Schizophrenia

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