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Schizophrenia

Definition
Schizophrenia is defined as a complex psychiatric condition characterized by symptoms of delusions, hallucinations, disorganized speech, and impaired cognitive functions.
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Pathophysiology
The exact cause of schizophrenia is unclear; however, in utero disorders (infections, obstetric complications, and fetal disturbances), and genetic and environmental factors (childhood trauma, social isolation, economic adversity, discrimination) have been implicated.
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Epidemiology
The annual prevalence of diagnosed schizophrenia in the US is 5.1 per 1,000 individuals.
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Disease course
Abnormalities (hypo/hyper) in neurotransmission of neurotransmitters (dopamine, serotonin, and glutamate), particularly dopamine results in either hyperdopaminergic function in the caudate nucleus or hypodopaminergic function in the frontal lobe, in addition to a complex interaction of nigrostriatal, mesolimbic, mesocortical, and tuberoinfundibular pathway leads to negative symptoms, positive symptoms, and cognitive deficits, in addition to detectable physical changes in the brain tissue.
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Prognosis and risk of recurrence
After 10-year follow up 80% of the schizophrenic patients require readmission after the first discharge. Non-adherence to anti-psychotic medication in the first year is associated with a 64% relapse rate while adherence during the first year is associated with a 27% relapse.
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Key sources
The following summarized guidelines for the evaluation and management of schizophrenia are prepared by our editorial team based on guidelines from the World Health Organization (WHO 2023), the American Psychiatric Association (APA 2020), and the United States Department of Defense (DoD/VA 2019).
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Guidelines

1.Diagnostic investigations

Initial assessment
Include the following in the initial assessment of patients with possible psychotic disorder:
reason the patient is presenting for evaluation
patient's goals and preferences for treatment
review of psychiatric symptoms and trauma history
psychiatric treatment history
assessment of tobacco use and other substance use
assessment of physical health
assessment of psychosocial and cultural factors
mental status examination, including cognitive assessment
assessment of risk of suicide and aggressive behaviors, as outlined in APA's Practice Guidelines for the Psychiatric Evaluation of Adults (3rd edition)
B
Include a quantitative measure in the initial psychiatric evaluation of patients with possible psychotic disorder to identify and determine the severity of symptoms and impairments of functioning that may be a focus of treatment.
B
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2.Medical management

Antipsychotics, indications, WHO: initiate an antipsychotic medication (such as aripiprazole, chlorpromazine, haloperidol, olanzapine, paliperidone, quetiapine, or risperidone) in adult patients with psychotic disorder (including schizophrenia), carefully balancing effectiveness, side effects, and individual preference.
B

More topics in this section

  • Antipsychotics (clozapine)

  • Antipsychotics (long-acting injectable agents)

  • Antipsychotics (management of side effects)

  • Maintenance therapy

3.Nonpharmacologic interventions

General principles
Ensure a documented, comprehensive, and person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments for patients with schizophrenia.
B
Manage patients with schizophrenia experiencing a first episode of psychosis in a coordinated specialty care program.
B

More topics in this section

  • Cognitive therapies (CBT)

  • Cognitive therapies (cognitive remediation)

  • Psychosocial interventions (psychoeducation)

  • Psychosocial interventions (supportive psychotherapy)

  • Psychosocial interventions (community treatment)

  • Psychosocial interventions (family interventions)

  • Psychosocial interventions (skills training)

  • Psychosocial interventions (supported employment)

4.Specific circumstances

Adolescent patients
Consider offering oral antipsychotics (such as aripiprazole, olanzapine, paliperidone, quetiapine, or risperidone) under specialist supervision in adolescent patients with psychotic disorders (including schizophrenia), carefully balancing effectiveness, side effects, and individual preference.
C
Consider offering clozapine in adolescent patients with treatment-resistant psychotic disorder (including schizophrenia) under specialist supervision, carefully balancing effectiveness, side effects, and individual preference.
C

More topics in this section

  • Pregnant patients