Inside the Schizophrenic Brain

With most forms of disease, a change occurs in the body that marks the presence of the illness. For example, with various forms of cancer, often a tumor develops. With certain lung conditions such as chronic obstructive pulmonary disease, structures inside the lungs suffer damage that can be observed on scans and in tissue that's removed during surgery.

The same is true of certain disorders that impact the brain. Recently, singer Ariana Grande made headlines by posting images of her brain that purportedly show evidence of post-traumatic stress disorder resulting from a terrorist bombing of the Manchester Arena in England where she was performing in 2017. But PTSD isn't the only mental health disorder that changes how the brain looks and works. Schizophrenia is another disease that occurs inside the brain that features lasting structural and functional changes.

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What Is Schizophrenia?

The American Psychiatric Association reports that "schizophrenia is a chronic brain disorder that affects less than one percent of the U.S. population. When schizophrenia is active, symptoms can include delusions, hallucinations, trouble with thinking and concentration, and lack of motivation." Psychosis is a hallmark symptom of schizophrenia, and these episodes can be scary for patients and their families. The disease is progressive and it can be debilitating. Although there's no cure for schizophrenia currently, there are safe treatments that can alleviate symptoms and improve quality of life for people with the disease.

How Does Schizophrenia Change the Brain?

"In a lot of ways, we still don't know a lot of what's happening" inside the brains of people with schizophrenia, says Aubrey Moe, a psychologist with the Early Psychosis Intervention Center at The Ohio State University Wexner Medical Center. That said, "there are some structural changes that can be observed in people who have schizophrenia. These are things like enlarged ventricles in the brain," which are small spaces in the brain that hold cerebral spinal fluid. "It sounds kind of strange that we're talking about having holes in the brain," Moe says, "but they're a good thing. We all have them. They help to create a little bit of cushion if there's an injury."

But too much of a good thing might be a problem. "In people with schizophrenia, these ventricles are enlarged. So those spaces are bigger and that indicates that there's been some sort of atrophy," meaning that some of the brain tissue that is expected to be there has been lost, compressed or shrunk. "That's been established in people with longer term disorder, so people who've been ill for a while," she says.

In patients who have been newly diagnosed, Moe says some changes may be observed in "the white matter and the gray matter where both parts of the brain seem to have some atrophy or seem not to be functioning" as expected.

"The gray matter is the outer portion of the brain, which is where most of the bodies of the neurons are located," says Dr. Andrei T. Nemoianu, a psychiatrist with Geisinger in Danville, Pennsylvania. This gray matter is, not surprisingly, pinkish-gray in color and contains several components, including:

-- Neural cell bodies, or the spherical part of the neuron that houses the nucleus.

-- Axon terminals, or the end points of the long, nerve cell branches that connect neural cells to one another.

-- Dendrites, which are branches of nerve cells.

-- Nerve synapses, the small gaps that separate neurons from one another across which signals pass.

The white matter consists of bundles of axons that connect various parts of the gray matter to each other. The white matter conducts nerve signals across the brain and throughout the central nervous system to allow your body and brain to do anything.

Nemoianu says that a decrease in gray matter is the "most commonly observed change," in the schizophrenic brain. This decrease in the size of the gray matter seems to come from some form of compression of the cells. "What seems to happen is that those cells are packed more tightly. There are not fewer of them, but the space between them is decreased and it seems to be most pronounced in the front part of the brain -- the frontal lobe -- and in the temporal lobes," which are the areas along either side of your head near where your temples are. "The changes do appear to be fairly widespread, but most prominently it seems to be in the frontal lobe."

These structural changes can lead to functional changes. "Structure just looks at things like the size of the brain and the size of different parts of the brain. But we are now able to look more at how the brain works together as a unit, how the different parts communicate with each other and how it metabolizes, through things like functional MRI and PET scanning," Nemoianu says.

Therefore, if the gaps between brain cells that are meant to help conduct signaling between them are altered, that could interfere with how that signaling works. "With the evolving technology now, we can see that when we look at functional imaging (of the brain) there seem to be differences in connectivity in certain parts of the brain," Moe says, "particularly in the frontal parts of the brain. This really means that there seems to be a change in how certain parts of the brain are communicating or not communicating with each other."

