Schizophrenia

Schizophrenia

Rhoda Hahn, MD, Lawrence Albers, MD, and Christopher Reist, MD


Schizophrenia is a disorder characterized by apathy, avolition, and affective blunting. These patients have alterations in thoughts, perceptions, mood, and behavior. Many schizophrenics display delusions, hallucinations and misinterpretations of reality.

DSM-IV Diagnostic Criteria for Schizophrenia
Two or more of the following symptoms present for one month:

Delusions

Hallucinations

Disorganized speech

Grossly disorganized or catatonic behavior

Negative symptoms (ie, affective flattening, alogia, avolition)

Decline in social and/or occupational functioning since the onset of illness.

Continuous signs of illness for at least six months with at least one month of active symptoms.

Schizoaffective disorder and mood disorder with psychotic features have been excluded.

The disturbance is not due to substance abuse or a medical condition

If history of autistic disorder or pervasive developmental disorder is present, schizophrenia may be diagnosed only if prominent delusions or hallucinations have been present for one month.

Clinical Features of Schizophrenia
A prior history of schizotypal or schizoid personality traits or disorder is often present. Depressive symptoms may be present, but the duration of these symptoms has usually been brief, compared to duration of the psychotic symptoms.

Symptoms of schizophrenia are categorized as either positive or negative.
Positive Symptoms

Hallucinations are most commonly auditory or visual, but hallucinations can occur in any sensory modality.

Delusions

Disorganized behavior

Thought disorder characterized by loose associations, tangentiality, incoherent thoughts, neologisms, thought blocking, thought insertion, thought broadcasting, and ideas of reference.

Negative Symptoms

Poverty of speech or poverty of thought content

Anhedonia

Flat affect

Loss of motivation (avolition)

Attentional deficits

The presence of tactile, olfactory or gustatory hallucinations may indicate an organic etiology such as complex partial seizures.

Sensorium and memory are intact. The patient, however, may be too psychotic to engage in testing.

Insight and judgment are frequently impaired. No sign or symptom is pathognomonic of schizophrenia.

Epidemiology of Schizophrenia
The lifetime prevalence of schizophrenia is one percent.

Onset of psychosis usually occurs in the late teens or early twenties.

Males and females are equally affected, but the mean age of onset is approximately six years later in females, and females frequently have a milder course of illness.

The suicide rate is 10-13%, similar to the rate that occurs in depressive illnesses. More than 75% of patients are smokers, and the incidence of substance abuse is increased (especially alcohol, cocaine, and marijuana).

Most patients do not return to baseline functioning, and most patients follow a chronic downward course, but some have a gradual improvement with a decrease in positive symptoms and increased functioning. Very patients few have a complete recovery.

Classification of Schizophrenia
Paranoid Type Schizophrenia

Characterized by a preoccupation with one or more delusions or frequent auditory hallucinations.

Paranoid type schizophrenia is characterized by the absence of prominent disorganization of speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Disorganized type schizophrenia is characterized by prominent disorganized speech, disorganized behavior, and flat or inappropriate affect.

Catatonic type schizophrenia is characterized by at least two of the following:

Motoric immobility

Excessive motor activity

Extreme negativism or mutism

Peculiar voluntary movements such as bizarre posturing

Echolalia or echopraxia

Undifferentiated type schizophrenia meets criteria for schizophrenia, but it can not be characterized as paranoid, disorganized, or catatonic type.

Residual type schizophrenia is characterized by the absence of prominent delusions, disorganized speech and grossly disorganized or catatonic behavior and continued negative symptoms or two or more attenuated positive symptoms.

Differential Diagnosis of Schizophrenia
Psychotic Disorder Due to a General Medical Condition, Delirium, or Dementia.

Substance Induced Psychotic Disorder. Amphetamines and cocaine frequently cause hallucinations, paranoia, or delusions. Phencyclidine (PCP) may lead to both positive and negative symptoms.

Schizoaffective Disorder. Mood symptoms are present for a significant portion of the illness. In schizophrenia, the duration of mood symptoms is brief compared to the entire duration of the illness.

Mood Disorder with Psychotic Features

Psychotic symptoms occur only during major mood disturbance (mania or major depression).

Disturbances of mood are frequent in all phases of schizophrenia.

Delusional Disorder. Non-bizarre delusions are present in the absence of other psychotic symptoms.

Schizotypal, Paranoid, Schizoid or Borderline Personality Disorders

Psychotic symptoms are generally mild and brief in duration.

Patterns of behavior are life-long, with no identifiable time of onset.

Brief Psychotic Disorder. Duration of symptoms is between one day to one month.

Schizophreniform Disorder. The criteria for schizophrenia is met, but the duration of illness is less than six months.

Treatment of Schizophrenia
Pharmacotherapy. Antipsychotic medications reduce core symptoms and are the cornerstone of treatment of schizophrenia.

Psychosocial treatments in conjunction with medications are often indicated. Day treatment programs, with emphasis on social skills training, can improve functioning and decrease relapse.

Family therapy and individual supportive psychotherapy are also instrumental in relapse prevention.

Electroconvulsive therapy is rarely used in the treatment of schizophrenia, but may be useful when catatonia or prominent affective symptoms are present.

Indications for Hospitalization.
Psychotic symptoms prevent the patient from caring for his basic needs.

Suicidal ideation, often secondary to psychosis, usually requires hospitalization.

Patients who are a danger to themselves or others require hospitalization.