Schizophrenia

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Introduction
Schizophrenia and the Delusional Disorders
Under this classification are the ‘serious brain disorders’ that are neither organic brain
disorders or severe mood disorders.
Schizophrenia is a chronic condition, but has a widely varying course. Some people make a
full recovery, whilst other may require institutionalised care for their whole lives.

Epidemiology
1% of the population will have a diagnosis of schizophrenia at some point in their
lives
Prevalence – 200 per 100 000
Incidence – 20 per 100 000
The incidence is roughly the same around the globe, however, the course of the
disease varies according to location. In the western world, it is less likely to be
‘cured’.
Higher incidence in inner city, low socioeconomic environments. However it is
thought that schizophrenia itself causes this socioeconomic depravation –
because the average patient has a lower than average status, but the parents
of the patient usually have an ‘average’ socioeconomic status.
This is sometimes referred to as downward drift / social drift
Peak incidence:
18-25 in men
25-30 in women
Equal incidence in both men and women

Aetiology
Tendency as a child to be withdrawn, eccentric, and/or clumsy, before developing the
disease later in life
For a period (perhaps lasting years) before ‘true symptoms’ develop, the individual may
show other symptoms, such as:
Loss of interest
Social withdrawal
Self-neglect
Depression
Anxiety
Brief psychotic episodes
This period is known as the prodromal period. A long prodromal period usually
means that the diagnosis is delayed, and in these situations, the prognosis is poor.

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Genetic factors
General risk – 1%
If sibling has condition – 9%
If parent has condition – 13%
If both parents have condition – 45%

Environmental factors thought to be negligible – studies have shown that children kept
away from their schizophrenic mothers are at the same risk of developing the condition as
those who grew up with their birth mother.
Obstetric complications –are found in increased incidence in those who go on to develop
the condition. This suggests that some kind of developmental abnormality may be
present.
‘Sensitive’ personalities – some people have a tendency to perceive critiscm harshly, and
to interpret non-critical comments as criticism. These people have an increased likelihood
of developing schizophrenia.

Predisposing factors
Certain events can trigger and episode of schizophrenia in a susceptible individual
Periods of increased stress
Periods of intense emotion (both positive and negative) – e.g. losing your job, winning
the lottery
Increased levels of criticism from friends and family members
Drugs – particularly hallucinogens, stimulants, including alcohol and cannabis.

Symptoms
General status of the patient:
Many cognitive functions remain intact
Only some functions affected
Perceived loss of boundaries between the individual and the outside world
E.g. thoughts/acts/emotions may be perceived to be controlled by outside
influences.
Preoccupied with thoughts about the self

Positive symptoms
These may often involve frightening experiences for the patient, because they seem to
have lost control. Stress, anxiety, and criticism can all exacerbate the symptoms
Auditory Hallucinations – the most common symptom, and often the easiest to elicit.
These can take several forms:
Third person – talking about the individual who hears them. May be single or
multiple voices. These are the most common type of auditory hallucination in
schizophrenia. The voices are often critical of the individual. With treatment, these
voices may not go away, but they may become quieter, and contain more positive
content
Thought echo – the individual hears their thoughts spoken aloud, either
simultaneously (as thinking the thought) or just afterwards.
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 Second person – talking to the individual – can still occur in schizophrenia, but also
present in lots of other mental disorders.
NOTE – auditory hallucinations in which the person talks to the voice they hear
are most commonly the result of TRAUMA or are fictitious.

Other hallucinations – e.g. visual, olfactory etc. again, can occur in schizophrenia, but
also common to other disorders. These are most common in organic conditions. If these
symptoms are present then they have to be medically investigated.
Passivity experiences – the patient believes that their movements, emotions or will is
being altered in a similar way to the thought issues, for examples, they believe their
movements are being controlled.
Incongruity of affect – the patient may burst out laughing or become very angry for no
apparent reason, or they may have inappropriate emotional reactions – e.g. laughing at
bad news.
Thought and speech disorders – their thought processes may be altered, for example,
their speech may be totally fragmented (word salad), or they may have some sort of
thought disorder – e.g. they can speak in normal sentences, but their ideas are linked in
strange ways, e.g. not by content, but because the words rhyme.

