Schizophrenia: Origin, Definition & Impact

Origin and Definition

• Schizophrenia was coined in 1908 by Swiss psychiatrist Eugen Bleuler from the Greek "skhizo" (split) and "phren" (mind).
• Explanations and diagnostic have been debated and redefined over time.
• Schizophrenia is considered part of a spectrum of related disorders, according to the DSM-5-TR.
• Considered a neurodevelopmental disorder, it arises from multiple factors: genetics, biochemical imbalances, physiological factors, and psychosocial stress
• Tripathi et al. suggest the brain changes in schizophrenic patients stem from cumulative neurodevelopmental abnormalities, altered neuroplasticity, and changes in neuronal maturation.
• Effective treatment involves a comprehensive, multidisciplinary approach including medication and psychosocial support, since there is no single cure.
• Comprehensive, patient-centered care provides the best hope for recovery and improved quality of life.

Impact

• Schizophrenia has a large impact due to longer hospital stays, disruption for families, high costs, and creates associated fear.
• Serious mental illness (SMI) manifests as mental, behavioral, or emotional disorders.
• SMI can cause significant problems in a person's ability to function in major life activities.
• People with SMI, including schizophrenia, have significantly shorter lifespans, averaging 25 years less than the general population.
• Schizophrenia presents a significant threat, so is one of the most studied mental disorders, despite mostly unknown causes.
• There's a noteworthy risk of suicide among those individuals.
• About 20% of people with schizophrenia attempt suicide; 5% to 6% die by suicide.
• Schizophrenia is a disabling psychological disorder leading to decline in social and occupational functioning.
• Decline in social and occupational functioning caused by disturbances in thinking, perception, and emotions

Prevalence and Onset

• Estimated lifetime prevalence is 0.3% to 0.7% in the general population.
• The symptoms typically appear in late adolescence or early adulthood, though can present later in life.
• Early-onset schizophrenia describes symptoms starting in childhood or adolescence (before age 18).
• Early-onset schizophrenia is a rare, progressive neurodevelopmental disorder with long-term symptoms.
• Research indicates it may occur more frequently and earlier in males than females.

Phases of Development

• Schizophrenia development progresses through four phases: premorbid, prodromal, active psychotic, and residual.

Phase I: Premorbid Phase

• Characterized by signs before clear illness evidence, such as specific personality traits or behaviors.
• Shy, withdrawn, poor peer relationships, struggling in school, and asocial behavior are characteristics
• Schizoid or schizotypal personalities, quiet, passive, and introverted as children may avoid social activities as adolescents.
• Focus of current research is to identify biomarkers and at-risk individuals in this stage, to prevent illness transition or enable early intervention.

Phase II: Prodromal Phase

• Prodromal is different from but follows premorbid.
• It contains clearer indications schizoprenia is developing.
• Marks a change from previous (premorbid) functioning; lasts until psychotic symptoms appear.
• Can be short (weeks or months), but often lasts 2 to 5 years.
• Noticeable decline in function, depressive symptoms (50%), social withdrawal, or cognitive problems are symptoms.
• Some adolescents may develop obsessive-compulsive behaviors.
• Recognizing these behaviors provides opportunities for early intervention, to improve long-term outcomes.
• Cognitive therapy to help with support for specific problems, lessen functional impairment, involve family in coping, and work with the patient's school to reduce failure can be beneficial.
• Debate over using medication during this phase exists.
• Beginning comprehensive treatment at the first psychotic episode correlates with better results.

Phase III: Active Psychotic Phase

• Long-term (chronic) illness with acute phases, where symptoms become more intense.
• Psychotic symptoms are particularly noticeable during the active phase.

