The Key Facts
- 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.
- 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
- Paranoid: most common type characterised by delusions of persecution, grandeur or jealousy, hallucinations (typically auditory) and perceptual disturbances.
- Hebephrenic: fluctuant mood, disintegrated personality, bizarre behaviour, delusions, hallucinations presenting in puberty.
- Catatonic: pronounced motor alterations causing overactivity (intense excitement) or underactivity (posturing, waxy flexibility, fixed stupor)
- Residual: negative symptoms predominate
- Undifferentiated: mixed clinical picture. Diagnosis of exclusion if it doesn’t fit into the other categories
- Organic cause: head trauma / drug abuse / CNS tumour / temporal lobe epilepsy / malignancy
- Organic delusional disorder
- Persistent delusional disorder
- Acute and transient psychotic disorders
- Bipolar disorder
- Severe depression with psychosis
- Schizo-affective disorder
- Personality disorder: paranoid, schizoid, emotionally unstable, borderline
- Dissociative disorders
- Temporal lobe epilepsy
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
- 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