Schizophrenia

What is Schizophrenia?

Schizophrenia is a mental health condition that affects about 1% of the global population, making it one of the top causes of disability around the world. It’s typically marked by symptoms like hallucinations, delusions, speech and behavior that is disordered, reduced motivation, less expressiveness, and cognitive challenges that affect memory, executive function, and mental processing speed. The impact of schizophrenia on a person’s day-to-day life can vary, with some people facing significant disability and incomplete recovery.

Social isolation, stigma, difficulties in forming close relationships, and high unemployment rates are common challenges faced by people with schizophrenia. These factors, along with unhealthy habits like a poor diet, weight gain, smoking, and substance abuse, can result in a shorter lifespan by 13 to 15 years. Additionally, there is a 5% to 10% lifetime risk of suicide among those diagnosed with schizophrenia.

While the diagnosis and treatment of schizophrenia have traditionally focused on psychotic symptoms, the disorder’s negative and cognitive symptoms can significantly impact social and workplace functioning and are often not improved by drugs used to control the psychotic symptoms. Historically, the primary symptoms of the disorder were not considered to be hallucinations or delusions, indicating the need for a wider understanding and management of the condition.

Identifying schizophrenia involves a thorough assessment of the individual’s mental health history and current mental status. Moreover, other mental and medical causes of psychosis must be ruled out. Risk indicators include birth complications, being born in certain seasons, severe malnutrition during the mother’s pregnancy, maternal flu during pregnancy, family history, childhood trauma, social isolation, cannabis use, belonging to an ethnic minority, and urban living. The exact cause and disease mechanisms of schizophrenia are still not fully understood due to its complexity and variety.

Despite affecting a relatively small portion of the population, schizophrenia significantly adds to the global disease burden. Over half of those diagnosed with schizophrenia also have multiple other mental and physical health conditions.

What Causes Schizophrenia?

Schizophrenia is a complex condition that develops due to a combination of genetic and environmental factors. These influences can affect how the brain develops early on and how it responds to life experiences, which can then influence when and how the condition develops.

Research involving twins and families shows that about 80% of the risk for developing schizophrenia can be traced back to genes. While common genetic variations have a smaller impact on risk, rare mutations can significantly increase it. An example of a significant rare mutation is a deletion on chromosome 22q11.2, which can increase the lifetime risk of schizophrenia 25-fold. Additionally, 130 genes have been found to increase the risk of schizophrenia through their involvement in various brain functions. These genes, interestingly, function by affecting gene expression, and about 30% of them play a role in how our neurons communicate using a chemical called glutamate.

However, even with the genetic risk, the fact that identical twins don’t always both have schizophrenia (only about 60% of the time) points to the importance of environmental factors. Things like complications during childbirth, early life adversities, growing up in urban settings, and being an immigrant can all interact with a person’s genetic risk to influence whether or not they develop schizophrenia.

People with schizophrenia often show certain changes in the structure and function of their brains. For instance, the spaces in the brain called the lateral ventricles are often roughly 25% larger, while the overall brain volume may be reduced by about 2%, mostly due to a decrease in grey matter. These changes are most notable in the frontal and temporal lobes and the hippocampus of the brain. There is also evidence of variations in brain activity patterns, such as reduced activity in a part of the brain called the dorsolateral prefrontal cortex.

The use of substances like cannabis, or its psychoactive ingredient THC, can also be a risk factor for schizophrenia. In fact, using these substances can even temporarily trigger psychotic effects. These risks are particularly high in those who start using at a younger age, use heavily, or use stronger strains. For example, in one study, heavy cannabis users were found to be six times more likely to be diagnosed with schizophrenia than non-users.

Several chemicals that neurons use to communicate, known as neurotransmitters, have been implicated in the development of schizophrenia, especially dopamine and glutamate. The “neurodevelopmental hypothesis” of schizophrenia suggests that a combination of genetic risks and environmental factors during early brain development leads to the disorder, setting the stage for symptoms to emerge in early adulthood.

Risk Factors and Frequency for Schizophrenia

Schizophrenia, a mental health disorder, has a lifetime risk of approximately 1%. This condition seems to affect men more than women, with 1.7 times more occurrences in men. Generally, men are most likely to be diagnosed in their early twenties, with the rate of diagnosis dropping afterwards, while women usually see a peak diagnosis rate later in their twenties, and their rate of diagnosis decreases more slowly.

Interestingly, after reaching their mid-forties, women are more likely to be newly diagnosed with schizophrenia than men. Men also tend to show signs of the disease earlier, function less well before the illness is recognized, and are more likely to have serious symptoms and engage in alcohol and substance abuse.

