Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect (restricted range of emotions), cognitive deficits (impaired reasoning and problem solving), and occupational and social dysfunction. The cause is unknown, but evidence for genetic and environmental components is strong. Symptoms usually begin in adolescence or early adulthood. One or more episodes of symptoms must last ≥ 6 months before the diagnosis is made. Treatment consists of drug therapy, cognitive therapy, and psychosocial rehabilitation. Early detection and early treatment improve long-term functioning. Show
Psychosis refers to symptoms such as delusions, hallucinations, disorganized thinking and speech, and bizarre and inappropriate motor behavior (including catatonia) that indicate loss of contact with reality. Worldwide, the prevalence of schizophrenia is about 1%. The rate is comparable among men and women and relatively constant cross-culturally. Urban living, poverty, childhood trauma, neglect, and prenatal infections are risk factors, and there is a genetic predisposition. The condition starts in late adolescence and lasts a lifetime, typically with poor psychosocial function throughout. The average age at onset is early to mid 20s in women and somewhat earlier in men; about 40% of males have their first episode before age 20. Onset is rare in childhood; early-adolescent onset or late-life onset (when it is sometimes called paraphrenia) may occur. Although its specific causes and mechanisms are unknown, schizophrenia has a biologic basis, as evidenced by
Some experts suggest that schizophrenia occurs more frequently in people with neurodevelopmental vulnerabilities and that the onset, remission, and recurrence of symptoms are the result of interactions between these enduring vulnerabilities and environmental stressors. Although schizophrenia rarely manifests in early childhood, childhood factors influence disease onset in adulthood. These factors include
Although many people with schizophrenia do not have a family history, genetic factors are strongly implicated. People who have a 1st-degree relative with schizophrenia have about a 10 to 12% risk of developing the disorder, compared with a 1% risk among the general population. Monozygotic twins have a concordance of about 45%. Symptoms and Signs of SchizophreniaSchizophrenia is a chronic illness that may progress through several phases, although duration and patterns of phases can vary. Patients with schizophrenia tend to have had psychotic symptoms an average of 8 to 15 months before presenting for medical care, but the disorder is now often recognized earlier in its course. Symptoms of schizophrenia typically impair the ability to perform complex and difficult cognitive and motor functions; thus, symptoms often markedly interfere with work, social relationships, and self-care. Unemployment, isolation, deteriorated relationships, and diminished quality of life are common outcomes. Phases of schizophreniaIn the prodromal phase, individuals may show no symptoms or may have impaired social competence, mild cognitive disorganization or perceptual distortion, a diminished capacity to experience pleasure (anhedonia), and other general coping deficiencies. Such traits may be mild and recognized only in retrospect or may be more noticeable, with impairment of social, academic, and vocational functioning. In the advanced prodromal phase, subclinical symptoms may emerge; they include withdrawal or isolation, irritability, suspiciousness, unusual thoughts, perceptual distortions, and disorganization (1 Symptoms reference Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect... read more ). Onset of overt schizophrenia (delusions and hallucinations) may be sudden (over days or weeks) or slow and insidious (over years). But, even in an advanced prodromal phase, only a fraction (< 40%) tend to convert to full schizophrenia. In the early psychosis phase, symptoms are active and often at their worst. In the middle phase, symptomatic periods may be episodic (with identifiable exacerbations and remissions) or continuous; functional deficits tend to worsen. In the late illness phase, the illness pattern may become established but there is considerable variability; disability may stabilize, worsen, or even diminish. Symptom categories in schizophreniaGenerally, symptoms are categorized as
Patients may have symptoms from one or all categories. Positive symptoms can be further categorized as
Delusions are erroneous beliefs that are maintained despite clear contradictory evidence. There are several types of delusions:
Delusions in schizophrenia tend to be bizarre—ie, clearly implausible and not derived from ordinary life experiences (eg, believing that someone removed their internal organs without leaving a scar). Hallucinations are sensory perceptions that are not perceived by anyone else. They may be auditory, visual, olfactory, gustatory, or tactile, but auditory hallucinations are the most common. Patients may hear voices commenting on their behavior, conversing with one another, or making critical and abusive comments. Delusions and hallucinations may be extremely vexing to patients. Negative (deficit) symptoms include
Negative symptoms often lead to poor motivation and a diminished sense of purpose and goals. Disorganized symptoms, which can be considered a type of positive symptom, involve
Thinking is disorganized, with rambling, non–goal-directed speech that shifts from one topic to another. Speech can range from mildly disorganized to incoherent and incomprehensible. Bizarre behavior may include childlike silliness, agitation, and inappropriate appearance, hygiene, or conduct. Catatonia is an extreme example of bizarre behavior, which can include maintaining a rigid posture and resisting efforts to be moved or engaging in purposeless and unstimulated motor activity. Cognitive deficits include impairment in the following:
