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Schizophrenia

Schizophrenias

Schizophrenia is a mental disorder that severely affects a person’s behaviour, compromises lifestyle, debilitates everyday actions and makes the patient unable to realize what is real.


Presentation

Initially, the disease presents as mild personality changes, slight paranoia and increased moodiness. It may then progress to a decreased emotional range, depression, noticeable personality changes, disorganized or ‘rambling’ speech, sudden mood swings usually without any precipitating factors and auditory hallucinations. Tactile hallucinations are rare but can possibly occur. The patient often gets delusional, with a firm, almost to the point of stubborn, belief that what he perceives is real. He/she may also get unnecessarily hostile and aggressive or closeted and withdrawn, depending upon his mental status.

Noncompliance
  • Long-term use can develop dependence and put the patient at risk if they are noncompliant.[emedicine.com]
  • Evaluation of noncompliance in schizophrenia patients using electronic monitoring (MEMS) and its relationship to sociodemographic, clinical and psychopathological variables. Schizophr Res. 2009; 107 ( 2-3 ):213–217. [ PubMed ] [ Google Scholar ] 31.[ncbi.nlm.nih.gov]
  • Evaluation of noncompliance in schizophrenia patients using electronic monitoring (MEMS) and its relationship to sociodemographic, clinical and psychopathological variables. Schizophr Res. 2009 ;107(2-3): 213 – 217.[doi.org]
  • Comorbidity between schizophrenia and substance abuse could lead to consequences such as noncompliance with medication, loss of control, violence and economic problems.[dx.doi.org]
Family History of Suicide
  • A family history of suicide, and comorbid substance misuse were also positively associated with later suicide. The only consistent protective factor for suicide was delivery of and adherence to effective treatment.[ncbi.nlm.nih.gov]
  • Family history of suicide among suicide victims. Am. J. Psychiatry 160, 1525 –1526 ( 2003 ).. Genetic association studies on suicide have mainly focused on serotonin-related genes.[dx.doi.org]
Delusion
  • The quality of the studies was evaluated and the effect size and the moderating variables of MCT on delusion were determined. Results A total of 11 studies on the effect of MCT for delusion were investigated.[doi.org]
  • Clarifying the role of the JTC bias in delusions. Cognitive Neuropsychiatry 12, 46 – 77. Freeman, D ( 2007 ). Suspicious minds: the psychology of persecutory delusions. Clinical Psychological Review 27, 425 – 457.[doi.org]
  • Delusions A delusion is a belief held with complete conviction, even though it's based on a mistaken, strange or unrealistic view. It may affect the way the person behaves. Delusions can begin suddenly, or may develop over weeks or months.[nhs.uk]
  • The quality of the studies was evaluated and the effect size and the moderating variables of MCT on delusion were determined. A total of 11 studies on the effect of MCT for delusion were investigated.[ncbi.nlm.nih.gov]
Auditory Hallucination
  • He uses the device all day and his auditory hallucinations have subsided. Improvement of schizophrenia symptoms has enabled the patient to reduce his psychiatric medications intake.[ncbi.nlm.nih.gov]
  • Temporal course of auditory hallucinations. Br. J. Psychiatry 185, 516–517 (2004). 56. Lennox, B. R., Park, S. B., Medley, I., Morris, P. G. & Jones, P. B. The functional anatomy of auditory hallucinations in schizophrenia.[doi.org]
  • Transcranial magnetic stimulation (TMS) has been proposed as a new treatment for people with schizophrenia, especially those who experience persistent auditory hallucinations.[ncbi.nlm.nih.gov]
  • Positive symptoms include auditory hallucinations, delusions, and thought disorder. Negative symptoms (demotivation, self-neglect, and reduced emotion) have not been consistently improved by any treatment.[ncbi.nlm.nih.gov]
