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Schizophrenia

Specialties > Mental health

Background knowledge 🧠

Definition

  • Schizophrenia is a severe mental disorder characterized by distorted thinking, perception, emotions, language, sense of self, and behavior.
  • It is considered a psychotic disorder due to the presence of hallucinations, delusions, and disorganized thinking.
  • Typically presents in late adolescence to early adulthood.
  • Diagnosis is primarily clinical, following criteria such as those in ICD-10 or DSM-5.

Epidemiology

  • Lifetime prevalence of schizophrenia is approximately 0.7% worldwide.
  • Slightly more common in males than females, with a male-to-female ratio of about 1.4:1.
  • Onset typically occurs between late teens and early 30s, earlier in males.
  • Higher prevalence in urban areas and lower socioeconomic groups.
  • Increased incidence in migrants and ethnic minorities, particularly in the UK.

Aetiology and Pathophysiology

  • Exact cause is unknown; likely multifactorial involving genetic, neurobiological, and environmental factors.
  • Genetic predisposition: risk increases with familial history of schizophrenia.
  • Neurodevelopmental abnormalities: abnormalities in brain structure and function, such as enlarged ventricles and reduced cortical thickness.
  • Dopamine hypothesis: overactivity of dopamine pathways, particularly in the mesolimbic system, is thought to contribute to positive symptoms.
  • Environmental factors: prenatal infections, malnutrition, and psychosocial stressors.
  • Cannabis use, particularly during adolescence, may increase risk.

Types

  • Paranoid schizophrenia: dominated by delusions and auditory hallucinations.
  • Hebephrenic (disorganized) schizophrenia: characterized by disorganized speech and behavior, flat or inappropriate affect.
  • Catatonic schizophrenia: marked by motor abnormalities, including stupor, rigidity, or excessive motor activity.
  • Residual schizophrenia: prominent negative symptoms with minimal positive symptoms.
  • Undifferentiated schizophrenia: does not fit neatly into the other subtypes.
  • Simple schizophrenia: predominantly negative symptoms with an insidious onset.

Clinical Features 🌡️

Symptoms

  • Positive symptoms: hallucinations (typically auditory), delusions (often persecutory or grandiose), disorganized speech, and behavior.
  • Negative symptoms: affective flattening, alogia (poverty of speech), avolition (lack of motivation), and anhedonia (inability to experience pleasure).
  • Cognitive symptoms: impaired attention, memory, and executive function.
  • Mood symptoms: depression, anxiety, and sometimes inappropriate affect.
  • Social/occupational dysfunction: difficulty in maintaining relationships, work, or academic performance.

Signs

  • Thought disorder: evidenced by disorganized thinking or speech.
  • Blunted or inappropriate affect.
  • Catatonia: motor disturbances, from stupor to excessive agitation.
  • Poor self-care and hygiene.
  • Social withdrawal and lack of interaction.
  • Poverty of speech and thought.

Investigations 🧪

Tests

  • Clinical assessment: thorough psychiatric history, mental state examination, and use of diagnostic criteria (e.g., DSM-5, ICD-10).
  • Physical examination: to rule out organic causes or comorbidities.
  • Blood tests: full blood count, electrolytes, liver function tests, thyroid function tests to exclude other causes.
  • Urine drug screen: to rule out substance-induced psychosis.
  • Imaging: brain MRI or CT may be considered to rule out structural abnormalities in new or atypical presentations.
  • Neuropsychological tests: assess cognitive impairment.

Management 🥼

Management

  • Pharmacological treatment: antipsychotics are the mainstay (e.g., risperidone, olanzapine, clozapine for treatment-resistant cases).
  • Psychological interventions: cognitive behavioral therapy (CBT), family therapy, and psychoeducation.
  • Social interventions: supported employment, housing, and social skills training.
  • Early intervention in psychosis services: important for reducing duration of untreated psychosis.
  • Hospitalization: may be necessary during acute episodes, particularly if there is a risk to self or others.
  • Long-term follow-up: regular monitoring of mental state, adherence to medication, and management of side effects.

Complications

  • High risk of suicide: approximately 10% lifetime risk.
  • Substance misuse: common comorbidity, particularly with alcohol and cannabis.
  • Cardiovascular disease: increased risk due to lifestyle factors and side effects of antipsychotic medication.
  • Metabolic syndrome: weight gain, diabetes, dyslipidemia related to antipsychotic use.
  • Social isolation and disability: significant impact on personal and occupational functioning.
  • Poor adherence to treatment: can lead to relapse and further functional decline.

Prognosis

  • Prognosis is highly variable: some individuals experience full recovery, while others have a relapsing-remitting course.
  • Approximately 20% achieve significant and lasting improvement.
  • About 50% have intermittent relapses with residual symptoms between episodes.
  • Around 30% have persistent symptoms and significant disability.
  • Poor prognostic factors include early onset, male gender, poor premorbid functioning, and lack of treatment adherence.
  • Better outcomes are associated with good social support, early treatment, and adherence to therapy.

Key Points

  • Schizophrenia is a complex, multifactorial mental illness with a significant impact on individuals and society.
  • Early diagnosis and treatment are crucial for better outcomes.
  • Management involves a combination of pharmacological, psychological, and social interventions.
  • Ongoing support and monitoring are necessary to manage symptoms and prevent relapse.
  • Patients are at high risk for comorbidities, including cardiovascular disease and substance misuse.

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Mental health