11/14/24, 10\:45 AM Schizophrenia

Schizophrenia

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Schizophrenia\: long-term mental health disorder a
men and women; onset 15-35 years.
Risk factors\: urban areas, migrants, lower socioeconomic classes, family history, advanced paternal age, pregnancy
complications, drug abuse, stressful life experiences, Afro-Caribbean ethnicity in the UK.
Aetiology\: unknown; combination of psychological, environmental, biological, and genetic factors; emotional life
experiences can act as a trigger.
Pathophysiology\:
Neurodevelopmental hypothesis\: increased risk with hypoxic brain injury at birth, viral infections in utero, temporal lobe
epilepsy, cannabis use.
Neurotransmitter hypothesis\: excess dopamine causes positive symptoms; less dopamine in mesocortical tracts causes
negative symptoms; serotonin increase, glutamate decrease also implicated.
Positive symptoms\: thought echo, thought insertion/withdrawal, thought broadcasting, auditory hallucinations, delusional
perception, passivity, disorganised behaviour, lack of insight, formal thought disorder.
Negative symptoms\: blunted a
Other symptoms\:
Depressive\: sadness, emptiness, anhedonia.
Manic\: euphoria, expansiveness, increased energy.
Psychomotor\: catatonic restlessness, posturing, stupor, mutism.
Investigations\: baseline blood tests (FBC, TFTs, U&Es, LFTs, CRP, fasting glucose), urine culture, urine drug screen, HIV and
syphilis testing if applicable, serum lipids, CT head if needed.
Diagnosis\: at least two symptoms present most of the time for at least one month, including one core symptom (delusions,
hallucinations, disorganised thinking, experiences of in
conditions or substance use.
Management\: multidisciplinary teams (early intervention, community mental health, crisis resolution); care programme
approach (CPA) with assessment, care plan, key worker, review.
Medications\:
Typical antipsychotics\: haloperidol, chlorpromazine; side e
hyperprolactinaemia, metabolic, anticholinergic, neurological e
Atypical antipsychotics\: olanzapine, risperidone, clozapine (for treatment-resistant cases); fewer EPSEs but similar other
side e
Psychological treatments\: cognitive behavioural therapy (CBT), family therapy.
Complications\: cardiovascular disease, suicide risk (5% lifetime risk), delayed cancer diagnosis, substance abuse, social
isolation; reduced life expectancy by 15-25 years.
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Introduction

Schizophrenia is a long-term mental health problem which a
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Schizophrenia a
of 15 and 35.
The age of onset tends to be slightly earlier in men (18-25) and later in women (25-35).
There is a higher incidence of schizophrenia in urban areas and among migrants. The incidence is also higher in lower
socioeconomic classes, but this may be a consequence, rather than a cause, of schizophrenia.
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We've also produced a video demonstration of how a patient with schizophrenia may present.
Psychosis (Schizophren
Psychosis (Schizophren… …

Aetiology

The precise cause of schizophrenia is unknown, but it is believed to be a consequence of a combination of psychological,
environmental, biological and genetic factors.
It is thought that people may have a susceptibility to schizophrenia and that emotional life experiences can act as a trigger
for developing the illness.
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Pathophysiology
Schizophrenia is believed to develop because of physical changes to the brain and changes in neurotransmitters.
Neurodevelopmental hypothesis
People who experienced hypoxic brain injury at birth or who were exposed to viral infections in utero are at greater risk of
developing schizophrenia.
Those with temporal lobe epilepsy or who smoke cannabis while their brain is still developing are also at higher risk. This
suggests that brain development is implicated in the pathophysiology of schizophrenia.
Imaging has shown changes in the brains of people with schizophrenia, including enlarged ventricles, small amounts of
grey matter loss and smaller, lighter brains.
Neurotransmitter hypothesis
An excess of dopamine and overactivity in the mesocorticolimbic system is believed to cause the positive symptoms of
schizophrenia. Dopamine antagonists are, therefore, used to treat schizophrenia.
There is also thought to be less dopamine activity in the mesocortical tracts, causing the negative symptoms of
schizophrenia. This explains why dopamine antagonists are more successful at treating positive than negative symptoms.
Psychotic symptoms are seen in people with Parkinson’s disease if they are overtreated with levodopa, as this increases the
amount of dopamine in the brain. Amphetamines and cocaine also increase dopamine release and lead to psychosis.
Dopamine is not the only neurotransmitter implicated in schizophrenia. There is also an increase in serotonin activity and a
decrease in glutamate activity.