Usually, the onset of schizophrenia is gradual during adolescence. However, the disease’s appearance before the age of 13, known as childhood-onset schizophrenia, is quite rare. This form of schizophrenia is often more severe and doesn’t respond well to antipsychotic medication.

Lastly, researchers have found a connection between higher rates of schizophrenia and living in urban areas and being a migrant.

• Schizophrenia has a lifetime risk of about 1%.
• Men are typically diagnosed more often than women, with 1.7 times more occurrences.
• Men’s peak diagnosis age is in their early twenties, while women’s peak diagnosis age is later in their twenties.
• After mid-forties, women are more subjected to new schizophrenia diagnoses than men.
• Men usually show symptoms earlier, function less well before the illness surfaces, and often experience more severe symptoms and substance abuse.
• Schizophrenia usually begins gradually during adolescence.
• Childhood-onset schizophrenia, diagnosed before age 13, is rare, severe, and often unresponsive to antipsychotic medication.
• People in urban areas and migrants have a higher risk of developing schizophrenia.

Signs and Symptoms of Schizophrenia

In determining whether someone has schizophrenia, a combination of a thorough history and mental status examination is needed. This includes an assessment to check whether the individual could be a danger to themselves or others, or if they have issues with substance abuse. Information from close friends or relatives is also beneficial. All of this is aimed to eliminate the chance of misdiagnosis and validate the condition through the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR), or the International Classification of Diseases, Tenth Revision (ICD-10) criteria.

Some of the crucial aspects of this process include:

• The individuals current illness and symptoms, as well as events leading up to the onset of the illness.
• Past mental health history including mood swings, hospitalizations, treatments, and any thoughts or attempts of suicide.
• The person’s substance use history, including usage of alcohol and drugs, and any prescription medications.
• Looking into any chronic health conditions, history of procedures, allergies, and disorders that affect the nervous and metabolic systems.
• Family history including presence any psychiatric illnesses and treatments among biological relatives.
• Understanding the person’s personal and societal history including their view towards mental health, stress, and trauma history.
• Information about their childhood and significant life events.

In terms of physical examination, care should be taken to understand the patient’s past trauma history and current symptoms. It is important to observe self-care habits, signs of any underlying health issues, co-existing conditions, and effects of medications.

The Mental Status Examination (MSE) for schizophrenia can differ based on symptom severity and other health conditions.
The MSE checks for:

• Appearance and behavior, which could indicate self-care issues.
• Changes in psychomotor activity, e.i., the physical effects of the person’s mood and thoughts.
• Disorganized or incoherent speech patterns.
• Mood and emotions that may be inappropriate to the context of conversation.
• Presence of delusions, which are firm beliefs in things that aren’t true.
• Signs of hallucinations or disturbances of perception.
• Risks of harm to self or others.
• Cognitive deficits, such as problems with memory or attention.
• Insight and judgment, e.i., awareness of their condition and ability to make rational decisions.

As of now, there are no lab or radiologic tests specifically for diagnosing schizophrenia.

Criteria for diagnosing schizophrenia can vary slightly between DSM-5-TR and ICD-10 systems. However, both generally require the presence of delusions, hallucinations, disorganized speech, and significant changes in functional behaviour for at least a month before a diagnosis can be made. It is also crucial that these symptoms cannot be explained by substance use, other medications, or any other health conditions.

Testing for Schizophrenia

Schizophrenia is primarily a clinical diagnosis and necessitates specific laboratory and radiographic investigations to exclude other potential causes. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia recommends the following investigations for an initial evaluation of a patient with schizophrenia.[21]

Hematology: A complete blood count (CBC) to check for anemia or signs of infection that mimic symptoms of schizophrenia. Absolute neutrophil count (ANC) should be obtained if considering or being treated with clozapine.

Blood chemistry panel: This includes testing electrolytes, renal function, liver function, and thyroid-stimulating hormone (TSH). Hypothyroidism can mimic psychiatric disorders, including depression and cognitive impairment.

Pregnancy test: A pregnancy test is recommended for women of childbearing age.

Electroencephalogram: An electroencephalogram (EEG) may be indicated based on the neurological examination or history to rule out a seizure disorder.

Imaging: Brain imaging, either CT or MRI (with MRI preferred), may be indicated based on the neurological examination or history.

Genetic testing: Chromosomal testing is suggested if indicated by physical examination or history, including developmental history.

Drug toxicology screen: This screen may be clinically indicated to detect substance use that could cause psychotic symptoms.

