1. Schizophrenia Although schizophrenia is discussed as if it is a single disease, it probably comprises a group of disorders with heterogeneous
... [Show More] etiologies, and it includes patients whose clinical presentations, treat- ment response, and courses of illness vary. Signs and symptoms are variable and include changes in perception, emotion, cognition, think- ing, and behavior. 2. Diagnosis, Signs, and Symptoms See Image 3. Typical Age of Schizophrenic onset? 4. The Four As of Schizophrenia 5. Reproductive Factors The disorder usually begins before age 25 years, persist- sthroughout life, and affects persons of all social classes. Autism, Affect, Associations, Ambivalence First-degree biological relatives of persons with schizo- phrenia have a ten times greater risk for developing the disease than the general population. 6. Medical Illness- es: Schizophre- nia 7. Infection and Birth Season Several studies have shown that up to 80 percent of all schizophrenia patients have significant con- current medical illnesses and that up to 50 percent of these conditions may be undiagnosed. Season-specic risk factors, such as a virus or a seasonal change in diet, may be operative. Another hypothesis is that persons with a genetic predisposition for schizophrenia have a de- creased biological advantage to survive season-specific insults. 8. Nicotine Up to 90 percent of schizophrenia patients may be depen- dent on nicotine. Apart from smoking-associated mortali- ty, nicotine decreases the blood concentrations of some antipsy- chotics. There are suggestions that the increased preva- lence in smoking is due, at least in part, to brain abnormalities in nicotinic receptors 9. Population Den- sity The effect of population density is consistent with the observation that the incidence of schizophrenia in children of either one or two parents with schizophrenia is twice as high in cities as in rural commu- nities. These observations suggest that social stressors in urban settings may aect the development of schizophrenia in persons at risk. 10. Socioeconomic and Cultural Factors: Schizophrenia Because schizophrenia begins early in life; causes sig- nificant and long-lasting impairments; makes heavy de- mands for hospital care; and requires ongoing clinical care, reha- bilitation, and support services, the financial cost of the illness in the United States is estimated to exceed that of all cancers combined. Pa- tients with a diagnosis of schizophrenia are reported to account for 15 to 45 percent of homeless Americans. 11. Hospitalization The probability of readmission within 2 years after dis- charge from the first hospitalization is about 40 to 60 percent. Patients with schizophrenia occupy about 50 percent of all mental hospital beds and account for about 16 percent of all psychiatric patients who receive any treatment. 12. ETIOLOGY Genetic Factors: Schizophrenia schizophrenia and schizophrenia-related disorders (e.g., schizotypal personality disorder) occur at an increased rate among the biological relatives of patients with schizophrenia. The likelihood of a person having schizophrenia is correlated with the closeness of the rela- tionship to an aected relative (e.g., rst- or second-degree relative). In the case of monozygotic twins who have identical genetic endow- ment, there is an approximately 50 percent concordance rate for schizophrenia 13. Biochemical Fac- tors: Dopamine Hypothesis. Excessive dopamine release in patients with schizophre- nia has been linked to the severity of positive psychotic symptoms. Position emission tomography studies of dopamine receptors doc- ument an increase in D2 receptors in the caudate nucleus of drug-free patients with schizophrenia. There have also been reports of increased dopamine concentration in the amygdala, decreased den- sity of the dopamine transporter, and increased numbers of dopamine type 4 receptors in the entorhinal cortex. 14. Serotonin Current hypotheses posit serotonin excess as a cause of both positive and negative symptoms in schizophrenia. The robust serotonin antagonist activity of clozapine and other second-generation antipsychotics coupled with the effectiveness of clozapine to decrease positive symptoms in chronic patients has contributed to the validity of this proposition. 15. Norepinephrine Anhedonia—the impaired capacity for emotional grati- fication and the decreased ability to experience plea- sure—has long been noted to be a prominent feature of schizophre- nia. A selective neuronal degeneration within the norepi- nephrine reward neural system could account for this aspect of schizophrenic symptomatology. However, biochemical and pharmaco- logical data bearing on this proposal are inconclusive. 16. GABA The inhibitory amino acid neurotransmitter ³aminobutyric acid (GABA) has been implicated in the pathophysiology of schizophrenia based on the finding that some patients with schizophrenia have a loss of GABAergic neurons in the hippocampus. GABA has a regulatory effect on dopamine activity, and the loss of inhibitory GABAergic neurons could lead to the hyperactivity of dopaminergic neurons. 17. Neuropeptides Neuropeptides, such as substance P and neurotensin, are localized with the catecholamine and indolamine neurotransmitters and influence the action of these neu- rotransmitters. Alteration in neuropeptide mechanisms could facilitate, inhibit, or otherwise alter the pattern of firing these neuronal sys- tems. 18. Glutamate Glutamate has been implicated because ingestion of phencyclidine, a glutamate antagonist, produces an acute syndrome similar to schizophrenia. The hypotheses proposed about glutamate include those of hyperactivity, hypoactivity, and glutamate-induced neurotoxicity. 