  • To treat his excitement and auditory hallucination, an intravenous drip (IVD) of haloperidol was initiated, but this treatment increased the patient's catatonic and psychotic symptoms, although his serum CPK level had remained within a normal range.[ncbi.nlm.nih.gov]
Anxiety Disorder
  • Among the anxiety disorders, the evidence at present is most abundant for an association with obsessive-compulsive disorder.[ncbi.nlm.nih.gov]
  • In multivariable analysis, complex polypharmacy was specifically associated with being white and disabled, and having a comorbid anxiety disorder, tobacco use disorder, metabolic condition, and neurological condition compared with noncomplex polypharmacy[ncbi.nlm.nih.gov]
  • Comorbidity with axis I anxiety disorders in remitted psychotic patients 1 year after hospitalization. CNS Spectr. 2007; 12 :913–919. [ PubMed ] [ Google Scholar ] 24. Craig T, Hwang MY, Bromet EJ.[ncbi.nlm.nih.gov]
  • Anxiety disorders were the most commonly treated (68.3 %).[doi.org]
Withdrawn
  • Symptoms such as becoming socially withdrawn and unresponsive or changes in sleeping patterns can be mistaken for an adolescent "phase".[nhs.uk]
  • Schizophrenia can leave its sufferer frightened and withdrawn. It is a life-long disease that cannot be cured but can be controlled with proper treatment. Contrary to popular belief, schizophrenia is not a split or multiple personality.[webmd.com]
  • Randomised trials of patients with schizophrenia continued on or withdrawn from any antipsychotic drug regimen after stabilisation were eligible. Our primary outcome was relapse between 7 and 12 months.[ncbi.nlm.nih.gov]
  • A person may seem depressed and withdrawn. Cognitive symptoms affect the thought process. These include trouble using information, making decisions, and paying attention. No one is sure what causes schizophrenia.[medlineplus.gov]
Social Isolation
  • Today, we have evidence that gene mutations, brain injury, drug use (cocaine, amphetamine, marijuana, phencyclidine, and steroids), prenatal infection and malnutrition, social isolation and marginalization, can all result in the signs and symptoms of[ncbi.nlm.nih.gov]
  • People with schizophrenia, and to some extent their families and friends, also need active help combating discrimination and social isolation. How to cite this report: SBU.[web.archive.org]
  • Social support for help with housing, vocational support, social isolation, employment and financial aid is important. Use of the Recovery Action Plan should also be promoted.[patient.info]
Confusion
  • ECT side effects and ongoing controversy In addition to confusion, memory loss and headaches commonly occur immediately following ECT treatment.[schizophrenic.com]
  • Thoughts and speech may become jumbled or confused, making conversation difficult and hard for other people to understand.[nhs.uk]
  • In the present paper, the authors review the main methodological issues which have led to the current confusion about the number of dimensions underlying schizophrenic psychopathology.[ncbi.nlm.nih.gov]
  • The world may seem like a jumble of confusing thoughts, images, and sounds. The behavior of people with schizophrenia may be very strange and even shocking.[webmd.com]
  • The hallucination is very real to the person experiencing it, and it may be very confusing for a loved one to witness. The voices in the hallucination can be critical or threatening.[nami.org]
Agitation
  • Repeat doses can be administered every 20–30 minutes as needed to control continued severe agitation. The haloperidol dose can be doubled each time up to 20 mg if prior dosing is inadequate for severe agitation.[emedicine.com]
  • People with schizophrenia may behave inappropriately or become extremely agitated and shout or swear for no reason.[nhs.uk]
  • Second level analyses isolated the individual symptoms of social inattention, poor overall attention, active social avoidance and agitated/aggressive behavior from PANSS, SANS, and SAPS as predictive of support intensity.[ncbi.nlm.nih.gov]
  • There were no external circumstances to explain the observed intensity of psychomotor agitation symptoms.[ncbi.nlm.nih.gov]
