Schizophrenia

What is schizophrenia?
• Schizophrenia is a serious mental illness that affects how a person
thinks, feels, and behaves. People with schizophrenia may seem like
they have lost touch with reality, which can be distressing for them
and for their family and friends.
• Schizophrenia causes psychosis and is associated with considerable
disability and may affect all areas of life including personal, family,
social, educational, and occupational functioning.
• Stigma, discrimination, and violation of human rights of people
with schizophrenia are common.
• More than two out of three people with psychosis in the world do
not receive specialist mental health care.
• A range of effective care options for people with schizophrenia
exist and at least one in three people with schizophrenia will be
able to fully recover.
Symptoms:
• persistent delusions: the person has fixed beliefs that something is
true, despite evidence to the contrary;
• persistent hallucinations: the person may hear, smell, see, touch, or
feel things that are not there;
• experiences of influence, control or passivity: the experience that
one’s feelings, impulses, actions, or thoughts are not generated by
oneself, are being placed in one’s mind or withdrawn from one’s mind
by others, or that one’s thoughts are being broadcast to others;
• disorganized thinking, which is often observed as jumbled or
irrelevant speech;
• highly disorganised behaviour e.g. the person does things that appear
bizarre or purposeless, or the person has unpredictable or
inappropriate emotional responses that interfere with their ability to
organise their behaviour;
• “negative symptoms” such as very limited speech, restricted
experience and expression of emotions, inability to experience
interest or pleasure, and social withdrawal; and/or
• extreme agitation or slowing of movements, maintenance of unusual
postures.
• People with schizophrenia often also experience persistent difficulties
with their cognitive or thinking skills, such as memory, attention, and
problem-solving.
• At least one third of people with schizophrenia experiences complete
remission of symptoms (1). Some people with schizophrenia
experience worsening and remission of symptoms periodically
throughout their lives, others a gradual worsening of symptoms over
time.
• Schizophrenia is frequently associated with significant distress and
impairment in personal, family, social, educational, occupational, and
other important areas of life. Schizophrenia is frequently associated
with significant distress and impairment in personal, family, social,
educational, occupational, and other important areas of life.
• People with schizophrenia are 2 to 3 times more likely to die early
than the general population (3). This is often due to physical illnesses,
such as cardiovascular, metabolic, and infectious diseases.
Causes of schizophrenia
• Research has not identified one single cause of schizophrenia. It is
thought that an interaction between genes and a range of
environmental factors may cause schizophrenia. Psychosocial factors
may also affect the onset and course of schizophrenia. Heavy use of
cannabis is associated with an elevated risk of the disorder.
Risk factors
• Genetics:
• Environment
• Brain structure and function
• Genetics: Schizophrenia sometimes runs in families. However, just
because one family member has schizophrenia, it does not mean that
other members of the family also will have it.
Studies suggest that many different genes may increase a person’s ch
ances of developing schizophrenia
, but that no single gene causes the disorder by itself.
• Environment: Research suggests that a combination of genetic
factors and aspects of a person’s environment and life experiences
may play a role in the development of schizophrenia. These
environmental factors that may include living in poverty, stressful or
dangerous surroundings, and exposure to viruses or nutritional
problems before birth.
• Brain structure and function: Research shows that people with
schizophrenia may be more likely to have differences in the size of
certain brain areas and in connections between brain areas. Some of
these brain differences may develop before birth. Researchers are
working to better understand how brain structure and function may
relate to schizophrenia.
• Schizophrenia is a complex mental disorder characterized by a range of
symptoms, including delusions, hallucinations, disorganized thinking,
and negative symptoms. However, there is no single laboratory
test that can definitively diagnose schizophrenia. Instead, doctors
typically rely on a combination of methods to evaluate and diagnose the
condition. Here are some key points about diagnosing schizophrenia:
1 Clinical Assessment: The initial step involves a thorough clinical
assessment by a specialist in mental health. This assessment includes:
• Physical Examination: A general physical exam to rule out any other medical
conditions that might be causing symptoms.
• Psychiatric History: Gathering information about your symptoms, family history of
mental illness, past medical and psychiatric problems, and previous treatments.
• Input from Family and Friends: Input from family members or friends who can
provide additional details about changes in behavior, social functioning, and
emotional state.
2. Symptoms Evaluation: Doctors diagnose schizophrenia based on
the presence of specific symptoms. The core symptoms include:
• Delusions: False beliefs that persist despite evidence to the contrary (e.g.,
believing someone is out to harm you).
