Psychology: Schizophrenia Overview

Schizophrenia Overview

• Schizophrenia is a chronic, debilitating mental disorder characterized by periods of loss of touch with reality (psychosis), persistent disturbances of thought, behavior, appearance, and speech, abnormal affect, and social withdrawal.
• Peak age of onset: 15-25 years for men and 25-35 years for women.
• Occurs equally in men and women, all cultures, and all ethnic groups studied.

Symptoms of Schizophrenia

• Positive symptoms:
  • Delusions
  • Hallucinations
  • Agitation
  • Talkativeness
  • Respond well to most traditional and atypical antipsychotic agents
• Negative symptoms:
  • Lack of motivation
  • Social withdrawal
  • Flattened affect
  • Cognitive disturbances
  • Poor grooming
  • Poor speech content
  • Respond better to atypical than to traditional antipsychotics

Course of Schizophrenia

• Three phases: prodromal, active, and residual
• Prodromal phase:
  • Occurs prior to the first psychotic episode
  • Includes avoidance of social activities, physical complaints, and new interest in religion, the occult, or philosophy
• Active phase:
  • Patient loses touch with reality
  • Disorders of perception, thought content, thought processes, and form of thought
• Residual phase:
  • Patient is in touch with reality but does not behave normally
  • Characterized by negative symptoms

Prognosis

• Involves repeated psychotic episodes and a chronic, downhill course over years
• Often stabilizes in midlife
• Suicide risk: >50% attempt, 10% die in the attempt
• Better prognosis and lower suicide risk if:
  • Older at onset of illness
  • Married
  • Has social relationships
  • Female
  • Has a good employment history
  • Has mood symptoms
  • Has few negative symptoms
  • Has few relapses

Etiology

• Genetic factors:
  • 1% of the population
  • Persons with a close genetic relationship to a patient with schizophrenia are more likely to develop the disorder
  • Markers on many chromosomes associated with schizophrenia
• Other factors:
  • Season of birth: more people with schizophrenia are born during cold weather months
  • No social or environmental factor causes schizophrenia
  • Downward drift hypothesis: patients tend to drift down the socioeconomic scale due to social deficits

Neural Pathology

• Anatomy:
  • Abnormalities of the frontal lobes
  • Lateral and third ventricle enlargement
  • Abnormal cerebral symmetry
  • Changes in brain density
  • Decreased volume of limbic structures (e.g., amygdala, hippocampus)
• Neurotransmitter abnormalities:
  • Dopamine hypothesis: excessive dopaminergic activity
  • Serotonin hyperactivity implicated
  • Glutamate implicated

Diagnosis and Severity

• DSM-5: no longer includes subtypes of schizophrenia, but rather distinguishes patients by the severity of their symptoms
• Dimensions of Psychotic Symptom Severity:
  • Hallucinations
  • Delusions
  • Disorganized speech
  • Abnormal psychomotor behavior
  • Negative symptoms

Differential Diagnosis

• Medical illnesses that can cause psychotic symptoms (e.g., neurologic infection, neoplasm, trauma, disease, temporal lobe epilepsy, endocrine disorders)
• Medications that can cause psychotic symptoms (e.g., analgesics, antibiotics, anticholinergics, antihistamines, antineoplastics, cardiac glycosides, stereotype hormones)
• Psychiatric illnesses other than schizophrenia that may be associated with psychotic symptoms (e.g., mood disorders, cognitive disorders, substance-related disorders)
• Schizotypal, paranoid, and borderline personality disorders are not characterized by frank psychotic symptoms

Treatment

• Pharmacologic treatments:
  • Traditional antipsychotics (dopamine-2 [D2]-receptor antagonists)
  • Atypical antipsychotic agents
  • Long-acting injectable "depot" forms
• Psychological treatments:
  • Individual, family, and group psychotherapy
  • Useful to provide long-term support and to foster compliance with the drug regimen