Neologism – this is a phenomenon that may occur with some patients. They may
make up a new word, or give an existing word a new meaning that is only apparent
to the individual, and does not make sense. They may keep repeating this word. E.g.
“I like to sprong”
Word salad – the form of the sentences makes no sense at all. Words are mixed up,
in the wrong place.
Flight of thought – this is where the patient moves quickly from one idea to another,
often half-way through a sentence, with no apparent association between ideas.
Knight’s move thinking (aka Derailment)- patient moves from one idea to another
with strage illogical associations between the ideas.
Pressure of speech – the patient speaks at a rate faster than normal
Circumstantiality – excessive ‘long-windedness’ – the patient takes forever to reach
the point when they talk.

Mannerisms – strange and pointless movements. This is often repeated frequently, and
accompanied by a strange facial expression.
Catatonia – a state where the person may not respond to stimuli and exhibits strange
physical behaviour. The state may involve a particular movement or posture that a patient
often performs. Can be associated with any mental health condition. Examples can include

Stupor – the patient is unable to move or speak except for moving their eyes.
Strange postures – that are normally very difficult to hold
Negativism – the patient does the exact opposite of what they are asked
Automatic obedience
Waxy flexibility – the patient has strange muscle tone that allows the doctor to put
the patient into physical position that would otherwise be very difficult and/or painful.

Schneider’s First Rank Symptoms of Schizophrenia

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These are a ‘sub-class’ of Positive symptoms and basically include:
Delusions – an unshakeable belief that is not in keeping with the person’s social,
cultural or educational background, for which there is no logical evidence basis.
Primary delusions – these appear with no apparent precipitating event. The
individual may enter a state of being ‘perplexed’ for several days or months, and as
the perplexity disappears, the delusion develops.
Persistent delusions – these arise with the period of perplexity. If other symptoms of
schizophrenia are present, this can be diagnostic for schizophrenia. If they are
not, then it can be diagnostic for delusional disorder.
Secondary delusions – these arise when other symptoms of schizophrenia have
been present for a period just before the delusion, and arise from strange
experiences the individual has as a result of their schizophrenia.

Thought issues

Thought insertion – the patient believessomebody or something is ‘planting’

thoughts into their mind. This happens against the person’s will.
Thought broadcast – the patient believes their thoughts are ‘broadcast’ to others
against their will
Thought withdrawal – the patient believes thoughts are being removed from their
mind against their will, and this leaves the mind ‘blank’.

Hallucinations in the general population – about 5-10% of the normal population have
hallucinations – but it is only when these are distressing that they become a medical
problem.

Negative symptoms

These are present in most, although not all patients with schizophrenia. They tend to lead
to reduced function (e.g. reduced social interaction, self care etc etc) and they are a very
poor prognostic sign. A lack of stimulation makes the symptoms worse.
They are often difficult to distinguish from symptoms of depression, and you may only be
able to do so by taking a full depression history and noting the absence of symptoms such
as:
Weight change
Sleep problems
Guilt / hopelessness / low self worth

The symptoms can also be attributed to sedative medications

Alogia – this is a general impoverished level of thinking, usually seen in the form of
poverty of speech – whereby the patient will give very short answers, and will not
voluntarily give any input to a conversation. They are unable to elaborate on their
thoughts. The patient feels as though their ‘mind is empty’.
Poverty of content of thoughts – is a less extreme version. The patient is able to
answer questions, but their thought process is not properly utilised and they cannot
explain their answers.
Blunting of Affect – the person has a lack of emotion
Avolition (loss of volition) – the patient has a general lack of interest in life, self care,
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 social activities and motivation.
Slowness of thought an movement

Other symptoms seen in schizophrenia

Depression
Anxiety
Agitation
Withdrawal
Inappropriate eating behaviour – e.g. stuffing themselves in an ‘uncivilised’ way,
and then vomiting.
Incontinence
Self harm
Destruction of possessions
Massive intake of water – causing water intoxication – which can lead to
hyponatraemia. This can inturn cause delirium, coma, and even death! In these
cases the person will drink all/any water they can find –even out of toilets.
Post psychotic depression –this is a prolonged depressive episode that occurs on
resolution of the psychosis. This can be distinguished from the negative symptoms of
schizophrenia because:
In schizophrenia – negative symptoms increase/decrease in conjunction with
the severity of positive symptoms
In post psychotic depression – the depressive type symptoms do not change
in concordance with any positive symptoms
This case can be extremely difficult to distinguish from the normal negative
symptoms of depression – but it requires different treatment – and so if you
suspect it, you should make the extra effort to try and find out. Patients with
post psychotic depression are at high risk of suicide, and they have a particular
feeling of hopelessness. In post-psychotic depression the patient often has a
good degree of insight – because the depression is often in response to their
diagnosis. It can also be a result of neuroleptic medication.

