Schizophrenia is a psychiatric disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations, delusions, and disorganized thinking. Other symptoms include social withdrawal, decreased emotional expression, and apathy. Symptoms typically come on gradually, begin in young adulthood, and in many cases, the symptoms never fully resolve. I’m going to be listing the schizophrenia symptoms and management involved in the process.
There is no objective diagnostic test. Diagnosis is based on observed behavior, a history that includes the person’s reported experiences. Reports of others familiar with the person are also considered. To be diagnosed with schizophrenia, symptoms and functional impairment need to be present for one to six months. Many people with schizophrenia have other mental disorders. Disorders includes an anxiety disorder like panic disorder, an obsessive–compulsive disorder, or a substance use disorder.
About 0.3% to 0.7% of people are affected by schizophrenia during their lifetime. There are an estimated 1 million new cases annually and a total of 20 million cases globally. Males are more often affected and on average have an earlier onset. The causes of schizophrenia include genetic and environmental factors. Genetic factors include a variety of common and rare genetic variants. Possible environmental factors include being raised in a city, cannabis use during adolescence, infections, the ages of a person’s mother and father, and poor nutrition during pregnancy.
About half of those diagnosed with schizophrenia will have a significant improvement over the long term with no further relapses. A small proportion of these will recover completely. The other half will have a lifelong impairment, and severe cases may be repeatedly admitted to hospital.
The mainstay of treatment is antipsychotic medication, along with counselling, job training, and social rehabilitation. Up to a third of people do not respond to initial antipsychotics, in which case the antipsychotic clozapine may be used. In situations where there is a risk of harm to self or others, a short involuntary hospitalization may be necessary. Long-term hospitalization may be needed for a small number of people with severe schizophrenia. In countries where supportive services are limited or unavailable, long-term hospital stays are more typical.
Social problems such as long-term unemployment, poverty, homelessness, exploitation, and victimization are common consequences of schizophrenia. Compared to the general population, people with schizophrenia have a higher suicide rate and more physical health problems, leading to an average decrease in life expectancy. There are an estimated 20,000 deaths being caused by schizophrenia a year.
Schizophrenia is a mental disorder characterized by significant alterations in perception, thoughts, mood, and behavior. Symptoms are described in terms of positive, and negative, and cognitive symptoms. The positive symptoms of schizophrenia are the same for any psychosis and are sometimes referred to as psychotic symptoms. These may be present in any of the different psychoses, and are often transient making early diagnosis of schizophrenia problematic. Psychosis noted for the first time in a person who is later diagnosed with schizophrenia is referred to as a first-episode psychosis (FEP).
Symptoms
Positive symptoms (Schizophrenia Symptoms and Management)
Positive symptoms are symptoms that are not normally experienced, but are present in people during a psychotic episode in schizophrenia. They include delusions, hallucinations, and disorganized thoughts and speech, typically regarded as manifestations of psychosis. Hallucinations most commonly involve the sense of hearing as hearing voices but can sometimes involve any of the other senses of taste, sight, smell, and touch. They are also typically related to the content of the delusional theme.
Cannabis-use may be a contributory factor in the development of schizophrenia, potentially increasing the risk of the disease in those who are already at risk. The increased risk may require the presence of certain genes within an individual. Its use is associated with doubling the rate. The use of more potent strains of cannabis having a high level of its active ingredient tetrahydrocannabinol (THC), increases the risk further. One of these strains is well known as skunk.
Delusions are bizarre or persecutory in nature. Distortions of self-experience are common. Symptoms such as feeling as if one’s thoughts or feelings are not really one’s own, to believing that thoughts are being inserted into one’s mind, sometimes termed passivity phenomena, are also common. Thought disorders can include thought blocking, and disorganized speech – speech that is not understandable is known as word salad. Positive symptoms generally respond well to medication, and become reduced over the course of the illness. This is possdibly related to the age-related decline in dopamine activity.
