven electrical activation of neurons. This experience-driven activation causes axons to sprout new branches and develop new presynaptic terminals. These new branches often lead to greater mental processing in different areas.

Taking advantage of the critical period

As previously discussed, the critical period is a time of neural pruning and great intellectual development.

Schizophrenia

From Wikipedia, the free encyclopedia
Schizophrenia
Embroidery art with nonlinear text sewn into it with multiple colors of thread
Cloth embroidered by a person diagnosed with schizophrenia
Pronunciation
SpecialtyPsychiatry
SymptomsHallucinations, delusions, disorganized thinking or behavior, flat or inappropriate affect
ComplicationsHarm to self or others, social isolation, heart disease, suicide, lifestyle diseasesobesity and type 2 diabetes arising from antipsychotic medication
Usual onsetAges 16 to 30
DurationChronic
CausesEnvironmental and genetic factors
Risk factorsFamily history, cannabis use in adolescence, hallucinogen- or amphetamine-associated psychosis, problems during pregnancy, childhood adversity, being born or raised in a city
Diagnostic methodBased on observed behavior, reported experiences, and reports of others familiar with the person
Differential diagnosisSubstance use disorder, Huntington's disease, mood disorders (bipolar disorder, major depressive disorder), autismborderline personality disorderschizophreniform disorder, schizotypal personality disorder, schizoid personality disorder, antisocial personality disorder, psychotic depression, anxiety, disruptive mood dysregulation disorder, sleep paralysis
ManagementCounseling, life skills training
MedicationAntipsychotics
Prognosis20–28 years shorter life expectancy
Frequency~0.32% (1 in 300) of the global population is affected
Deaths~17,000 (2015)

Schizophrenia is a mental disorder characterized variously by hallucinations (typically, hearing voices), delusions, disorganized thinking or behavior, and flat or inappropriate affect. Symptoms develop gradually and typically begin during young adulthood. There is no objective diagnostic test; diagnosis is based on observed behavior, a psychiatric history that includes the person's reported experiences, and reports of others familiar with the person. For a formal diagnosis, the described symptoms need to have been present for at least six months (according to the DSM-5) or one month (according to the ICD-11). Many people with schizophrenia have other mental disorders, especially mood, anxiety, and substance use disorders, as well as obsessive–compulsive disorder (OCD).

The lifetime prevalence of developing schizophrenia is about 0.3% to 0.7%. In 2017, there were an estimated 1.1 million new cases and in 2022 a total of 24 million cases globally. Males are more often affected and on average have an earlier onset than females. The causes of schizophrenia may include genetic and environmental factors. Genetic factors include a variety of common and rare genetic variants. Possible environmental factors include being raised in a city, childhood adversity, cannabis use during adolescence, infections, the age of a person's mother or father, and poor nutrition during pregnancy.

About half of those diagnosed with schizophrenia will experience a marked improvement over the long term with no further relapses, and a small proportion of these will recover completely. The other half will have a lifelong impairment. In severe cases, people may be admitted to hospitals. Social problems such as long-term unemployment, poverty, homelessness, exploitation, and victimization are commonly correlated with schizophrenia. Compared to the general population, people with schizophrenia have a higher suicide rate (about 5% overall) and more physical health problems, leading to an average decrease in life expectancy by 20 to 28 years. In 2015, an estimated 17,000 deaths were linked to schizophrenia.

The mainstay of treatment is antipsychotic medication, including olanzapine and risperidone, along with counseling, job training, and social rehabilitation. Up to a third of people do not respond to initial antipsychotics, in which case clozapine is offered. Most antipsychotics improve schizophrenia symptoms, with clozapine the most effective overall; side effects vary considerably and guide treatment choices. In situations where doctors judge that there is a risk of harm to self or others, they may impose short involuntary hospitalization. Long-term hospitalization is used on a small number of people with severe schizophrenia. In some countries where supportive services are limited or unavailable, long-term hospital stays are more common.

Signs and symptoms

Schizophrenia is a mental disorder characterized by significant alterations in perception, thoughts, mood, and behavior. Symptoms are described in terms of positive, negative, and cognitive symptoms. The positive symptoms of schizophrenia are the same for any psychosis and are sometimes referred to as psychotic symptoms. These may be present in any of the different psychoses and are often transient, making early diagnosis of schizophrenia problematic. Psychosis noted for the first time in a person who is later diagnosed with schizophrenia is referred to as a first-episode psychosis (FEP).

Positive symptoms

Example of delusional obsession with numbers, disorganized thoughts, occurring with paranoid schizophrenia.

Positive symptoms are those that are not normally experienced, but are present in people during a psychotic episode in schizophrenia, including delusions, hallucinations, and disorganized thoughts, speech and behavior or inappropriate affect, typically regarded as manifestations of psychosis. Hallucinations occur at some point in the lifetimes of 80% of those with schizophrenia and most commonly involve the sense of hearing (most often hearing voices), but can sometimes involve any of the other senses such as taste, sight, smell, and touch. The frequency of hallucinations involving multiple senses is double the rate of those involving only one sense. They are also typically related to the content of the delusional theme.

Delusions are bizarre or persecutory in nature. Distortions of self-experience such as feeling that others can hear one's thoughts (thought broadcasting delusion) or that thoughts are being inserted into one's mind, sometimes termed passivity phenomena, are also common. The type and content of auditory and visual hallucinations is influenced by the cultural and social background of the patient. Positive symptoms generally respond well to medication and become reduced over the course of the illness, perhaps linked to the age-related decline in dopamine activity.[10]

Negative symptoms

Negative symptoms are deficits of normal emotional responses, or of other thought processes. The five recognized domains of negative symptoms are: blunted affect – showing flat expressions (monotone) or little emotion; alogia – a poverty of speech; anhedonia – an inability to feel pleasure; asociality – the lack of desire to form relationships, and avolition – a lack of motivation and apathy. Avolition and anhedonia are seen as motivational deficits resulting from impaired reward processing. Reward is the main driver of motivation and this is mostly mediated by dopamine. It has been suggested that negative symptoms are multidimensional and they have been categorised into two subdomains of apathy or lack of motivation, and diminished expression. Apathy includes avolition, anhedonia, and social withdrawal; diminished expression includes blunt affect and alogia. Sometimes diminished expression is treated as both verbal and non-verbal.

