Schizophrenia

Original article by Tom Leach | Last updated on 17/6/2016
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Introduction 

Schizophrenia and the Delusional Disorders
Under this classification are the ‘serious brain disordersthat are neither organic brain disorders or severe mood disorders.
Schizophrenia is a chronic condition, but has a widely varying course. Some people make a full recovery, whilst other may require institutionalised care for their whole lives.
 

Epidemiology

  • 1% of the population will have a diagnosis of schizophrenia at some point in their lives
    • Prevalence – 200 per 100 000
    • Incidence - 20 per 100 000
  • The incidence is roughly the same around the globe, however, the course of the disease varies according to location. In the western world, it is less likely to be ‘cured’.
    • Higher incidence in inner city, low socioeconomic environments. However it is thought that schizophrenia itself causes this socioeconomic deprivation – because the average patient has a lower than average status, but the parents of the patient usually have an ‘average’ socioeconomic status.
    • This is sometimes referred to as downward drift / social drift
  • Peak incidence:
    • 18-25 in men
    • 25-30 in women
  • Equal incidence in both men and women
 

Aetiology

Tendency as a child to be withdrawn, eccentric, and/or clumsy, before developing the disease later in life
For a period (perhaps lasting years) before ‘true symptoms’ develop, the individual may show other symptoms, such as:
  • Loss of interest
  • Social withdrawal
  • Self-neglect
  • Depression
  • Anxiety
  • Brief psychotic episodes
  • This period is known as the prodromal period. A long prodromal period usually means that the diagnosis is delayed, and in these situations, the prognosis is poor.

Genetic factors

  • General risk – 1%
  • If sibling has condition - 9%
  • If parent has condition – 13%
  • If both parents have condition – 45%

Environmental factors thought to be negligible – studies have shown that children kept away from their schizophrenic mothers are at the same risk of developing the condition as those who grew up with their birth mother.
Obstetric complications –are found in increased incidence in those who go on to develop the condition. This suggests that some kind of developmental abnormality may be present.
‘Sensitive’ personalities – some people have a tendency to perceive critiscm harshly, and to interpret non-critical comments as criticism. These people have an increased likelihood of developing schizophrenia.

 

Predisposing factors

Certain events can trigger and episode of schizophrenia in a susceptible individual
  • Periods of increased stress
  • Periods of intense emotion (both positive and negative) – e.g. losing your job, winning the lottery
  • Increased levels of criticism from friends and family members
  • Drugs – particularly hallucinogens, stimulants, including alcohol and cannabis.
 

Symptoms

General status of the patient:
  • Many cognitive functions remain intact
  • Only some functions affected
  • Perceived loss of boundaries between the individual and the outside world
    • E.g. thoughts/acts/emotions may be perceived to be controlled by outside influences.
  • Preoccupied with thoughts about the self
 

Positive symptoms

These may often involve frightening experiences for the patient, because they seem to have lost control. Stress, anxiety, and criticism can all exacerbate the symptoms
Auditory Hallucinations – the most common symptom, and often the easiest to elicit. These can take several forms:
  • Third person – talking about the individual who hears them. May be single or multiple voices. These are the most common type of auditory hallucination in schizophrenia. The voices are often critical of the individual. With treatment, these voices may not go away, but they may become quieter, and contain more positive content
  • Thought echo the individual hears their thoughts spoken aloud, either simultaneously (as thinking the thought) or just afterwards.
  • Second person – talking to the individual – can still occur in schizophrenia, but also present in lots of other mental disorders.
  • NOTE – auditory hallucinations in which the person talks to the voice they hear are most commonly the result of TRAUMA or are fictitious.

Other hallucinations – e.g. visual, olfactory etc. again, can occur in schizophrenia, but also common to other disorders. These are most common in organic conditions. If these symptoms are present then they have to be medically investigated.
Passivity experiences – the patient believes that their movements, emotions or will is being altered in a similar way to the thought issues, for examples, they believe their movements are being controlled.
Incongruity of affect – the patient may burst out laughing or become very angry for no apparent reason, or they may have inappropriate emotional reactions – e.g. laughing at bad news.
Thought and speech disorders their thought processes may be altered, for example, their speech may be totally fragmented (word salad), or they may have some sort of though disorder – e.g. they can speak in normal sentences, but their ideas are linked in strange ways, e.g. not by content, but because the words rhyme.