Negative symptoms (Schizophrenia Symptoms and Management)
Negative symptoms are deficits of normal emotional responses, or of other thought processes. The five recognized domains of negative symptoms are:
- blunted affect – showing flat expressions or little emotion
- alogia – a poverty of speech
- anhedonia – an inability to feel pleasure
- asociality – the lack of desire to form relationships
- avolition – a lack of motivation and apathy
Avolition and anhedonia are seen as motivational deficits resulting from impaired reward processing.
Scales for specifically assessing the presence of negative symptoms, and for measuring their severity, and their changes have been introduced since the earlier scales such as the PANNS that deals with all types of symptoms. These scales are the Clinical Assessment Interview for Negative Symptoms (CAINS), and the Brief Negative Symptom Scale (BNSS) also known as second-generation scales.
Reward is the main driver of motivation and this is mostly mediated by dopamine. It has been suggested that negative symptoms are multidimensional. They have been categorized into two subdomains of apathy or lack of motivation, and diminished expression. Apathy includes avolition, anhedonia, and social withdrawal; diminished expression includes blunt effect, and alogia. Sometimes diminished expression is treated as both verbal and non-verbal. Apathy accounts for around fifty percent of the most often found negative symptoms. This apathy affects functional outcome and subsequent quality of life.
Ten years after its introduction a cross-cultural study of the use of BNSS found valid and reliable psychometric evidence for the five-domain structure cross-culturally. The BNSS is designed to assess both the presence and severity and change of negative symptoms of the five recognized domains, and the additional item of reduced normal distress. BNSS can register changes in negative symptoms in relation to psycho-social and pharmacological intervention trials. BNSS has also been used to study a proposed non-D2 treatment called SEP-363856. Findings supported the favoring of five domains over the two-dimensional proposition.
Apathy is related to disrupted cognitive processing affecting memory and planning including goal-directed behavior. The two subdomains has suggested a need for separate treatment approaches. A lack of distress – relating to a reduced experience of depression and anxiety is another noted negative symptom. A distinction is often made between those negative symptoms that are inherent to schizophrenia, termed primary; and those that result from positive symptoms, from the side effects of anti-psychotics, substance abuse, and social deprivation – termed secondary negative symptoms. Negative symptoms are less responsive to medication and the most difficult to treat. However if properly assessed, secondary negative symptoms are amenable to treatment.
Cognitive Symptoms (Schizophrenia Symptoms and Management)
Cognitive deficits are the earliest and most constantly found symptoms in schizophrenia. They are often evident long before the onset of illness in the prodromal stage. These symptoms may be present in early adolescence, or childhood. They are a core feature but not considered to be core symptoms, as are positive and negative symptoms. However, their presence and degree of dysfunction is taken as a better indicator of functionality than the presentation of core symptoms. Cognitive deficits become worse at first episode psychosis but then return to baseline, remaining fairly stable over the course of the illness.
Cognitive symptoms include problems in attention, concentration, and memory. For some individuals, the cognitive symptoms of schizophrenia are subtle, but for others, they are more prominent and interfere with activities like following conversations, learning new things, or remembering appointments.
The deficits in cognition are seen to drive the negative psycho-social outcome in schizophrenia. They are claimed to equate to a possible reduction in IQ from the norm of 100 to 70-85. Cognitive deficits may be of neurocognition (nonsocial) or of social cognition. Neurocognition is the ability to receive and remember information. This includes verbal fluency, memory, reasoning, problem solving, speed of processing, and auditory and visual perception. Verbal memory and attention are seen to be the most affected. Verbal memory impairment is associated with a decreased level of semantic processing (relating meaning to words).
Schizophrenia sometimes runs in families. However, it is important to know that just because someone in a family has schizophrenia, it does not mean that other members of the family will have it as well. Genetic studies strongly suggest that many different genes increase the risk of developing schizophrenia, but that no single gene causes the disorder by itself. It is not yet possible to use genetic information to predict who will develop schizophrenia.
