Schizophrenia

1. Introduction

  • Definition: Schizophrenia is a chronic and severe mental health disorder characterised by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions.
  • Epidemiology: Affects approximately 1% of the global population, with onset typically between ages 15–35. Equal prevalence in men and women, though men often develop symptoms earlier.
  • Significance: Schizophrenia is one of the top causes of disability worldwide, profoundly affecting quality of life and requiring lifelong management.

2. Causes and Risk Factors

  • Causes:
    • Genetic predisposition: Family history of schizophrenia increases risk.
    • Neurobiological factors: Imbalance in dopamine and glutamate neurotransmitter systems.
    • Environmental factors: Prenatal infections, malnutrition, or stress during pregnancy.
  • Risk Factors:
    • Urban upbringing or social adversity.
    • Cannabis use, particularly in adolescence.
    • Childhood trauma or abuse.

3. Pathophysiology

  • Dysregulation of dopamine pathways, particularly hyperactivity in the mesolimbic system, leads to positive symptoms (e.g., hallucinations, delusions), while hypofunction in the mesocortical pathway contributes to negative symptoms (e.g., emotional flatness, social withdrawal). Structural brain abnormalities, such as enlarged ventricles, are also observed.

4. Symptoms and Features

  • Positive Symptoms:
    • Hallucinations (commonly auditory).
    • Delusions (false, fixed beliefs, e.g., persecution or grandeur).
    • Disorganised speech and behaviour.
  • Negative Symptoms:
    • Affective flattening (reduced emotional expression).
    • Alogia (poverty of speech).
    • Anhedonia (inability to feel pleasure).
  • Cognitive Symptoms:
    • Impaired memory, attention, and executive functioning.
  • Mood Symptoms:
    • Depression, anxiety, and suicidal thoughts.

5. Complications

  • Impaired social and occupational functioning.
  • Increased risk of substance abuse and homelessness.
  • Suicidal behaviour (5–10% lifetime risk).
  • Higher risk of physical health conditions, such as cardiovascular disease and diabetes, due to lifestyle factors and side effects of medications.

6. