SCHIZOPHRENIA
Fact Sheet and TR Application
Aly Peterson
Joshua Boaz
Table of Contents
A.
Title Page
B.
Table of Contents…………………………………………………………………....1
About Schizophrenia………………………………………………………………..2
Definitions……………………………………………………………………...2
Causes…………………………………………………………………………2
Epidemiology…………………………………………………………………..2
Metacognition Theory………………………………………………………...3
Symptoms………………………………………………………………………….....4
Positive…………………………………………………………………………4
Negative………………………………………………………………………..4
Cognitive…………………………………………………………………….....4
Diagnosis………………………………………………………………………………5
By Symptoms…………………………………………………………………..5
Schizophrenia Subtypes…………………………………………………………….6
Prognosis………………………………………………………………………………8
Treatment and Special Needs………………………………………………………9
Medications…………………………………………………………………………...12
Schizophrenia Screening Test………………………………………………….....14
TR Implications……………………………………………………………………….17
Resources……………………………………………………………………………..19
References…………………………………………………………………………….21
1
About Schizophrenia
Definition:
Schizophrenia is a severe brain disorder in which people interpret reality abnormally.
Schizophrenia may result in some combination of hallucinations, delusions, and
extremely disordered thinking and behavior.
Contrary to popular belief, schizophrenia isn't a split personality or multiple personality.
The word "schizophrenia" does mean "split mind," but it refers to a disruption of the
usual balance of emotions and thinking.
Schizophrenia is a chronic condition, requiring lifelong treatment. [1]
Causes:
Genetic Influences: People who have a close relative with schizophrenia are more likely
to develop the disorder than are people who have no relatives with the illness. In one’s
family, a genetic predisposition can be inherited for schizophrenia. However, the
specific type of schizophrenia cannot be inherited.
Psychological and Social Influences: Level of social and family support. Also, Events in
a person’s environment may trigger schizophrenia. For example, problems during
development while mother is pregnant and at birth may increase risk of baby developing
schizophrenia later in life.
Neurobiological Influences: Thought to be caused by an imbalance of chemicals-serotonin and dopamine-- that are found in the brain. [2]
Epidemiology:
Schizophrenia occurs throughout the world. The prevalence of schizophrenia (ie, the
number of cases in a population at any one time point) approaches 1 percent
internationally. The incidence (the number of new cases annually) is about 1.5 per
10,000 people. Slightly more men are diagnosed with schizophrenia than women, and
women tend to be diagnosed later in life than men. There is also some indication that
2
the prognosis is worse in men. A number of risk factors have been associated with the
development of schizophrenia, including living in an urban area, immigration, obstetrical
complications, and a late winter-early spring time of birth (perhaps reflecting exposure
to influenza virus during neural development). [3]
Metacognition Theory:
There’s an innate self-awareness of one’s own thinking process. Recognition between
one’s own thoughts and external thoughts (own voice vs. others’ voice). For individuals
with schizophrenia, there is a confusion between the Broca’s and the Wernicke’s Area
of the brain. When they hear voices, activity occurs in Broca’s area, instead of
Wernicke’s area. Mix-up in understanding can hinder their overall perception. Prosody is
known as the emotional impact of language. Inflection relays meaning and emotion.
Schizophrenics may misread inflections and misunderstand messages.
3
Symptoms
Positive: symptoms that reflect an excess or distortion of normal functions
1. Delusions: Not based in reality and usually involve misinterpretation of perception
or experience. Most common of all the symptoms.
2. Hallucinations: Seeing or hearing things that do not exist, although hallucinations
can be in any of the senses. Hearing voices is the most common hallucination
among people with schizophrenia.
3. Thought Disorder: Difficulty speaking, stopping speech mid-sentence, putting
together meaningless words
4. Disorganized Behavior: Can be shown in many different ways including childlike
behavior or unpredictable behavior.
Negative: symptoms that refer to a diminishment or absence of characteristics of
normal function. They may appear months or years before positive symptoms. (5 A’s):
1. Anhedonia: Loss of motivation Loss of interest in everyday activities
2. Affective Flattening: Lack of facial emotion
3. Avolition: Neglect of personal hygiene. Lack ability to plan or carry out activities
4. Asociality: Social withdrawal.
5. Alogia: Lack of constant conversation, responsiveness.
Cognitive: symptoms that involve problems with thought processes
1. Problems with making sense of information. Drop of IQ.
2. Difficulty paying attention, retaining memory, and carrying out executive function.
3. Loose associations: Variety of speech tendencies. (e.g. alliterations and run-on
with certain thoughts)
4. Rigidity or literal thinking: Their reasoning is always black and white, difficult to
compromise with.
4
Diagnosis
There is no test that can make a schizophrenia diagnosis. People with schizophrenia
usually come to the attention of a mental health professional after others see them
acting strangely.
Doctors make a diagnosis through interviews with the patient as well as with friends and
family members.
Psychiatrists have the most experience with diagnosing schizophrenia. A psychiatrist or
other licensed mental health professional should be involved in making a schizophrenia
diagnosis whenever possible.
A schizophrenia diagnosis can be made when all of the following are true about a
patient:

Schizophrenia symptoms have been present for at least six months.

Patient is significantly impaired by the symptoms. For example, has serious
difficulty working or with social relationships, compared to the period before
symptoms began.

Symptoms can't be explained by another diagnosis, such as drug use or another
mental illness.
Some people with schizophrenia are afraid of their symptoms. Or they may be
suspicious of others (paranoid). They may conceal their symptoms from doctors or
loved ones. This can make it more difficult to confirm a schizophrenia diagnosis. [4]
Diagnosing Schizophrenia by Symptoms
People with schizophrenia have at least some of its main symptoms. For a psychiatrist
to make a confident schizophrenia diagnosis, some of these symptoms must be
present:

Hallucinations. This means hearing voices or other sounds that aren't there or
seeing things that don't exist.

Delusions (unshakeable beliefs that aren't true).
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
Disorganized speech and behavior (talking and acting strangely).

Lack of motivation and emotional expression.

Lack of energy.

Poor grooming habits.
Specific types of psychotic symptoms (called first-rank symptoms), when present, make
a schizophrenia diagnosis more likely:

Hearing your own thoughts spoken aloud.

Feeling that thoughts are being inserted into your mind, or removed from it, by an
outside force.

Feeling like other people can read your mind.

Feeling that an outside force is making you feel something, want something, or
act in a certain way.

Hearing voices discuss you or argue about you.

Hearing voices narrate your actions as you perform them.
A person with schizophrenia may describe these symptoms openly. Or a psychiatrist
may deduce they are likely present based on observations of a person's speech and
behavior.
Schizophrenia Subtypes
As schizophrenia progresses, its symptoms can change. Its course is categorized
clinically by whatever type of behavior is prominent during an episode. The following
five main subtypes are used to classify schizophrenia:

Catatonic

Paranoid

Disorganized

Undifferentiated

Residual
6
Catatonic Schizophrenia:
People with catatonic type assume peculiar postures and are usually speechless. They
may be both rigid and motionless, or they may seem agitated and move around
excessively, but always without external stimulus.
Catatonic people may also have strange facial expressions, may mimic the behavior of
others, and may repeat words that others say. Catatonic behavior is also seen in mood
disorders, like bipolar disorder and major depressive disorder, and occasionally in
diseases of the central nervous system, like Parkinson's disease.
Paranoid Schizophrenia:
Paranoid schizophrenia is marked primarily by delusions that follow a theme, like
persecution or grandeur. Auditory hallucinations may accompany a delusion and are,
therefore, usually related to its theme.
Symptoms common to other subtypes, like disorganized speech and flattened affect,
are not usually prominent in episodes of paranoia, but anger, irritability, and extreme
anxiety are. People suffering from paranoid delusions become particularly preoccupied
with them and may be especially prone to violence.
Interestingly, people with paranoid schizophrenia may experience less dysfunction than
people with other subtypes. They are often able to live, work, and care for themselves.
The onset of paranoid schizophrenia is often later in life, and, with time, it may
characterize most or all episodes.
Disorganized Schizophrenia:
Disorganized type, which is marked by disorganized speech, behavior, and flattened
affect is particularly disruptive. The disorganized episode (also known as hebephrenic
schizophrenia) often features fragmented speech and inappropriate or unexpected
behavior that does not reflect ideas expressed verbally. Strange mannerisms, gestures,
and surprising behavior are common.
This type of schizophrenia typically causes significant dysfunction in daily life, self-care,
and interaction with others, as well as notable thought disturbance and loss of goaldirected behavior. People in the midst of a disorganized episode show no catatonic
signs.
7
Undifferentiated Schizophrenia:
Undifferentiated schizophrenia is the type given to a lack of catatonia, paranoia, or
disorganized speech. Undifferentiated schizophrenia might resemble other illnesses,
including neurological disorders. However, people suffering from non-psychiatric
diseases typically have insight into their condition and they understand the medical
basis for its presence.
Residual Schizophrenia:
Finally, the residual type of schizophrenia is diagnosed when positive symptoms like
delusions, hallucinations, and grossly disorganized behavior have disappeared.
Negative symptoms remain and may be interrupted only briefly by mildly disorganized
speech or strange behavior.
Prognosis
No known cure exists for individuals with schizophrenia. But many people with this
illness can lead productive and fulfilling lives with the proper treatment. The traditional
clinical and societal view of schizophrenia is of a debilitating and deteriorating disorder
with poor outcome. However, most patients now live independently outside the hospital
and the typical duration of admission is short (a few weeks). Although most patients
need some degree of formal or informal financial and daily-living support, the
perspective now is one of recovery, where the patient takes an active role in the
development of new meaning and purpose while growing beyond the misfortune of
mental illness. [5]
About three fourths of persons with schizophrenia have recurrent relapse and continued
disability, although the proportion of persons with significant improvement increased
after the mid-1950s (mean: 48.5 percent from 1956 to 1985 versus 35.4 percent from
1895 to 1956). Outcome may be worse in persons with insidious onset and delayed
initial treatment, social isolation, or a strong family history; persons living in
industrialized countries; men; and persons who misuse drugs. Pharmacologic treatment
is generally successful in treating positive symptoms, but up to one third of persons
derive little benefit, and negative symptoms are notoriously difficult to treat. About one
8
half of persons with schizophrenia do not adhere to treatment in the short term. The
figure is even higher in the longer term. [6]
Treatment and Special Needs
Treatment
Schizophrenia is a chronic condition, and people with schizophrenia need continued
help and support. With proper medication and treatment, people with schizophrenia can
live by themselves and work. Some individuals might have a more severe case and will
require hospitalization or daily care. Every individual is different, and a majority of
people can improve their symptoms and daily functioning with support.
Treatment for schizophrenia includes medication, therapy, hospitalization, support
groups, and vocational programs. Medication for mental illness is often a trial-and-error
process, and psychiatrists will likely need to try out a combination of medicines with
varying doses to evaluate which ones are best and have the least amount of side
effects with the best benefit. Individual and group therapy is important for people with
schizophrenia, and these sessions can help you determine appropriate goals and teach
you strategies for reaching those goals. Sometimes changes in medication or stressful
life events can bring about acute symptoms, and hospitalization might be required to
stabilize symptoms of schizophrenia. Vocational programs and other day treatment
centers can help give you skills you need to hold relationships and work, and these
programs can also help you find recreational activities and find the best living
arrangements.
Some individuals with schizophrenia find they do not have family support, and it can be
difficult to live on one’s own. Through a support group or social worker, you can apply
for SSD or SSI, which is Social Security benefits that will give you money for housing
and treatment. Many hospitals will also pay individuals with schizophrenia for
participating in drug and treatment research. Additionally, you can get support and find
resources from the National Alliance for the Mentally Ill. [7]
Family psycho-education: In addition to educating family members about the symptoms,
course, and treatment of schizophrenia, this form of treatment consists of providing
9
family support, problem-solving skills, and access to care providers during times of
crises. When this intervention is consistently provided for at least several months, it has
been found to decrease the relapse rate for the individual with schizophrenia and
improve the person's social and emotional outcomes. Also, the burden that family
members experience as a result of having a loved one with schizophrenia is lessened,
family members tend to be more knowledgeable about the disorder and feel more
supported by the professionals involved, and family relationships are improved.
Assertive community treatment (ACT): This intervention consists of members of the
person's treatment team meeting with that individual on a daily basis, in community
settings (for example, home, work, or other places the person with schizophrenia
frequents) rather than in an office or hospital setting. The treatment team is made up of
a variety of professionals. For example, a psychiatrist, nurse, case manager,
employment counselor, and substance-abuse counselor often make up an ACT team.
ACT tends to be successful in reducing how often people with schizophrenia are
hospitalized or become homeless.
Substance abuse treatment: Providing medical and psychosocial interventions that
address substance abuse should be an integral part of treatment as about 50% of
individuals with schizophrenia suffer from some kind of substance abuse or
dependence.
Social skills training: Also called illness management and recovery programming, socialskills training involves teaching clients ways to handle social situations appropriately. It
often involves the person scripting (thinking through or role-playing) situations that occur
in social settings in order to prepare for those situations when they actually occur. This
treatment type has been found to help people with schizophrenia resist using drugs of
abuse, as well as improve their relationships with health-care professionals and with
people at work.
10
Supported employment: This intervention provides supports like a work coach
(someone who periodically or consistently counsels the client in the workplace), as well
as instruction on constructing a résumé, interviewing for jobs, and education and
support for employers to hire individuals with chronic mental illness. Supported
employment has been found to help schizophrenia sufferers secure employment, earn
more money, and increase the number of hours they are able to work.
Cognitive behavioral therapy (CBT): CBT is a reality-based intervention that focuses on
helping a client understand and change patterns that tend to interfere with his or her
ability to interact with others and otherwise function. Except for people who are actively
psychotic, CBT has been found to help individuals with schizophrenia decrease
symptoms and improve their ability to function socially. This intervention can be done
either individually or in group sessions.
Weight management: Educating people with schizophrenia about weight gain and
related health problems that can be a side effect of some antipsychotic and other
psychiatric medications has been found to be helpful in resulting in a modest weight
loss. That is also true when schizophrenia sufferers are provided with behavioral
interventions to assist with weight loss. [8]
Specific Needs
People living with schizophrenia need a correct diagnosis and early treatment of their
illness. They also need understanding, compassion, and respect. They also need an
effectively functioning mental health system, which is a rarity in the United States today.
NAMI’s Grading The States report (2006) reviews the care systems in every state and
provides advocacy points as well as outlining strengths and urgent needs for each state.
The report is available at www.nami.org/grades.
Like anyone else living with a serious, ongoing illness, a person living with
schizophrenia needs help with the fear and isolation associated with this illness as well
as the negative cultural attitudes surrounding it.
11
Because in the beginning the illness may make it so difficult to do even everyday things
they did before, some who live with this illness need help with their physical care, from
staying clean and eating well to following medical treatment. Although new and better
treatments allow many people to return to more active lives, many people living with
schizophrenia may need help over the long term with their basic needs, such as money,
housing, food, and clothing. [9]
Medications
In schizophrenia, antipsychotic medications are proven effective in treating acute
psychosis and reducing the risk of future psychotic episodes. The treatment of
schizophrenia thus has two main phases: an acute phase, when higher doses might be
necessary in order to treat psychotic symptoms, followed by a maintenance phase,
which is usually life-long. During the maintenance phase, dosage is often gradually
reduced to the minimum required to prevent further episodes and control inter-episode
symptoms. If symptoms reappear or worsen on a lower dosage, an increase in dosage
may be necessary to help prevent further relapse.
Even with continued treatment, some patients experience relapses. The most common
cause of a relapse is stopping medications.
Since it is difficult to predict which patients will fall into what groups, it is essential to
have long-term follow-up, so that the treatment can be adjusted and any problems
addressed promptly.
Antipsychotic drugs are the cornerstone in the management of schizophrenia. They
have been available since the mid-1950s, and although antipsychotics do not cure the
illness, they greatly reduce the symptoms and allow the patient to function better, have
better quality of life, and enjoy an improved outlook. The choice and dosage of
medication is individualized and is best done by a physician who is well trained and
experienced in treating severe mental illness.
The first antipsychotic drug was discovered by accident and then used for
schizophrenia. This was Thorazine, which was soon followed by medications such as
12
Haldol, Prolixin, Navane, Loxapine, Stelazine, Trilafon, and Mellaril. These drugs have
become known as "neuroleptics" (meaning, "take the neuron") because, although
effective in treating positive symptoms (acute symptoms such as hallucinations,
delusions, thought disorder, loose associations, ambivalence, or emotional lability), they
can cause cognitive dulling and involuntary movements, among other side effects.
These older medications also are not so effective against so-called negative symptoms
such as apathy, decreased motivation, and lack of emotional expressiveness.
In 1989, a new generation of antipsychotics -- called atypical antipsychotics -- was
introduced. At the correct doses, fewer of the neurological side effects -- which often
include such symptoms as muscular rigidity, painful spasms, restlessness, or tremors -are seen.
The first of the new generation, Clozaril is the only drug that has been shown to be
effective where other antipsychotics have failed. It is not linked with the side effects
mentioned above, but it does produce other side effects, including weight gain, changes
in blood sugar and cholesterol, and possible decrease in the number of infection-fighting
white blood cells. Blood counts need to be monitored every week during the first six
months of treatment and then every two weeks and eventually once a month indefinitely
in order to catch this side effect early if it occurs.
Other atypical antipsychotics include Abilify, Geodon, Invega, Latuda, Risperdal,
Saphris, Seroquel, and Zyprexa. Another atypical antipsychotic, Fanapt, has been FDAapproved for acute (but not long-term) treatment of schizophrenia. The use of all of
these medications has allowed successful treatment and release back to their homes
and the community for many people suffering from schizophrenia.
Although sometimes more effective and better tolerated than older conventional
neuroleptics, atypical antipsychotics also have side effects, and current medical practice
is developing better ways of understanding these effects, identifying people at risk, and
managing complications. Importantly, all atypical antipsychotics carry the possible risk
for causing weight gain and raising blood sugar, cholesterol, and triglyceride levels,
which must be periodically monitored during treatment. Some antipsychotics -- typical
13
and atypical -- can cause heart rhythm problems that may require monitoring by a
doctor.
Most of these medications take two to four weeks to take effect. Patience is required if
the dose needs to be adjusted, the specific medication changed, and another
medication added. In order to be able to determine whether an antipsychotic is effective
or not, it should be tried for at least four weeks (or even as long as several months in
the case of Clozaril).
Because the risk of relapse of illness is higher when antipsychotic drugs are taken
irregularly or discontinued, it is important that people with schizophrenia follow a
treatment plan developed in collaboration with their doctors and with their families. The
treatment plan will involve taking the prescribed medication in the correct amount and at
the times recommended, attending follow-up appointments, and following other
treatment recommendations.
People with schizophrenia often do not believe that they are ill or that they need
treatment. Other possible things that may interfere with the treatment plan include side
effects from medications, substance abuse, negative attitudes towards treatment from
families and friends, or even unrealistic expectations. When present, these issues need
to be acknowledged and addressed for the treatment to be successful. [10]
Yale University PRIME Early Psychosis/Schizophrenia Screening Test [11]
Instructions: This free screening test is for anyone who wants to see if they may have the
symptoms commonly associated with a schizophrenia-specific disorder, such as
Schizophrenia or schizophreniform disorder. Answer the questions below based upon how
you currently feel or have felt in the past month.
1. I feel that others control what I think and feel.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
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2. I hear or see things that others do not hear or see.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
3. I feel it is very difficult for me to express myself in words that
others can understand.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
4. I feel I share absolutely nothing in common with others, including
my friends and family.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
5. I believe in more than one thing about reality and the world
around me that nobody else seems to believe in.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
15
6. Others don't believe me when I tell them the things I see or hear.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
7. I can't trust what I'm thinking because I don't know if it's real or
not.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
8. I have magical powers that nobody else has or can explain.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
9. Others are plotting to get me.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
10. I find it difficult to get a hold of my thoughts.
16

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
11. I am treated unfairly because others are jealous of my special
abilities.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
12. I talk to another person or other people inside my head that
nobody else can hear.

Not at all

Just a little

Somewhat

Moderately

Quite a lot

All the time
Therapeutic Recreation Implications
One of the main components for schizophrenia is social rehabilitation to help patients
reintegrate into the community and regain educational or occupational functioning. The
problems in living experienced by people with schizophrenia are social, personal,
clinical, and sometimes political (e.g., discrimination). Because the impact of
schizophrenia is felt in so many areas of life, effective treatment must address multiple
problems, including early recognition of relapse, relapse prevention, improved insight
17
and adherence to treatment, psychoeducation, family living, community care and care in
other special settings, social and coping skills, and rehabilitation.
Each therapeutic discipline has the responsibility of demonstrating that treatment leads
to functional change through supportive data. Without the use of an outcome measure,
Recreational Therapy research aimed at the effectiveness of interventions and
outcomes of practice to promote efficiency of treatment cannot be conducted.
Recreational therapists have a responsibility to provide a measure for outcomes of RT
to enhance professional growth and to assure quality treatment of clients.
A CTRS helping a patient with schizophrenia must understand all forms of the disorder
to help manage the symptoms associated with it. Undergoing therapeutic recreation can
help in the following ways:

Aid the patient in sharing his/her thoughts more easily

Improve relationships

Find enjoyable activities to participate in during free time

Learn new skills and also for rehab purposes

Improve his/her self-image and improve their overall quality of life

Help learn skills that would be beneficial at work, home, or school

Learn coping strategies.

Exhibit higher levels of appropriate behaviors than when engaged in vocational
rehabilitation services

Find meaning in life, which can help avoid indulging in their delusions

Recognize common surroundings, which can help a person distinguish between
reality and hallucinations/delusions

Learn how to make individual and group decisions
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Resources for Schizophrenia
The following organizations are effective resources for Information, support, and
advocacy. For any questions, concerns, or doubts about schizophrenia, use the contact
information below:
National Alliance for the Mentally Ill (NAMI)
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042
Phone: 1-800-950-NAMI (6264) or (703) 524-7600
Internet: http://www.nami.org
National Mental Health Association (NMHA)
2001 N. Beauregard Street, 12th Floor
Alexandria, VA 22311
Phone: 1-800-969-6942 or (703) 684-7722
TTY-800-443-5959
Internet: http://www.nmha.org
National Mental Health Consumers' Self-Help Clearinghouse
1211 Chestnut Street, Suite 1000
Philadelphia, PA 19107
Phone: 1-800-553-4key (4539) or (215) 751-1810
Internet: http://www.mhselfhelp.org/index2.html
National Alliance for Research on Schizophrenia and Depression (NARSAD)
60 Cutter Mill Road, Suite 404
Great Neck, NY 11021
Phone: (516) 829-0091
Infoline 1-800-829-8289
Internet: http://www.narsad.org
19
For more information on research into the brain, behavior, and mental disorders contact:
National Institute of Mental Health (NIMH)
Office of Communication and Public Liaison
Information Resources and Inquiries Branch
6001 Executive Boulevard, Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513
Fax: 301-443-4279
E-mail: nimhinfo@nih.gov
Fax back system: Mental Health FAX4U at 301-443-5158
Web site address: http://www.nimh.nih.gov/
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References
[1] http://www.mayoclinic.org/diseases-conditions/schizophrenia/basics/definition/con20021077
[2] http://psychcentral.com/lib/what-causes-schizophrenia/000715
[3] http://www.uptodate.com/contents/schizophrenia-epidemiology-and-pathogenesis
[4] http://www.webmd.com/schizophrenia/guide/schizophrenia-tests
[5] http://www.sciencedirect.com/science/article/pii/S0140673609609958
[6] http://www.aafp.org/afp/2010/0815/p338.html
[7] http://www.specialneeds.com/children-and-parents/general-special-needs/helpschizophrenia
[8] http://www.medicinenet.com/schizophrenia/page5.htm
[9] http://www.nami.org/Template.cfm?Section=By_Illness&Template=/
ContentManagement/ContentDisplay.cfm&ContentID=67729
[10] http://www.webmd.com/schizophrenia/guide/schizophrenia-medications?page=2
[11] http://www.schizophrenia.com/sztest/primetest.pdf
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