19. Acetylcholine and Nicotine Postmortem studies in schizophrenia have demonstrat- ed decreased muscarinic and nicotinic receptors in the caudate-putamen, hippocampus, and selected regions of the prefrontal cortex. These receptors play a role in the regulation of neurotransmitter systems involved in cognition, which is impaired in schizophrenia. Also: https://www-ncbi-nlm-nih-gov.ezp.waldenuli- brary.org/pmc/articles/PMC3881431/?report=reader 20. Neuropathology In the 19th century, neuropathologists failed to nd a neuropathological basis for schizophrenia, and thus they classied schizophrenia as a functional disorder. By the end of the 20th century, how- ever, researchers had made signicant strides in revealing a potential neuropathological basis for schizophrenia, primarily in the limbic system and the basal ganglia, including neu- ropathological or neurochemical abnormalities in the cerebral cortex, the thalamus, and the brainstem. The loss of brain volume widely reported in schizophrenic brains appears to result from reduced den- sity of the axons, dendrites, and synapses that mediate associative functions of the brain. 21. Cerebral Ventri- cles Computed tomography (CT) scans of patients with schiz- ophrenia have consistently shown lateral and third ven- tricular enlargement and some reduction in cortical vol- ume. Reduced volumes of cortical gray matter have been demonstrated during the earliest stages of the disease. Several investigators have attempted to determine whether the abnormalities detect- ed by CT are progressive or static. Some studies have concluded that the lesions ob- served on CT scan are present at the onset of the illness and do not progress. Other studies, however, have concluded that the pathological process visualized on CT scan continues to progress during the illness. Thus, whether an active pathological process is continuing to evolve in schizophrenia patients is still uncertain. 22. Reduced Sym- metry There is a reduced symmetry in several brain areas in schizophrenia, including the temporal, frontal, and occipital lobes. This reduced symmetry is believed by some investigators to originate during fetal life and to be indicative of a disruption in brain lateralization during neurodevelopment. 23. Limbic System Because of its role in controlling emotions, the limbic system has been hypothesized to be involved in the pathophysiology of schizophrenia. Studies of postmortem brain samples from schizophrenia patients have shown a decrease in the size of the region, including the amygdala, the hippocampus, and the parahippocampal gyrus. 24. Prefrontal Cortex There is considerable evidence from postmortem brain studies that supports anatomical abnormalities in the prefrontal cortex in schizophrenia. Functional deficits in the prefrontal brain imaging region have also been demonstrated. It has long been noted that several symptoms of schizophrenia mimic those found in persons with prefrontal lobotomies or frontal lobe syndromes. 25. Thalamus Some studies of the thalamus show evidence of volume shrinkage or neuronal loss, in particular subnuclei. The medial dorsal nucleus of the thalamus, which has reciprocal con- nections with the prefrontal cortex, has been reported to contain a reduced number of neurons. The total number of neurons, oligodendrocytes, and astrocytes is reduced by 30 to 45 percent in schizophrenia patients. This puta- tive finding does not appear to be due to the effects of antipsychotic drugs because the volume of the thalamus is similar in size between patients with schizophrenia treated chronically with medication and neuroleptic-naive subjects. 26. Basal Ganglia and Cerebellum The basal ganglia and cerebellum have been of theoreti- cal interest in schizophrenia for at least two reasons. First, many patients with schizophrenia show odd movements, even in the absence of medication-induced movement disorders (e.g., tardive dyskinesia). The odd movements can include an awkward gait, facial grimacing, and stereotypies. Be- cause the basal ganglia and cerebellum are involved in the control of movement, dis- ease in these areas is implicated in the pathophysiology of schizophrenia. 27. Neural Circuits There has been a gradual evolution from conceptualizing schizophrenia as a disorder that involves discrete areas of the brain to a perspective that views schizophrenia as a disorder of brain neural circuits. For example, as mentioned previous- ly, the basal ganglia and cerebellum are reciprocally connected to the frontal lobes, and the abnormalities in frontal lobe function seen in some brain imaging studies may be due to disease in either area rather than in the frontal lobes themselves 28. Brain Metabo- lism Studies using magnetic resonance spectroscopy, a tech- nique that measures the concentration of specic mole- cules in the brain, found that patients with schizophrenia had lower levels of phospho- monoester and inorganic phosphate and higher levels of phosphodiester than a control group. Furthermore, concentrations of N-acetyl aspartate, a marker of neurons, were lower in the hip- pocampus and frontal lobes of patients with schizophrenia. 29. Applied Electro- physiology 30. Complex Partial Epilepsy 31. Evoked Poten- tials Electroencephalographic studies indicate that many schizophrenia patients have abnormal records, increased sensitivity to activation procedures (e.g., frequent spike activity after sleep de- privation), decreased alpha activity, increased theta and delta activity, possibly more epileptiform activity than usual, and possibly more left-sided abnormalities than usual. Schizophrenia pa- tients also exhibit an inability to lter out irrelevant sounds and are extremely sensitive to background noise. Schizophrenia-like psychoses have been reported to oc- cur more frequently than expected in patients with complex partial seizures, especially seizures involving the temporal lobes. Factors associated with the development of psychosis in these patients include a left-sided seizure focus, medial tempo- ral location of the lesion, and an early onset of seizures. The first-rank symptoms described by Schneider may be similar to symptoms of patients with complex partial epilepsy and may reflect the presence of a temporal lobe disorder when seen in patients with schizophrenia. A large number of abnormalities in evoked potential among patients with schizophrenia has been described. The P300 has been most studied and is defined as a large, positive evoked-potential wave that occurs about 300 milliseconds after a sensory stimulus is detected. The major source of the P300 wave may be located in the limbic system structures of the medial temporal lobes. In patients with schizophrenia, the P300 has been report- ed to be statistically smaller than in comparison groups. Abnormalities in the P300 wave have also been reported to be more common in children who, because they have affected parents, are at high risk for schizophrenia. 