Schizophrenia is part of a cluster of diagnoses called the schizophrenia spectrum and other psychotic disorders. Schizophrenia spectrum and other psychotic disorders are a group of psychiatric conditions that include:
These disorders are characterized by symptoms that can be divided into two groups: positive and negative.
Positive symptoms include delusions, hallucinations, disorganized thinking (speech), and grossly disorganized or abnormal motor behavior (including catatonia). Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence. Hallucinations are perception-like experiences that occur without external stimulus. Disorganized thinking/speech is characterized by a derailment or loose associations in an individual's speech pattern. Grossly disorganized or abnormal motor behavior is a difficulty in sustaining goal-oriented behavior. This may manifest itself in a variety of ways, ranging from childlike "silliness" to unpredictable agitation.
Negative symptoms include diminished emotional expression, avolition, alogia and anhedonia. Negative symptoms are those that involve a loss of normal function or experience. Diminished emotional expression is the reductions in the expression of emotions in the face, eye contact, intonation of speech, and movement of hand, head, and face that normally give an emotional emphasis to speech. Avolition is a decrease in motivated self-initiated purposeful movement. Alogia is manifested by diminished speech output. Anhedoia is the decreased ability to experience pleasure from positive stimuli.
Schizophrenia is a serious and typically chronic mental illness characterized by psychotic "positive" symptoms (hallucinations and delusions), negative symptoms (lacking emotional display, enjoyment of previously enjoyed activities, and/or motivations, impairments in role functioning, and cognitive deficits.
Schizophrenia affects approximately 1% of the adult population and affects men and women in equal numbers.
Schizophrenia symptoms typically begin in late adolescence or early adulthood. However, related but less severe (prodromal) symptoms may start during the teenage years. It is uncommon for symptoms of schizophrenia to begin after age 45.
Schizophrenia is characterized by five main sets of symptoms:
For a diagnosis, at least two symptoms must have been present for six months and include at least one month of active symptoms.
Schizophrenia involves chronic or recurrent psychosis, and is commonly associated with substantial impairments in social and occupational functioning. In addition, schizophrenia is associated with deficits in cognitive impairment such as deficits in attention or vigilance, memory, and executive functioning.
A generalized or global impairment (e.g., subaverage IQ) is also common in this population. For these reasons, it is among the most disabling and economically catastrophic psychiatric disorders, and is ranked by the World Health Organization as one of the top 10 illnesses contributing to the global burden of disease.
Family, twin, and adoption studies support a strong genetic component for schizophrenia. The lifetime risk of developing the illness is 5-20 times higher in first-degree relatives when compared to the general population. Risk factors that include paternal age and in utero exposure to maternal famine have also been hypothesized to contribute to the development of schizophrenia.
The development of schizophrenia involves abnormalities in the neurobiological changes that occur during puberty and adolescence. These abnormalities may include progressive ventricular enlargement, reduction in total brain and thalamus volume, changes in temporal lobe structures, reductions in frontal metabolism, volume reduction of the associative cortex and hippocampus, synaptic elimination of the prefrontal cortex, diminishing of cerebral plasticity, and changes in neurotransmission.
Rates of comorbidity with substance-related disorders are high. Over half of individuals with schizophrenia have tobacco use disorder. In addition, comorbidity with anxiety disorders is increasingly observed; rates of obsessive-compulsive disorder and panic disorder are elevated.
Pharmacological treatment is considered the cornerstone of schizophrenia treatment and typically targets psychotic symptoms. For best results, behavioral and psychosocial treatments should be used in combination with medications to improve functioning and help manage the chronic condition.
The American Psychiatric Association's Practice Guidelines and the Society of Clinical Psychology suggest the following for treatment of schizophrenia in adults:
First Line Treatments
Pharmacological Treatments - Antipsychotic Medications
A word about antipsychotic medications (from uptodate.com): These medications are commonly grouped into two categories, with "second-generation" (or "atypical") applied to clozapine all antipsychotics first marketed after clozapine was approved in 1989, and "first-generation" applied to antipsychotics marketed previously. Recent clinical research, however, has strongly suggested that the distinction between first- and second-generation antipsychotics has questionable validity and is confusing. The pharmacologic properties, therapeutic effects, and adverse effects are not distinct between and are heterogeneous within the groups. Nevertheless, the terms first- and second-generation antipsychotic are still in widespread use. A valid distinction is that the newer (second-generation) antipsychotics tend to cause fewer extrapyramidal side effects than the older ones, particularly at the high end of approved dosage ranges.
Behavioral and Psychosocial Treatments
Second Line Treatments
Pharmacological Treatments
In cases of nonresponse the above treatments, adjunctive treatments to be used in conjunction with antipsychotic medications with reasonable evidence of efficacy include:
Behavioral and Psychosocial Treatments
Additional Treatments to Consider
Preliminary evidence suggests that the following strategies, while not a substitute for better validated treatments described above, might be considered.