Diagnosis
The diagnosis of schizophrenia has to be distinguished from that of just a brief psychotic
episode – thus when at least one of the following has been apparent for at least one
month we say schizophrenia is present:
Auditory hallucinations
Thought echo
Thought insertion
Thought broadcast
Thought withdrawal
Delusion (primary or persistent)
Passivity experiences

OR at least two of the following for more than one month

Persistent hallucinations
Incoherent/irrelevant speech (including neologisms)
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 Mannerisms
Catatonia
Negative Symptoms

Differential Diagnosis
Brief Psychotic disorder – symptoms are present for less than a month, then
disappear. Often sudden onset, and in some cases a precipitating factor (e.g. severe
psychological stress) may be identified.
Delusional disorder – basically, might appear like schizophrenia, but, there are only
hallucinations and /or delusions, and no other signs of schizophrenia. We say that
delusional disorder exists when an individual has a complex and logical system of
beliefs that are based on one or more delusional beliefs. There may also be
auditory hallucinations, but there are usually no other schizophrenia-like
symptoms. The delusions are usually either persecutory or grandiose. Three
particularly common delusions are:
Dysmorphophobia – a delusion that their body is particularly deformed (e.g.
they think they have a massive nose when they clearly don’t), to that it is
always giving off a particularly foul smell
Morbid Jealousy – a delusion that the patient’s partner is cheating on them,
despite very little evidence – e.g. they were late home one night
Erotomania – this is where the patient loves another individual, and believes
the other individual also loves them – but that they are unable to show it
Often these patients have a history of paranoid personality, particularly
sensitive to criticism, have a very rigid belief system, or a history of sensory
depravation or temporal or parietal lobe defects.
Treatment – it can be very difficult to persuade the patient that they need
treatment! treatment from the GP is often more accepted than from the mental
health practitioner. The first line drug is pimozide – but other neuroleptics can
be used. (NB neuroleptic just means antipsychotic). Full recovery is seen in
½ of patients, with a further 33% showing improvement.
Manic depression – often may have symptoms of schizophrenia, such as
schneider’s first rank symptoms. Usually can be distinguished, due to the elation,
erratic behaviour, grandiose delusions (usually schizophrenia is persecutory) and
increased activity.
Alcoholic Hallucinations – alcohol withdrawal may mimic schizophrenia for a short
period (up to 2 weeks, usually less) may have second person hallucinations.
Organic Psychosis – this can present with very similar symptoms to
schizophrenia – but here is an organic causatory factor – such as drug abuse, or a
neurological disorder.
Drugs – The drugs that cause these symptoms can be stimulants or hallucinogens.
Examples include:
Cannabis
Steroids – These two drugs produce symptoms particularly consistent with
schizophrenia
Cocaine
Ecstasy
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 LSD
Magic mushrooms (psilocybin)
Mescaline
Phencyclidine
Neurological symptoms associated with schizophrenia type symptoms
Epilepsy – particularly temporal lobe seizures
Dementia
B12 def
Hypoglycaemia
Trauma/head injury
In trauma and head injury, the patient may hear voices that they can ‘talk to’. In
psychiatric disease, this does usually not occur (or if the patient claims it does
occur, it is often fictitious)

History Taking
‘I want to ask you if you have had any unusual experiences that people often
feel. Do you ever think that people are talking about you, or taking special
notice of you?’ if yes – ask more about it. Why do they think this? Do they have any
evidence?
E.g. this may be perfectly logical if for example, the family have been involved
with the police.
Is anyone trying to harm you? – persecutory delusions
Do you have any special powers? – grandiose delusions
Do you ever feel someone is controlling you in some way? – passivity
experiences
Have you ever had thoughts put into your head that are not your own?–
thought insertion
Etc etc!

Mental state exam

Appearance & behaviour – may show self neglect, restlessness or odd, or lack of
movements, and odd appearance(e.g. hair / makeup / clothes)
Speech – Tangential speech – one though is unrelated to the next. Often
neologisms, may be incoherent, jumps from subject to subject.
Mood – suspicious, may often seem deep in though and perplexed/confused
Thoughts – delusions,though disorder, persecutory
Perceptions – hallucinations – most commonly auditory
Cognition – poor attention span and concentration, unshakable beliefs (‘concrete
thinking’)

Risk
Suicide risk is just as high as other mental disorders. Maybe hard to assess when a lot of
other symptoms are present, but you should play it safe. Signs that this could be a risk are:
Thoughts of suicide
Plans for suicide
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 Auditory hallucinations relating to suicide

