DEFINITION
Schizophrenia is a thought disorder that impairs judgment, behavior, and ability to interpret reality. Symptoms must be present for a period of least 6 months to be able to make a diagnosis.
RISK FACTORS / ETIOLOGY
Men have an earlier onset, usually at 15 to 25 years of age. Many theories have evolved regarding the cause of schizophrenia. Schizophrenia has been associated with high levels of dopamine and abnormalities in serotonin. Many believe the family may be the cause of the patient's schizophrenia. If the mother gives mixed messages, it is called the double-bind theory. There are families that are critical, intrusive, and hostile to the patient. When this occurs, it has been linked to high rates of relapse. Because there is an increase in the number of schizophrenics born in the winter and early spring, many believe it may be viral in origin. Schizophrenia is more prevalent in the low socioeconomic status (SES) groups, either as a result of downward drift or social causation.
PREVALENCE
| General population | 1% |
| Monozygotic twin | 47% |
| Dizygotic twin | 12% |
| One schizophrenic parent | 12% |
| Two schizophrenic parents | 40% |
| First-degree relative | 12% |
| Second-degree reative | 5-6% |
PSYCHICAL AND PSYCHIATRIC PRESENTING SYMPTOMS
- Hallucinations (mostly auditory)
- Delusions (mostly bizarre)
- Disorganized speech or behavior
- Catatonic behavior
- Negative symptoms
- Usually experience social and or occupational dysfunction
- Physical exam usually unremarkable, but may find saccadic eye movements, hypervigilance, etc.
BRAIN IMAGING FINDINGS
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Computed tomography (CT): Lateral and third ventricular enlargement, reduction in cortical volume (associated with the presence of negative symptoms, neuropsychiatric impairment, increased neurologic signs, and poor premorbid adjustment)
- Magnetic Resonance Imaging (MRI): Increased cerebral ventricles
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Positron emission tomography (PET): Hypoactivity of the frontal lobes and hyperactivity of the basal ganglia relative to the cerebral cortex
PSYCHOLOGIC TESTS
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IQ tests: Will score lower on all IQ tests, maybe due to low intelligence at the onset or to deterioration as a result of the disease
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Neuropsychologic: Tests usually are consistent with bilateral frontal and temporal lobe dysfunction, including deficits in attention, retention time, and problem-solving ability
- Personality: May give abnormal findings, such as bizarre ideations, etc.
TREATMENT
Hospitalization is usually recommended for either stabilization or safety of the patient. If you decide to use medications, antipsychotic medications are most indicated to help control both positive and negative symptoms. If no response, consider using clozapine after other medications have failed. The suggested psychotherapy will be supportive psychotherapy with the primary aim of having the patient understand that the therapist is trustworthy and has an understanding of the patient, no matter how bizarre.
DIFFERENTIAL DIAGNOSIS
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Substance-induced: Psychostimulants, hallucinogens, alcohol hallucinosis, barbiturate withdrawal, etc. Consider urine drugs screen to rule out.
- Epilepsy: Temporal lobe epilepsy.
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Other psychotic disorders: Schizoaffective, schizophreniform, brief reactive psychosis, delusional disorder
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Malingering and factitious disorder: Must access whether the patient is in control of the symptoms and whether there is an obvious gain
- Mood disorders: Look at duration of mood symptoms: these tend to be brief in schizophrenia
- Medical: HIV, steroids, tumors, CVAs, etc. Need medical work-up to rule out
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Personality disorders: Schizotypal, schizoid, and borderline personality disorders have the most similar symptoms. Must look at duration of symptoms as well as patient's level of functioning.
TYPES OF SCHIZOPHRENIA
Schizophrenia, Paranoid Type
A 24-year-old man is brought to the emergency department by his parents after they found him covering the windows with aluminum foil because "they" were after his ideas. When asked who "they" are, he looks up at the sky and points to a faraway planet.
Presenting Symptoms
These patients typically have preoccupation with one or more delusions and/or hallucinations, usually involving grandeur or persecution.
