The Key Facts

Schizophrenia:

  • Schizophrenia is an often severe, chronic and debilitating neuropsychological disorder related to dopamine dysregulation, hence the alternative name “dopamine dysregulatory disorder”.
  • It affects about 24 million people worldwide irrespective of culture or geographical location.
  • Peak onset age 18-25 years old, but presents about 2-3 years earlier in men.
  • Low incidence (2-3/10,000/year) but high lifetime prevalence due to chronicity (~1% of population).
  • Susceptibility genes implicate dopamine and glutamate: COMT gene, NRG1, DTNBP1 and DAOA
  • Environmental risk factors: early development factors (maternal starvation in pregnancy, prematurity, low birth weight, winter birth, incubation), social adversity (urban upbringing, social anxiety, stress, isolation), drug use (amphetamines, cannabis), male gender.

Presentation

 Presentation:

  • POSITIVE symptoms (an excess or distortion of normal functioning; things that shouldn't be there but are): hallucinations, delusions
  • NEGATIVE symptoms (a decrease or loss of functioning; things that should be there but aren't): Affect (blunt or flat), Alogia, Avolition, Apathy, Anhedonia and Asociality
  • Disorganisation symptoms: incongruous mood, abnormalities of speech and thought
  • Cognitive deficits: attention, memory, concentration
  • Common psychiatric comorbidities: depression, suicidal ideation, substance misuse, OCD and anxiety.

Types of Schizophrenia

  1. Paranoid: most common type characterised by delusions of persecution, grandeur or jealousy, hallucinations (typically auditory) and perceptual disturbances.
  2. Hebephrenic: fluctuant mood, disintegrated personality, bizarre behaviour, delusions, hallucinations presenting in puberty.
  3. Catatonic: pronounced motor alterations causing overactivity (intense excitement) or underactivity (posturing, waxy flexibility, fixed stupor)
  4. Residual: negative symptoms predominate
  5. Undifferentiated: mixed clinical picture. Diagnosis of exclusion if it doesn’t fit into the other categories

Differential Diagnosis

  1. Organic cause: head trauma / drug abuse / CNS tumour / temporal lobe epilepsy / malignancy
  2. Organic delusional disorder
  3. Persistent delusional disorder
  4. Acute and transient psychotic disorders
  5. Bipolar disorder
  6. Severe depression with psychosis
  7. Schizo-affective disorder
  8. Schizoid
  9. Delirium
  10. Dementia
  11. Personality disorder: paranoid, schizoid, emotionally unstable, borderline
  12. Dissociative disorders
  13. Temporal lobe epilepsy

Treatment

The 1st Schizophrenic Episode

Range of possible presentations is wide.

However, there are a number of common presentations that are seen;

  • A relative noticing bizarre or withdrawn behaviour
  • Presentation via the criminal justice system
  • Poor performance at school/college with referral by school or student health services
  • Presentation following deliberate self harm or suicide attempt
  • Regularly complaining to council/police etc..on basis of delusional symptoms (e.g. hearing neighbours voices)
  • Occasionally the 1st sign may be symptoms more typically characteristic of another disorder e.g. depression, mania, OCD
  • Onset of social withdrawal, personality change or 'odd' behaviour

Prognosis

  • 1/3 recover, 1/3 relapse and remit, 1/3 chronic
  • 6-10% suicidal
  • ~ 40% affected experience recurrent psychotic episodes.
  • Progression of disease à less positive but more negative symptoms.
  • High rates of violence, dependent living, homelessness and unemployment

 

POOR Prognostic Factors: (include)

- Insidious onset

- Onset in childhood or adolescence

- Cognitive impairment

- poor premorbid adjustment

 

GOOD Prognostic factors: (include)

- FHx of affective disorder

- Female sex

- living in a developing country

- marked mood disturbance (esp. elation) during initial presentation

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