• Hallucinations: Sensing things that are not actually present (most commonly
hearing voices).
• Disorganized Thought or Speech: Difficulty making sense when talking, leading
to word salads or unrelated answers.
• Disorganized Movements or Behavior: Abnormal movements or lack of
movement, along with bizarre or inappropriate behavior.
• Negative Symptoms: Reduced ability to function normally, such as neglecting
personal hygiene or withdrawing from social activities.
3. Ruling Out Other Causes
: Doctors may perform additional tests (such as blood tests, neuroimagi
ng, or brain scans) to rule out other conditions that could mimic schizop
hrenia symptoms, such as brain injuries or infections
12
.
4. Early Intervention: Early diagnosis and treatment are crucial for
managing schizophrenia effectively. If you suspect you may be
experiencing symptoms of schizophrenia, seek medical evaluation
promptly.
What laboratory tests are run for
schizophrenia?
• Complete blood count (CBC)
• A CBC may be ordered to rule out other medical conditions that can
cause symptoms similar to those seen in schizophrenia.
• A CBC measures levels of different blood components, including:
• red and white blood cells
• platelets
• hemoglobin and hematocrit
• Comprehensive metabolic panel (CMP)
• A CMP is a blood test that measures the levels of different chemicals in your blood. Like a CBC,
its purpose is to evaluate your overall health and exclude other medical conditions that can
cause psychiatric symptoms.
• A CMP includes the following measurements:
• glucose
• electrolytes
• liver enzymes
• kidney function
• protein/albumin
• Urine and drug screening tests
• There are some drugs that can create symptoms such as hallucinations and paranoia, which
resemble positive schizophrenia symptoms (such as hallucinations or delusions). The purpose
of urine and drug screening tests is to detect the presence of these drugs.
• Urine tests involve collecting a sample of your urine for analysis, and other drug screening tests
typically involve collecting a blood sample. Both samples are analyzed for the amount of the
specific substance being tested for in your blood or urine.
• Brain MRI
• Magnetic resonance imaging (MRI) is an imaging study that can be
ordered when a tumor is suspected. A tumor may impact the brain and
cause symptoms seen in schizophrenia.
• An MRI also produces detailed images of your brain to look for structural
abnormalities, which can sometimes be observed in schizophrenia.
• Brain CT
• Computed tomography (CT) scans may be ordered for a similar purpose
as brain MRIs. However, CT scans are often faster than MRIs and can also
provide imaging of the bones as well as the soft tissues.
• CT scans are sometimes preferred over MRIs if you have a metallic
implant or if a rapid diagnosis is needed. The major downside to CT
scans is that you’d be exposed to high levels of harmful radiation.
• PET Scan
• Positron emission tomography (PET) scans use a radioactive tracer and a special
camera to create images of your brain’s activity. The tracer is injected into your
blood and then releases measurable radioactive signals (positrons).
• A PET scan can provide information about the specific function of certain brain
regions. Whereas an MRI and CT scan can identify structural changes, a PET
scan can identify functional changes.
• EEG/MEG
• An electroencephalogram (EEG) evaluates the electrical activity in your brain.
Similar to PET scans, EEGs seek to identify differences in brain activity that may
be contributing to schizophrenia symptoms.
• Magnetoencephalography (MEG) is similar to an EEG but measures magnetic
field activity in your brain rather than electrical activity. MEG is thought to be
more precise than EEG.
How is schizophrenia diagnosed?
• A clinical evaluation is often the first step in establishing a schizophrenia diagnosis. This means
you’ll speak with a mental health professional and answer a number of questions about your
medical history and symptoms. Labs and imaging studies would also be ordered at this step.
• To make a diagnosis, a mental health professional will determine whether or not your
symptoms fit into the diagnostic criteria for schizophrenia. According to the
Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision, a diagnosis of
schizophrenia occurs when the following criteria are met:
• presence of at least one positive symptom
• presence of at least one negative symptom
• other medical conditions have been excluded
• symptoms interfere with work or social life
• symptoms are experienced for most days of at least 1 month over a 6 month time period
Other physical or medical conditions known to
increase the risk of death in people with
schizophrenia include:
• diabetes and metabolic syndrome
• lung and other cancers
• chronic obstructive pulmonary disease
• influenza
• pneumonia
• substance abuse
• Although cardiovascular disease is the top cause of lost years of life with
this condition, complications from the psychological toll of
schizophrenia can’t be ignored.