Risk Factors
These patients tend to be older; typical age of onset is in their late twenties or thirties.
Schizophrenia, Disorganized Type
A 21-year-old man is taken to the hospital by his mother because of his bizarre behavior at home. He appears somewhat disheveled and is wearing many layers of clothes, despite that it is summer. While in the waiting room, he appears to be very child-like and frequently barks at others. He admits to auditory hallucinations but is unable to elaborate on their content. His mother reports that he has been this way for several years.
Presenting Symptoms
- Disorganized speech and behavior
- Flat or inappropriate affect
- Marked regression to primitive, disinhibited behavior
- Severe thought disorder
- Poor contact with reality
Risk Factors
These patients tend to be younger than 25.
Schizophrenia, Catatonic Type
While working in a psychiatric unit, you notice a 43-year-old woman who has been hospitalized for many years due to mental illness. While on the ward, she remains mute and does not respond to questions. While in groups, she stares at the wall and stays in a fixed position until the group ends. You learn she was hospitalized many years ago because she believed others were reading her mind and sending her messages.
Presenting Symptoms
- Psychomotor disturbances, ranging from severe retardation to excitation
- Extreme negativism
- Peculiarities of voluntary movements
- Mutism is very common
Complications
Medical care may be necessary because of exhaustion, malnutririon, self-inflicted injury, or hyperpyrexia.
Schizophrenia, Undifferentiated Type
A psychiatrist evaluates a 19-year-old man after he complains to his friends of hearing voices that ask him questions and talk to him. When asked what the voices talk to him about he is not sure, but he knows that the voices are coming from outside his head and are not heard by others. He also presents with loose associations and frequent derailment.
Presenting Symptoms
- Meet criteria for schizophrenia
- Do not meet criteria for paranoid type, catatonic type, or disorganized type
Schizophrenia, Residual Type
A 50-year-old homeless man is taken to the hospital after he was hit by a motor vehicle. Staff who question him note that his thoughts are illogical. He appears to have poor grooming, emotional blunting, and loose associations.
Presenting Symptoms
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An absence of prominent delusions, hallucinations, disorganized speech/behavior, or catatonic behavior
- Despite an absence of overt psychotic symptoms, tend to have negative symptoms
OTHER PSYCHOTIC DISORDERS
Brief Psychotic Disorder
A 35-year-old female Chinese immigrant is brought in by neighbors after she was found wandering in the streets yelling out someone's name. She appears disheveled and grossly disorganized. You learn that she arrived in the U.S. several days ago and upon her arrival, witnessed the death of her 3-year-old son. While in the waiting room, she appears to be responding to internal stimuli.
Presenting Symptoms
- Hallucinations
- Delusions
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Symptoms more than one day but less than 30 days
Risk Factors
Seen most frequently in one low socioeconomic status as well as in those who have preexisting personality disorders or the presence of psychological stressors.
Treatment
Hospitalization is warranted if the patient is acutely psychotic, to assure the safety of her/himself or of others. Pharmacotherapy will include both antipsychotics and benzodiazepines. The benzodiazepines may be used for short-term treatment of psychotic symptoms.
Schizophreniform Disorder
Mrs. Jones is evaluated at a nearby clinic after she was noticed acting inappropriately at work. According to her coworkers, she began to act strangely 3 months ago. She began wearing a hard hat to work and when asked why, she replied, "I will not let you read my mind". She also believed that others were talking about her and routinely asked them to stop. On several occasions she had to be escorted out of the room because she started to argue with others whom she believed were controlling her mind.
Presenting Symptoms
- Hallucinations
- Delusions
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms
- Social and/or occupational dysfunction
- Symptoms are present more than one month but less than six months
- Most of the patients return to their baseline level of functioning
Risk Factors
Many of these patients have affective symptoms as compared with schizophrenics. Suicide is a risk factor given that the patient is likely to have a depressive episode after the psychotic symptoms resolve.