Phase IV: Residual Phase

• Schizophrenia alternates between periods of symptom exacerbation (worsening) and remission (lessening).
• Following the active phase, this phase typically occurs.
• Obvious active phase either disappear or are less intense.
• Positive symptoms may improve, while negative symptoms (loss of emotion) in addition to difficulty functioning daily.
• Symptoms are originally believed to be permanent, but research suggests they can improve (though hard to treat).
• Residual impairment often worsens is the result of each new active psychotic episode.

Prognosis

• It's hard to predict since outcomes vary from person to person.
• Long-term studies indicated that around 44% of patients with schizophrenia experience significant clinical improvement.
• Better outcomes are associated with god prior functioning to diagnosis, later age of start, female, sudden symptom onset with a clear trigger and lower levels of depression.
• Better outcomes also come from quick resolution of active symptoms; minimal lasting symptoms after an episode; no structural abnormalities in the brain; ability to live independently; no family history of schizophrenia and good social support.

Predisposing Factors

• The exact cause is unknown.
• Likely caused by a combination of biological, psychological, and environmental influences, not just one thing
• Genetics increases chances of vulnerability to schizophrenia.
• Relatives are more likely to develop the disorder than the general public.
• A relative increases risk from regular 0.3-0.7% to 9% higher for a first-degree relative.
• Twin studies have provided the stongest eidence for a genetic component.
• Identical (monozygotic) twins have a 50% concordance rate, meaning if one has it, the other has the same odds of schizoprenia
• Rate is 4-5 times higher in fraternal twins (dizygotic) or other first-degree relatives, showing a stronger genetic link in identical twins.
• Identical twins raised separately have equal rates of disease, further supporting genetics.
• Genes aren't the only cause, since only one twin develops schizophrenia in about half of monozygotic (identical) twin cases.
• Combination of multiple genes, environmental factors, and how genes are expressed through interaction with the environment may all contribute.
• Specific way schizophrenia is inherited is unclear at this time.
• Recent research is aiming to identify the particular genes contributing to susceptibility and biomarkers.
• A gene expression study (Okazaki et al., 2016) revealed a gene combination (CDK4, MCM7, and POLD4) that could distinguish patients with acute psychosis from healthy individuals.
• This specific gene combination may be a genetic biomarker and could help researchers understand the disease.
• Researchers concluded a messenger RNA (mRNA) expression changes in the CDK4 gene could be biomarkers for both consistent (trait) and temporary (state) symptoms.
• Strongest genetic links involve variations in the major histocompatibility complex (MHC), specifically C4 alleles, connected to synaptic pruning during adolescence/young adulthood.
• Research continues to pinpoint the specific genetics that contribut.
• Improving understanding of the many different factors involved.
• May lead to identification of new/more effective treatment strategies is the ultiamte need.

Biochemical Theory

• The most investigated biological explanation is that the problems originate in brain chemistry.
• Possible origin of issue can be attributed to "chemical disturbance dating back to the mid-1800s.

Dopamine Hypothesis

• Schizophrenia and related symptoms arise from too much activity of dopamine.
• It can be due to increased production/release, receptor sensitivity, receptor count, or combination.
• Amphetamines (which increase dopamine) can cause these psychosis-like symptoms, and first-gen antipsychotics reduce psychosis by lowering dopamine levels; they block dopamine receptors, esp. D2 receptors.
• Postmortem and in vivo studies (PET/SPECT) revealed increased capacity to synthesize dopamine.
• Medications that lower dopamine are more effective in treating positive symptoms, compared to negative ones.
• There are different dopamine receptors (D1-D5); research continues on how they affect treatment and what their roles are.
• Example: clozapine (an atypical antipsychotic) is high-affinity for D4 receptors; D3 receptors are linked to negative symptoms.
• Outside of dopamine, other neurotransmitter imbalances are also present.