Stroke
  • Both groups need careful monitoring as they are associated with increased risk of diabetes , stroke and cardiac death.[healthnavigator.org.nz]
  • .: An increased risk of stroke among young schizophrenia patients. Schizophrenia Research 101(1–3):234–241, 2008 PubMed CrossRef Google Scholar 17.[doi.org]
  • Minocycline to improve neurologic outcome in stroke (minos): a dose-finding study. Stroke. 2010; 41 (10):2283–7. [ PMC free article ] [ PubMed ] [ Google Scholar ] 99. Andrade C. Anti-inflammatory strategies in the treatment of schizophrenia.[ncbi.nlm.nih.gov]
  • Minocycline to improve neurologic outcome in stroke (minos): a dose-finding study. Stroke. 2010;41(10):2283–7. PubMed PubMedCentral CrossRef Google Scholar 99. Andrade C. Anti-inflammatory strategies in the treatment of schizophrenia.[doi.org]
  • Stroke, multiple sclerosis, hyperthyroidism, hypothyroidism, and dementias such as Alzheimer's disease, Huntington's disease, frontotemporal dementia, and the Lewy body dementias may also be associated with schizophrenia-like psychotic symptoms.[en.wikipedia.org]
Amnesia
  • Deficits" Electroconvulsive Therapy Causes Permanent Amnesia and Cognitive Deficits[schizophrenic.com]
  • Information obtained included the socio-demographic characteristics, type of injury, durations of unconsciousness (LOC) and posttraumatic amnesia (PTA), psychiatric and psychoactive substance use history.[ncbi.nlm.nih.gov]
  • Amnesia and recognition memory: A re-analysis of psychometric data. Neuropsychologia 34 : 51-62. PubMed Google Scholar Albus, M., Hubman, W., Ehrenberg, C., Forcht, U., Mohr, F., Sobizack, N., et al. (1996).[doi.org]
  • Differential Diagnosis Conditions to consider in the differential diagnosis of schizophrenia include the following: [6] Delirium, dementia, and amnesia Severe depressive episode with psychotic features Neuroleptic malignant syndrome Personality disorders[emedicine.com]
Stupor
  • In a monograph titled Benign Stupors, August Hoch described 25 psychiatric patients in stupor.[ncbi.nlm.nih.gov]
  • This is a life-threatening condition, characterized by stupor or excitement, hyperthermia, clouded consciousness and autonomic dysregulation.....The literature on this syndrome, which consists solely of case series, suggests that neuroleptic treatment[schizophrenia.com]
  • In the International Pilot Study of Schizophrenia [ 10 ] and the Determinants of Outcome of Severe Mental Disorders study [ 12 ], catatonia (a form of schizophrenia characterized by a tendency to remain in a fixed stuporous state for long periods) was[dx.doi.org]
  • Stupor revisited , Compr Psychiatry , 1981 , vol. 22 (pg. 466 - 478 ) 4. , The History of Mental Symptoms , 1996 Cambridge, UK Cambridge University Press 5.[doi.org]
  • Hospitalized patients are more likely to present with acute and prominent psychomotor abnormalities (eg, mutism and stupor), often seen in patients with medical and neurological conditions associated with catatonia.[doi.org]
Sexual Dysfunction
  • RESULTS: Consensus recommendations included regular monitoring of body mass index, plasma glucose level, lipid profiles, and signs of prolactin elevation or sexual dysfunction.[ajp.psychiatryonline.org]
  • […] at higher doses Sexual dysfunction Amisulpiride: Hyperprolactinaemia Insomnia Extrapyramidal effects Quetiapine: Hypotension Dyspepsia Drowsiness Clozapine Sedation Hypersalivation Constipation Reduced seizure threshold Hypotension and hypertension Tachycardia[ncbi.nlm.nih.gov]
  • dysfunction, which can be adverse reactions to antipsychotic medication or to anticholinergic drugs taken for prophylaxis of dystonia Find out about threats made to others, expressions of suicidal intent, and possession of weapons at home or on the person[emedicine.com]
  • Frequency of sexual dysfunctions in patients with schizophrenia on haloperidol, clozapine or risperidone. Schizophr Res 2001 ; 48: 155 – 158. Google Scholar Crossref Medline 56. Perdigues, SR, Quecuti, RS, Mane, A.[doi.org]