Another memory impairment is that of episodic memory. An impairment in visual perception that is consistently found in schizophrenia is that of visual backward masking. Visual processing impairments include an inability to perceive complex visual illusions. Social cognition is concerned with the mental operations needed to interpret, and understand the self and others in the social world. This is also an associated impairment, and facial emotion perception is often found to be difficult. Facial perception is critical for ordinary social interaction. Cognitive impairments do not usually respond to anti-psychotics. There are a number of interventions that are used to try to improve them; cognitive remediation therapy has been found to be of particular help.
Onset and Risk Factors
Onset typically occurs between the late teens and early thirties. The peak incidence occurring in males is in the early to mid twenties, and in females in the late twenties. Onset before the age of 17 is known as early-onset. Before the age of 13, as can sometimes occur, is known as childhood schizophrenia (very early-onset). A later stage of onset can occur between the ages of 40 and 60, known as late-onset schizophrenia. A later onset over the age of 60, which may be difficult to differentiate as schizophrenia, is known as very-late-onset schizophrenia-like psychosis.
Onset may happen suddenly or may occur after the slow and gradual development of a number of signs and symptoms, a period known as the prodromal stage. Up to 75% of those with schizophrenia go through a prodromal stage (early stage).
Late onset has shown that a higher rate of females are affected; they have less severe symptoms and need lower doses of anti-psychotics. The tendency for earlier onset in males is later seen to be balanced by a post-menopausal increase in the development in females. Estrogen produced pre-menopause has a dampening effect on dopamine receptors, but its protection can be overridden by a genetic overload. There has been a dramatic increase in the numbers of older adults with schizophrenia. An estimated 70% of those with schizophrenia have cognitive deficits, and these are most pronounced in early onset and late-onset illness.
The negative and cognitive symptoms in the prodrome stage can precede FEP by many months and up to five years. The period from FEP and treatment is known as the duration of untreated psychosis (DUP) which is seen to be a factor in functional outcome.
The prodromal stage is the high-risk stage for the development of psychosis. Since the progression to first episode psychosis is not inevitable, an alternative term is often preferred of at risk mental state Cognitive dysfunction at an early age impact a young person’s usual cognitive development. Recognition and early intervention at the prodromal stage would minimize the associated disruption to educational and social development and has been the focus of many studies. It is suggested that the use of anti-inflammatory compounds such as D-serine may prevent the transition to schizophrenia. Cognitive symptoms are not secondary to positive symptoms or to the side effects of anti-psychotics.
Cognitive impairments in the prodromal stage become worse after first episode psychosis (after which they return to baseline and then remain fairly stable), making early intervention to prevent such transition of prime importance.
Schizophrenia is described as a neurodevelopmental disorder. It has no precise boundary, or single cause. Schizophrenia is thought to develop from gene-environment interactions with involved vulnerability factors. The interactions of these risk factors are complex, as numerous and diverse insults from conception to adulthood can be involved. A genetic predisposition on its own, without interacting environmental factors, will not give rise to the development of schizophrenia. The genetic component means that prenatally brain development is disturbed, and environmental influence affects the postnatal development of the brain. Evidence suggests that genetically susceptible children are more likely to be vulnerable to the effects of environmental risk factors.
Early treatment with cognitive behavioral therapies are the gold standard. Neurological soft signs of clumsiness and loss of fine motor movement are often found in schizophrenia, which may resolve with effective treatment of FEP.
About half of those with schizophrenia use recreational drugs, including cannabis, tobacco, and alcohol excessively. Use of stimulants such as amphetamine and cocaine can lead to a temporary stimulant psychosis, which presents very similarly to schizophrenia. Rarely, alcohol use can also result in a similar alcohol-related psychosis. Drugs may also be used as coping mechanisms by people who have schizophrenia, to deal with depression, anxiety, boredom, and loneliness. The use of cannabis and tobacco are not associated with the development of cognitive deficits, and sometimes a reverse relationship is found where their use improves these symptoms. However, substance abuse is associated with an increased risk of suicide, and a poor response to treatment.