32. Eye Movement Dysfunction 33. Psychoneuroim- munology The inability to follow a moving visual target accurately is the dening basis for the disorders of smooth visual pursuit and disinhibition of saccadic eye movements seen in patients with schizo- phrenia. Eye movement dysfunction may be a trait marker for schizophrenia; it is independent of drug treatment and clinical state and is also seen in rst-degree relatives of probands with schiz- ophrenia. Various studies have reported abnormal eye movements in 50 to 85 per- cent of patients with schizophrenia compared with about 25 percent in psychiatric patients without schizophrenia and fewer than 10 percent in nonpsychiatrically ill control participant Many reports describe neuroendocrine dierences be- tween groups of patients with schizophrenia and groups of control subjects. For example, results of the dexamethasone-suppression test have been reported to be abnormal in various subgroups of patients with schizophrenia, although the practical or predictive value of the test in schizophrenia has been questioned. One carefully done report, however, has correlated persistent nonsuppression on the dexamethasone-suppression test in schizophrenia with a poor long-term outcome. Some data suggest decreased concentrations of luteiniz- ing hormone or follicle-stimulating hormone, perhaps cor- related with age of onset and length of illness. Two additional reported abnormal- ities may be correlated with the presence of negative symptoms: a blunted release of prolactin and growth hormone on gonadotropin-releasing hormone or thyrotropin-releasing hormone stimulation and a blunted release of growth hormone on apomorphine stimulation. 34. PSYCHOSO- CIAL AND PSYCHOANA- LYTIC THEORIES 35. Learning Theo- ries Sigmund Freud postulated that schizophrenia resulted from developmental fixations early in life. These fixations produce defects in ego development, and he postulated that such defects contributed to the symptoms of schizophrenia. Ego disintegration in schizophrenia represents a return to the time when the ego was not yet developed or had just begun to be established. Because the ego affects the interpretation of reality and the control of inner drives, such as sex and aggression, these ego functions are impaired. Thus, intrapsychic conflict arising from the early fixations and the ego defect, which may have resulted from poor early object relations, fuel the psychotic symptoms. According to learning theorists, children who later have schizophrenia learn irrational reactions and ways of thinking by imitating parents who have their own signif- icant emotional problems. In learning theory, the poor interpersonal relationships of persons with schizophrenia develop because of poor models for learning during childhood. 36. Family Dynamics In a study of British 4-year-old children, those who had a poor mother-child relationship had a sixfold increase in the risk of developing schizophrenia, and ospring from schizophrenic mothers who were adopted away at birth were more likely to de- velop the illness if they were reared in adverse circumstances compared with those raised in loving homes by stable adoptive parents. 37. Double Bind An example of a double bind is a parent who tells a child to provide cookies for his or her friends and then chastises the child for giving away too many cookies to playmates. 38. Schisms and Theodore Lidz described two abnormal patterns of family Skewed Families behavior. In one family type, with a prominent schism between the parents, one parent is overly close to a child of the opposite gender. In the other family type, a skewed relationship between a child and one parent involves a power struggle between the parents and the resulting dominance of one parent. These dynamics stress the ten- uous adaptive capacity of the person with schizophrenia. 39. Pseudomutual As described by Lyman Wynne, some families suppress and emotional expression by Pseudohostile consistently using pseudomutual or pseudohostile verbal Families communication. In such families, a unique verbal com- munication develops, and when a child leaves home and must relate to other persons, problems may arise. The child's verbal communication may be incomprehensible to outsiders. 40. Expressed Emo- Parents or other caregivers may behave with overt criti- tion cism, hostility, and overinvolvement toward a person with schizophrenia. Many studies have indicated that in fam- ilies with high levels of expressed emotion, the relapse rate for schizophrenia is high. The assessment of expressed emotion involves analyzing both what is said and the manner in which it is said. 41. Schizophrenia Diagnosis 42. Subtypes: schiz- ophrenia The DSM-5 diagnostic criteria include course speciers (i.e., prognosis) that oer clinicians several options and describe actual clinical situations (Table 7.1-1). The presence of hallucinations or delusions is not necessary for a diagnosis of schizophre- nia; the patient's disorder is diagnosed as schizophrenia when the patient exhibits two of the symptoms listed in symptoms 1 through 5 of Criterion A in Table 7.1-1 (e.g., disorganized speech). Criterion B requires that im- paired functioning, although not deteriorations, be pre- sent during the active phase of the illness. Symptoms must persist for at least 6 months, and a diagnosis of schizoaffective disorder or mood dis- order must be absent. Five subtypes of schizophrenia have been described based predominantly on clinical presentation: paranoid, disorganized, catatonic, undierentiated, and residual. DSM-5 no longer uses these subtypes but they are listed in the 10th revision of the International Statistical Classication of Diseases and Related Health Problems (ICD-10). They are included in this text because the au- thors believe them to be of clinical signicance and they are still used by most clini- cians in the United States and around the world to de- scribe the phenomenology of schizophrenia. 