Schizophrenia in Adults

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:

• Delusions: Fixed beliefs that are not amenable to change in light of conflicting evidence. Their content may include a variety of themes (e.g., persecutory, referential, somatic, religious, grandiose).
• Hallucinations: Perception-like experiences that occur without an external stimulus
• Disorganized Speech/Disorganized Thinking:  Disorganized Thinking is typically inferred from the individual’s speech. The individual may switch from one topic to another (derailment or loose associations). Answers to questions may be minimally or completely unrelated (tangentiality).
• Grossly Disorganized or Catatonic Behavior: This may manifest itself in a variety of ways, ranging from childlike “silliness” to unpredictable agitation. Problems may be noted in any form of goal-directed behavior, leading to difficulties in performing activities of daily living. Catatonic behavior is a marked decrease in reactivity to the environment.
• Negative Symptoms: These account for a substantial portion of the morbidity associated with schizophrenia. Two negative symptoms are particularly prominent in schizophrenia: diminished emotional expression and avolition.
• Diminished emotional expression includes reductions in the expression of emotions in the face, eye contact, intonation of speech (prosody), and movements of the hand, head, and face that normally give an emotional emphasis to speech.
• Avolition is a decrease in motivated self-initiated purposeful activities. The individual may sit for long periods of time and show little interest in participating in work or social activities.
• Alogia is manifested by diminished speech output.
• Anhedonia is the decreased ability to experience pleasure from positive stimuli or problems recalling pleasure previously experienced.
• Asociality refers to the apparent lack of interest in social interactions and may be associated with avolition.

For a diagnosis, at least two symptoms must have been present for six months and include at least one month of active symptoms.

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.

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.

• Second Generation Antipsychotic medications

• Aripiprazole

• Clozapine

• Olanzapine

• Paliperidone

• Quetiapine

• Risperidone

• Ziprasidone

• First Generation Antipsychotic medications
• Haloperidol
• Thioridazine
• Perphenazine
• Fluphenazine

• Longer acting injectable versions of antipsychotic medications described above can be helpful with patients who have recurrent relapses or nonadherence to oral medications

Behavioral and Psychosocial Treatments

• Social Skills Training: Uses the principles of behavior therapy to teach communication skills, assertiveness skills, and other skills related to disease management and independent living.

• Cognitive Behavioral Therapy: This treatment involves cognitive restructuring, behavioral experiments / reality testing, self-monitoring and coping skills training, with an emphasis on a non-confrontational style and on normalizing psychotic experiences as part of a continuum with non-psychotic experiences. CBT for schizophrenia can focus specifically on psychotic symptoms (i.e. hallucinations or delusional beliefs) but has also been shown to be helpful for addressing depression and / or anxiety associated with psychotic symptoms and their impact on the person’s life.

• Assertive Community Treatment: A multidisciplinary team approach to intensive case management involving a high frequency of patient contact (typically at least once a week), low patient to staff ratios, and community outreach, allowing integration of medication management, rehabilitation, and social services as well as individualization to patients.

• Family Psychoeducation and Support: Because families can have a significant impact on their affected relative’s recovery and functioning, this treatment helps reduce the distress associated with caring for a family member’s illness, improving patient-family relations and communications, assisting with crisis intervention, problem-solving training, and relapse prevention.

• Supported Employment: An approach to vocational rehabilitation for individuals with serious mental illness that emphasizes integration of employment and mental health services, rapid community employment, individualized job development, and ongoing job support.

• Cognitive Remediation: These interventions are designed to improve cognitive function through repeated practice of cognitive tasks and / or strategy training, taking into account the motivational and emotional deficits that are often present in schizophrenia.

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:

• Beta-blockers (hostility, aggression)

• Mood stabilizers (mood instability, aggression)

• Antidepressants (depression, negative symptoms) – may exacerbate psychotic symptoms

• Benzodiazepines (anxiety, agitation, insomnia, akathisia)

Behavioral and Psychosocial Treatments

• Acceptance and Commitment Therapy: This treatment aims to change the relationship individuals have with their own thoughts, feelings, memories, and physical sensations that are feared or avoided. Acceptance and mindfulness strategies are used to teach patients to decrease avoidance, attachment to cognitions, and increase focus on the present.

• Cognitive Adaptation Training: This treatment teaches the individual with schizophrenia to use strategies that compensate for (or work around) the cognitive deficits associated with schizophrenia.

• Illness Management and Recovery: This treatment emphasizes recovery by helping clients set and pursue personally meaningful goals. IMR combines 1) psychoeducation about mental illness, 2) cognitive-behavioral approaches to medication management, 3) planning for relapse prevention, 4) social skills training to strengthen social support, and 5) coping skills to manage symptoms of mental illness.

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for better validated treatments described above, might be considered.

• Electroconvulsive Therapy (ECT)
• Omega-3 Fatty Acid Supplements