The patient’s thinking may be inflexible, and the ability to problem solve, understand the viewpoints of other people, and learn from experience may be diminished. Severity of cognitive impairment is a major determinant of overall disability. Subtypes of schizophreniaSome experts classify schizophrenia into deficit and nondeficit subtypes based on the presence and severity of negative symptoms, such as blunted affect, lack of motivation, and diminished sense of purpose. Patients with the deficit subtype have prominent negative symptoms unaccounted for by other factors (eg, depression, anxiety, an understimulating environment, drug adverse effects). Those with the nondeficit subtype may have delusions, hallucinations, and thought disorders but are relatively free of negative symptoms. The previously recognized subtypes of schizophrenia (paranoid, disorganized, catatonic, residual, undifferentiated) have not proved valid or reliable and are no longer used. SuicidePatients who have late onset and good premorbid functioning—the very patients with the best prognosis for recovery—are also at the greatest risk of suicide. Because these patients retain the capacity for grief and anguish, they may be more prone to act in despair based on a realistic recognition of the effect of their disorder. ViolenceSchizophrenia is a surprisingly modest risk factor for violent behavior. Threats of violence and aggressive outbursts are more common than seriously dangerous behavior. Indeed, people with schizophrenia are overall less violent than people without schizophrenia. Symptoms reference
The earlier the diagnosis is made and treated, the better the outcome. No definitive test for schizophrenia exists. Diagnosis is based on a comprehensive assessment of history, symptoms, and signs. Information from collateral sources, such as family members, friends, teachers, and coworkers, is often important. According to the DSM-5, the diagnosis of schizophrenia requires both of the following:
Other mental disorders with similar symptoms include several that are related to schizophrenia: Certain personality disorders (especially schizotypal) cause symptoms similar to those of schizophrenia, although they are usually milder and do not involve psychosis.
During the first 5 years after onset of symptoms, functioning may deteriorate and social and work skills may decline, with progressive neglect of self-care. Negative symptoms may increase in severity, and cognitive functioning may decline. Thereafter, the level of disability tends to plateau. Some evidence suggests that severity of illness may lessen in later life, particularly among women. Spontaneous movement disorders may develop in patients who have severe negative symptoms and cognitive dysfunction, even when antipsychotics are not used. For the first year after diagnosis, prognosis is closely related to adherence to prescribed psychoactive drugs and avoiding recreational drug use. Overall, one third of patients achieve significant and lasting improvement; one third improve somewhat but have intermittent relapses and residual disability; and one third remain severely incapacitated. Only about 15% of all patients fully return to their pre-illness level of functioning. Factors associated with a good prognosis include
Factors associated with a poor prognosis include
Men have poorer outcomes than women; women respond better to treatment with antipsychotic drugs.
The time between onset of psychotic symptoms and first treatment correlates with the rapidity of initial treatment response and quality of treatment response. When treated early, patients respond more quickly and fully. Without ongoing use of antipsychotics after an initial episode, 70 to 80% of patients have a subsequent episode within 12 months. Continuous use of antipsychotics can reduce the 1-year relapse rate to about 30% or lower with long-acting drugs. Drug treatment is continued for at least 1 to 2 years after a first episode. If patients have been ill longer, it is given for many years. Early detection and multifaceted treatment has transformed care of patients with psychotic disorders like schizophrenia. Coordinated specialty care, which includes resilience training, personal and family therapy, addressing cognitive dysfunction, and supported employment, is an important contribution to psychosocial recovery. General goals for schizophrenia treatment are to
Antipsychotic drugs Antipsychotic Drugs Antipsychotic drugs are divided into conventional antipsychotics and 2nd-generation antipsychotics (SGAs) based on their specific neurotransmitter receptor affinity and activity. SGAs may offer... read more are divided into first-generation antipsychotics (FGAs) Conventional antipsychotics Antipsychotic drugs are divided into conventional antipsychotics and 2nd-generation antipsychotics (SGAs) based on their specific neurotransmitter receptor affinity and activity. SGAs may offer... read more and 2nd-generation antipsychotics Second-generation antipsychotics Antipsychotic drugs are divided into conventional antipsychotics and 2nd-generation antipsychotics (SGAs) based on their specific neurotransmitter receptor affinity and activity. SGAs may offer... read more (SGAs) based on their specific neurotransmitter receptor affinity and activity. SGAs may offer some advantages, both in terms of modestly greater efficacy (although recent evidence casts doubt on SGAs' advantage as a class) and reduced likelihood of an involuntary movement disorder and related adverse effects Adverse effects of antipsychotic drugs Antipsychotic drugs are divided into conventional antipsychotics and 2nd-generation antipsychotics (SGAs) based on their specific neurotransmitter receptor affinity and activity. SGAs may offer... read more . However, risk