Some of the best ways to help extend the life of
someone with schizophrenia is to offer things
like:
• access to quality healthcare
• smoking cessation program
• substance-use disorder treatment
• counseling and other mental healthcare services
• nutrition counseling and support
• exercise programming
• socioeconomic supports
Types of schizoprenia
 WHAT IS SCHIZOPRENIA
• Schizophrenia causes distorted and bizarre thoughts, perceptions,
emotions, movements, and behavior. It cannot be defined as a single
illness; rather, schizophrenia is thought of as a syndrome or as a
disease process with many different varieties and symptoms, much
like the varieties of cancer.
• It is usually diagnosed in late adolescence or early adulthood. Rarely
does it manifest in childhood. The peak incidence of onset is 15 to 25
years of age for men and 25 to 35 years of age for women. The
prevalence of schizophrenia is estimated at about 1% of the total
population.
• symptoms of schizophrenia are divided into two major categories:
positive or hard symptoms/signs, which include delusions,
hallucinations, and grossly disorganized thinking, speech, and
behavior, and negative or soft symptoms/signs, which include flat
affect, lack of volition, and social withdrawal or discomfort.
• Positive: characterized by the presence of unusual perceptions,
thoughts, or behaviors. Refers to the fact that symptoms are salient,
added experiences (delusions and hallucinations).
• -Negative: characterized by losses or deficits in certain domains.
Refers to the absence of behaviors, feelings, experiences.
Positive or Hard Symptoms
• Ambivalence: Holding seemingly contradictory beliefs or feelings
about the same person, event, or situation
• Associative looseness: Fragmented or poorly related thoughts and
ideas
• Delusions: Fixed false beliefs that have no basis in reality
• Echopraxia: Imitation of the movements and gestures of another
person whom the client is observing
• Flight of ideas: Continuous flow of verbalization in which the person
jumps rapidly from one topic to another
• Hallucinations: False sensory perceptions or perceptual experiences
that do not exist in reality
• Ideas of reference: False impressions that external events have
special meaning for the person
• Perseveration: Persistent adherence to a single idea or topic; verbal
repetition of a sentence, word, or phrase; resisting attempts to
change the topic
• Bizarre behavior: Outlandish appearance or clothing; repetitive or
stereotyped, seemingly purposeless movements; unusual social or
sexual behavior
Negative or Soft Symptoms
• Alogia: Tendency to speak little or to convey little substance of
meaning (poverty of content)
• Anhedonia: Feeling no joy or pleasure from life or any activities or
relationships
• Apathy: Feelings of indifference toward people, activities, and events
• Asociality: Social withdrawal, few or no relationships, lack of
closeness
• Blunted affect: Restricted range of emotional feeling, tone, or mood
• Catatonia: Psychologically induced immobility occasionally marked
by periods of agitation or excitement; the client seems motionless, as
if in a trance
• Flat affect: Absence of any facial expression that would indicate
emotions or mood
• Avolition or lack of volition: Absence of will, ambition, or drive to take
action or accomplish tasks
• Inattention: Inability to concentrate or focus on a topic or activity,
regardless of its importance
RELATED DISORDERS
Schizoaff ective disorder was described earlier. Other disorders
are related to but distinguished from schizophrenia in terms of
presenting symptoms and the duration or magnitude of
impairment. Mojtabai et al. (2017) identify:

• Schizophreniformdisorder: The client exhibits an acute, reactive psychosis

for less than the 6 months necessary to meet the diagnostic criteria for
schizophrenia. If symptoms persist over 6 months, the diagnosis is changed
to schizophrenia. Social or occupational functioning may or may not be
impaired.
• Catatonia: Catatonia is characterized by marked psychomotor disturbance,
either excessive motor activity or virtual immobility and motionlessness.
Motor immobility may include catalepsy (waxy flexibility) or stupor.
Excessive motor activity is apparently purposeless and not influenced by
external stimuli. Other behaviors include extreme negativism, mutism,
peculiar movements, echolalia, or echopraxia. Catatonia can occur with
schizophrenia, mood disorders, or other psychotic disorders.
• Delusional disorder: The client has one or more nonbizarre delusions
— that is, the focus of the delusion is believable. The delusion may be
persecutory, erotomanic, grandiose, jealous, or somatic in content.