Additional tests

• Rapid plasma reagin (RPR) test is used to screen for syphilis, which can cause psychiatric symptoms.
• HIV testing may be advisable, as HIV infection can mimic psychiatric disorders.
• Electrocardiogram (ECG) is performed before initiating treatment with chlorpromazine, droperidol, iloperidone, pimozide, thioridazine, or ziprasidone, especially for patients with cardiac risk factors, elevated baseline QTc intervals, or when adding other medications that can increase QTc intervals.
• Abnormal Involuntary Movement Scale (AIMS) or Dyskinesia Identification System: The Condensed Use Scale (DISCUS) is used to assess baseline abnormal movements and is conducted every 6 to 12 months after initiating antipsychotic medication.

The American Psychiatric Association (APA) advises that the initial evaluation of a patient suspected of having a psychotic disorder should incorporate a quantitative assessment. This assessment aims to identify and evaluate the severity of symptoms and functional impairments, which could be crucial treatment targets.[21] 

Some objective quantitative rating scales that can be used in evaluation include:

• The Positive and Negative Syndrome Scale (PANSS) is used for measuring the symptom severity of patients with schizophrenia and for monitoring improvement. There are 2 versions, the PANSS-30 and the PANSS-6. The PANSS-30 is a comprehensive tool that includes 30 items, subdivided into positive symptoms, negative symptoms, and general psychopathology. The PANSS-6 is a shorter version, focusing on 6 essential items, and correlates well with the longer version.
• The Brief Psychiatric Rating Scale (BPRS) assesses the positive, negative, and affective/anxiety symptoms of individuals with psychotic disorders. It contains 18 items and is known for its usefulness in evaluating symptom changes over time.
• The World Health Organization Disability Assessment Schedule (WHODAS) is a tool designed to measure health and disability across various domains of life. It assesses the level of impairment in daily activities and participation in society, thereby providing a holistic view of a patient’s functioning.

Treatment Options for Schizophrenia

When it comes to treating schizophrenia, it’s crucial to tailor treatment plans to each patient’s unique needs. This involves a combination of non-drug and drug treatments to reduce symptoms and boost the patient’s overall functioning. Key elements include choosing the right healthcare setting, managing any risks associated with treatment, dealing with any issues that may prevent the patient from sticking to their treatment, and getting the patient’s support network involved. These people can help spot early signs of a relapse and learn how to utilize community resources. An integral part of this process is obtaining informed consent, which involves educating patients and their family members about the benefits and risks associated with various treatment options.

Antipsychotic medications are an important part of schizophrenia treatment. These medicines are typically divided into first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs). Second-generation drugs usually have fewer side effects and are less likely to cause a condition called tardive dyskinesia than first-generation drugs. However, they are more likely to cause metabolic syndrome, a group of conditions that increase your risk for heart disease, stroke, and diabetes. There seems to be no general preference for one or the other, and what works best can vary from person to person. Clozapine, a second-generation drug, might work best for people with hard-to-treat schizophrenia and those at a high risk of aggressive behavior or suicide.

The main goal of antipsychotic treatment is to lessen symptoms and help the patient return to their normal activities. Continuous therapy helps prevent symptoms from coming back, reduces hospitalizations, and improves overall quality of life. When starting a patient on antipsychotic medication, many factors influence the initial dose, such as how the drug is formulated, the patient’s characteristics, and any history of using antipsychotics. It’s important to keep in mind that although some medications can be increased to treatment levels quickly, it may take 2 to 4 weeks for the patient to show an initial response.

Approximately a third of patients with schizophrenia don’t respond well to treatment, despite various attempts with different antipsychotic medications. For these individuals, clozapine is often recommended. This drug proves effective for about 40% of those unresponsive to other treatments. However, clozapine is not used as often as it should be and should be considered earlier on in treatment strategies.

As well as medication, evidence supports a variety of psychosocial interventions for individuals with schizophrenia. These include psychoeducation, assertive community treatment, coordinated specialty care programs, cognitive-behavioral therapy, supportive employment services, supportive psychotherapy, social skills training, family interventions, and cognitive remediation.

What else can Schizophrenia be?