Self-neglect – this can occur to such a great degree, that the patient’s health can be put at
risk, and even death can result.
Risk to others – the risk of a violent attack on another individual is relatively low, but in
those with a history of impulsive behaviour and violence, you should be careful.
Particular symptoms that might put others at risk include:

Passivity experiences
Morbid jealousy
Persecutory delusions directly involving others

Pathology
Not fully understood. It is thought that it is related to excess dopaminergic activity. This
theory comes from the observance of two main factors:
Most anti-psychotic drugs block dopaminergic transmission, and are able to reduce
symptoms
Many dopamine agonists have psychotic side effects (e.g. in Parkinson’s disease)

It is also thought that the excitory neurotransmitter glutamate is involved, as glutamate

agonists cause psychotic symptoms. In post mortems of patients, there are often
increased glutamate receptors and cells in the frontal cortex, but decreased in the
medial and temporal lobes. This suggests some abnormal ‘wiring’ of glutamate circuits.

Nueroimaging sometimes shows

Increased size of lateral ventricles

Reduced brain size (usually in temporal lobes)
Negative symptoms – often correlated with reduced blood flow and other
abnormalities in the frontal cortex.
Reduced connections between different brain areas can often be deduced from
EEG’s.

Investigations
Drug screening – to rule out amphetamines and cannabis as the cause
EEG – to rule out epilepsy
Fasting glucose – to rule out diabetes
Full neuro exam – checking for an organic cause
Other blood tests – t check baseline levels before starting anti-psychotic medication.
These levels need to be monitored as medication is continued.
CT/MRI – looks for atrophy of the lateral ventricles. Also space occupying lesions
can cause schizophrenia, but these are rare!

Management
Many patients can be managed at home, with the help of the CRT (Crisis resolution team)
with acute attacks managed in outpatients. Based on the level of risk, some patients may
need to be detained under the mental health act.

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There are more details about psychiatric medications in the Psychiatric medications
article

Acute attack
First line – Neuroleptics – typical or atypical. Which drug is used depends on the
patient. Can be given in oral tablet form, or oral liquid, or IM injection. There is no
need to ever give one IV. If adherence is an issue, consider depot preparation given
IV every 2-4 weeks. Main side effects include sedation, and extrapyramidal side
effects (e.g. Parkinsonism). These effects are reduced in atypical antipsychotics
(which are newer), but these have their own problems, namely, weight gain, and
increased risk of diabetes.
Second line – Clozapine – atypical antipsychotic – this is not included as a first line
treatment, as requires close monitoring as it has a tendency to cause aplastic
anaemia, which can be fatal. If two other anti-psychotics have not been effective,
then clozapine should be considered. It is highly effective in 30% of patients.
CPMS – Clozepine monitoring system. A national service in the UK, that gives advice
on the drug dosage to use, depeninding on the blood test results you send to them.
Compulsory for anyone on clozepine. Only consultant psychiatrists can prescribe
clozepine.

Psychological therapies
These may often be implemented (e.g. CBT, early warning sign interventions), but there
isn’t much evidence that they are any more effective than normal, regular contact with a
support worker, and follow-ups with a prescribing psychiatrist. However, outcomes
are very much worse when there is no contact with a support worker or not
psychological therapies, despite regular contact with a psychiatrist.
Psychotherapies are particularly useful for treating negative symptoms (e.g. the
depression and LOF (loss of function) type symptoms)
Family therapy involves educating the family to recognise the early signs of an attack, and
also to help them be more supportive, and to remove any precipitating factors from the
patients direct environment (e.g. criticism).

Social care
A supportive environment is essential. Many negative symptoms can be relieved just
through structured weekly activities – giving some purpose to the patient’s life.
This is sometimes referred to as downward drift / social drift
ECT – electro-convulsive therapy – may be used to treat catatonic symptoms.

Impact on society
Very expensive to treat
If not diagnosed, can cause harm to others

Prognosis
20% of patients will make a full recovery with drug and supportive treatments
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 A further 35% have long periods of remission
35% will have persistent mild positive and negative symptoms, that can be managed
in the community
10% have severe schizophrenia that is unresponsive to treatment, and these
people will often require institutionalised care.
A small number of patients may require forensic care, due to high risk.

Factors that decrease the change of a positive outcome are:

Pre-morbid factors – e.g. poor educational background, poor achievement at work,
social problems
Drug and alcohol abuse
Features of the condition – long slow onset, delay of first treatment, catatonic
symptoms, strong negative symptoms, thought disorder
Current social / living situation – e.g. lack of structure to daily living, lack of social
network, exposure to stress and high emotions at home.

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