Workup

Laboratory tests

The main purpose of laboratory tests is to exclude any systemic or metabolic disease.

Imaging 

CT scan and MRI of the brain to check for structural abnormalities, signs of trauma and tumors can be conducted.

Test results

Once any sign of preexisting disease has been ruled out and if the history and clinical signs point towards a mental disorder, a tentative diagnosis of schizophrenia can be made. It is confirmed by psychoanalysis.

Treatment

Pharmacological treatment

Antipsychotic medication is the mainstay of pharmacological treatment. Randomized trials have shown that antipsychotics reduce positive symptoms of schizophrenia, such as hallucinations, delusions, and suspiciousness, compared to placebo [8]. They include drugs like clozapine, amisulpride and risperidone. All antipsychotics have a wide range of adverse effects and close monitoring is generally indicated.

Non-pharmacological treatment

It includes cognitive-behavioral therapy (CBT) and emotional support by family and/or friends. Cognitive training involves structured exercises prescribed and undertaken with the intention of enhancing cognitive abilities such as attention, memory, and problem solving. Thus, cognitive training represents a potentially promising intervention for enhancing cognitive abilities in schizophrenia [9]. Participation in support groups also helps in reducing depression and anxiety of the patient.

Prognosis

Schizophrenia is a chronic, progressive disease with a negative prognosis. Life expectancy is reduced by as much as 10-25 years [7]. Social as well as personal life is severely compromised and the patient becomes a victim of depression. Not surprisingly, patients are estimated to have a 5% increased chance of committing suicide. Early identification and diagnosis followed by adequate treatment can help reduce the severity of symptoms, decrease mortality rate and increase the quality of life.

Etiology

Various genetic and environmental factors work together to develop this disease. A number of risk factors have been associated with the development of schizophrenia, including living in an urban area [2], immigration, obstetrical complications [3] and advanced paternal age at conception. Childhood trauma or being a victim of bullying, substance abuse and severe emotional trauma can all set the ground work of this disease.

The tendency of schizophrenia to run in families is a clear indicator of genetic involvement. Several likely candidates have been implicated like NOTCH4, zinc finger protein 804A and the histone protein loci. The likelihood of a child having schizophrenia when one parent already suffers from this disease is 13%, and as high as 50% if both parents do.

Epidemiology

Incidence

Approximately 1% of the population will be affected by this disease worldwide in its lifetime.

Age

The onset of this disease occurs typically between late teens and mid thirties. Schizophrenia is extremely rare in children.

Sex

Slightly more men are diagnosed with schizophrenia than women (on the order of 1.4:1) [4]. Also, the onset of this disease is later in females than in males, possibly due to the antidopaminergic effect of estrogen in females.

Sex distribution
Age distribution

Pathophysiology

Schizophrenia is a result of several pathways that together act to create the disease. The pathogenesis comprises three main mechanisms.

The first is anatomical abnormalities. A meta-analysis of studies using diffusion tensor imaging (DTI) to examine white matter found that 2 networks of white matter tracts are reduced in schizophrenia [5]. The abnormalities identified included loss of whole-brain volume in both gray and white matter and increases in lateral ventricular volume [6]. The exact cause of these structural anomalies is unclear.

The second is abnormally working dopaminergic pathways. It is known that schizophrenics suffer from a hypodopaminergic state which leads to a decrease in mental capabilities and degeneration of involved neurons.

The third mechanism is a defective or disturbed immune system. Schizophrenia is not a strictly autoimmune condition but due to an infection or some other illness, overactivation of the immune system may occur. This would lead to overproduction of cytokines and other inflammatory mediators that could easily penetrate the blood brain barrier and damage the neurons. This excessive inflammation could be both a direct association to schizophrenia or secondary to metabolic diseases like diabetes.