Apathy accounts for around 50% of the most often found negative symptoms and affects functional outcome and subsequent quality of life. Apathy is related to disrupted cognitive processing affecting memory and planning, including goal-directed behaviour. The two subdomains have suggested a need for separate treatment approaches. A lack of distress is another noted negative symptom. A distinction is often made between those negative symptoms that are inherent to schizophrenia, termed primary; and those that result from positive symptoms, from the side effects of antipsychotics, substance use disorder, and social deprivation, termed secondary negative symptoms. Negative symptoms are less responsive to medication and the most difficult to treat. However, if properly assessed, secondary negative symptoms are amenable to treatment. There is some evidence that the negative symptoms of schizophrenia are amenable to psychostimulant medication, although such drugs have varying degrees of risk for causing positive psychotic symptoms.

Scales for specifically assessing the presence of negative symptoms, and for measuring their severity, and their changes have been introduced since the earlier scales such as the PANSS that deals with all types of symptoms. These scales are the Clinical Assessment Interview for Negative Symptoms (CAINS), and the Brief Negative Symptom Scale (BNSS) also known as second-generation scales. In 2020, ten years after its introduction, a cross-cultural study of the use of BNSS found valid and reliable psychometric evidence for its five-domain structure cross-culturally. The BNSS can assess both the presence and severity of negative symptoms of the five recognized domains and an additional item of reduced normal distress. It has been used to measure changes in negative symptoms in trials of psychosocial and pharmacological interventions.

Cognitive symptoms

Map of deficits in neural tissue throughout the human brain in a patient with schizophrenia. The most deficient areas are magenta, while the least deficient areas are blue.
Diagram of the brain in schizophrenia

An estimated 70% of those with schizophrenia have cognitive deficits, and these are most pronounced in early-onset and late-onset illness. These are often evident long before the onset of illness in the prodromal stage, and may be present in childhood or early adolescence. They are core features but not considered core symptoms, as are positive and negative symptoms. However, their presence and degree of dysfunction are taken as better indicators of functionality than the presentation of core symptoms. Cognitive deficits become worse at first episode psychosis but then return to baseline, and remain fairly stable over the course of the illness.

Cognitive deficits may be of neurocognition (nonsocial) or of social cognition. Neurocognition is the ability to receive and remember information, and includes verbal fluency, memory, reasoning, problem solving, speed of processing, and auditory and visual perception. Verbal memory and attention are seen to be the most affected. Verbal memory impairment is associated with a decreased level of semantic processing (relating meaning to words). Another memory impairment is that of episodic memory. An impairment in visual perception that is consistently found in schizophrenia is that of visual backward masking.[64] Visual processing impairments include an inability to perceive complex visual illusions. Social cognition is concerned with the mental operations needed to interpret, and understand the self and others in the social world. This is also an associated impairment, and facial emotion perception is often found to be difficult. Cognitive impairments do not usually respond to antipsychotics, and there are a number of interventions that are used to try to improve them; cognitive remediation therapy is of particular help.

Neurological soft signs of clumsiness and loss of fine motor movement are often found in schizophrenia, which may resolve with effective treatment of FEP.

Onset

Onset typically occurs between the late teens and early 30s, with the peak incidence occurring in males in the early to mid-twenties, and in females in the late twenties. Onset before the age of 17 is known as early-onset, and before the age of 13, as can sometimes occur, is known as childhood schizophrenia or very early-onset. Onset can occur between the ages of 40 and 60, known as late-onset schizophrenia. Onset over the age of 60, which may be difficult to differentiate as schizophrenia, is known as very-late-onset schizophrenia-like psychosis. Late onset has shown that a higher rate of females are affected; they have less severe symptoms and need lower doses of antipsychotics. The tendency for earlier onset in males is later seen to be balanced by a post-menopausal increase in the development in females. Estrogen produced pre-menopause has a dampening effect on dopamine receptors but its protection can be overridden by a genetic overload. There has been a dramatic increase in the numbers of older adults with schizophrenia.

Onset may happen suddenly or may occur after the slow and gradual development of a number of signs and symptoms, a period known as the prodromal stage. Up to 75% of those with schizophrenia go through a prodromal stage. The negative and cognitive symptoms in the prodrome stage can precede FEP (first episode psychosis) by many months and up to five years. The period from FEP and treatment is known as the duration of untreated psychosis (DUP) which is seen to be a factor in functional outcome. The prodromal stage is the high-risk stage for the development of psychosis. Since the progression to first episode psychosis is not inevitable, an alternative term is often preferred of at risk mental state. Cognitive dysfunction at an early age impacts a young person's usual cognitive development. Recognition and early intervention at the prodromal stage would minimize the associated disruption to educational and social development and has been the focus of many studies.

Risk factors

Schizophrenia is described as a neurodevelopmental disorder with no precise boundary, or single cause, and is thought to develop from gene–environment interactions with involved vulnerability factors. The interactions of these risk factors are complex, as numerous and diverse insults from conception to adulthood can be involved. A genetic predisposition on its own, without interacting environmental factors, will not give rise to the development of schizophrenia. The genetic component means that prenatal brain development is disturbed, and environmental influence affects the postnatal development of the brain. Evidence suggests that genetically susceptible children are more likely to be vulnerable to the effects of environmental risk factors.

Genetic

Estimates of the heritability of schizophrenia are between 70% and 80%, which implies that 70% to 80% of the individual differences in risk of schizophrenia are associated with genetics. These estimates vary because of the difficulty in separating genetic and environmental influences, and their accuracy has been queried. The greatest risk factor for developing schizophrenia is having a first-degree relative with the disease (risk is 6.5%); more than 40% of identical twins of those with schizophrenia are also affected. If one parent is affected the risk is about 13% and if both are affected the risk is nearly 50%. However, the DSM-5 indicates that most people with schizophrenia have no family history of psychosis. Results of candidate gene studies of schizophrenia have generally failed to find consistent associations, and the genetic loci identified by genome-wide association studies explain only a small fraction of the variation in the disease.