Prevention and Management (Schizophrenia Symptoms and Management)
Prevention of schizophrenia is difficult as there are no reliable markers for the later development of the disorder. There is tentative though inconclusive evidence for the effectiveness of early intervention to prevent schizophrenia in the prodrome phase. There is some evidence that early intervention in those with first-episode psychosis may improve short-term outcomes. However, there is little benefit from these measures after five years. Cognitive behavioral therapy may reduce the risk of psychosis in those at high risk after a year and is recommended in this group.
By the National Institute for Health and Care Excellence (NICE). Another preventive measure is to avoid drugs that have been associated with development of the disorder, including cannabis, cocaine, and amphetamines.
The primary treatment of schizophrenia is the use of anti-psychotic medications, often in combination with psycho-social interventions and social supports. Community support services including drop-in centers, visits by members of a community mental health team, supported employment, and support groups are common. The time between the onset of psychotic symptoms to being given treatment – the duration of untreated psychosis (DUP) is associated with a poorer outcome in both the short term and the long term.
Anti-psychotics are prescribed following a first-episode psychosis, and following remission a preventive maintenance use is continued to avoid relapse. However, it is recognized that some people do recover following a single episode and that long-term use of anti-psychotics will not be needed but there is no way of identifying this group.
Voluntary or involuntary admittance to hospital may be needed to treat a severe episode, however, hospital stays are as short as possible. In the UK large mental hospitals termed asylums began to be closed down in the 1950s with the advent of antipsychotics, and with an awareness of the negative impact of long-term hospital stays on recovery. This process was known as deinstitutionalization, and community and supportive services were developed in order to support this change. Many other countries followed suit with the US starting in the 60s. There will still remain a few people who do not improve enough to be discharged. In those countries that lack the necessary supportive and social services long-term hospital stays are more usual.
Additional Thoughts (Schizophrenia Symptoms and Management)
Violence (Schizophrenia Symptoms and Management)
Most people with schizophrenia are not aggressive. They are more likely to be victims of violence rather than perpetrators. However, though the risk of violence in schizophrenia is small, the association is consistent. There are minor subgroups where the risk is high. This risk is usually associated with a co-morbid disorder such as a substance use disorder – in particular alcohol, or with antisocial personality disorder. Substance abuse is strongly linked, and other risk factors are linked to deficits in cognition and social cognition including facial perception and insight that are in part included in theory of mind impairments. Poor cognitive functioning, decision-making, and facial perception may contribute to making a wrong judgement of a situation that could result in an inappropriate response such as violence. These associated risk factors are also present in antisocial personality disorder which when present as a co-morbid disorder greatly increases the risk of violence.
History (Schizophrenia Symptoms and Management)
Accounts of a schizophrenia-like syndrome are rare in records before the 19th century. The earliest cases detailed were reported in 1797, and 1809. Dementia praecox, meaning premature dementia was used by German psychiatrist Heinrich Schüle in 1886, and then in 1891 by Arnold Pick in a case report of hebephrenia. In 1893 Emil Kraepelin used the term in making a distinction, known as the Kraepelinian dichotomy, between the two psychoses – dementia praecox, and manic depression (now called bipolar disorder). Kraepelin believed that dementia praecox was probably caused by a systemic disease that affected many organs and nerves, affecting the brain after puberty in a final decisive cascade. It was thought to be an early form of dementia, a degenerative disease. When it became evident that the disorder was not degenerative it was renamed schizophrenia by Eugen Bleuler in 1908.
Culture (Schizophrenia Symptoms and Management)
The book A Beautiful Mind chronicled the life of John Forbes Nash who had been diagnosed with schizophrenia but who went on to win the Nobel Memorial Prize in Economic Sciences. This was later made into the film with the same name. An earlier documentary was made with the title A Brilliant Madness.
