Schizophrenia is a severe, long-term mental health disorder characterised by psychosis. It most often presents between ages 15 and 30 and earlier in men than women. The symptoms must be present for at least six months before schizophrenia is diagnosed.
Schizoaffective disorder combines the symptoms of schizophrenia with bipolar disorder. Patients have psychosis and symptoms of depression and mania.
Schizophreniform disorder presents with the same features as schizophrenia but lasts less than six months.
TOM TIP: You might have to explain schizophrenia simply to a relative in your OSCEs. A helpful example may be: “Schizophrenia is a condition that affects how the brain processes information. Normally, the brain is very good at understanding reality, deciding what is important and what is not, and organising thoughts in a structured way. With schizophrenia, the brain struggles to understand the world, makes mistakes in deciding what information is important and organises thoughts in a confused way. This can lead to strong beliefs that do not fit with reality, called delusions. They may also experience voices that are not there, called hallucinations. The disorganised thoughts can lead to unusual speech and behaviours, which is called thought disorder. When these symptoms occur, it is called psychosis.”
Differential Diagnosis
Other causes of psychosis include:
- Mania
- Psychotic depression
- Drugs (e.g., hallucinogens and cannabis)
- Stroke
- Brain tumours
- Cushing’s syndrome (e.g., patients taking systemic steroids)
- Hyperthyroidism
- Huntington’s disease
Cause
Schizophrenia is considered to be the result of genetic and environmental factors. Specific genes that increase the risk of schizophrenia have been identified. Having an affected family member is a risk factor.
Presentation
A prodrome phase often precedes the full symptoms of psychosis. During this prodrome phase, the patient may experience subtle symptoms, such as poor memory, reduced concentration, mood swings, suspicion of others, loss of appetite, difficulty sleeping, social withdrawal and decreased motivation.
Psychosis is the central feature of schizophrenia. The key features of psychosis, called positive symptoms, are:
- Delusions (beliefs that are strongly held and clearly untrue)
- Hallucinations (perceiving things that are not real)
- Thought disorder (disorganised thoughts causing abnormal speech and behaviour)
Lack of insight is an important feature of psychosis. They lack awareness that the delusions and hallucinations are not based in reality.
Key positive symptoms that are typical in schizophrenia include:
- Auditory hallucinations (hearing voices, particularly a voice narrating the patient’s actions)
- Somatic passivity (believing that an external entity is controlling their sensations and actions)
- Thought insertion or thought withdrawal (believing that an external entity is inserting or removing their thoughts)
- Thought broadcasting (believing that others are overhearing their thoughts)
- Persecutory delusions (a false belief that a person or group is going to harm them)
- Ideas of reference (a false belief that unconnected events or details in the world directly relate to them)
- Delusional perceptions
A delusional perception occurs when the patient experiences an ordinary and unremarkable perception (e.g., a cat crossing the road) that triggers a sudden, often self-related delusion (e.g., “and I knew I would be meeting the aliens on behalf of humanity”).
Negative symptoms of schizophrenia include the four As:
- Affective flattening (minimal emotional reaction to emotive subjects or events)
- Alogia (“poverty of speech” – reduced speech)
- Anhedonia (lack of interest in activities)
- Avolition (lack of motivation in working towards goals or completing tasks)
A reduced level of functioning is an important feature. This involves reduced or impaired:
- Social engagement
- Productivity and achievement at work or school
- Self-care
Patterns
Schizophrenia may involve different patterns of symptoms. When observed over time (e.g., over at least one year), the active-phase symptoms of psychosis may be:
- Continuous
- Episodic (relapsing and remitting)
- A single episode only
Diagnosis
A specialist will make the diagnosis based on the DSM-5 criteria. The symptoms (including the prodrome phase) must have been present for at least six months, with symptoms of the active phase (delusions, hallucinations, and thought disorder) present for at least one month (or less if treatment is successful).
Management
A specialist psychiatry service will manage patients with schizophrenia:
- Early intervention in psychosis services are available for the first episodes of psychosis
- Crisis resolution and home treatment teams provide urgent support for patients in a crisis
- Acute hospital admission (under the Mental Health Act when required)
- Community mental health team for ongoing monitoring and management
Treatment involves:
- Antipsychotic medications
- Cognitive behavioural therapy
Key associations with schizophrenia and antipsychotic drugs are metabolic syndrome and cardiovascular disease. Physical health is monitored, including smoking status, alcohol consumption, illicit drug use, weight, activity levels, blood lipids and glucose, with interventions when indicated (e.g., smoking cessation and statins).
Antipsychotic Medications
Antipsychotic medication work by inhibiting dopamine receptors, specifically D2 receptors.
Antipsychotic drugs can be classified as typical or atypical, or as first or second-generation. Neither classification is particularly useful, as they relate more to when they were introduced rather than their mechanism or effects.
Oral antipsychotics include:
- Chlorpromazine (typical – first-generation)
- Haloperidol (typical – first-generation)
- Quetiapine (atypical – second generation)
- Aripiprazole (atypical – second generation)
- Olanzapine (atypical – second generation)
- Risperidone (atypical – second generation)
Depot antipsychotics are given as an intramuscular injection every 2 weeks – 3 months. This can be helpful where adherence may be an issue. Examples include:
- Aripiprazole
- Flupentixol
- Paliperidone
- Risperidone
Clozapine is used where other treatments do not control the symptoms. It can only be taken by mouth. Clozapine is very effective but comes with significant adverse effects. Patients taking clozapine have very close monitoring for evidence of complications. Key complications include:
- Agranulocytosis, with a severely low neutrophil count (predisposing to severe infections)
- Myocarditis or cardiomyopathy, which can be fatal
- Constipation (rarely to the point of intestinal obstruction)
- Seizures
- Excessive salivation
Monitoring requirements before starting and during antipsychotic treatment include:
- Weight and waist circumference
- Blood pressure and pulse rate
- Bloods, including HbA1c, lipid profile and prolactin
- ECG
Side effects of antipsychotic drugs include:
- Weight gain
- Diabetes
- Prolonged QT interval
- Raised prolactin
- Extrapyramidal symptoms
Extrapyramidal side-effects include:
- Akathisia (psychomotor restlessness, with an inability to stay still)
- Dystonia (abnormal muscle tone, leading to abnormal postures)
- Pseudo-parkinsonism (tremor and rigidity, similar to Parkinson’s disease)
- Tardive dyskinesia (abnormal movements, particularly affecting the face)
Neuroleptic Malignant Syndrome
Neuroleptic malignant syndrome is a potentially life-threatening complication of antipsychotic treatment. Key features are:
- Muscle rigidity
- Hyperthermia (raised body temperature)
- Altered consciousness
- Autonomic dysfunction (e.g., fluctuating blood pressure and tachycardia)
Key blood test findings are:
- Raised creatine kinase
- Raised white cell count (leukocytosis)
Management involves stopping the causative medications and supportive care (e.g., IV fluids and sedation with benzodiazepines). Severe cases may require treatment with bromocriptine (a dopamine agonist) or dantrolene (a muscle relaxant).
Last updated June 2024
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