Many genes are known to be involved in schizophrenia, each with small effects and unknown transmission and expression. The summation of these effect sizes into a polygenic risk score can explain at least 7% of the variability in liability for schizophrenia. Around 5% of cases of schizophrenia are understood to be at least partially attributable to rare copy number variations (CNVs); these structural variations are associated with known genomic disorders involving deletions at 22q11.2 (DiGeorge syndrome) and 17q12 (17q12 microdeletion syndrome), duplications at 16p11.2 (most frequently found) and deletions at 15q11.2 (Burnside–Butler syndrome). Some of these CNVs increase the risk of developing schizophrenia by as much as 20-fold, and are frequently comorbid with autism and intellectual disabilities.

The genes CRHR1 and CRHBP are associated with the severity of suicidal behavior. These genes code for stress response proteins needed in the control of the HPA axis, and their interaction can affect this axis. Response to stress can cause lasting changes in the function of the HPA axis possibly disrupting the negative feedback mechanism, homeostasis, and the regulation of emotion leading to altered behaviors.

The question of how schizophrenia could be primarily genetically influenced, given that people with schizophrenia have lower fertility rates, is a paradox. It is expected that genetic variants that increase the risk of schizophrenia would be selected against, due to their negative effects on reproductive fitness. A number of potential explanations have been proposed, including that alleles associated with schizophrenia risk confers a fitness advantage in unaffected individuals. While some evidence has not supported this idea, others propose that a large number of alleles each contributing a small amount can persist.

A meta-analysis found that oxidative DNA damage was significantly increased in schizophrenia.

Environmental

Environmental factors, each associated with a slight risk of developing schizophrenia in later life include oxygen deprivation, infection, prenatal maternal stress, and malnutrition in the mother during prenatal development. A risk is associated with maternal obesity, in increasing oxidative stress, and dysregulating the dopamine and serotonin pathways. Both maternal stress and infection have been demonstrated to alter fetal neurodevelopment through an increase of pro-inflammatory cytokines. There is a slighter risk associated with being born in the winter or spring possibly due to vitamin D deficiency or a prenatal viral infection. Other infections during pregnancy or around the time of birth that have been linked to an increased risk include infections by Toxoplasma gondii and Chlamydia. The increased risk is about five to eight percent. Viral infections of the brain during childhood are also linked to a risk of schizophrenia during adulthood. Cat exposure is also associated with an increased risk of broadly defined schizophrenia-related disorders, with an odds ratio of 2.4. Exposure to specific medications such as tramadol and desmopressin has been found be associated with an increased risk of incident schizophrenia, while other medications including anti-protozoans were associated with a decrease in schizophrenia risk.

Adverse childhood experiences (ACEs), severe forms of which are classed as childhood trauma, range from being bullied or abused, to the death of a parent. Many adverse childhood experiences can cause toxic stress and increase the risk of psychosis. Chronic trauma, including ACEs, can promote lasting inflammatory dysregulation throughout the nervous system. It is suggested that early stress may contribute to the development of schizophrenia through these alterations in the immune system. Schizophrenia was the last diagnosis to benefit from the link made between ACEs and adult mental health outcomes.

Living in an urban environment during childhood or as an adult has consistently been found to increase the risk of schizophrenia by a factor of two, even after taking into account drug use, ethnic group, and size of social group. A possible link between the urban environment and pollution has been suggested to be the cause of the elevated risk of schizophrenia. Other risk factors include social isolation, immigration related to social adversity and racial discrimination, family dysfunction, unemployment, and poor housing conditions. Having a father older than 40 years, or parents younger than 20 years are also associated with schizophrenia.

Substance use

About half of those with schizophrenia use recreational drugs including alcohol, tobacco, and cannabis excessively. Use of stimulants such as amphetamine and cocaine can lead to a temporary stimulant psychosis, which presents very similarly to schizophrenia. Rarely, alcohol use can also result in a similar alcohol-related psychosis. Drugs may also be used as coping mechanisms by people who have schizophrenia, to deal with depression, anxiety, boredom, and loneliness. The use of cannabis and tobacco are not associated with the development of cognitive deficits, and sometimes a reverse relationship is found where their use improves these symptoms. However, substance use disorders are associated with an increased risk of suicide, and a poor response to treatment.

Cannabis use may be a contributory factor in the development of schizophrenia, potentially increasing the risk of the disease in those who are already at risk. The increased risk may require the presence of certain genes within an individual. Its use is associated with doubling the rate.

Causes

The causes of schizophrenia are still unknown. Several models have been put forward to explain the link between altered brain function and schizophrenia. The prevailing model of schizophrenia is that of a neurodevelopmental disorder, and the underlying changes that occur before symptoms become evident are seen as arising from the interaction between genes and the environment. Extensive studies support this model. Maternal infections, malnutrition and complications during pregnancy and childbirth are known risk factors for the development of schizophrenia, which usually emerges between the ages of 18 and 25, a period that overlaps with certain stages of neurodevelopment. Gene-environment interactions lead to deficits in the neural circuitry that affect sensory and cognitive functions.

The common dopamine and glutamate models proposed are not mutually exclusive; each is seen to have a role in the neurobiology of schizophrenia. The most common model put forward was the dopamine hypothesis of schizophrenia, which attributes psychosis to the mind's faulty interpretation of the misfiring of dopaminergic neurons. This has been directly related to the symptoms of delusions and hallucinations. Abnormal dopamine signaling has been implicated in schizophrenia based on the usefulness of medications that affect the dopamine receptor and the observation that dopamine levels are increased during acute psychosis. A decrease in D1 receptors in the dorsolateral prefrontal cortex may also be responsible for deficits in working memory.