Prevention

Cognitive behaviour therapy (CBT) is the primary modality for preventing the onset, and mainly, the progression of schizophrenia. The use of a psychological interventional approach that involved CBT and counselling of family members along with group skills training of the patient delayed the onset of psychosis for at least 2 years, as shown by a German study [10]. Avoiding drugs like cocaine and amphetamines can also help prevent this disease.

Summary

Schizophrenia is a mental disorder characterized by a myriad of personality changes, most striking of which are extreme paranoia, auditory and sometimes even tactile hallucinations and delusions. It is among the most disabling and economically catastrophic medical disorders, ranked by the World Health Organization as one of the top ten illnesses contributing to the global burden of disease [1]. Schizophrenia tends to run in families, indicating a genetic predisposition. It mainly affects the ability of a person to think and rationalize, but it is also associated with a number of other conditions and comorbidities.

Patient Information

Definition

Schizophrenia is a mental disorder characterized by personality changes, paranoia and hallucinations. It is a common psychological disorder and tends to run in families.

Cause

Schizophrenia is not due to a specific cause; rather it is a combination of various factors that precipitate the disease. They include genetic factors, environmental factors like severe stress, change in living place, physiological changes like pregnancy, pathological conditions like chronic diseases and emotional and/or physical trauma

Signs and symptoms

It begins with mild personality changes and mood swings and is followed by hallucinations, paranoia and delusions. The patient may have disorganized speech, wild ideas and the inability to differentiate between what is real and what is not.

Diagnosis

Diagnosis is made first by excluding any underlying disease and then performing a thorough physical and psychological examination. Input from family and close friends or colleagues can also help pinpoint the changes in behaviour, making the diagnosis somewhat easier.

Treatment

Schizophrenia does not have a cure but it can be appropriately managed with the help of antipsychotic drugs and cognitive behaviour therapy. Regular sessions with a psychiatrist and participating in support groups can also help.

References

Article

  1. Murray CJL, Lopez AD. The Global Burden of Disease, Harvard University Press, Cambridge, MA 1996. p.21 
  2. Pedersen CB, Mortensen PB. Evidence of a dose-response relationship between urbanicity during upbringing and schizophrenia risk. Arch Gen Psychiatry 2001; 58:1039.
  3. Clarke MC, Harley M, Cannon M. The role of obstetric events in schizophrenia. Schizophr Bull 2006; 32:3.
  4. Abel KM, Drake R, Goldstein JM. Sex differences in schizophrenia. Int Rev Psychiatry 2010; 22:417.
  5. Ellison-Wright I, Bullmore E. Meta-analysis of diffusion tensor imaging studies in schizophrenia. Schizophr Res. Mar 2009;108(1-3):3-10.
  6. Olabi B, Ellison-Wright I, McIntosh AM, et al. Are there progressive brain changes in schizophrenia? A meta-analysis of structural magnetic resonance imaging studies. Biol Psychiatry. Jul 1 2011;70(1):88-96. 
  7. Laursen TM, Munk-Olsen T, Vestergaard M. "Life expectancy and cardiovascular mortality in persons with schizophrenia". Current opinion in psychiatry. Mar 2012, 25 (2): 83–8. 
  8. Buchanan RW, Kreyenbuhl J, Kelly DL, et al. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull 2010; 36:71.
  9. Lawlor-Savage L, Goghari VM. Working memory training in schizophrenia and healthy populations. Behav Sci (Basel). 2014 Sep 3;4(3):301-19. 
  10. Bechdolf A, Wagner M, Ruhrmann S, Harrigan S, Putzfeld V, Pukrop R, et al. Preventing progression to first-episode psychosis in early initial prodromal states. Br J Psychiatry. Jan 2012;200(1):22-9 

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Last updated: 2019-07-11 22:14