43. Paranoid Type The paranoid type of schizophrenia is characterized by preoccupation with one or more delusions or frequent auditory hallucinations. Classically, the paranoid type of schizophrenia is characterized mainly by the presence of 44. Disorganized Type delusions of persecution or grandeur (Fig. 7.1-4). Patients with paranoid schizo- phrenia usually have their first episode of illness at an older age than do patients with catatonic or disorganized schizophrenia. Patients in whom schizophrenia occurs in the late 20s or 30s have usually established a social life that may help them through their illness, and the ego resources of paranoid patients tend to be greater than those of patients with catatonic and disorganized schizophrenia. Patients with the para- noid type of schizophrenia show less regression of their mental faculties, emotional responses, and behavior than do patients with other types of schizophrenia. The disorganized type of schizophrenia is characterized by a marked regression to primitive, disinhibited, and unorganized behavior and by the absence of symptoms that meet the criteria for the catatonic type. The onset of this subtype is generally early, occurring before age 25 years. Disorganized pa- tients are usually active but in an aimless, nonconstructive manner. Their thought disorder is pronounced, and their contact with reality is poor. Their personal appearance is disheveled, and their social behavior and their emotional responses are inappropriate. They often burst into laughter without any apparent reason. Incongruous grinning and grimacing are common in these patients, whose behavior is best de- scribed as silly or fatuous. 45. Catatonic Type The catatonic type of schizophrenia, which was common several decades ago, has become rare in Europe and North America. The classic feature of the catatonic type is a marked disturbance in motor function; this disturbance may involve stupor, negativism, rigidity, excitement, or posturing. Sometimes the patient shows a rapid alteration between extremes of excitement and stupor. Associated features include stereotypies, mannerisms, and waxy flexibility. Mutism is particularly common. Dur- ing catatonic excitement, patients need careful supervision to prevent them from hurting themselves or others. Medical care may be need- ed because of malnutrition, exhaustion, hyperpyrexia, or self-inflicted injury. 46. Undifferentiated Type Frequently, patients who clearly have schizophrenia can- not be easily fit into one type or another. These patients are classified as having schizophrenia of the undifferentiated type. 47. Residual Type nia is characterized by continuing evidence of the schiz- ophrenic disturbance in the sis of another type of schizophrenia. Emotio absence of a comple nal blunting, social withdrawal, eccentric behavior, illogical thinking, and mild loosening of associations c residual type. When delusions or hallucinations occur, they are neither prominent nor accompanied by strong affect. 48. Bouffée Déli- rante (Acute Delusional Psychosis). This French diagnostic concept differs from a diagnosis of schizophrenia primarily on the basis of a symptom duration of less than 3 months. The diagnosis is similar to the DSM-5 diagnosis of schizophreniform disorder. French clinicians report that about 40 percent of patients with a diagnosis of bouffée délirante progress in their illness and are eventually classified as having schizophrenia. 49. Latent Latent schizophrenia, for example, was often the diagno- sis used for what are now called borderline, schizoid, and schizotypal personality disorders. These patients may occasionally show peculiar behaviors or thought disorders but do not consistently manifest psychotic symptoms. In the past, the syndrome was also termed borderline schizophrenia. 50. Oneiroid The oneiroid state refers to a dream-like state in which patients may be deeply perplexed and not fully oriented in time and place. The term oneiroid schizophrenia has been used for patients who are engaged in their hallucinatory experi- ences to the exclusion of involvement in the real world. When an oneiroid state is present, clinicians should be particularly careful to exam- ine patients for medical or neurological causes of the symptoms. 51. Paraphrenia The term paraphrenia is sometimes used as a synonym for paranoid schizophrenia or for either a progressively deteriorating course of illness or the presence of a well-systemized delusional system. The multiple mean- ings of the term render it ineffectual in communicating information. 52. Pseudoneurotic Occasionally, patients who initially have such symptoms Schizophrenia as anxiety, phobias, obsessions, and compulsions later reveal symptoms of thought disor- der and psychosis. These patients are characterized by symptoms of pananxiety, panphobia, panambivalence, and sometimes chaotic sex- uality. Unlike persons with anxiety disorders, pseudoneu- rotic patients have freefloating anxiety that rarely subsides. In clinical descriptions, the patients seldom become overtly and severely psychotic. This condition is currently diagnosed as borderline personality disorder. 