  • Neologism – this is a phenomenon that may occur with some patients. They may make up a new word, or give an existing word a new meaning that is only apparent to the individual, and does not make sense. They may keep repeating this word. E.g. “I like to sprong”
  • Word salad – the form of the sentences makes no sense at all. Words are mixed up, in the wrong place.
  • Flight of thought – this is where the patient moves quickly from one idea to another, often half-way through a sentence, with no apparent association between ideas.
  • Knight’s move thinking (aka Derailment)- patient moves from one idea to another with strage illogical associations between the ideas.
  • Pressure of speech – the patient speaks at a rate faster than normal
  • Circumstantiality – excessive ‘long-windedness’ – the patient takes forever to reach the point when they talk.

Mannerisms – strange and pointless movements. This is often repeated frequently, and accompanied by a strange facial expression.
Catatonia – a state where the person may not respond to stimuli and exhibits strange physical behaviour. The state may involve a particular movement or posture that a patient often performs. Can be associated with any mental health condition. Examples can include

  • Stupor the patient is unable to move or speak except for moving their eyes.
  • Strange postures – that are normally very difficult to hold
  • Negativism – the patient does the exact opposite of what they are asked
  • Automatic obedience
  • Waxy flexibility – the patient has strange muscle tone that allows the doctor to put the patient into physical position that would otherwise be very difficult and/or painful.
 

Schneider’s First Rank Symptoms of Schizophrenia

These are a ‘sub-class’ of Positive symptoms and basically include:
Delusions – an unshakeable belief that is not in keeping with the person’s social, cultural or educational background, for which there is no logical evidence basis.
  • Primary delusions – these appear with no apparent precipitating event. The individual may enter a state of being ‘perplexed’ for several days or months, and as the perplexity disappears, the delusion develops.
  • Persistent delusions – these arise with the period of perplexity. If other symptoms of schizophrenia are present, this can be diagnostic for schizophrenia. If they are not, then it can be diagnostic for delusional disorder.
  • Secondary delusions – these arise when other symptoms of schizophrenia have been present for a period just before the delusion, and arise from strange experiences the individual has as a result of their schizophrenia.

Thought issues

  • Thought insertion – the patient believessomebody or something is ‘planting’ thoughts into their mind. This happens against the person’s will.
  • Thought broadcast – the patient believes their thoughts are ‘broadcast’ to others against their will
  • Thought withdrawal – the patient believes thoughts are being removed from their mind against their will, and this leaves the mind ‘blank’.
Hallucinations in the general population – about 5-10% of the normal population have hallucinations – but it is only when these are distressing that they become a medical problem.
 

Negative symptoms

These are present in most, although not all patients with schizophrenia. They tend to lead to reduced function (e.g. reduced social interaction, self care etc etc) and they are a very poor prognostic sign. A lack of stimulation makes the symptoms worse.
They are often difficult to distinguish from symptoms of depression, and you may only be able to do so by taking a full depression history and noting the absence of symptoms such as:
  • Weight change
  • Sleep problems
  • Guilt / hopelessness / low self worth
The symptoms can also be attributed to sedative medications
  • Alogia – this is a general impoverished level of thinking, usually seen in the form of poverty of speech – whereby the patient will give very short answers, and will not voluntarily give any input to a conversation. They are unable to elaborate on their thoughts. The patient feels as though their ‘mind is empty’.
  • Poverty of content of thoughts – is a less extreme version. The patient is able to answer questions, but their thought process is not properly utilised and they cannot explain their answers.
  • Blunting of Affect – the person has a lack of emotion
  • Avolition (loss of volition) – the patient has a general lack of interest in life, self care, social activities and motivation.
  • Slowness of thought an movement
 

Other symptoms seen in schizophrenia

  • Depression
  • Anxiety
  • Agitation
  • Withdrawal
  • Inappropriate eating behaviour – e.g. stuffing themselves in an ‘uncivilised’ way, and then vomiting.
  • Incontinence
  • Self harm
  • Destruction of possessions
  • Massive intake of water – causing water intoxication – which can lead to hyponatraemia. This can inturn cause delirium, coma, and even death! In these cases the person will drink all/any water they can find –even out of toilets.
  • Post psychotic depressionthis is a prolonged depressive episode that occurs on resolution of the psychosis. This can be distinguished from the negative symptoms of schizophrenia because:
    • In schizophrenia negative symptoms increase/decrease in conjunction with the severity of positive symptoms
    • In post psychotic depression the depressive type symptoms do not change in concordance with any positive symptoms
    • This case can be extremely difficult to distinguish from the normal negative symptoms of depressionbut it requires different treatment – and so if you suspect it, you should make the extra effort to try and find out. Patients with post psychotic depression are at high risk of suicide, and they have a particular feeling of hopelessness. In post-psychotic depression the patient often has a good degree of insight – because the depression is often in response to their diagnosis. It can also be a result of neuroleptic medication.
 