The glutamate hypothesis of schizophrenia links alterations between glutamatergic neurotransmission and the neural oscillations that affect connections between the thalamus and the cortex. Studies have shown that a reduced expression of a glutamate receptorNMDA receptor, and glutamate blocking drugs such as phencyclidine and ketamine can mimic the symptoms and cognitive problems associated with schizophrenia. Post-mortem studies consistently find that a subset of these neurons fail to express GAD67 (GAD1), in addition to abnormalities in brain morphometry. The subsets of interneurons that are abnormal in schizophrenia are responsible for the synchronizing of neural ensembles needed during working memory tasks. These give the neural oscillations produced as gamma waves that have a frequency of between 30 and 80 hertz. Both working memory tasks and gamma waves are impaired in schizophrenia, which may reflect abnormal interneuron functionality. An important process that may be disrupted in neurodevelopment is astrogenesis – the formation of astrocytes. Astrocytes are crucial in contributing to the formation and maintenance of neural circuits and it is believed that disruption in this role can result in a number of neurodevelopmental disorders including schizophrenia. Evidence suggests that reduced numbers of astrocytes in deeper cortical layers are associated with a diminished expression of EAAT2, a glutamate transporter in astrocytes; supporting the glutamate hypothesis.

Deficits in executive functions, such as planning, inhibition, and working memory, are pervasive in schizophrenia. Although these functions are separable, their dysfunction in schizophrenia may reflect an underlying deficit in the ability to represent goal related information in working memory, and to use this to direct cognition and behavior. These impairments have been linked to a number of neuroimaging and neuropathological abnormalities. For example, functional neuroimaging studies report evidence of reduced neural processing efficiency, whereby the dorsolateral prefrontal cortex is activated to a greater degree to achieve a certain level of performance relative to controls on working memory tasks. These abnormalities may be linked to the consistent post-mortem finding of reduced neuropil, evidenced by increased pyramidal cell density and reduced dendritic spine density. These cellular and functional abnormalities may also be reflected in structural neuroimaging studies that find reduced grey matter volume in association with deficits in working memory tasks.

Positive symptoms have been linked to cortical thinning in the superior temporal gyrus. The severity of negative symptoms has been linked to reduced thickness in the left medial orbitofrontal cortex. Anhedonia, traditionally defined as a reduced capacity to experience pleasure, is frequently reported in schizophrenia. However, a large body of evidence suggests that hedonic responses are intact in schizophrenia, and that what is reported to be anhedonia is a reflection of dysfunction in other processes related to reward. Overall, a failure of reward prediction is thought to lead to impairment in the generation of cognition and behavior required to obtain rewards, despite normal hedonic responses.

Another theory links abnormal brain lateralization to the development of being left-handed which is significantly more common in those with schizophrenia. This abnormal development of hemispheric asymmetry is noted in schizophrenia. Studies have concluded that the link is a true and verifiable effect that may reflect a genetic link between lateralization and schizophrenia.

Bayesian models of brain functioning have been used to link abnormalities in cellular functioning to symptoms. Both hallucinations and delusions have been suggested to reflect improper encoding of prior expectations, thereby causing expectation to excessively influence sensory perception and the formation of beliefs. In approved models of circuits that mediate predictive coding, reduced NMDA receptor activation, could in theory result in the positive symptoms of delusions and hallucinations.

From an evolutionary perspective, schizophrenia is regarded as an "evolutionary puzzle" because it shows high heritability (~60-80 %) and significant impairment in reproduction, yet persists at ~1 % prevalence. One hypothesis suggests that mild schizotypal traits may have historically conferred advantages (such as enhanced creativity or verbal ability,) while more severe forms represent the breakdown of these systems. Experimental models also propose that selection for language and social-cognitive complexity may have increased vulnerability to psychosis when environmental or developmental stressors intervene.

Diagnosis

Criteria

Schizophrenia is diagnosed based on criteria in either the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association or the International Statistical Classification of Diseases and Related Health Problems (ICD) published by the World Health Organization (WHO). These criteria use the self-reported experiences of the person and reported abnormalities in behavior, followed by a psychiatric assessment. The mental status examination is an important part of the assessment. An established tool for assessing the severity of positive and negative symptoms is the Positive and Negative Syndrome Scale (PANSS). This has been seen to have shortcomings relating to negative symptoms, and other scales – the Clinical Assessment Interview for Negative Symptoms (CAINS), and the Brief Negative Symptoms Scale (BNSS) have been introduced. The DSM-5, published in 2013, gives a Scale to Assess the Severity of Symptom Dimensions outlining eight dimensions of symptoms.

DSM-5 states that to be diagnosed with schizophrenia, two diagnostic criteria have to be met over the period of one month, with a significant impact on social or occupational functioning for at least six months. One of the symptoms needs to be either delusions, hallucinations, or disorganized speech. A second symptom could be one of the negative symptoms, or severely disorganized or catatonic behaviour. A different diagnosis of schizophreniform disorder can be made before the six months needed for the diagnosis of schizophrenia.

In Australia, the guideline for diagnosis is for six months or more with symptoms severe enough to affect ordinary functioning. In the UK diagnosis is based on having the symptoms for most of the time for one month, with symptoms that significantly affect the ability to work, study, or carry on ordinary daily living, and with other similar conditions ruled out.

The ICD criteria are typically used in European countries; the DSM criteria are used predominantly in the United States and Canada, and are prevailing in research studies. In practice, agreement between the two systems is high. The current proposal for the ICD-11 criteria for schizophrenia recommends adding self-disorder as a symptom.

A major unresolved difference between the two diagnostic systems is that of the requirement in DSM of an impaired functional outcome. WHO for ICD argues that not all people with schizophrenia have functional deficits and so these are not specific for the diagnosis.

Neuroimaging techniques

Functional magnetic resonance imaging (fMRI) has become a tool in understanding brain activity and connectivity differences in individuals with schizophrenia. Through resting-state fMRI, researchers have observed altered connectivity patterns within several key brain networks, such as the default mode network (DMN), salience network (SN), and central executive network (CEN). Alterations may underlie cognitive and emotional symptoms in schizophrenia, such as disorganized thinking, impaired attention, and emotional dysregulation.