53. Simple Deterio- rative Disorder 54. Postpsychotic Depressive Disorder of Schizophrenia 55. Early-Onset Schizophrenia (Simple Schizophrenia). Simple deteriorative disorder is characterized by a gradual, insidious loss of drive and ambition. Patients with the disorder are usually not overtly psychotic and do not experience persistent hallucinations or delusions. Their primary symptom is withdrawal from so- cial and work-related situations. The syndrome must be differentiated from depression, a phobia, a dementia, or an exacerbation of personality traits. Clinicians should be sure that patients truly meet the diagnostic criteria for schizophrenia before making the diagnosis. After an acute schizophrenia episode, some patients be- come depressed. The symptoms of postpsychotic depressive disorder of schizophrenia can closely resemble the symptoms of the residual phase of schizophrenia and the adverse effects of commonly used antipsychotic medications. The diagnosis should not be made if they are substance induced or part of a mood disorder due to a general medical condition. These depressive states occur in up to 25 percent of patients with schizophrenia and are associated with an increased risk of suicide. A small minority of patients manifest schizophrenia in childhood. Such children may at first present diagnostic problems, particularly with differentiation from mental retardation and autistic disorder. Recent studies have established that the diagnosis of childhood schizophrenia may be based on the same symptoms used for adult schizophrenia. Its onset is usually insidious, its 56. Late-Onset Schizophrenia 57. Deficit Schizo- phrenia 58. CLINICAL FEA- TURES course tends to be chronic, and the prognosis is mostly unfavorable. Late-onset schizophrenia is clinically indistinguishable from schizophrenia but has an onset after age 45 years. This condition tends to appear more frequently in women and tends to be characterized by a predominance of paranoid symptoms. The prognosis is favorable, and these patients usually do well on antipsychotic medication. In the 1980s, criteria were promulgated for a subtype of schizophrenia characterized by enduring, idiopathic negative symptoms. These patients were said to exhibit the deficit syndrome. This group of patients is now said to have deficit schizophrenia (see the criteria for that putative disease diagnosis in Table 7.1-2). Patients with schizophrenia with positive symptoms are said to have nondeficit schizophrenia. The symptoms used to define deficit schizophrenia are strongly interre- lated, although various combinations of the six negative symptoms in the criteria can be found. A discussion of the clinical signs and symptoms of schiz- ophrenia raises three key issues. First, no clinical sign or symptom is pathognomonic for schizophrenia; every sign or symptom seen in schizo- phrenia occurs in other psychiatric and neurological dis- orders. This observation is contrary to the often-heard clinical opinion that certain signs and symptoms are diagnostic of schizophrenia. Therefore, a patient's history is essential for the diagnosis of schizophrenia; clinicians cannot diagnose schizophrenia simply by results of a mental status examination, which may vary. Second, a patient's symptoms change with time. 59. Premorbid Signs and Symptoms 60. Prodromal Signs of Schizophrenia In theoretical formulations of the course of schizophrenia, premorbid signs and symptoms appear before the prodro- mal phase of the illness. The dierentiation implies that premorbid signs and symp- toms exist before the disease process evidences itself and that the prodromal signs and symptoms are parts of the evolving disorder. In the typical, but not invariable, premorbid history of schizo- phrenia, patients had schizoid or schizotypal personalities characterized as quiet, pas- sive, and introverted; as children, they had few friends. Preschizophrenic adolescents may have no close friends and no dates and may avoid team sports. They may enjoy watching movies and televi- sion, listening to music, or playing computer games to the exclusion of social activi- ties. Some adolescent patients may show a sudden onset of obsessive-compulsive behavior as part of the prodromal picture. The validity of the prodromal signs and symptoms, almost invariably recognized after the diagnosis of schizophrenia has been made, is uncertain; after schizophrenia is diagnosed, the retro- spective remembrance of early signs and symptoms is aected. Nevertheless, although the rst hospitalization is often believed to mark the begin- ning of the disorder, signs and symptoms have often been present for months or even years. The signs may have started with complaints about somatic symptoms, such as headache, back and 61. Mental Status Examination 62. Mood, Feelings, and Affect muscle pain, weakness, and digestive problems. The initial diagnosis may be malinger- ing, chronic fatigue syndrome, or somatization disorder. Family and friends may eventually notice that the person has changed and is no longer functioning well in occupational, social, and personal activities. During this stage, a patient may begin to develop an interest in ab- stract ideas, philosophy, and the occult or religious ques- tions (Fig. 7.1-5). Additional prodromal signs and symptoms can include markedly pe- culiar behavior, abnormal aect, unusual speech, bizarre ideas, and strange perceptual experiences. The appearance of a patient with schizophrenia can range from that of a completely disheveled, screaming, agitated person to an obsessively groomed, completely silent, and immobile person. Between these two poles, patients may be talkative and may exhibit bizarre postures. Their behavior may become agitated or violent, apparently in an unprovoked manner, but usually in response to hallucinations. In contrast, in catatonic stupor, often referred to as catatonia, patients seem completely lifeless and may exhibit such signs as muteness, negativism, and automatic obedience. Two common aective symptoms in schizophrenia are reduced emotional responsiveness, sometimes severe enough to warrant the label of anhedonia, and overly active and inappropriate emotions such as extremes of rage, happiness, and anxiety. A at or blunted aect can be a symptom of the illness itself, of the parkinsonian adverse eects of antipsychotic medications, or of depression, and dierentiating these 63. Perceptual Dis- turbances 