Diagnosis

The diagnosis of schizophrenia has to be distinguished from that of just a brief psychotic episode – thus when at least one of the following has been apparent for at least one month we say schizophrenia is present:
  • Auditory hallucinations
  • Thought echo
  • Thought insertion
  • Thought broadcast
  • Thought withdrawal
  • Delusion (primary or persistent)
  • Passivity experiences
 
OR at least two of the following for more than one month
  • Persistent hallucinations
  • Incoherent/irrelevant speech (including neologisms)
  • Mannerisms
  • Catatonia
  • Negative Symptoms
 

Differential Diagnosis

  • Brief Psychotic disorder – symptoms are present for less than a month, then disappear. Often sudden onset, and in some cases a precipitating factor (e.g. severe psychological stress) may be identified.
  • Delusional disorder – basically, might appear like schizophrenia, but, there are only hallucinations and /or delusions, and no other signs of schizophrenia. We say that delusional disorder exists when an individual has a complex and logical system of beliefs that are based on one or more delusional beliefs. There may also be auditory hallucinations, but there are usually no other schizophrenia-like symptoms. The delusions are usually either persecutory or grandiose. Three particularly common delusions are:
    • Dysmorphophobia – a delusion that their body is particularly deformed (e.g. they think they have a massive nose when they clearly don’t), to that it is always giving off a particularly foul smell
    • Morbid Jealousy – a delusion that the patient’s partner is cheating on them, despite very little evidence – e.g. they were late home one night
    • Erotomania – this is where the patient loves another individual, and believes the other individual also loves them – but that they are unable to show it
    • Often these patients have a history of paranoid personality, particularly sensitive to criticism, have a very rigid belief system, or a history of sensory depravation or temporal or parietal lobe defects.
    • Treatment – it can be very difficult to persuade the patient that they need treatment! treatment from the GP is often more accepted than from the mental health practitioner. The first line drug is pimozide – but other neuroleptics can be used. (NB neuroleptic just means antipsychotic).  Full recovery is seen in ½ of patients, with a further 33% showing improvement.
  • Manic depressionoften may have symptoms of schizophrenia, such as schneider’s first rank symptoms. Usually can be distinguished, due to the elation, erratic behaviour, grandiose delusions (usually schizophrenia is persecutory) and increased activity.
  • Alcoholic Hallucinations – alcohol withdrawal may mimic schizophrenia for a short period (up to 2 weeks, usually less) may have second person hallucinations.
  • Organic Psychosis – this can present with very similar symptoms to schizophrenia – but here is an organic causatory factor – such as drug abuse, or a neurological disorder.
  • Drugs - The drugs that cause these symptoms can be stimulants or hallucinogens. Examples include:
    • Cannabis
    • Steroids - These two drugs produce symptoms particularly consistent with schizophrenia
    • Cocaine
    • Ecstasy
    • LSD
    • Magic mushrooms (psilocybin)
    • Mescaline
    • Phencyclidine
  • Neurological symptoms associated with schizophrenia type symptoms
    • Epilepsy – particularly temporal lobe seizures
    • Dementia
    • B12 def
    • Hypoglycaemia
    • Trauma/head injury
    • In trauma and head injury, the patient may hear voices that they can ‘talk to’. In psychiatric disease, this does usually not occur (or if the patient claims it does occur, it is often fictitious)
 

History Taking

  • ‘I want to ask you if you have had any unusual experiences that people often feel. Do you ever think that people are talking about you, or taking special notice of you?’ if yes – ask more about it. Why do they think this? Do they have any evidence?
    • E.g. this may be perfectly logical if for example, the family have been involved with the police.
  • Is anyone trying to harm you? – persecutory delusions
  • Do you have any special powers? – grandiose delusions
  • Do you ever feel someone is controlling you in some way? – passivity experiences
  • Have you ever had thoughts put into your head that are not your own? – thought insertion
  • Etc etc!
 

Mental state exam

  • Appearance & behaviour – may show self neglect, restlessness or odd, or lack of movements, and odd appearance(e.g. hair / makeup / clothes)
  • Speech – Tangential speech – one though is unrelated to the next. Often neologisms, may be incoherent, jumps from subject to subject.
  • Mood – suspicious, may often seem deep in though and perplexed/confused
  • Thoughts – delusions,though disorder, persecutory
  • Perceptions – hallucinations – most commonly auditory
  • Cognition – poor attention span and concentration, unshakable beliefs (‘concrete thinking’)
 

Risk

Suicide risk is just as high as other mental disorders. May e hard to asses when a lot of other symptoms are present, but you should play it safe. Signs that this could be a risk are:

