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Definition

Schizophrenia is a long-term mental health problem which affects thinking, perception and affect.1

ICD-10 lists six key types of schizophrenia:

  • Paranoid schizophrenia
  • Hebephrenic schizophrenia
  • Catatonic schizophrenia
  • Undifferentiated schizophrenia
  • Residual schizophrenia
  • Simple schizophrenia

Epidemiology

Schizophrenia affects about 1 in 100 people. It affects men and women equally and is usually diagnosed between the ages of 15 and 35. Age of onset tends to be slightly earlier in men (18-25) and later in women (25-35).

There is a higher incidence of schizophrenia in urban areas and among migrants. The incidence is also higher in lower socioeconomic classes, but this may be a consequence, rather than a cause, of schizophrenia.2


Signs and symptoms

Symptoms can be divided into positive and negative. Positive symptoms tend to represent a change in behaviour or thought; while negative symptoms usually involve a decline in normal functioning.3

Positive symptoms 4,5

  • Thought echo (hearing your own thoughts out loud)*
  • Thought insertion or withdrawal*
  • Thought broadcasting*
  • 3rd person auditory hallucinations*
  • Delusional perception *
  • Passivity and somatic passivity*
  • Odd behaviour
  • Thought disorder
  • Lack of insight

*These are also referred to as Schneider’s First Rank Symptoms.

Negative symptoms 5

  • Blunted affect
  • Apathy
  • Social isolation
  • Poverty of speech
  • Poor self-care

Aetiology and Risk Factors

The precise cause of schizophrenia is unknown but it is believed to be a consequence of a combination of psychological, environmental, biological and genetic factors. It is thought that people may have a susceptibility to schizophrenia and that emotional life experiences can act as a trigger for developing the illness.3

 

Family history and genetics

You are more likely to develop schizophrenia if there is a family history of the illness. For example, the monozygotic twin of a person with schizophrenia has a 50% chance of developing schizophrenia, while a dizygotic twin has a 15% chance. An adopted child still has a 12% chance of developing schizophrenia if their birth parent was a sufferer.4 The chance is 48% for a child where both parents are affected.6

There is also some increased risk with advanced paternal age, where the father was aged over 55.7

 

Pregnancy

Malnutrition and viral infections during pregnancy increase the chance of developing schizophrenia. Other complications such as pre-eclampsia and emergency caesarean section also increase the risk.6

 

Drug abuse

Using cannabis is known to increase the risk of developing schizophrenia, particularly when used as a teenager. Many other drugs can also cause psychotic symptoms, including amphetamines, cocaine and LSD.6

 

Social and environmental

Schizophrenia is more prevalent in urban areas and among lower socioeconomic classes, but this may be a consequence of living with schizophrenia, rather than being a cause. Stressful life experiences are known to increase the risk of developing schizophrenia and this is seen particularly among first- and second-generation migrants. Those who have experienced physical or sexual abuse during childhood are also more at risk.

 

Ethnicity

In the UK, Afro-Caribbean men are more affected than other ethnicities.


Pathophysiology

Schizophrenia is believed to develop as a result of physical changes to the brain and to changes in neurotransmitters.

Neurodevelopmental hypothesis

People who experienced hypoxic brain injury at birth or who were exposed to viral infections in-utero are at greater risk of developing schizophrenia. Those with temporal lobe epilepsy or who smoke cannabis while their brain is still developing are also at higher risk. This suggests that brain development is implicated in the pathophysiology of schizophrenia. Imaging has shown changes in the brains of people with schizophrenia, including enlarged ventricles, small amounts of grey matter loss and smaller, lighter brains.

 

Neurotransmitter hypothesis

An excess of dopamine and overactivity in the mesocorticolimbic system are believed to cause the positive symptoms of schizophrenia. Dopamine antagonists are therefore used to treat schizophrenia. There is also thought to be less dopamine activity in the mesocortical tracts, causing the negative symptoms in schizophrenia. This is why dopamine antagonists are more successful at treating positive than negative symptoms.

Psychotic symptoms are seen in people with Parkinson’s disease if they are overtreated with levodopa as this increases the amount of dopamine in the brain. Amphetamines and cocaine also increase dopamine release and lead to psychosis.