64. Cenesthetic Hal- lucinations symptoms can be a clinical challenge. Overly emotional patients may describe exultant feelings of omnipotence, religious ecstasy, terror at the disintegration of their souls, or paralyzing anxiety about the destruction of the universe. Other feeling tones include perplexity, a sense of isolation, overwhelming ambivalence, and depression HALLUCINATIONS. Any of the five senses may be affect- ed by hallucinatory experiences in patients with schizo- phrenia. The most common hallucinations, however, are auditory, with voices that are often threatening, obscene, accusatory, or insulting. Two or more voices may converse among themselves, or a voice may comment on the patient's life or behavior. Visual hallucinations are common (Fig. 7.1-6), but tactile, olfactory, and gustatory hallucinations are unusu- al; their presence should prompt the clinician to consider the possibility of an underlying medical or neurological disorder that is caus- ing the entire syndrome. Cenesthetic hallucinations are unfounded sensations of altered states in bodily organs. Examples of cenesthetic hallucinations include a burning sensation in the brain, a pushing sensation in the blood vessels, and a cutting sensation in the bone marrow. Bodily distortions may also occur. 65. ILLUSIONS. As differentiated from hallucinations, whereas illusions are distortions of real images or sensations, hallucina- tions are not based on real images or sensations. Illusions can occur in schiz- ophrenia patients during active phases, but they can also occur during the prodromal phases and during periods of remission. Whenever illusions or hallucinations occur, clinicians should consider the possibility of a substance-related cause for the symptoms, even when patients have already received a diagnosis of schizophrenia. 66. Thought Disorders of thought are the most difficult symptoms for many clinicians and students to understand, but they may be the core symptoms of schizophrenia. Dividing the disorders of thought into disorders of thought content, form of thought, and thought process is one way to clarify them. 67. THOUGHT CON- Disorders of thought content reflect the patient's ideas, TENT beliefs, and interpretations of stimuli. Delusions, the most obvious example of a disorder of thought content, are varied in schizophrenia and may assume persecutory, grandiose, religious, or somatic forms. Patients may believe that an outside entity controls their thoughts or behavior or, conversely, that they control out- side events in an extraordinary fashion (such as causing the sun to rise and set or by preventing earthquakes). Patients may have an intense and consuming preoccupation with esoteric, abstract, symbolic, psycho- logical, or philosophical ideas. Patients may also worry about allegedly lifethreatening but bizarre and implausible somatic conditions, such as the presence of aliens inside the patient's testicles afect- ing his ability to father children 68. The phrase loss describes the lack of a clear sense of where the patient's of ego bound- own body, mind, and inuence end and where aries those of other animate and inanimate objects begin. For example, patients may think that other persons, the tele- vision, or the newspapers are referring to them (ideas of reference). Other symp- toms of the loss of ego boundaries include the sense that the patient has physically fused with an outside object (e.g., a tree or another per- son) or that the patient has disintegrated and fused with the entire universe (cosmic identity). With such a state of mind, some patients with schizophrenia doubt their gender or their sexual orienta- tion. These symptoms should not be confused with transvestism, transsexuality, or other gender identity problems. 69. FORM OF Disorders of the form of thought are objectively observ- THOUGHT able in patients' spoken and written language (Fig. 7.1-7). The disorders include looseness of associations, derailment, incoherence, tangentiality, circumstantiality, neologisms, echolalia, verbigeration, word salad, and mutism. Although looseness of associa- tions was once described as pathognomonic for schizo- phrenia, the symptom is frequently seen in mania. Distinguishing between loose- ness of associations and tangentiality can be difficult for even the most experienced clinicians. 70. Impulsiveness Patients with schizophrenia may be agitated and have little impulse control when ill. They may also have decreased social sensitivity and appear to be impulsive when, for example, they grab another patient's cigarettes, change television channels abruptly, or throw food on the floor. Some apparently impulsive behavior, including suicide and homicide attempts, may be in response to hallucinations commanding the patient to act. 71. VIOLENCE Violent behavior (excluding homicide) is common among untreated schizophrenia patients. Delusions of a perse- cutory nature, previous episodes of violence, and neurological deficits are risk factors for violent or impulsive behavior. Manage- ment includes appropriate antipsychotic medication. Emergency treatment consists of restraints and seclusion. Acute sedation with lo- razepam (Ativan), 1 to 2 mg intramuscularly, repeated every hour as needed, may be necessary to prevent the patient from harming others. If a clinician feels fearful in the presence of a schizophrenia patient, it should be taken as an internal clue that the patient may be on the verge of acting out violently. In such cases, the interview should be terminated or be conducted with an attendant at the ready. 72. SUICIDE Suicide is the single leading cause of premature death among people with schizophrenia. Suicide attempts are made by 20 to 50 percent of the patients, with long-term rates of suicide estimated to be 10 to 13 percent. According to DSM-5 approximately 5 to 6 percent of schizophrenic patients die by suicide, but this is prob- ably an underestimation. Often, suicide in schizophrenia seems to occur "out of the blue," without prior warnings or expressions of verbal intent. 