Psychosis
Schizophrenia
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Schizophrenia
See Also
Schizophrenia Diagnosis
Psychosis
Psychosis Symptoms
Psychosis Exam
Psychosis Type
s
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
Antipsychotic
s 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 Type
s
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
Gene
ral
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
Antipsychotic
s
Do not use a loading dose of
Antipsychotic
s
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 Antipsychotic
s 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 Effect
s 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
Antidepressant
s 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 Hallucination
s,
Delusion
s,
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]
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