Schizophrenia is a heterogenous group of disorders characterized by a constellation of symptoms and signs including delusions, hallucinations, disorganized thoughts and behavior, apathy, avolition, amotivation, anhedonia and abstracting difficulties.It affects one out of 100 individuals globally. It usually begins in adolescence or early adulthood and affects both sexes equally. In more than 90% of cases individuals will have a "prodromal phase". The diagnosis is made by careful history from the patient, family or caregivers along with a complete physical and mental status examination. About 10% of patients with schizophrenia will commit suicide. Most patients will benefit from medications and psychosocial treatments in combination. The atypical antipsychotics like risperidone, aripirazole, quetiapine, lurasidone, ziprasidone, olanzapine and asenapine are commonly prescribed. Psychosocial treatments found to be helpful include cognitive behavior therapy (CBT), assertive community treatment (ACT), psychoeducation and social skills training. Unfortunately there are still many unmet needs in the treatment of schizophrenia.
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What is Schizophrenia?
Schizophrenia is a serious chronic psychiatric illness. There is no single symptom that defines schizophrenia. Usually patients have “positive symptoms” including:
- Delusions (fixed false beliefs not amenable to reasoning and not culturally explained)
- Hallucinations (perceptual disturbances like hearing voices, feeling the presence of others etc.
- Disorganized speech ( incoherence, difficulty organizing thoughts etc.)
- Disorganized behavior or “negative symptoms” (avolition, apathy, amotivation etc.)
There is marked impairment in:
- Interpersonal relationships as a consequence of the illness.
The illness affects one in 100 individuals globally.
The term schizophrenia was coined by Eugen Bleuler a Swiss psychiatrist to denote schizo (split) and phrene (mind). It is often mistakenly confused with split personality which is inaccurate.
Age of onset is usually between the ages of 16-30 and shows up earlier in males.
One in 10 cases start after the age of 40.
- 90% of patients with schizophrenia experience a “prodromal phase”.
- The symptoms include attenuated forms of the symptoms of schizophrenia.
- About 35% of patients who have a “prodrome” will go on to develop schizophrenia.
- Intervening early in the “prodrome” can potentially prevent schizophrenia or improve its outcome.
How is schizophrenia diagnosed?
The diagnosis is based on a thorough longitudinal history from the patient and family members since patients may have no insight into their psychotic symptoms and may deny them. A thorough mental status and physical exam is necessary to confirm the diagnosis and rule out secondary causes (like medical illnesses, drugs, medications etc.) of psychotic symptoms particularly in patients with sudden onset of symptoms.
Neuroimaging is usually not necessary in most patients to make a diagnosis.
Laboratory tests are usually normal although drug screens may be positive.
The results of the evaluation the patient may be diagnosed with one of the following subtypes of schizophrenia:
- first episode
- multiple episodes
What Are the Main Changes in DSM 5 for Schizophrenia?
- Schizophrenia is now part of schizophrenia spectrum (includes schizophrenia, schizotypal personality disorder and schizophreniform disorder) and other psychotic disorders category.
- Two out of five symptoms (one must be delusions, hallucinations or disorganized speech) are now required.
- Bizarre delusions alone are not sufficient for a diagnosis of schizophrenia.
- The previous subtypes of schizophrenia like paranoid, catatonic, disorganized, undifferentiated and residual have been eliminated.
- New course specifiers have been added after the illness has been present for at least one year. These include single episode, multiple episodes, continuous, and unspecified. Presence of catatonia and current severity of symptoms are also specifiers.
Suicide and Schizophrenia
About 10% of patients will commit suicide.
Risk factors include:
- younger age, males
- comorbid substance abuse
- delusions of persecution
- non-adherence to treatment
Violence and Schizophrenia
Most patients with schizophrenia are not violent. However schizophrenia is overrepresented in individuals who commit violent crimes.
Risk factors include:
- Younger male
- First episode
- Cultural and language barriers
- Prior aggressive behavior
-delusions of threat or being spied upon
- Anger issues
- Substance abuse
- Non-adherence to medications
- Access to firearms.
What Causes Schizophrenia?
A combination of genetic and environmental factors contribute.
Schizophrenia runs in families. If you have a first degree relative with schizophrenia your risk of developing the illness is 10 times greater. Patients with schizophrenia have rare genetic mutations but no single gene has been implicated.
50% Risk of schizophrenia in identical twins
Environmental factors implicated include:
- Exposure to malnutrition or certain viruses (influenza, rubella or respiratory) prior to birth
- Obstetric complications or hypoxia during birth
- Social adversity
- Traumatic brain injury in those at genetic risk
- Excessive cannabis use
Myths About Schizophrenia
1. Schizophrenia is a progressive disease in all patients.
2. Most patients with schizophrenia are violent.
3. Recovery is not possible in schizophrenia.
4. Patients with schizophrenia have a “split personality”.
5. Bad parenting can cause schizophrenia.
6. Patients with schizophrenia do not need medications.
How Can Schizophrenia Be Treated?
Hospitalization: Patients with severe psychosis, those that are suicidal or homicidal and those with comorbid substance abuse or uncontrolled medical illnesses may need to be hospitalized
Initial Treatment: Most patients will benefit from a combination of medications and psychosocial treatments. Atypical antipsychotics ( so called because they are less likely to cause parkinsonian side effects compared to the older or conventional antipsychotics) like risperidone, ziprasidone,quetiapine, olanzapine,aripiprazole, lurasidone, asenapine are the treatments of choice. Many patients may need adjunctive benzodiazepines or hypnotics acutely for the control of psychosis. Patients who do not respond to or develop side effects with one drug can be switched to other antipsychotics. Patients who fail two or more drugs should be considered candidates for clozapine which is FDA approved for treatment resistant schizophrenia but is very under-utilized.
Long Acting Injectable antipsychotics like aripiprazole long acting, risperidone microspheres, paliperidone palmitate and olanzapine pamoate are very helpful to ensure adherence but are extremely under-utilized in the US compared to the rest of the world
Long term Treatment: Most patients will need maintenance antipsychotics and adjunctive psychosocial therapies. Often the dose of the antipsychotic can be reduced during the maintenance phase. Only a small minority of patients with good prognosis schizophrenia can be managed without long term medications.
50%-75% of patients with schizophrenia do not take the medications as prescribed.
Risk of relapse off medications is 3X greater than on medications.
Clozapine has anti-suicidal effects in patients with schizophrenia
Psychosocial treatments found to be effective as adjuncts to medications include:
- Cognitive behavior therapy (CBT)
- Assertive community treatment (ACT)
- Social skills training
- Vocational rehabilitation and family intervention (decreasing emotional over-involvement, critical comments and hostility towards patient)
Side effects of antipsychotics commonly include:
- Parkinsonism (rigidity, tremor, restlessness ,or gait abnormalities)
- Weight gain and metabolic abnormalities (increased lipids, glucose, cholesterol etc.)
- Some antipsychotics like olanzapine, quetiapine and clozapine are particularly likely to cause weight gain and metabolic problems.
- Children and adolescents are most sensitive to these side effects.
- Patients should have their weight, waist circumference, glucose and lipids monitored regularly.
- Tardive dyskinesia is a rare but serious side effect than can occur in a small minority of patients on atypical antipsychotics and should be monitored for annually.
- Agranulocytosis is a blood disorder which is a rare side effect of clozapine and should be monitored for especially early in treatment.