Psychosocial functioning is not markedly impaired, and behavior is
not obviously odd or bizarre.
• Brief psychotic disorder: The client experiences the sudden onset of
at least one psychotic symptom, such as delusions, hallucinations, or
disorganized speech or behavior, which lasts from 1 day to 1 month.
The episode may or may not have an identifiable stressor or may
follow childbirth
• Shared psychotic disorder (folie à deux): Two people share a similar
delusion. The person with this diagnosis develops this delusion in the
context of a close relationship with someone who has psychotic
delusions, most commonly siblings, parent and child, or husband and
wife. The more submissive or suggestible person may rapidly improve
if separated from the dominant person.
• Schizotypal personality disorder: This involves odd, eccentric
behaviors, including transient psychotic symptoms. Approximately
20% of persons with this personality disorder will eventually be
diagnosed with schizophrenia
ETIOLOGY
• In the 1950s and 1960s, the emphasis shifted to examination of
psychological and social causes. Interpersonal theorists suggested
that schizophrenia resulted from dysfunctional relationships in early
life and adolescence. None of the interpersonal theories has been
proved, and newer scientific studies are finding more evidence to
support neurologic/neurochemical causes. However, some therapists
still believe that schizophrenia results from dysfunctional parenting
or family dynamics. For parents or family members of persons
diagnosed with schizophrenia, such beliefs cause agony over what
they did “wrong” or what they could have done to help prevent it.
• Newer scientific studies began to demonstrate that schizophrenia
results from a type of brain dysfunction. In the 1970s, studies began
to focus on possible neurochemical causes, which remain the primary
focus of research and theory today. These neurochemical/neurologic
theories are supported by the effects of antipsychotic medications,
which help control psychotic symptoms, and neuroimaging tools such
as computed tomography, which have shown that the brains of
people with schizophrenia differ in structure and function from those
of control subjects.
Biologic Theories
• The biologic theories of schizophrenia focus on genetic factors,
neuroanatomic and neurochemical factors (structure and function of
the brain), and immunovirology (the body’s response to exposure to a
virus)
Genetic Factors
• Most genetic studies have focused on immediate families (i.e., parents, siblings, and
offspring) to examine whether schizophrenia is genetically transmitted or inherited.
Few have focused on more distant relatives. The most important studies have
centered on twins; these findings have demonstrated that identical twins have a
50% risk of schizophrenia; that is, if one twin has schizophrenia, the other has a 50%
chance of developing it as well. Fraternal twins have only a 15% risk. This finding
indicates a genetic vulnerability or risk of schizophrenia. Other important studies
have shown that children with one biologic parent with schizophrenia have a 15%
risk; the risk rises to 35% if both biologic parents have schizophrenia. Children
adopted at birth into a family with no history of schizophrenia but whose biologic
parents have a history of schizophrenia still reflect the genetic risk of their biologic
parents. All these studies have indicated a genetic risk or tendency for
schizophrenia, but Mendelian genetics cannot be the only factor; identical twins
have only a 50% risk even though their genes are 100% identical. Rather, recent
studies indicate that the genetic risk of schizophrenia is polygenic, meaning several
genes contribute to the development (Kendall, Kirov, & Owen, 2017).
Neuroanatomic and Neurochemical Factors
• With the development of noninvasive imaging techniques, such as computed tomography,
magnetic resonance imaging, and positron emission tomography, in the past 25 years, scientists
have been able to study the brain structure (neuroanatomy) and activity (neurochemistry) of
people with schizophrenia. Findings have demonstrated that people with schizophrenia have
relatively less brain tissue and cerebrospinal fluid than those who do not have schizophrenia; this
could represent a failure in the development or a subsequent loss of tissue. Computed
tomography scans have shown enlarged ventricles in the brain and cortical atrophy. Positron
emission tomography studies suggest that glucose metabolism and oxygen are diminished in the
frontal cortical structures of the brain. The research consistently shows decreased brain volume
and abnormal brain function in the frontal and temporal areas of persons with schizophrenia.
This pathology correlates with the positive signs of schizophrenia (temporal lobe), such as
psychosis, and the negative signs of schizophrenia (frontal lobe), such as lack of volition or
motivation and anhedonia. It is unknown whether these changes in the frontal and temporal
lobes are the result of a failure of these areas to develop properly or whether a virus, trauma, or
immune response has damaged them. Intrauterine influences, such as poor nutrition, tobacco,
alcohol, and other drugs, and stress are also being studied as possible causes of the brain
pathology found in people with schizophrenia (Kendall et al., 2017).