Comorbidities

Euler diagram showing overlapping clinical phenotypes in genes associated with monogenic forms of autism spectrum disorder (ASD), dystonia, epilepsy and schizophrenia:
  Genes associated with epilepsy
  Genes associated with schizophrenia
  Genes associated with autism spectrum disorder
  Genes associated with dystonia

Many people with schizophrenia may have one or more other mental disorders, such as anxiety disorders, obsessive–compulsive disorder, or substance use disorder. These are separate disorders that require treatment. When comorbid with schizophrenia, substance use disorder and antisocial personality disorder both increase the risk for violence. Comorbid substance use disorder also increases the risk of suicide.

Sleep disorders often co-occur with schizophrenia, and may be an early sign of relapse. Sleep disorders are linked with positive symptoms such as disorganized thinking and can adversely affect cortical plasticity and cognition. The consolidation of memories is disrupted in sleep disorders. They are associated with severity of illness, a poor prognosis, and poor quality of life. Sleep onset and maintenance insomnia is a common symptom, regardless of whether treatment has been received or not. Genetic variations have been found associated with these conditions involving the circadian rhythm, dopamine and histamine metabolism, and signal transduction.

Schizophrenia is also associated with a number of somatic comorbidities including diabetes mellitus type 2, autoimmune diseases, and cardiovascular diseases. The association of these with schizophrenia may be partially due to medications (e.g. dyslipidemia from antipsychotics), environmental factors (e.g. complications from an increased rate of cigarette smoking), or associated with the disorder itself (e.g. diabetes mellitus type 2 and some cardiovascular diseases are thought to be genetically linked). These somatic comorbidities contribute to reduced life expectancy among persons with the disorder.

Differential diagnosis

To make a diagnosis of schizophrenia other possible causes of psychosis need to be excluded. Psychotic symptoms lasting less than a month may be diagnosed as brief psychotic disorder, or as schizophreniform disorder. Psychosis is noted in Other specified schizophrenia spectrum and other psychotic disorders as a DSM-5 category. Schizoaffective disorder is diagnosed if symptoms of mood disorder are substantially present alongside psychotic symptoms. Psychosis that results from a general medical condition or substance is termed secondary psychosis.

Psychotic symptoms may be present in several other conditions, including bipolar disorderborderline personality disordersubstance intoxication, substance-induced psychosis, and a number of drug withdrawal syndromes. Non-bizarre delusions are also present in delusional disorder, and social withdrawal in social anxiety disorder, avoidant personality disorder and schizotypal personality disorder. Schizotypal personality disorder has symptoms that are similar but less severe than those of schizophrenia. Schizophrenia occurs along with obsessive–compulsive disorder (OCD) considerably more often than could be explained by chance, although it can be difficult to distinguish obsessions that occur in OCD from the delusions of schizophrenia. There can be considerable overlap with the symptoms of post-traumatic stress disorder.

A more general medical and neurological examination may be needed to rule out medical illnesses which may rarely produce psychotic schizophrenia-like symptoms, such as metabolic disturbance, systemic infection, syphilis, HIV-associated neurocognitive disorder, epilepsy, limbic encephalitis, and brain lesions. Stroke, multiple sclerosis, hyperthyroidism, hypothyroidism, and dementias such as Alzheimer's disease, Huntington's disease, frontotemporal dementia, and the Lewy body dementias may also be associated with schizophrenia-like psychotic symptoms. It may be necessary to rule out a delirium, which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness, and indicates an underlying medical illness. Investigations are not generally repeated for relapse unless there is a specific medical indication or possible adverse effects from antipsychotic medication. In children hallucinations must be separated from typical childhood fantasies. It is difficult to distinguish childhood schizophrenia from autism.

Prevention

Prevention of schizophrenia is difficult as there are no reliable markers for the later development of the disorder.

Early intervention programs diagnose and treat patients in the prodromal phase of the illness. There is some evidence that these programs reduce symptoms. Patients tend to prefer early treatment programs to ordinary treatment and are less likely to disengage from them. As of 2020, it is unclear whether the benefits of early treatment persist once the treatment is terminated.

Cognitive behavioral therapy may reduce the risk of psychosis in those at high risk after a year and is recommended in this group, by the National Institute for Health and Care Excellence (NICE).[35] Another preventive measure is to avoid drugs that have been associated with development of the disorder, including cannabis, cocaine, and amphetamines.

Antipsychotics are prescribed following a first-episode psychosis, and following remission, a preventive maintenance use is continued to avoid relapse. However, it is recognized that some people do recover following a single episode and that long-term use of antipsychotics will not be needed but there is no way of identifying this group.

Management

The primary treatment of schizophrenia is the use of antipsychotic medications, often in combination with psychosocial interventions and social supports. Community support services including drop-in centers, visits by members of a community mental health team, supported employment, and support groups are common. The time between the onset of psychotic symptoms to being given treatment – the duration of untreated psychosis (DUP) – is associated with a poorer outcome in both the short term and the long term.

Voluntary or involuntary admission to hospital may be imposed by doctors and courts who deem a person to be having a severe episode. In the UK, large mental hospitals termed asylums began to be closed down in the 1950s with the advent of antipsychotics, and with an awareness of the negative impact of long-term hospital stays on recovery. This process was known as deinstitutionalization, and community and supportive services were developed to support this change. Many other countries followed suit with the US starting in the 60s. There still remain a smaller group of people who do not improve enough to be discharged. In some countries that lack the necessary supportive and social services, long-term hospital stays are more usual.

Medication

Risperidone (trade name Risperdal) is a common atypical antipsychotic medication.

Most antipsychotics reduce overall, positive, negative, and depressive symptoms in schizophrenia, with clozapine showing the largest overall effect, though efficacy differences between drugs are mostly gradual. Side-effect profiles, including weight gain, sedation, prolactin elevation, and QTc prolongation, vary more distinctly; clinicians weigh benefits against risks based on patient factors and preferences.