73. Orientation Patients with schizophrenia are usually oriented to per- son, time, and place. The lack of such orientation should prompt clinicians to investigate the possibility of a medical or neu- rological brain disorder. Some patients with schizophrenia may give incorrect or bizarre answers to questions about orientation, for exam- ple, "I am Christ; this is heaven; and it is AD 35." 74. Memory Memory, as tested in the mental status examination, is usually intact, but there can be minor cognitive deficien- cies. It may not be possible, however, to get the patient to attend closely enough to the memory tests for the ability to be assessed adequately 75. Cognitive Impair- ment 76. Judgment and Insight An important development in the understanding of the psychopathology of schizophrenia is an appreciation of the importance of cognitive impairment in the disorder. In outpatients, cognitive impairment is a better predictor of level of function than is the severity of psychotic symptoms. Patients with schizophrenia typically exhibit subtle cognitive dysfunc- tion in the domains of attention, executive function, working memory, and episodic memory. Although a substantial percentage of patients have normal intelligence quotients, it is possible that every person who has schizophrenia has cognitive dysfunction compared with what he or she would be able to do without the disorder. Although these im- pairments cannot function as diagnostic tools, they are strongly related to the functional outcome of the illness and, for that reason, have clinical value as prognostic variables, as well as for treatment planning. Classically, patients with schizophrenia are described as having poor insight into the nature and the severity of their disorder. The so-called lack of insight is associated with poor compliance with treatment. When examining schizophrenia patients, clinicians should carefully define various aspects of in- sight, such as awareness of symptoms, trouble getting along with people, and the reasons for these problems. Such information can be clinically useful in tailoring a treatment strategy and the- oretically useful in postulating what areas of the brain contribute to the observed lack of insight (e.g., the parietal lobes). 77. Reliability Localizing and nonlocalizing neurological signs (also known as hard and soft signs, respectively) have been reported to be more common in patients with schizophre- nia than in other psychiatric patients. Nonlocalizing signs include dysdiadochokinesia, astereognosis, primitive reflexes, and diminished dexterity. The presence of neurological signs and symptoms correlates with increased severity of illness, affective blunting, and a poor prognosis. Other abnormal neurological signs in- clude tics, stereotypies, grimacing, impaired fine motor skills, abnormal motor tone, and abnormal movements. 78. Eye Examination In addition to the disorder of smooth ocular pursuit (sac- cadic movement), patients with schizophrenia have an elevated blink rate. The elevated blink rate is believed to reflect hyperdopaminergic activity. In primates, blinking can be increased by dopamine agonists and reduced by dopamine antago- nists. 79. Speech Although the disorders of speech in schizophrenia (e.g., looseness of associations) are classically considered to indicate a thought disorder, they may also indicate a forme fruste of aphasia, perhaps implicating the dominant parietal lobe. The inability of schizophrenia patients to perceive the prosody of speech or to inflect their own speech can be seen as a neurological symptom of a disorder in the nondominant parietal lobe. Other parietal lobe-like symptoms in schizophrenia include the inability to carry out tasks (i.e., apraxia), right-left disorientation, and lack of concern about the disorder. 80. Obesity Patients with schizophrenia appear to be more obese, with higher body mass indexes (BMIs) than age- and gender-matched cohorts in the general population. This is due, at least in part, to the effect of many antipsychotic medications, as well as poor nutritional balance and decreased motor activity. This weight gain, in turn, contributes to an increased risk of cardiovascular morbidity and mortality, an increased risk of diabetes, and other obesity-related conditions such as hyperlipidemia and obstructive sleep apnea. 81. Diabetes Mellitus Schizophrenia is associated with an increased risk of type II diabetes mellitus. This is probably due, in part, to the association with obesity noted previously, but there is also evidence that some antipsychotic medications cause diabetes through a direct mechanism 82. Cardiovascular Disease Many antipsychotic medications have direct effects on cardiac electrophysiology. In addition, obesity; increased rates of smoking, diabetes, hyperlipidemia; and a sedentary lifestyle all independently increase the risk of cardiovascular morbidity and mortality. 83. HIV Patients with schizophrenia appear to have a risk of HIV infection that is 1.5 to 2 times that of the general popula- tion. This association is thought to be due to increased risk be- haviors, such as unprotected sex, multiple partners, and increased drug use. 84. Chronic Obstruc- tive Pulmonary Disease 85. Rheumatoid Arthritis 86. 