Risk factors

Family history and genetics
Patients are more likely to develop schizophrenia if there is a family history of the illness. The chance of developing
schizophrenia is approximately 40% for a child where both parents are a
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There is thought to be a strong genetic link. For example, the monozygotic twin of a person with schizophrenia has a 50%
chance of developing schizophrenia, while a dizygotic twin has a 15% chance. 5
An adopted child still has a 12% chance of
developing schizophrenia if their birth parent was a su
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There is also some increased risk with advanced paternal age, where the father was aged over 55.
Pregnancy
Malnutrition and viral infections during pregnancy increase the chance of developing schizophrenia. Other complications,
such as pre-eclampsia and emergency caesarean section, also increase the risk.
Drug abuse
Using cannabis is known to increase the risk of developing schizophrenia, particularly when used as a teenager. Many other
drugs can also cause psychotic symptoms, including amphetamines, cocaine and LSD.
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Social and environmental
Schizophrenia is more prevalent in urban areas and among lower socioeconomic classes, but this may be a consequence
of living with schizophrenia rather than being a cause.
Stressful life experiences are known to increase the risk of developing schizophrenia, and this is seen particularly among

more at risk.
Ethnicity
In the United Kingdom, Afro-Caribbean men are more a

Clinical features

The subtypes of schizophrenia that featured in ICD-10 were removed in the updated ICD-11 and replaced with a symptom
speci
Symptom speci
The symptom speci
to treatment.
It includes the following categories\: positive, negative, depressive, manic, psychomotor, and cognitive de
de
Symptoms are assessed from zero (absent) to four (severe). The speci
course.
Positive symptoms
Positive symptoms tend to represent a change in behaviour or thought. In contrast, negative symptoms usually involve a
decline in normal functioning.
Examples of positive symptoms of schizophrenia include\:
Thought echo (hearing your own thoughts out loud)*
Thought insertion or withdrawal*
Thought broadcasting*
Third person auditory hallucinations*
Delusional perception *
Passivity and somatic passivity
*
Grossly disorganised behaviour that impedes goal-directed activity
Lack of insight
Formal thought disorder (e.g. neologisms)
*These are also referred to as Schneider’s
exploring .
Negative symptoms
Examples of negative symptoms of schizophrenia include\:
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Blunted a
Apathy / avolition
Social isolation
Poverty of speech (alogia)
Poor self-care
Depressive mood symptoms
Examples of depressive mood symptoms of schizophrenia include\:
Feelings of sadness
Feelings of emptiness
Inability to feel pleasure in activities (anhedonia)
Manic mood symptoms
Examples of manic mood symptoms of schizophrenia include\:
Euphoria
Expansiveness
The subjective experience of increased energy
Psychomotor disturbance symptoms
Examples of psychomotor disturbance symptoms of schizophrenia include\:
Catatonic restlessness
Posturing
Stupor
Mutism
Course speci
According to ICD-11, a presentation of the disorder should be categorised as either a
episodes, part of a continuous course, or unspeci
Within the
episode, a partial or total remission of symptoms, or unspeci
Specifying the ‘

Investigations

If a patient is suspected of having schizophrenia, they will be referred to the local community mental health team, where a
psychiatrist or specialist nurse carries out a detailed assessment.
Investigations are used to rule out the other causes of confusion/psychotic symptoms.
Laboratory investigations
Relevant laboratory investigations include\:
Baseline blood tests\: including FBC, TFTs, U&Es, LFTs, CRP and a fasting glucose
Urine culture\: to rule out urinary tract infection causing delirium
Urine drug screen\: to rule out drug intoxication
HIV testing if applicable
Syphilis serology if applicable
Serum lipids\: before starting antipsychotics
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Imaging
Relevant imaging investigations include\:
CT head\: if an organic neurological cause is suspected