The first-line treatment for schizophrenia is an antipsychotic. The first-generation antipsychotics, now called typical antipsychotics, like haloperidol, are dopamine antagonists that block D2 receptors, and affect the neurotransmission of dopamine. Those brought out later, the second-generation antipsychotics known as atypical antipsychotics, including olanzapine and risperidone, can also have an effect on another neurotransmitter, serotonin. Antipsychotics can reduce the symptoms of anxiety within hours of their use, but, for other symptoms, they may take several days or weeks to reach their full effect. They have little effect on negative and cognitive symptoms, which may be helped by additional psychotherapies and medications. There is no single antipsychotic suitable for first-line treatment for everyone, as responses and tolerances vary between people. Stopping medication may be considered after a single psychotic episode where there has been a full recovery with no symptoms for twelve months. Repeated relapses worsen the long-term outlook and the risk of relapse following a second episode is high, and long-term treatment is usually recommended.

About half of those with schizophrenia will respond favourably to antipsychotics, and have a good return of functioning. However, positive symptoms persist in up to a third of people. Following two trials of different antipsychotics over six weeks, that also prove ineffective, they will be classed as having treatment-resistant schizophrenia (TRS), and clozapine will be offered. Clozapine is of benefit to around half of this group although it has the potentially serious side effect of agranulocytosis (lowered white blood cell count) in less than 4% of people.

About 30 to 50 percent of people with schizophrenia do not accept that they have an illness or comply with their recommended treatment. For those who are unwilling or unable to take medication regularly, long-acting injections of antipsychotics may be used, which reduce the risk of relapse to a greater degree than oral medications. When used in combination with psychosocial interventions, they may improve long-term adherence to treatment.

A 2025 meta-analysis showed xanomeline and trospium's effect in the improvement of symptoms of schizophrenia. The fixed-dose combination medication xanomeline/trospium chloride (Cobenfy) was approved for medical use in the United States in September 2024. It is the first cholinergic agonist approved by the US Food and Drug Administration (FDA) to treat schizophrenia.

Negative and cognitive symptoms are an unmet clinical need in antipsychotic-based treatment approaches. Psychostimulant drugs have been found effective in the treatment of negative symptoms, but are rarely prescribed due to concerns about the exacerbation of positive symptoms. It is possible that low-dose psychedelic therapies could be of benefit in schizophrenia through their prosocial and procognitive effects, although there is a serious risk that high dose psychedelic therapies could lead to worsening of positive symptoms.

Adverse effects

Extrapyramidal symptoms, including akathisia, are associated with all commercially available antipsychotic to varying degrees. There is little evidence that second generation antipsychotics have reduced levels of extrapyramidal symptoms compared to typical antipsychotics. Tardive dyskinesia can occur due to long-term use of antipsychotics, developing after months or years of use. The antipsychotic clozapine is also associated with thromboembolism (including pulmonary embolism), myocarditis, and cardiomyopathy.

Psychosocial interventions

A number of psychosocial interventions that include several types of psychotherapy may be useful in the treatment of schizophrenia such as: family therapygroup therapy, cognitive remediation therapy (CRT), cognitive behavioral therapy (CBT), and metacognitive training. Skills training, help with substance use, and weight management – often needed as a side effect of an antipsychotic – are also offered. In the US, interventions for first episode psychosis have been brought together in an overall approach known as coordinated speciality care (CSC) and also includes support for education. In the UK care across all phases is a similar approach that covers many of the treatment guidelines recommended. The aim is to reduce the number of relapses and stays in the hospital.

Other support services for education, employment, and housing are usually offered. For people with severe schizophrenia, who are discharged from a stay in the hospital, these services are often brought together in an integrated approach to offer support in the community away from the hospital setting. In addition to medicine management, housing, and finances, assistance is given for more routine matters such as help with shopping and using public transport. This approach is known as assertive community treatment (ACT) and has been shown to achieve positive results in symptoms, social functioning and quality of life. Another more intense approach is known as intensive care management (ICM). ICM is a stage further than ACT and emphasises support of high intensity in smaller caseloads, (less than twenty). This approach is to provide long-term care in the community. Studies show that ICM improves many of the relevant outcomes including social functioning.

Some studies have shown little evidence for the effectiveness of CBT in either reducing symptoms or preventing relapse. However, other studies have found that CBT does improve overall psychotic symptoms (when in use with medication) and it has been recommended in Canada, but has been seen to have no effect on social function, relapse, or quality of life. In the UK it is recommended as an add-on therapy in the treatment of schizophrenia. Arts therapies are seen to improve negative symptoms in some people, and are recommended by NICE in the UK. This approach is criticised as having not been well-researched, and arts therapies are not recommended in Australian guidelines for example. Peer support, in which people with personal experience of schizophrenia, provide help to each other, is of unclear benefit.

Daily interventions

Forming a structured routine can be beneficial for those with schizophrenia. Depending on the severity of the individual's diagnosis, independent living may not be an option. The Mental Health Center Amager is a psychiatric hospital in Copenhagen that performed a study among seventeen participants evaluated under five themes of social interaction, volunteering to assist with basic tasks, self initiated routines, exoskeleton (structure provided by others), and having pets. The 17 participants ranging in ages 18-65 were sectioned into 2 groups, homeless and domiciled. Both groups lacked a means of structure and maintained distance from social interactions, though the homeless group had more frequent engagements. The homeless group also presented a more organized routine, as activities organized by the shelter were low-energy and accessible. Findings indicated that the patients who had moderate antisocial tendencies (e.g., very few interpersonal relations), yet still took part in distanced outings such as observing others in a park, were least likely to be re-admitted into psychiatric care. Pets were shown to be a consistent motivator for both groups.

Other

Exercise including aerobic exercise has been shown to improve positive and negative symptoms, cognition, working memory, and improve quality of life. Exercise has also been shown to increase the volume of the hippocampus in those with schizophrenia. A decrease in hippocampal volume is one of the factors linked to the development of the disease. However, there still remains the problem of increasing motivation for, and maintaining participation in physical activity. Supervised sessions are recommended. In the UK healthy eating advice is offered alongside exercise programs.