Other Biochemical Hypotheses

• Other neurotransmitters besides dopamine involved include norepinephrine, serotonin, acetylcholine, as well as neuroregulators like prostaglandins and endorphins.
• Serotonin excess may contribute to both positive and negative symptoms.
• Effectiveness of clozapine, a strong serotonin antagonist, supports this.
• Glutamate is involved, activating NMDA receptors in the brain activated by glutamate and glycine.
• Studies showed glutamate antagonists (like PCP and ketamine) can cause schizophrenia-like symptoms in some people.
• One study found a glycine transporter-1 inhibitor reduced ketamine-induced symptoms, helping regulate glutamate.
• Despite the above, more research is needed to understand how glutamate can be targeted for treatment.
• Recent new findings show high glutamate is important in the transition to psychosis.
• Stress can trigger first episodes, and glutamate increases under stress.
• High glutamate can cause the hippocampus to become overactive and then atrophy, common in schizophrenia.
• Future research may explore glutamate as a target to help at-risk individuals or to slow/prevent the illness' development.

Physiological Factors

• Medical literature identifies physiological factors in the disorder.
• How these factors work and what they mean for the cause of schizophrenia is unclear.
• Risks, environmental factors, and vulnerabilities combine during brain development, to increase likelihood.
• Viral infection can link a possible relation between viral infections and schizophrenia.
• Studies found a higher rate of schizophrenia after a mother's exposure to influenza during pregnancy.
• Possible signs of viral connection include physical abnormalities at birth, increased pregnancy/birth complications, viral infection birth seasonality, clusters of cases, seasonal hospitalizations.
• Research explores if autoimmune antibodies in the brain contribute to schizophrenia, especially after a neurotoxic virus infection like prenatal exposure to Toxoplasma gondii.
• T. gondii can cause delusions, hallucinations, and other psychotic symptoms, is transmitted via undercooked meat/cat feces.
• Cytokines (immune system chemicals) are dysregulated in schizophrenia patients, influencing its issues, possibly through genetics/trauma.
• Brain scans revealed structural differences in schizophrenia brains.
• Enlarged ventricles (fluid-filled spaces in the brain) may be present.
• Some studies also report reduction in gray matter (brain tissue).
• A smaller hippocampus (memory/learning implicated in first psychotic espisode).
• Focus is important because early treatment is linked to better results.
• Goal is that these studies will eventually lead to prevention.
• Reduced symmetry in the lobes of the brain and in size of the limbic system (involved in emotion and memory) may be visible on MRI.
• Postmortem studies show prefrontal cortex abnormalities (involved in higher-level thinking and behavior).
• Individuals who have had prefrontal lobotomies (outdated surgery now) exhibit flat affect and cognitive decline, which are also common in schizophrenia.
• Diffusion tensor imaging (DTI) studies have found widespread abnormalities in white matter.
• The above white matter changes correlate to negative symptoms (like flat affect) and psychomotor behavior abnormalities.

Treatment Implications

• Unclear implications of antipsychotic medication on brain volume necessitate further research to understand their long-term effects.
• Clinicians must weigh the benefits of symptom management against potential structural brain changes
• The 40-Hz auditory steady-state response (ASSR) is a measure of electrical activity in the brain, specifically in response to auditory stimuli.
• Schizophrenic individuals exhibit abnormalities, indicating neural circuit dysfunctions.
• The ASSR is an indication of the brain's ability to process auditory information (often impaired in schizophrenia).
• A meta-analysis (Thunè et al., 2016) provided evidence for neural circuit dysfunctions in those diagnosed.
• The 40-Hz ASSR could be a biomarker for determining who is at risk.
• Exact implications of circuit dysfunctions are unclear, further research is needed.
• Understanding could lead to improved diagnostic tools/treatment strategies.
• Future studies may explore the relationship between ASSR abnormalities and other cognitive deficits.
• Medical conditions can lead to acute psychotic episodes, highlighting the importance of differential diagnosis in psychiatric practice.
• Huntington's disease and temporal lobe epilepsy are known to have psychosis as a symptom, careful neurological health assessment should be included.