Diagnosis

According to ICD-11, a diagnosis of schizophrenia requires\:
At least two symptoms to be present most of the time for at least one month, including positive, negative, depressive,
manic, psychomotor, and cognitive symptoms,
AND of the two symptoms, one core symptom needs to be present\:
1. Persistent delusions
2. Persistent hallucinations
3. Disorganised thinking
4. Experiences of in
generated by oneself)
AND the symptoms are not a manifestation of another medical condition and are not due to the e
medication on the central nervous system, including withdrawal e

Management

The management of schizophrenia may involve several multidisciplinary teams including\:
Early intervention team (initial referral after the
Community mental health team (provide day-to-day support and treatment)
Crisis resolution team (for patients experiencing an acute psychotic episode)
Care programme approach
Patients with schizophrenia will usually have a care programme approach (CPA).
There are four stages to a CPA\:
Assessing health and social needs
Creating a care plan
Appointing a key worker to be the
Reviewing treatment
Voluntary and compulsory hospital admission
Some patients with schizophrenia may require an inpatient stay, and they may be detained under the Mental Health Act.
Antipsychotic medication
The drugs used to treat schizophrenia are D2 (dopamine) receptor antagonists. They can be divided into ‘
(typical) and 'second generation' (atypical) antipsychotics.
First-generation antipsychotics
The ‘typical’ group are older and thought to primarily exert their e
include\:
Haloperidol
Chlorpromazine
Flupentixol decanoate (depot injection)
Side e
Extrapyramidal side e\: parkinsonism, akathisia, dystonia, dyskinesia Hyperprolactinaemia\: leads to sexual
dysfunction, increased risk of osteoporosis, amenorrhoea in women, galactorrhoea, gynaecomastia and hypogonadism
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in men
Metabolic side e
developing metabolic syndrome
Anticholinergic side e
Neurological side e
Atypical antipsychotics
‘Atypical’ antipsychotics are more selective in their dopamine blockade and also block serotonin 5-HT2 receptors.
They are less likely to cause EPSEs and usually cause less hyperprolactinaemia, but they still cause the other debilitating
side e
Examples of atypical antipsychotics include\:
Olanzapine
Risperidone (depot injection)
Clozapine
Amisulpride
Quetiapine
Aripiprazole is a partial dopamine agonist, and so is less likely to cause EPSEs than the others.
Clozapine is indicated when two anti-psychotics, including an atypical antipsychotic, have been ine
patients on clozapine require regular blood tests to check their neutrophil levels, as clozapine can cause agranulocytosis,
which is potentially life-threatening.
Psychological treatments
Psychological therapies used include\:
Cognitive behavioural therapy (CBT)
Family therapy

Complications

As well as the side e
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Cardiovascular disease\: there is an increased risk of premature death due to cardiovascular disease; in addition, patients
with schizophrenia are more likely to smoke
Suicide\: the lifetime risk of suicide is about 5%
Cancer\: delayed diagnosis and late presentation of cancer
Substance abuse\: up to 1/3 of patients with schizophrenia use substances
Social isolation
Overall, the life expectancy of patients with schizophrenia is reduced by approximately 15 -25 years.
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References

World Health Organization, 2004. I n t e r n a t i o n a l s t a t i s t i c a l c l a s s i
m a n u a l (Vol. 2). World Health Organization.
World Health Organization. ICD-11
Torrey EF, Buka S, Cannon TD, Goldstein JM, Seidman LJ, Liu T, Hadley T, Rosso IM, Bearden C, Yolken RH. Paternal age as a
risk factor for schizophrenia\: how important is it? S c h i z o p h r e n i a R e s e a r c h . 2009 Oct;114(1-3)\:1-5.
McDonald C, Murphy KC. The new genetics of schizophrenia.P s y c h i a t r C l i n N o r t h A m .2003;26(1)\:41–63.
Fischer M. Psychoses in the o
P s y c h i a t r y . 1971;118\:43–52.
https\://app.geekymedics.com/notebook/2554/ 6/711/14/24, 10\:45 AM Schizophrenia
Wildgust HJ, Hodgson R, Beary M. The paradox of premature mortality in schizophrenia\: new research questions. J
Psychopharmacol. 2010 Nov;24(4 Suppl)\:9-15.

Reviewer

Dr Emily Jackson
Psychiatry registrar

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Contents

Introduction
Aetiology
Risk factors
Clinical features
Investigations
Diagnosis
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