An inadequate diet is often found in schizophrenia, and associated vitamin deficiencies including those of folate, and vitamin D are linked to the risk factors for the development of schizophrenia and for early death including heart disease. Those with schizophrenia possibly have the worst diet of all the mental disorders. Lower levels of folate and vitamin D have been noted as significantly lower in first episode psychosis. The use of supplemental folate is recommended. A zinc deficiency has also been noted. Vitamin B12 is also often deficient and this is linked to worse symptoms. Supplementation with B vitamins has been shown to significantly improve symptoms, and to put in reverse some of the cognitive deficits. It is also suggested that the noted dysfunction in gut microbiota might benefit from the use of probiotics.

Prognosis

Disability-adjusted life years lost due to schizophrenia per 100,000 inhabitants in 2004

Schizophrenia has great human and economic costs. It decreases life expectancy by between 10 and 28 years. This is primarily because of its association with heart disease, diabetes, obesity, poor diet, a sedentary lifestyle, and smoking, with an increased rate of suicide playing a lesser role. Side effects of antipsychotics may also increase the risk.

Almost 40% of those with schizophrenia die from complications of cardiovascular disease, which is seen to be increasingly associated with the disorder. An underlying factor of sudden cardiac death may be Brugada syndrome (BrS) – BrS mutations that overlap with those linked with schizophrenia are the calcium channel mutations. BrS may also be drug-induced from certain antipsychotics and antidepressants. Primary polydipsia, or excessive fluid intake, is relatively common in people with chronic schizophrenia. This may lead to hyponatremia which can be life-threatening. Antipsychotics can lead to a dry mouth, but there are several other factors that may contribute to the disorder; it may reduce life expectancy by 13 percent. Barriers to improving the mortality rate in schizophrenia are poverty, overlooking the symptoms of other illnesses, stress, stigma, and medication side effects.

Schizophrenia is a major cause of disability. In 2016, it was classed as the 12th most disabling condition. Approximately 75% of people with schizophrenia have ongoing disability with relapses. Some people do recover completely and others function well in society. Most people with schizophrenia live independently with community support. About 85% are unemployed. In people with a first episode of psychosis in schizophrenia a good long-term outcome occurs in 31%, an intermediate outcome in 42% and a poor outcome in 31%. Males are affected more often than females, and have a worse outcome. Studies showing that outcomes for schizophrenia appear better in the developing than the developed world have been questioned. Social problems, such as long-term unemployment, poverty, homelessness, exploitation, stigmatization and victimization are common consequences, and lead to social exclusion.

There is a higher than average suicide rate associated with schizophrenia estimated at 5% to 6%, most often occurring in the period following onset or first hospital admission. Several times more (20 to 40%) attempt suicide at least once. There are a variety of risk factors, including male sex, depression, a high IQ, heavy smoking, and substance use. Repeated relapse is linked to an increased risk of suicidal behavior. The use of clozapine can reduce the risk of suicide, and of aggression.

A strong association between schizophrenia and tobacco smoking has been shown in worldwide studies. Smoking is especially high in those diagnosed with schizophrenia, with estimates ranging from 80 to 90% being regular smokers, as compared to 20% of the general population. Those who smoke tend to smoke heavily, and additionally smoke cigarettes with high nicotine content. Some propose that this is in an effort to improve symptoms. Among people with schizophrenia use of cannabis is also common.

Schizophrenia leads to an increased risk of dementia.

Violence

Most people with schizophrenia are not aggressive, and are more likely to be victims of violence rather than perpetrators. People with schizophrenia are commonly exploited and victimized by violent crime as part of a broader dynamic of social exclusion. People diagnosed with schizophrenia are also subject to forced drug injections, seclusion, and restraint at high rates.

The risk of violence by people with schizophrenia is small. There are minor subgroups where the risk is high. This risk is usually associated with a comorbid disorder such as a substance use disorder – in particular alcohol, or with antisocial personality disorder. Substance use disorder is strongly linked, and other risk factors are linked to deficits in cognition and social cognition including facial perception and insight that are in part included in theory of mind impairments. Poor cognitive functioning, decision-making, and facial perception may contribute to making a wrong judgement of a situation that could result in an inappropriate response such as violence. These associated risk factors are also present in antisocial personality disorder which when present as a comorbid disorder greatly increases the risk of violence.

Epidemiology

Schizophrenia prevalence

In 2017, the Global Burden of Disease Study estimated there were 1.1 million new cases; in 2022 the World Health Organization (WHO) reported a total of 24 million cases globally. Schizophrenia affects around 0.3–0.7% of people at some point in their life. In areas of conflict this figure can rise to between 4.0 and 6.5%. It occurs 1.4 times more frequently in males than females and typically appears earlier in men.

Worldwide, schizophrenia is the most common psychotic disorder. The frequency of schizophrenia varies across the world, within countries, and at the local and neighborhood level; this variation in prevalence between studies over time, across geographical locations, and by gender is as high as fivefold.

Schizophrenia causes approximately one percent of worldwide disability adjusted life years and resulted in 17,000 deaths in 2015.

In 2000, WHO found the percentage of people affected and the number of new cases that develop each year is roughly similar around the world, with age-standardized prevalence per 100,000 ranging from 343 in Africa to 544 in Japan and Oceania for men, and from 378 in Africa to 527 in Southeastern Europe for women.

History

Conceptual development

The term schizophrenia was coined by Eugen Bleuler.

Accounts of a schizophrenia-like syndrome are rare in records before the 19th century; the earliest case reports were in 1797 and 1809. The term dementia praecox ("premature dementia") was used by German psychiatrist Heinrich Schüle in 1886 and then in 1891 by Arnold Pick in a case report of hebephrenia. In 1893 Emil Kraepelin used the term in making a distinction, known as the Kraepelinian dichotomy, between the two psychoses: dementia praecox and manic depression (now called bipolar disorder). When it became evident that the disorder was not a degenerative dementia, it was renamed schizophrenia by Eugen Bleuler in 1908.

The word schizophrenia ("splitting of the mind") is Modern Latin, derived from the Greek schizein (Ancient Greek: σχίζειν, lit.'to split') and phrēn (Ancient Greek: φρήν, lit.'mind'). Its use was intended to describe the separation of function between personality, thinking, memory, and perception.