• Currently, the most prominent neurochemical theories involve dopamine and
serotonin. One prominent theory suggests excess dopamine as a cause. This theory
was developed on the basis of two observations: First, drugs that increase activity in
the dopaminergic system, such as amphetamine and levodopa, sometimes induce a
paranoid psychotic reaction similar to schizophrenia. Second, drugs blocking
postsynaptic dopamine receptors reduce psychotic symptoms; in fact, the greater the
ability of the drug to block dopamine receptors, the more effective it is in decreasing
symptoms of schizophrenia (Perez & Ghose, 2017). More recently, serotonin has been
included among the leading neurochemical factors affecting schizophrenia. The
theory regarding serotonin suggests that serotonin modulates and helps to control
excess dopamine. Some believe that excess serotonin itself contributes to the
development of schizophrenia. Newer atypical antipsychotics, such as clozapine
(Clozaril), are both dopamine and serotonin antagonists. Drug studies have shown
that clozapine can dramatically reduce psychotic symptoms and ameliorate the
negative signs of schizophrenia (Kane & Correll, 2017).
Immunovirologic Factors
• Popular theories have emerged, stating that exposure to a virus or the body’s
immune response to a virus could alter the brain physiology of people with
schizophrenia. Although scientists continue to study these possibilities, few
findings have validated them. Cytokines are chemical messengers between
immune cells, mediating inflammatory and immune responses. Specific cytokines
also play a role in signaling the brain to produce behavioral and neurochemical
changes needed in the face of physical or psychological stress to maintain
homeostasis. It is believed that cytokines may have a role in the development of
major psychiatric disorders such as schizophrenia (Dahan et al., 2018). Recently,
researchers have been focusing on infections in pregnant women as a possible
origin for schizophrenia. Waves of schizophrenia in England, Wales, Denmark,
Finland, and other countries have occurred a generation after influenza
epidemics. Also, there are higher rates of schizophrenia among children born in
crowded areas in cold weather, conditions that are hospitable to respiratory
ailments (Kendall et al., 2017).
TREATMENT
• Psychopharmacology The primary medical treatment for schizophrenia is
psychopharmacology. In the past, electroconvulsive therapy, insulin shock therapy,
and psychosurgery were used, but since the creation of chlorpromazine
(Thorazine) in 1952, other treatment modalities have become all but obsolete.
Antipsychotic medications, also known as neuroleptics, are prescribed primarily for
their efficacy in decreasing psychotic symptoms. They do not cure schizophrenia;
rather, they are used to manage the symptoms of the disease. The conventional, or
first-generation, antipsychotic medications are dopamine antagonists. The
atypical, or second-generation, antipsychotic medications are both dopamine and
serotonin antagonists (see Chapter 2). These medications, usual daily dosages, and
their common side effects are listed in Table 16.1. The first-generation
antipsychotics target the positive signs of schizophrenia, such as delusions,
hallucinations, disturbed thinking, and other psychotic symptoms, but have no
observable effect on the negative signs. The second-generation antipsychotics not
only diminish positive symptoms but also lessen the negative signs of lack of
volition and motivation, social withdrawal, and anhedonia for many clients.
Maintenance Therapy
• Six antipsychotics are available as long-acting injections (LAIs),
formerly called depot injections, for maintenance therapy. They are
the following: • Fluphenazine (Prolixin) in decanoate and enanthate
preparations • Haloperidol (Haldol) in decanoate • Risperidone
(Risperdal Consta) • Paliperidone (Invega Sustenna) • Olanzapine
(Zyprexa Relprevv) • Aripiprazole (Abilify Maintena)
Side Effects
• Dystonic reactions
• Tardive Dyskinesia
• Neuroleptic malignant syndrome
• Akathasia
• EPSs or Nueroleptic induced Parkinsonism
• Seizures
• Sedation
• Photosensitivity
• Weight gain
• Anticholinergic symptoms
• Dry mouth
• Blurred Vision
• Constipation
• Urinry Retention
• Orthostatic Hypotension
Psychosocial Treatment
• In addition to pharmacologic treatment, many other modes of
treatment can help the person with schizophrenia. Individual and
group therapies, family therapy, family education, and social skills
training can be instituted for clients in both inpatient and community
settings.