Conditions with Psychosis

• Include Huntington's, Hypo/hyperthyroidism, Hypoglycemia, Calcium imbalances, Wilson's disease, CNS neoplasms, Encephalitis, Meningitis, Neurosyphilis, Stroke.
• Any can affect brain function and lead to symptoms similar or inducing psychosis.
• Medical evaluation is key to ruling them out in patients presenting psychotic symptoms.
• Early identification/treatment can prevent progression of psychotic outcomes.
• Providers should be aware of overlap.

Psychosocial Factors

• While family dynamics aren't causative, they can affect the patient’s experience/symptom.
• The disease can disrupt communication and family relationships.
• Family members may experience stress/confusion, leading to possible conflict.
• Effective family communication helps to manage relational disruptions.
• There's a strong connection between trauma and the development of schizophrenia, especially in vulnerable populations.
• Trauma compounds risk when combined with genetic/environmental factors.
• Trauma-informed care is essential for recognizing the impact of trauma on mental health.

Trauma Strategies

• Assess/address current mental state including impact of stressors.
• Ensure approaches address trauma/its effects.
• Comprehensive assessment of schizophrenia includes psychosocial factors such as family dynamics/trauma history.
• Understanding background/experiences informs approaches while psychosocial assessments help identify support.
• Interventions tailored to biological/social factors are key.
• Care involves trauma recognizing prevalence/impact.
• Approaches emphasize safety/empowerment.
• Training in practices is key for effective care/healing.

Sociocultural Factors

• Status affects schizophrenia and social class.
• Data indicates individuals from lower backgrounds exhibit higher rates (Os/Reininghaus, 2017).
• The status prevalence indicates it affects onset/severity of this disorder.
• Lack of resources/access is correlated with increased risk.
• Social cohesion/cohesion serves as protective factors, potentially mitigating risk.
• The drift hypothesis states those with schizophrenia have difficulties maintaining employment.
• Proponents state that symptoms drive individuals into lower strata.
• Shifting focus from socioeconomic factors to internal challenges is key.

Protective and Stressful Factors

• Social cohesion increases mental health.
• Ethnic density area helps to further provide support and reduce overall stigma.
• Communities with strong social support give individuals better ways to work with stressors.
• The balance of the above highlights overall prevention and management of Schizophrenia.
• Research is working to identify/enhance factors within diverse communities.
• No definitive evidence links stress directly to schizophrenia but does effect its severity and overall progression.
• Extreme stress can trigger episodes, especially in individuals with a genetic predisposition.

Impacts of Stress

• Increases of existing schizophrenia with increase in stress.
• Increased reoccurrence in patient indicate a potential cycle between stress and symptom.
• Understanding its impacts is key to developing helpful approaches of stress management training.
• The above have showed in studies reduced relapses and better improved overall health.

Mechanisms of Stress Impact

• Can affect neurotransmitter systems, particularly dopamine increase those chances.
• The hypothalamic-pituitary-adrenal (HPA) axis is activated during stress/increased cortisol levels worsen psychotic symptoms increase risk.
• Chronic stress changes the brain (often with reduced hippocampal volume). CBT, shown improved quality of overall living.
• Social support can mitigate and highlight the importance of overall community.
• Cannabis has been shown to effect genetics within genetic markers known ( COMT/ACT1).
• Adolescents who use genetics at a higher risk of developing psychosis gene.

Cannabis + Risks

• Genetic vulnerability isn't always guaranteed.
• Family studies have shown patients that when are combined increase psychosis symptoms.
• Testing provides greater inside to risks.
• This research can inform policy makers with public health safety.
• Long-term studies would greatly improve mental health specially within the vulnerable populations.