In the early 20th century, the psychiatrist Kurt Schneider categorized the psychotic symptoms of schizophrenia into two groups: hallucinations and delusions. The hallucinations were listed as specific to auditory and the delusions included thought disorders. These were seen as important symptoms, termed first-rank. The most common first-rank symptom was found to belong to thought disorders. In 2013 the first-rank symptoms were excluded from the DSM-5 criteria; while they may not be useful in diagnosing schizophrenia, they can assist in differential diagnosis.

Subtypes of schizophrenia—classified as paranoid, disorganized, catatonic, undifferentiated, and residual—were difficult to distinguish and are no longer recognized as separate conditions by DSM-5 (2013) or ICD-11.

Breadth of diagnosis

Before the 1960s, nonviolent petty criminals and women were sometimes diagnosed with schizophrenia, categorizing the latter as ill for not performing their duties as wives and mothers. In the mid- to late 1960s, black men were categorized as "hostile and aggressive" and diagnosed as schizophrenic at much higher rates, their civil rights and Black Power activism labeled as delusions.

In the early 1970s in the United States, the diagnostic model for schizophrenia was broad and clinically based using DSM II. Schizophrenia was diagnosed far more in the United States than in Europe, where the ICD-9 criteria were followed. The US model was criticised for failing to demarcate clearly those people with a mental illness. In 1980 DSM III was published and showed a shift in focus from the clinically based biopsychosocial model to a reason-based medical model. DSM IV brought an increased focus on an evidence-based medical model.

Historical treatment

A molecule of chlorpromazine, the first antipsychotic developed in the 1950s

In the 1930s a number of shock procedures which induced seizures (convulsions) or comas were used to treat schizophrenia. Insulin shock involved injecting large doses of insulin to induce comas, which in turn produced hypoglycemia and convulsions. The use of electricity to induce seizures was in use as electroconvulsive therapy (ECT) by 1938.

Carried out from the 1930s until the 1970s in the United States and until the 1980s in France, psychosurgery, including such modalities as the lobotomy, is recognized as a human rights abuse. In the mid-1950s, chlorpromazine, the first typical antipsychotic, was introduced, followed in the 1970s by clozapine, the first atypical antipsychotic.

Political abuse

From the 1960s until 1989, psychiatrists in the USSR and Eastern Bloc diagnosed thousands of people with sluggish schizophrenia, without signs of psychosis, based on "the assumption that symptoms would later appear". Now discredited, the diagnosis provided a convenient way to confine political dissidents.

Society and culture

Stigma

John Nash, an American mathematician and joint recipient of the 1994 Nobel Memorial Prize in Economic Sciences, had schizophrenia. His life was the subject of the 1998 book, A Beautiful Mind, by Sylvia Nasar.

In 2002, the term for schizophrenia in Japan was changed from seishin-bunretsu-byō (精神分裂病; lit. 'mind-split disease') to tōgō-shitchō-shō (統合失調症; lit. 'integration–dysregulation syndrome') to reduce stigma and confusion with "multiple personalities". The new name, also interpreted as "integration disorder", was inspired by the biopsychosocial model. A similar change was made in South Korea in 2012 to attunement disorder.

Stigma may prevent further research and treatment as in history treated some in the past invariably worse to recovery.

Cultural depictions

Media coverage, especially movies, reinforce the public perception of an association between schizophrenia and violence. A majority of movies have historically depicted characters with schizophrenia as criminal, dangerous, violent, unpredictable and homicidal, and depicted delusions and hallucinations as the main symptoms of schizophrenic characters, ignoring other common symptoms, furthering stereotypes of schizophrenia including the idea of a split personality.

The book A Beautiful Mind chronicled the life of John Forbes Nash who had been diagnosed with schizophrenia and won the Nobel Memorial Prize in Economic Sciences. The book was made into a film with the same name; an earlier documentary film was A Brilliant Madness.

In the UK, guidelines for reporting conditions and award campaigns have shown a reduction in negative reporting since 2013.

In 1964 a case study of three males diagnosed with schizophrenia who each had the delusional belief that they were Jesus Christ was published as The Three Christs of Ypsilanti; a film with the title Three Christs was released in 2020.

Systemic influences

In 2002, US healthcare and societal spending related to schizophrenia was estimated at US$62.7 billion, covering direct treatment costs alongside broader economic factors such as unemployment and modeled workplace productivity impacts. In the UK, annual expenditures reached £11.8 billion in 2016, with roughly a third funding hospital, social care, and clinical treatment.

Research

A 2015 Cochrane review found unclear evidence of benefit from brain stimulation techniques to treat the positive symptoms of schizophrenia, in particular auditory verbal hallucinations (AVHs). Most studies focus on transcranial direct-current stimulation (tDCM), and repetitive transcranial magnetic stimulation (rTMS). Techniques based on focused ultrasound for deep brain stimulation could provide insight for the treatment of AVHs.

The study of potential biomarkers that would help in diagnosis and treatment of schizophrenia is an active area of research as of 2020. Possible biomarkers include markers of inflammation, neuroimagingbrain-derived neurotrophic factor (BDNF), and speech analysis. Some markers such as C-reactive protein are useful in detecting levels of inflammation implicated in some psychiatric disorders but they are not disorder-specific. Other inflammatory cytokines are found to be elevated in first episode psychosis and acute relapse that are normalized after treatment with antipsychotics, and these may be considered as state markers. Deficits in sleep spindles in schizophrenia may serve as a marker of an impaired thalamocortical circuit, and a mechanism for memory impairment. MicroRNAs are highly influential in early neuronal development, and their disruption is implicated in several CNS disorders; circulating microRNAs (cimiRNAs) are found in body fluids such as blood and cerebrospinal fluid, and changes in their levels are seen to relate to changes in microRNA levels in specific regions of brain tissue. These studies suggest that cimiRNAs have the potential to be early and accurate biomarkers in a number of disorders including schizophrenia.

Ongoing fMRI research aims to identify biomarkers within these brain networks, potentially aiding in earlier diagnosis and better tracking of treatment responses in schizophrenia.

Critical period

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