Nemoianu agrees, noting that "the overall general observation is that in schizophrenia, there seems to be an impairment in connectivity in the way that the different parts of the brain work together and, so to speak, talk to each other."

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How Can We See These Changes?

There are several different types of brain imaging tools that can help doctors get a glimpse inside your skull and deep into the brain while you're still breathing.

-- Computerized tomography. CT scanning can be thought of as a high-tech X-ray. "Brain CT scans can provide more detailed information about brain tissue and brain structure than standard X-rays of the head, thus providing more data related to injuries and/or diseases of the brain," reports Johns Hopkins Health.

-- Magnetic resonance imaging. MRI machines use magnetic fields and radio waves to produce detailed images of the brain and brain stem. It gives doctors a view of the soft tissue inside the skull and is used to help detect brain tumors, traumatic brain injury, structural or development abnormalities and a variety of medical conditions such as stroke, dementia or infection.

-- Functional MRI. fMRI uses MRI technology to measure brain activity. While lying in an MRI machine, the patient is asked to perform certain mental tasks while the machine measures the changes in blood flow that occur in different areas of the brain during that activity. It can be used to see the effects of stroke and other traumas.

-- Positron emission tomography. PET scans use a special dye that has radioactive tracers in it to help your doctor see how the brain is functioning. The radioactive tracer is taken up by specific tissues that are more active, such as cancerous tumors, the Mayo Clinic reports. PET scanning is also sometimes used to look for signs of Alzheimer's disease in the brain.

-- Single-photon emission tomography. Similar to PET scanning, SPECT scans use small amounts of radioactive dye that allow your doctor to see the function of internal organs.

Can These Changes Be Reversed?

It's unclear exactly how the structural and functional changes observed in the brains of schizophrenic patients occur to begin with, and it's equally unclear whether they can be reversed or even whether that's a desirable outcome. "In order to really determine what's reversible rather than the progression of the illness, there's been increased interest in looking at structural and functional imaging of people who are either going through their first episode of schizophrenia -- their first episode of psychosis -- and even looking at the brains of people who are identified as being at high risk of developing psychosis based on things like family history," Nemoianu says.

Research is ongoing into what occurs inside the brains of these individuals. The hope is that as we gain a deeper understanding of the human brain, how it works and how schizophrenia alters normal structures and their functioning, the closer scientists can get to curing the disease.

Nevertheless, there are treatments available today that can make an enormous difference in how people with schizophrenia experience the world. "The gold standard treatment for anybody experiencing schizophrenia is a combination of medication and therapy," Moe says.

Antipsychotic medications are the most commonly prescribed drugs to treat schizophrenia. These powerful medications block the effects of a brain chemical called dopamine -- a neurotransmitter that's integral to how brain cells communicate with one another that is found in overabundance in the brains of patients with schizophrenia. Too little dopamine, on the other hand, is implicated in Parkinson's disease, so it's an important chemical and one that needs to be dialed in at the right level.

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Once medications have stabilized patients' brain chemistry, they're typically encouraged to engage in individual, group and family therapy sessions. Social skills training and vocational rehabilitation may also come into play for certain patients, depending on their needs and goals.

Moe says the important thing is to ask for help if you or a loved one is dealing with psychosis or if you suspect that schizophrenia may be present. Connecting with "a psychiatrist with expertise and also individual and group therapies can be very important as well in helping patients achieve the goals they want to achieve. With many people, symptom reduction is part of that. For a lot of folks we work with, that's not the only thing they want. We work with a lot of young people, and their goals typically involve wanting to go back to school, wanting to go to work and wanting to make more friends."

Nemoianu adds that "it really takes a team approach to achieve the best outcomes for people with schizophrenia. Ideally, that team is led by the patient him or herself, but family members are also critically important. The degree to which people's families can remain as actively involved and engaged in their loved one's lives when they have schizophrenia, that helps tremendously in terms of achieving a good outcome with a chronic illness."