Schizophrenia

Background/Epidemiology

  • Most common condition of psychosis; often lifelong (either chronic or relapsing/remitting)
  • ~15/100,000 per year; age of onset usually early 20s/adolescence

Aetiology/Risk

  • Family history is probably the greatest risk factor (6.5 x more likely if 1st degree relative; 40x between twins)
    • There are likely to be a number of other risk/influencing factors e.g. early environmental factors (viruses, prematurity, low birth weight etc); later environmental factors (e.g. social isolation; migration; drug use)

Presentation

Positive symptoms

  • Lack of insight (97%)
  • Hallucinations (auditory most common) (74%)
    • Often persecutory, critical or abusive
    • Can be in the first but more commonly in the third person (can have discussions about the patient)
    • Thought echo
  • Delusions (often of…
    • Persecution (64%)
    • Passivity (believe their thoughts/actions are being controlled by an external force/person/source)
    • Ideas/delusions of reference (a seemingly minor event has a powerful and unconnected meaning or consequence (often manifests as ‘nothing is a coincidence’)
      • Suspiciousness
  • Thought disorder
    • Distorted/illogical speech
    • ‘Knight’s move’ thinking (thoughts proceed in one direction then suddenly change without reason)
    • Thoughts spoken out loud

Negative symptoms

  • Social withdrawal; self neglect; loss of motivation; loss of initiative; emotional blunting; paucity of speech

Classic Triad of SZD

  • Auditory hallucinations
  • Delusions of passivity
  • Disturbance of affect

Diagnosis (ICD-10)

  • At least one for most of the time for a month of
    • Thought echo, insertion or withdrawal; or thought broadcast
    • Delusions of control referred to body parts, actions or sensations (passivity)
    • Delusional perception
    • Hallucinatory voices giving a running commentary, discussing the patient, or coming from some part of the patient’s body
    • Persistent bizarre or culturally inappropriate delusions
  • OR at least two of
    • Persistent daily hallucinations accompanied by delusions
    • Incoherent or irrelevant speech
    • Catatonic behaviour (stupor or posturing)
    • Negative symptoms such as marked apathy, blunted or incongruous mood

Suggested screening questions

  1. Do you hear voices when no one is around?  What do they say?
  2. Do you ever think that people are talking about you or gossiping about you, maybe even thinking about trying to get you?
  3. Do you ever think that somehow people can pick up on what you are thinking or can manipulate what you are thinking?

Types of Schizophrenia

  • Simple Schizophrenia
    • Insidious onset negative symptoms e.g. social withdrawal, odd behaviour, emotional blunting; often without any delusions or hallucinations
    • Can be a difficult diagnosis to make and so is often avoided
  • Paranoid Schizophrenia
    • Thought process and affect can be relatively spared but there are prominent delusions often of a paranoid nature
    • Can be difficult to distinguish from paranoid delusional disorder (although in this delusions are non-bizarre and hallucinations are rare)
  • Hebephrenic Schizophrenia
    • Prominent affective symptoms; whilst delusions and hallucinations can be fleeting; behaviour is often unpredictable and irresponsible (mannerisms common)
    • Mood is shallow (inappropriate)- giggling/self-satisfied, self-absorbed smiling, pranks, reiterated phrases, hypochondriac tendences (slight grandeur)
    • Though is disorganised and speech is often rambling and incoherent.  Behaviour is often non-purposeful.
    • Tendency to remain solitary, and often patients lose affect and volition as the condition progresses (can have a poor prognosis)
  • Catatonic Schizophrenia
    • Prominent motor symptoms e.g. posturing, stereotypes, mannerisms, ‘waxy’ flexibility (patient remains in uncomfortable positions)
  • Residual Schizophrenia
    • Negative symptoms which remain after episodes of delusions/hallucinations

Management

  • For patients presenting with their first episode of psychosis, referral to a specialist is important
  • The first line drug for a patient with a first episode of psychosis is an oral atypical antipsychotic e.g. olanzapine, risperidone or quetiapine
    • Most patients should be offered a maintenance drug treatment for a minimum of 2 years
  • SIGN guidelines suggest amisulpride, olanzapine or respiridone for acute exacerbation or recurrence
    • Chlorpromazine and other low-potency first-generation antipsychotics as alternative
  • NB If a patient has been treated with a typical antipsychotic which works for them, there is no reason to switch to an atypical (efficacy is equal)
  • Aripiprazole can be used for patients intolerant (or there is contra-indications) of respiridone and sedation is a problem with other drugs
    • Haloperidol may also be used
  • Clozapine is generally reserved for treatment refractory SZD
  • Smoking cessation is advised (as is stopping illicit drug use)
  • Psychological treatment
    • CBT and Family therapy interventions can be beneficial

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