Schizophrenia is a complex mental condition. It isn’t always easy to diagnose because, according to the Diagnostic and Statistical Manual of Mental Disorders, it shares common features with a wide range of other mental disorders. Here are some conditions that may need to be considered before a definitive schizophrenia diagnosis is reached:

• Major depressive or bipolar disorder with psychotic or catatonic features. This is diagnosed when someone only experiences hallucinations or delusions during major depressive or manic episodes.
• Schizoaffective disorder. This is where someone has concurrent depressive or manic episodes along with active-phase symptoms of schizophrenia.
• Schizophreniform and brief psychotic disorder. The former is diagnosed when the psychotic symptoms last less than 6 months, and the latter refers to having psychotic symptoms for 1 day to less than 1 month.
• Delusional disorder. This differs from schizophrenia in that it doesn’t include other characteristic symptoms of schizophrenia, such as pronounced hallucinations or disorganized speech.
• Schizotypal personality disorder: This is marked by longstanding personality traits and symptoms that are similar to, but not as severe as, schizophrenia.
• Obsessive-compulsive disorder and body dysmorphic disorder: These conditions focus more on intense obsessions, compulsions, or body-focused worries, rather than delusions.
• Posttraumatic stress disorder (PTSD): This includes hallucination-like flashbacks and paranoia due to a traumatic event.
• Autism spectrum and communication disorders: They may present symptoms that look like schizophrenia, but mainly involve social interaction difficulties and repetitive behaviors. Schizophrenia can only be diagnosed if there are significant hallucinations or delusions for at least a month.
• Other mental disorders that involve psychotic episodes: Schizophrenia is only diagnosed if the psychosis is constant and not caused by substances or other medical conditions.

The symptoms of schizophrenia can look like a number of other mental disorders, so a careful review of symptoms is important for making an accurate diagnosis.

What to expect with Schizophrenia

The factors indicating a challenging outcome in schizophrenia include a gradual beginning, starting in childhood or adolescence, few social skills before the illness, substance use, and mental impairment. In contrast, a sudden onset of symptoms and living in a developed country suggest better outcome chances. Suicide is the leading cause of early death in people with schizophrenia, with two-thirds experiencing at least one instance of suicidal thoughts.

While antipsychotic drugs can often control the more obvious symptoms or “positive symptoms” of schizophrenia, they do not significantly improve the “negative symptoms” or cognitive issues, unless these result from the positive symptoms. Through the right combination of medication and social support, people with schizophrenia can have better life outcomes, although only about 13.5% completely recover.

It’s important to note that the life expectancy of an individual living with schizophrenia is about 15 years shorter than that of the average person.

Possible Complications When Diagnosed with Schizophrenia

Schizophrenia can cause several issues. One of the main issues is that it often leads to serious problems with memory, attention, and decision-making. These cognitive disruptions can make it extremely difficult for people to carry out their everyday activities. It can also cause people to withdraw from social interactions and become isolated, which can lead to feelings of loneliness.

People with schizophrenia are also at higher risk of using substances like drugs or alcohol. They are more likely to develop physical health problems, including heart diseases, metabolism disorders, and infectious diseases. A particularly concerning problem is the increased likelihood of having suicidal thoughts or behaviors.

Schizophrenia can also make it hard for people to maintain a job and find stable housing, as the disease can cause frequent hospital stays. And people might find it difficult to take care of personal hygiene. Anxiety and depression can also be problems for people with schizophrenia, adding to an already heavy burden. In addition, they may face legal and financial problems as well as being stigmatized or discriminated against because of their illness.

Despite these challenges, the right combination of medical treatments, therapy, and supportive services like housing assistance and help in finding work can help manage these problems and improve the quality of life for people with schizophrenia.

Schizophrenia Complications:

• Memory, attention and decision-making challenges impacting daily life
• Social withdrawal and isolation due to struggles with social interactions
• Increased risk of substance use disorders
• Potentially serious physical health problems
• Increased likelihood of suicidal thoughts and actions
• Difficulty in maintaining stable employment and housing due to frequent hospital visits
• Issues with personal hygiene
• Co-occurring mental health disorders such as anxiety and depression
• Legal and financial troubles
• Experience of stigmatization and discrimination

Strategizing with medication, therapy, and support services can help overcome these complications and enhance the quality of life.

Preventing Schizophrenia

It’s really important to help patients understand their diagnosis of schizophrenia, including the pros and cons of different drug and social therapy options. This will aid in establishing a trustful doctor-patient relationship and speed up recovery. If patients ever feel they might harm themselves or others, they should be urged to call the 988 Suicide and Crisis Lifeline.

Patients also need to know how essential it is to stick to their prescribed schizophrenia medication schedule. Regular visits with their primary healthcare provider can help keep an eye on other common health issues that are often found alongside serious mental illnesses and are sometimes a side-effect of the medication itself.

Education about the dangers of drug use and the treatments available for any coexisting drug use disorders is also key. This includes discussions about stopping smoking if applicable.