Dopamine is not the only neurotransmitter implicated in schizophrenia. There is also an increase in serotonin activity and a decrease in glutamate activity.6


Investigations

If a patient is suspected to have schizophrenia, they will be referred to the local community mental health team where a psychiatrist or specialist nurse carries out a detailed assessment.3

 

According to ICD-101, a diagnosis of schizophrenia requires…

A first rank symptom or persistent delusion present for at least one month:

  • Delusional perception
  • Passivity
  • Delusions of thought interference: thought insertion, thought withdrawal and/or thought broadcasting
  • Auditory hallucinations: thought echo, third person voices and/or running commentary

No other cause for psychosis such as drug intoxication or withdrawal, brain disease (including dementia/delirium/epilepsy), or extensive depressive or manic symptoms (unless it is clear that schizophrenic symptoms antedate the affective disturbance)

 

Other investigations used to rule out the other causes of confusion / psychotic symptoms 6:

  • MSU to rule out UTI causing delirium
  • Urine drug screen to rule out drug intoxication
  • CT scan if organic neurological cause is suspected
  • HIV testing if applicable
  • Syphilis serology if applicable
  • Check lipids before starting antipsychotics
  • Full physical examination
  • Bloods including FBC, TFTs, U+Es, LFTs, CRP and a fasting glucose

Treatment

Teams involved:

  • Early intervention team (initial referral after first psychotic episode)
  • Community mental health team (provide day-to-day support and treatment)
  • Crisis resolution team (for patients experience an acute psychotic episode)

 

Care programme approach

Patients with schizophrenia will usually have a care programme approach.

 

There are four stages to a CPA:

  • Assessing health and social needs
  • Creating a care plan
  • Appointing a key worker to be a first point of contact
  • Reviewing treatment

 

Voluntary and compulsory hospital admission

Psychiatrists may sometimes recommend an inpatient stay. Most patients are admitted voluntarily but occasionally they may be detained under the Mental Health Act.q

 

Antipsychotic medication

The drugs used to treat schizophrenia are D2 (dopamine) receptor antagonists. They can be divided into ‘typical’ and ‘atypical’ antipsychotics.

The ‘typical’ group are older and cause generalised dopamine receptor blockade. They include:

  • Haloperidol
  • Chlorpromazine
  • Flupenthixol decanoate (depot injection)

 

They have numerous side effects, including…

Extrapyramidal side effects (EPSEs):

  • Parkinsonism
  • Akathisia
  • Dystonia
  • Dyskinesia

 

Hyperprolactinaemia leading to:

  • Sexual dysfunction
  • An increased risk of osteoporosis
  • Amenorrhoea in women
  • Galactorrhoea, gynaecomastia and hypogonadism in men

 

Metabolic side effects:

  • Weight gain
  • Increased risk of developing type 2 diabetes
  • Hyperlipidaemia
  • Increased risk of developing metabolic syndrome

 

Anticholinergic side effects:

  • Tachycardia
  • Blurred vision
  • Dry mouth
  • Constipation
  • Urinary retention

 

Neurological side effects:

  • Seizures
  • Neuroleptic malignant syndrome (potentially life-threatening)

 

‘Atypicals’ are more selective in their dopamine blockade and also block serotonin 5 HT2 receptors. They are less likely to causes EPSEs and raised prolactin level, but still cause the other debilitating side effects seen above.

Examples include:

  • Olanzapine
  • Risperidone (depot injection)
  • Clozapine
  • Amisulpride
  • Quetiapine

Aripiprazole is a partial dopamine agonist and so is less likely to cause EPSEs than the others.

Clozapine is often used when both a typical and atypical antipsychotic have been ineffective. However, patients on clozapine require regular blood tests to check their neutrophil levels as clozapine can cause agranulocytosis, which is potentially life-threatening. 6

 

Psychological treatments

Therapies used include:

  • Cognitive behavioural therapy (CBT)
  • Family therapy

Subtypes of schizophrenia

Paranoid schizophrenia

Paranoid schizophrenia is the most common type and is characterised by paranoid delusions and auditory hallucinations

Hebephrenic schizophrenia

Hebephrenic schizophrenia is usually diagnosed in adolescents and young adults. It is characterised by mood changes, unpredictable behaviour, shallow affect and fragmentary hallucinations. The outlook is often poor as negative symptoms may develop rapidly.

Simple schizophrenia

Simple schizophrenia is similar to hebephrenic schizophrenia in that it is characterised by negative symptoms. However, in simple schizophrenia, patients have never experienced positive symptoms.

Catatonic schizophrenia

Catatonic schizophrenia is characterised by its psychomotor features, such as posturing, rigidity and stupor.

Undifferentiated schizophrenia

Patients are designated as having undifferentiated schizophrenia when their symptoms do not fit neatly into one of the other categories of schizophrenia.

Residual schizophrenia

Residual schizophrenia is again characterised by negative symptoms. It usually occurs when the positive symptoms have ‘burnt out’.6


References

  1. ICD-10
  2. Crash Course: Psychiatry
  3. NHS Choices website
  4. Psychiatry At a Glance
  5. Lecture Notes: Psychiatry
  6. Psychiatry PRN
  7. Torrey EF, Buka S, Cannon TD, Goldstein JM, Seidman LJ, Liu T, Hadley T, Rosso IM, Bearden C, Yolken RH. Paternal age as a risk factor for schizophrenia: how important is it? Schizophrenia Research. 2009 Oct;114(1-3):1-5. Available from: doi: 10.1016/j.schres.2009.06.017. Epub 2009 Aug 14.