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Schizophrenia
Aka: Schizophrenia
- See Also
- Schizophrenia Diagnosis
- Psychosis
- Psychosis Symptoms
- Psychosis Exam
- Psychosis Types
- Psychosis Differential Diagnosis
- Drug Induced Psychosis
- Psychosis Diagnostic Testing
- Delirium
- Epidemiology
- Prevalence (world): 0.3 to 0.7% across all ethnicity, nationality
- Most common Psychotic Disorder
- However, in U.S., black patients are disproportionately diagnosed over non-hispanic whites
- Gara (2012) Arch Gen Psychiatry 69(6): 593-600 [PubMed]
- Gender: Equal among men and women
- Men present ages 18 to 25 years old
- Women present age 25 to mid-30s and also after age 40 years old
- Children have rarely presented as young as 5 years old
- Age
- Age onset in transition from Adolescence to Adulthood
- Men present earlier than women (see above)
- First attack usually occurs before 40 years old (although some women may present later)
- Pathophysiology
- Polygenic condition (expression impacted by environment)
- Heredity Concordance
- Monozygotic twins: 69%
- Dizygotic: 13%
- Schizoid Personality Disorder
- Associated with Schizophrenia (RR=50)
- Protective factors in the family environment
- Uncommon criticism
- Straightforward communication
- Neurotransmitter Dopamine
- Increased Dopamine exacerbates positive symptoms
- Antipsychotics are primarily reduce Dopamine
- Other factors
- Endocrine, Physical associations are only coincidental
- Neurohumoral: Super sensitive receptors
- Neurophysiologic: Spiking or slow waves at Hippocampus
- Risk Factors
- Family History (most significant risk)
- However, most patients with Schizophrenia have no Family History
- Schizophrenia confers an increased risk of mental illness to family members
- Increased risk includes Schizophrenia, schizoaffective disorder, Bipolar Disorder, Major Depression
- Monozygotic twin: 50% lifetime Incidence
- Dizygotic twin: 17% lifetime Incidence
- First degree relative: 6-17% lifetime Incidence
- Lewis (2000) Neuron 28:325-34 [PubMed]
- Other risks
- Marijuana use
- Obstetric complications
- Maternal infections with Toxoplasmosis
- Early childhood CNS Infection
- Advanced paternal age (over 55 years old)
- Types
- See Psychosis Types
- History
- Abrupt onset
- Psychosis for > 1 month
- Signs of disorder for > 6 months
- Deterioration
- Social
- Occupational function
- Self care
- Symptoms
- See Psychosis Symptoms
- Often preceded by prodromal phase
- Social withdrawal
- Loss of interest in school or work
- Hygiene and grooming deteriorate
- Angry outbursts
- Unusual behavior
- Signs
- See Psychosis Exam
- Labs
- See Psychosis Labs
- Differential Diagnosis
- See Psychosis Differential Diagnosis
- Diagnosis
- Schizophrenia Diagnosis
- Associated Conditions
- Anxiety Disorder
- Panic Disorder
- Postraumatic Stress Disorder
- Obsessive Compulsive Disorder
- Management: General
- See Psychosis for acute management
- See Neuroleptic Medications
- Urgent psychiatry referral
- Admission to a controlled setting is preferred for acute Psychosis
- Medication initiation
- Patients should be offered medication management at the time of initial diagnosis
- In the primary care setting, consult with a psychiatrist if considering the start of an Antipsychotic
- Medication adverse effects and monitoring requirements should be discussed prior to starting Antipsychotics
- Do not use a loading dose of Antipsychotics
- Response to first 2-4 weeks of therapy is predictive of longterm response
- Maximal effect may not be evident for months after initiating therapy
- Adjunctive therapy (improves quality of life, relapse rates, Medication Compliance)
- Cognitive Behavioral Therapy should be offered to patients with Schizophrenia
- Family interventions
- Social skill training
- Management: Pitfalls
- Atypical Antipsychotics offer no significant effectiveness benefit over first generation agents
- Select agents based on which adverse effects are expected to be least tolerated
- First generation agents cause Extrapyramidal Side Effects most significantly
- Second generation agents (atypicals) cause weight gain and metabolic changes most significantly
- Patients stop their medications frequently
- Patients who stopped meds within 18 months: 74%
- Relapse is very high risk after stopping medications (within 1-2 years)
- Lieberman (2005) New Engl J Med 353:1209-23 [PubMed]
- Delay in treatment significantly worsens prognosis
- Wyatt (1997) Psychol Med 27:261-8 [PubMed]
- Monotherapy with a single Antipsychotic may be preferred
- However more than 50% of Schizophrenia patients may be on more than one Antipsychotic
- Consider adjunctive use of Antidepressants or mood stabilizers where appropriate
- Consider switching to a different Antipsychotic after an adequate duration and dose
- Consider Clozapine
- If a second Antipsychotic is required, consider an agent that balances the adverse effects of the first
- Barbui (2009) Schizophr Bull 35(2):458-68 [PubMed]
- Prognosis
- High risk of Suicide
- Lifetime risk: 5-10% (13 fold higher than the general population)
- Increased risk with Auditory Hallucinations, Delusions, Substance Abuse or prior Suicide attempt
- Higher rate of overall mortality
- Death rates are 2-3 fold higher than the general population
- Increased risks of cardiovascular disease, respiratory disease, stroke, cancer and Venous Thromboembolism
- References
- (2000) DSM IV, American Psychiatric Association, p. 297-343
- (2013) DSM V, American Psychiatric Association, p. 99
- Freedman (2003) N Engl J Med 349:1738-49 [PubMed]
- Holder (2014) Am Fam Physician 90(11): 775-82 [PubMed]
- Lewis (2000) Neuron 28:325-34 [PubMed]
- Schultz (2007) Am Fam Physician 75:1821-9 [PubMed]