Treatment
Must access whether the patient needs hospitalization, to assure safety of patient and/or others.
Antipsychotic medication is indicated for a 3-6-month course. Individual psychotherapy may be indicated to help the patient assimilate the psychotic experience into his/her life.
Schizoaffective Disorder
A 25-year-old woman is found walking nude in the shopping mall. When asked why, she replies, "I am making it easy for others to have sex with me since I know they all want me". She states she heard a voice telling her she was irresistible and everyone wanted her. When she speaks, she cannot focus on one topic at a time and frequently jumps from one topic to another. Her mood is described as euphoric and her affect labile.
Presenting Symptoms
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Uninterrupted period of symptoms meeting criteria for major depressive episode, manic episode, or mixed episode
- Symptoms for schizophrenia
- Delusions or hallucinations for at least 2 weeks in the abscence of mood symptoms
Prognosis
Better prognosis than patients with schizophrenia. Worse prognosis than patients with affective disorders.
Treatment
Must first determine whether hospitalization is necessary. Use antidepressant medications and/or anticonvulsants to control the mood symptoms. If these are not effective, consider the use of antipsychotic medications to help control the ongoing symptoms.
Delusional Disorder
Mr. Smith has been married for approximately 10 years, and during most of those years, he believed his wife was trying to poison him to get his money. He frequently complains of stomach pains, which he believes are due to the poison in the food. His thoughts are logical and coherent. He denies any hallucinations. His wife, and independently wealthy woman, does not understand her husband's logic because she has more money than he does.
Presenting Symptoms
- Nonbizarre delusions for at least one month
- No impairment in level of functioning
- The patients are usually reliable unless it is in relationship to their delusions.
- Types include erotomanic, jealous, grandiose, somatic, mixed, unspecified.
Risk Factors
Mean age of onset is about 40 years. Seen more commonly in women, and most of these patients are married and employed. Delusional disorder has been associated with low socioeconomic status as well as recent immigration.
Can usually see conditions in either the limbic system or basal ganglia, if medical causes are determined to be the cause of the delusions.
Treatment
Outpatient treatment is usually preferred, but the patient may need hospitalization while you rule out medical causes for the delusional disorder. Pharmacotherapy consists of antipsychotic medications; however, most studies indicate that many patients do not respond to treatment. Individual psychotherapy is recommended, in whish the focus would be on having the patient trust the physician so the physician can point out to the patient how the delusions both are distressing and interfere with normal life.
REVIEW QUESTIONS
1. A 23-year-old woman was seen today after she complained that her neighbors were talking about her. According to the neighbors, her behavior started 3 weeks ago after she was involved in a car accident. Since then, she has been following the neighbors for several days and harassing them at work. She believes that the neighbors are putting poison in her food and want to kill her. When asked why, she is unable to give a clear explanation but insists that what she is saying is true. She states that the voice in her head told her it is true and that you should stop asking questions. While in the waiting room, you observe her to be dressed bizarrely and laughing inappropriately. Which of the following is most indicated in the management of this patient?
- Haloperidol
- Clozapine
- Lorazepam
- Risperidone
- Fluphenazine decanoate
2. If her symptoms do not improve within the next week, which of the following is she at greatest risk of developing?
- Schizophrenia, paranoid type
- Schizoaffective disorder
- Schizophreniform disorder
- Schizotypal personality disorder
- Delusional disorder
Explanations
1. Answer: D. The patient clearly has psychotic symptoms; therefore, you would want to give her medication with the least amount of side effects. Choices A aand E are typical antipsychotics with many side effects.Choices B and D are atypical antipsychotics; however, clozapine is not used first line in the treatment of psychotic symptoms. Lorazepam is not an antipsychotic medication. However, it can be used in psychotic patients to reduce agitation.
2. Answer: C. Because her symptoms have occured for only three weeks, this patient has a diagnosis of brief psychotic disorder. But should the symptoms persist for more than one month, her diagnosis would be schizophreniform disorder. Schizophrenia is given when the symptoms are present for more than six months.