86. Rates of chronic obstructive pulmonary disease are re- portedly increased in schizophrenia compared with the general population. The increased prevalence of smoking is an obvious contribu- tor to this problem and may be the only cause. Patients with schizophrenia have approximately one-third the risk of rheumatoid arthritis that is found in the general population. This inverse association has been replicated several times, the significance of which is unknown. Secondary Psy- chotic Disorders 87. Differential Diagnosis of Schizophre- nia-Like Symptoms 88. Other Psychotic Disorders Secondary Psychotic Disorders A wide range of nonpsychiatric medical conditions and a variety of substances can induce symptoms of psychosis and catatonia (Table 7.1- 3). The most appropriate diagnosis for such psychosis or catatonia is psychotic disorder due to a general medical condition, catatonic disorder due to a general medical condition, or sub- stance-induced psychotic disorder. See Graphic The psychotic symptoms of schizophrenia can be identi- cal with those of schizophreniform disorder, brief psychot- ic disorder, schizoaective disorder, and delusional disorders. Schizophreniform dis- order diers from schizophrenia in that the symptoms have a duration of at least 1 month but less than 6 months. Brief psychotic disorder is the appropriate diagnosis when the symptoms have lasted at least 1 day but less than 1 month and when the patient has not returned to the premorbid state of functioning within that time. There may also be a precipitating traumatic event. When a manic or depressive syndrome develops concurrently with the major symp- toms of schizophrenia, schizoaective disorder is the appropriate diagnosis. Non- bizarre delusions present for at least 1 month without other symptoms of schizophrenia or a mood disorder warrant the diagnosis of delusional disorder. 89. Mood Disorders A patient with a major depressive episode may present with delusions and hallucinations, whether the patient has unipolar or bipolar mood disorder. Delusions seen with psychotic depression are typically mood congruent and involve themes such as guilt, self-depreciation, deserved punishment, and incurable illnesses. In mood disorders, psychotic symptoms resolve completely with the resolution of depression. A depressive episode that is this severe may also result in loss of functioning, decline in self-care, and social isolation, but these are secondary to the depressive symptoms and should not be confused with the negative symptoms of schizophrenia. 90. Personality Dis- orders 91. Malingering and Factitious Disor- ders Various personality disorders may have some features of schizophrenia. Schizotypal, schizoid, and borderline personality disorders are the personality disorders with the most similar symptoms. Severe obsessive-compulsive personality disorder may mask an underlying schizophrenic process. Personality disorders, unlike schizophrenia, have mild symptoms and a history of oc- curring throughout a patient's life; they also lack an identifiable date of onset. may be an appropriate diagnosis. Persons have faked schizophrenic symptoms and have been admitted into and treated at psychiatric hospitals. The condition of patients who are completely in control of their symptom production may qualify for a diagnosis of malingering; such patients usually have some obvious nancial or legal reason to want to be considered mentally ill. The condition of patients who are less in control of their falsication of psychotic symptoms may qualify for a diagnosis of factitious disorder. Some patients with schizophrenia, however, may falsely com- plain of an exacerbation of psychotic symptoms to obtain increased assistance benets or to gain admission to a hospital. 92. COURSE AND A premorbid pattern of symptoms may be the best evi- PROGNOSIS: dence of illness, although the importance of the symp- Course toms is usually recognized only retrospectively. Characteristically, the symptoms begin in adolescence and are followed by the development of prodromal symptoms in days to a few months. Social or environmental changes, such as going away to college, using a substance, or a relative's death, may precipitate the disturbing symptoms, and the prodromal syndrome may last a year or more before the onset of overt psychotic symptoms. The classic course of schizophrenia is one of exacerba- tions and remissions. After the rst psychotic episode, a patient gradually recovers and may then function relatively normally for a long time. 93. Prognosis Several studies have shown that over the 5- to 10-year period only about 10 to 20 percent of patients can be de- scribed as having a good outcome. More than 50 percent of patients can be described as having a poor outcome, with repeated hospitalizations, exacerbations of symptoms, episodes of major mood disorders, and suicide attempts. Despite these glum figures, schizophrenia does not always run a deteri- orating course, and several factors have been associated with a good prognosis 94. Features Weight- See Graphic ing Toward Good to Poor Progno- sis in Schizo- phrenia 95. TREATMENT Although antipsychotic medications are the mainstay of the treatment for schizophrenia, research has found that psychosocial interventions, including psychotherapy, can augment the clinical im- provement. Just as pharmacological agents are used to treat presumed chemical imbalances, nonpharmacological strategies must treat nonbiological issues. The complexity of schizophrenia usually renders any single therapeutic approach inadequate to deal with the multi- faceted disorder. Psychosocial modalities should be inte- grated into the drug treatment regimen and should support it. Patients with schizophrenia benefit more from the combined use of antipsychotic drugs and psychosocial treatment than from either treatment used alone. 96. Hospitalization Hospitalization is indicated for diagnostic purposes; for stabilization of medications; for patients' safety because of suicidal or homicidal ideation; and for grossly disorganized or inappropriate behavior, including the inability to take care of basic needs such as food, clothing, and shelter. Establishing an effective association between patients and community support systems is also a prima- ry goal of hospitalization. 97. Pharmacothera- py The drugs used to treat schizophrenia have a wide variety of pharmacological properties, but all share the capacity to antagonize postsynaptic dopamine receptors in the brain. Antipsy- chotics can be categorized into two main groups: the older conventional antipsychotics, which have also been called rst-gener- ation antipsychotics or dopamine receptor antagonists, and the newer drugs, which have been called second-generation antipsychotics or serotonin dopamine antagonists (SDAs). [Show Less]