of metabolic syndrome Metabolic Syndrome Metabolic syndrome is characterized by a large waist circumference (due to excess abdominal fat), hypertension, abnormal fasting plasma glucose or insulin resistance, and dyslipidemia. Causes... read more (excess abdominal fat, insulin resistance, dyslipidemia, and hypertension) is greater with SGAs than with conventional antipsychotics. Several antipsychotics in both classes can cause long QT syndrome Long QT Syndrome and Torsades de Pointes Ventricular Tachycardia Torsades de pointes is a specific form of polymorphic ventricular tachycardia in patients with a long QT interval. It is characterized by rapid, irregular QRS complexes, which appear to be twisting... read more and ultimately increase the risk of fatal arrhythmias; these drugs include thioridazine, haloperidol, olanzapine, risperidone, and ziprasidone. Psychosocial skill training and vocational rehabilitation programs help many patients work, shop, and care for themselves; manage a household; get along with others; and work with mental health care practitioners. Supported employment, in which patients are placed in a competitive work setting and provided with an on-site job coach to promote adaptation to work, may be particularly valuable. In time, the job coach acts only as a backup for problem solving or for communication with employers. Support services enable many patients with schizophrenia to reside in the community. Although most can live independently, some require supervised apartments where a staff member is present to ensure drug adherence. Programs provide a graded level of supervision in different residential settings, ranging from 24-hour support to periodic home visits. These programs help promote patient autonomy while providing sufficient care to minimize the likelihood of relapse and need for inpatient hospitalization. Assertive community treatment programs provide services in the patient’s home or other residence and are based on high staff-to-patient ratios; treatment teams directly provide all or nearly all required treatment services. Hospitalization or crisis care in a hospital alternative may be required during severe relapses, and involuntary hospitalization may be necessary if patients pose a danger to themselves or others. Despite the best rehabilitation and community support services, a small percentage of patients, particularly those with severe cognitive deficits and those poorly responsive to drug therapy, require long-term institutional or other supportive care. Cognitive remediation therapy helps some patients. This therapy is designed to improve neurocognitive function (eg, attention, working memory, executive functioning) and to help patients learn or relearn how to do tasks. This therapy may enable patients to function better. The goal of psychotherapy in schizophrenia is to develop a collaborative relationship between the patients, family members, and physician so that patients can learn to manage their illness, take drugs as prescribed, and handle stress more effectively. Although individual psychotherapy plus drug therapy is a common approach, few empirical guidelines are available. Psychotherapy that begins by addressing the patient’s basic social service needs, provides support and education regarding the nature of the illness, promotes adaptive activities, and is based on empathy and a sound dynamic understanding of schizophrenia is likely to be most effective. Many patients need empathic psychologic support to adapt to what is often a lifelong illness that can substantially limit functioning. In addition to individual psychotherapy, there has been significant development of cognitive behavioral therapy for schizophrenia. For example, this therapy, done in an individual or a group setting, can focus on ways to diminish delusional thoughts. For patients who live with their families, psychoeducational family interventions can reduce the rate of relapse. Support and advocacy groups, such as the National Alliance on Mental Illness, are often helpful to families.
The following are some English-language resources that may be useful. Please note that The Manual is not responsible for the content of these resources.
Click here for Patient Education Which defense mechanism is most commonly used by clients who are alcoholics?Rationalization. In those with substance use disorder, rationalization is providing good reasons for the use of drugs or alcohol, instead of the real and true reasons. It is used to defend oneself against feelings of guilt, as well as to protect oneself against criticism and maintain self-respect.
Can you be schizophrenic and OCD?OCD is a common comorbid condition in those with schizophrenia and BD. There is some evidence that a diagnosis of OCD may be associated with a higher risk for later development of both schizophrenia and BD, but the nature of the relationship with these disorders is still unclear.
How can you tell the difference between schizophrenia and OCD?Symptoms of OCD include often include obsessions and unwanted or intrusive thoughts, as well as compulsions, or urges to act out specific — and often repetitive — behaviors. Meanwhile, schizophrenia typically looks like: hallucinations: seeing or hearing things that don't line up with reality.
Which feelings are often the basis of obsessive compulsive disorder?Obsessions. Fear of getting contaminated by people or the environment.. Disturbing sexual thoughts or images.. Fear of blurting out obscenities or insults.. Extreme concern with order, symmetry, or precision.. Recurrent intrusive thoughts of sounds, images, words, or numbers.. Fear of losing or discarding something important.. |
Which defense mechanism is most commonly used by clients who are diagnosed with schizophrenia undifferentiated type?
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