Schizophrenia

Subtypes

There are many types of schizophrenia. The most common is paranoid schizophrenia. Other types are

• Hebephrenic schizophrenia
• Catatonic schizophrenia
• Simple schizophrenia

However, the different types all share a different mix of common symptoms and signs, so general "schizophrenia" will be covered below:

Schizophrenia

A classic presentation of schizophrenia. Here, the homeless man suffers from frequent first person thought delusions.

Definition

Schizophrenia is the stereotypical psychiatry condition. It is generally understood to be a one month history of specific psychotic symptoms. Auditory hallucinations, broadcast thoughts, control delusions and delusionary beliefs.

Epidemiology

Lifetime risk of about 0.8%. At any one time, 0.4% of the population will have schizophrenia. Generally the same problem all over the world, but more common in lower social classes, probably due to the downwards spiral of mental illness: a high level banker goes mad, he will lose his job, and default on his mortgage, ending up bankrupt and poor.

Pathophysiology

There is a genetic link that appears fairly strong. The psychotic symptoms of the condition can be linked to raised dopamine levels. No idea why drug abuse can cause it, but it does.

Risk Factors

• Family History
• Past psychiatric illness
• Alcohol/Drug abuse
• Life event - both negative and, unlike depression, positive. So if you get a fired or hired it may trigger the disease.

Clinical Features

Schizophrenia Mental State Exam
Appearance & Behaviour: possibly unkempt, physically unwell, poor eye-contact; suspicious rapport, poor eye contact, looking around a lot
Speech: normal volume, rate, rhythm, no dysprosody, makes sense
Mood & Affect: scared objectively and subjectively;blunt affect
Thoughts: form: potentially normal but flight of ideas, tangentiality, circumstantiality; content: persecutory delusions, thought alienation/blocking/withdrawal/broadcast, delusions of control
Perceptions: 3rd person auditory hallucinations (running commentary) and 2nd person, no other hallucinations or illusions
Cognition: normal
Insight: no insight

Paranoid schizophrenia can present in a variety of different ways but there are some symptoms which have been identified as characteristic of the disease. These are Schneider's first-rank symptoms. These are not diagnostic individually but in groups they are highly indicative of schizophrenia.

• Audible thoughts - 1st person auditory hallucinations
• Arguing voices in their head - 2nd person auditory hallucinations (if talking directly to the patient)
• Running commentary in their head - 3rd person auditory hallucinations
• Passivity delusions - Feel like being controlled by outside forces.
• Thought alienation:
  • Thought withdrawal - delusion of thoughts being taken out the patient's head.
  • Thought insertion - thoughts being put into the patient's head. **Thought broadcast - thoughts being broadcast to people outside the patient's body.
• Other delusional perceptions

Nice way of rememebering it is ABCD: Auditory hallucinations, Broadcasting of thought, Controlled thought (delusions of control), Delusional perception.

Disorganised thinking can also be a symptom of schizophrenia. This is where the patient shows evidence of formal thought disorder - any symptoms of this can be associated with schizophrenia.

Negative Symptoms

All of the above are positive symptoms. These are symptoms that are abnormal clinical features that are gained through developing the disease. Schizophrenia also has negative symptoms where patients lose something they would normally. Those typical in schizophrenia are:

• Poverty of speech
• Anhedonia (loss of pleasure in things)
• Avolition (loss of motivation)
• flat affect

These are often not elicited due to the presence of the positive, psychotic symptoms above.

Management

Acute management of Schizophrenic patients depends mainly on their threat to themselves, and their risk to others. If they are very psychotic, they may be unwilling to take medication, and it may be necessary to use intramuscular haloperidol against the patient's will, in order to deal with the acute psychosis.

Long term management still involves anti-psychotic medication, but haloperidol is less well suited, since it has such strong extra pyramidal side effects.

1. NICE guidelines recommend first trying at least two atypical anti-psycotics, such as olanzipine.
2. Try another one after that, for example, amisulpride or risperidone.
3. If that fails, try clozapine, which is very effective where the others have failed, but can cause agranulocytosis (not nice), so it's best to try and avoid giving people that if you can.

For more information, check the page on Psychiatric Medication.

Prognosis

Outcomes in schizophrenia vary considerably. The level of of support required for sufferers varies widely as does the number and severity of relapses. Support is, as such, tailored towards patients' needs with 2 in 10 not responding to treatment and requiring long-term care, potentially in secured accomodation.

The are things which improve prognosis:

• Abstaining from smoking and alcohol (a third do both with 90% smoking)
• Rapid treatment
• Prevalence of positive rather than negative symptoms
• Development of condition after age 25
• Compliant patient
• Good family and social support