Treatment and Models

• The transactional Model of stress model to under the on set within patients.
• Individual response can vary and effect overall level of the disorder depending on reactions.
• DSM-5-TR classification has categorized disorder with longer ranges/levels of severity/duration.
• Disorders range from less (ex Schizotypical) to to higher forms of overall psychosis.
• The dsm greatly improves assess and greatly increases functioning based on overall symptoms.
• It can occur in certain categories to help provide catatonia in psychotic disorder.
• It can occur with varying overall degrees such as affective behavior etc.
• Bettering a greater understanding with approaches allows for increase overall interventions. The spectrum begins with Schizotypal (which can be reviewed in chapter 31/textbook).
• This then provides more insight into (brief psycotic/Schizphorenic/or major depresive).
• Approach allows and overall better/increases understanding based on overall severity.
• Delusional : presence last for +1-month with little present hallucination.
• Behavior isn't typically too bazaar separating disorders out.
• S0me sub types can include : (Erotomatic/grandiose/jealous and persecutory/somatic/mixed).
• Treatment can have approaches of phycotheraphy often sometimes given medication.
• Supportive greatly improves and increases great comfort.

Brief Psychotic Disorder

• Def: It is characterized by onsets (followed by severe stress.
• Symptoms: usually lasts(1days < 1 month with full recovery).
• Can range many symptom's such has(hallucinations incoherent and bazaar behavior).
• Individuals can experience : confusion turmoil and disorientation during episodes.
• The disorder itself can cause great stress for patients and their families. overall understanding improves with treatment and support.
• Management/ treatments- It often involves a combination of phycotherphy depending on severity.and also include short-term stabilization for safety and stabilization.
• Psycho education greatly helps patients/family help understanding (overall stigma).
• Medication induced (psycoitic dissorder).
• Symp: is heavily linked/cause to the said substance(withdraw and toxin).
• It often require significant evidence. to substances + withdraw.
• features include (prominent delusions which distingush and require significant treatment due to effect(cantontic)
• Great treatment can be improved with great with draw symtp/ better supporting over time better/ rehab.
• Pstcihyotic disorders are identified through through emotion dissturbances.
• And also require an assess/rule out medical issues.

Diagnostics

• 2022 APA has states duration .
• Symptoms that occur during delirum aren't identified/ important accurate testing.
• Categorization that stem from etiology including that secondary to medical to primary psychotic disorders.
• And also contains ( Schizo-phrenfrorm ).
• It may be defined has false as ( hallucinations with real stimulus/ without and external).
• May effect senses(auditory/visual/gustatory/and factory).
• Can also show general underlying men health .

Positive type symptoms

• 3. Auditory/visual/ tactile with all 3 ranging certain levels.
• This also has high effects among the varying levels of disorder.
• Illusions with disturbances will vary within all of them . such has a (disorganized thoughts . delusion .s/with hallucinations as well as reality being separate).
• One key effect to focus on ( reality and environmental stim).
• The environment stimuli can cause issues as well .
• 50-70 % is very consistent with many individuals (overtime).
• 2:3 . have also improved better than many different counter parts from med.
• There needs to be much interventions with trust and respect. for all patients.

Various key steps for Nursing

• Assess is crucial influences criteria (objective/outcome/problem identification)
• assessment and needs and is also important for data collecting.
• Must have understanding if (-) or + ( signs).
• It is important that nurse must also structure tool and asses how to use the tools gathering it all together .
• 7 domain with the cognitive include. include these listed bellow
• 1 WORKING MEMORY
• 2 ATTENTION .
• 3 SPEED OF PROCESS.
• 5 LEARNING .
• 7REASONING
• 6. SOLVING
• These can also be in cognitive defects.
• The issues are mainly cause from decrease in all around functional quality.
• It can also stem to other aspects ( like genetics.environment. and the illness itself).
• Psychological factors includes a large amount of stress that negatively can effect the brain/overall mental state of individual.
• Social defeat can and also attribute to feelings of hopeless as well as great cognitive incline.
• Limits . pharms have showed limits when used for overall cognitive abilities for schizo .
• This highlights the alternate that may include in proving those such as therapy over long-term.