Self-neglect – this can occur to such a great degree, that the patient’s health can be put at risk, and even death can result.
Risk to others – the risk of a violent attack on another individual is relatively low, but in those with a history of impulsive behaviour and violence, you should be careful. Particular symptoms that might put others at risk include:

  • Passivity experiences
  • Morbid jealousy
  • Persecutory delusions directly involving others
 

Pathology

Not fully understood. It is thought that it is related to excess dopaminergic activity. This theory comes from the observance of two main factors:
  • Most anti-psychotic drugs block dopaminergic transmission, and are able to reduce symptoms
  • Many dopamine agonists have psychotic side effects (e.g. in Parkinson’s disease)
 
It is also thought that the excitory neurotransmitter glutamate is involved, as glutamate agonists cause psychotic symptoms. In post mortems of patients, there are often increased glutamate receptors and cells in the frontal cortex, but decreased in the medial and temporal lobes. This suggests some abnormal ‘wiring’ of glutamate circuits.
 

Nueroimaging sometimes shows

  • Increased size of lateral ventricles
  • Reduced brain size (usually in temporal lobes)
  • Negative symptoms – often correlated with reduced blood flow and other abnormalities in the frontal cortex.
  • Reduced connections between different brain areas can often be deduced from EEG’s.
 

Investigations

  • Drug screening – to rule out amphetamines and cannabis as the cause
  • EEG – to rule out epilepsy
  • Fasting glucose – to rule out diabetes
  • Full neuro exam - checking for an organic cause
  • Other blood tests – t check baseline levels before starting anti-psychotic medication. These levels need to be monitored as medication is continued.
  • CT/MRI – looks for atrophy of the lateral ventricles. Also space occupying lesions can cause schizophrenia, but these are rare!
 
Management
Many patients can be managed at home, with the help of the CRT (Crisis resolution team) with acute attacks managed in outpatients. Based on the level of risk, some patients may need to be detained under the mental health act.
There are more details about psychiatric medications in the Psychiatric medications article
 

Acute attack

  • First line – Neuroleptics – typical or atypical. Which drug is used depends on the patient. Can be given in oral tablet form, or oral liquid, or IM injection. There is no need to ever give one IV. If adherence is an issue, consider depot preparation given IV every 2-4 weeks. Main side effects include sedation, and extrapyramidal side effects (e.g. Parkinsonism). These effects are reduced in atypical antipsychotics (which are newer), but these have their own problems, namely, weight gain, and increased risk of diabetes.
  • Second line – Clozapine – atypical antipsychotic – this is not included as a first line treatment, as requires close monitoring as it has a tendency to cause aplastic anaemia, which can be fatal. If two other anti-psychotics have not been effective, then clozapine should be considered. It is highly effective in 30% of patients.
  • CPMS - Clozepine monitoring system. A national service in the UK, that gives advice on the drug dosage to use, depeninding on the blood test results you send to them. Compulsory for anyone on clozepine. Only consultant psychiatrists can prescribe clozepine.
 

Psychological therapies

These may often be implemented (e.g. CBT, early warning sign interventions), but there isn’t much evidence that they are any more effective than normal, regular contact with a support worker, and follow-ups with a prescribing psychiatrist. However, outcomes are very much worse when there is no contact with a support worker or not psychological therapies, despite regular contact with a psychiatrist.
Psychotherapies are particularly useful for treating negative symptoms (e.g. the depression and LOF (loss of function) type symptoms)
 
Family therapy involves educating the family to recognise the early signs of an attack, and also to help them be more supportive, and to remove any precipitating factors from the patients direct environment (e.g. criticism).
 

Social care

A supportive environment is essential. Many negative symptoms can be relieved just through structured weekly activities – giving some purpose to the patient’s life.
This is sometimes referred to as downward drift / social drift
 
ECT – electro-convulsive therapy – may be used to treat catatonic symptoms.
 

Impact on society

  • Very expensive to treat
  • If not diagnosed, can cause harm to others
 

Prognosis

  • 20% of patients will make a full recovery with drug and supportive treatments
  • A further 35% have long periods of remission
  • 35% will have persistent mild positive and negative symptoms, that can be managed in the community
  • 10% have severe schizophrenia that is unresponsive to treatment, and these people will often require institutionalised care.
  • A small number of patients may require forensic care, due to high risk.
 
Factors that decrease the change of a positive outcome are:
  • Pre-morbid factors – e.g. poor educational background, poor achievement at work, social problems
  • Drug and alcohol abuse
  • Features of the conditionlong slow onset, delay of first treatment, catatonic symptoms, strong negative symptoms, thought disorder
  • Current social / living situation – e.g. lack of structure to daily living, lack of social network, exposure to stress and high emotions at home.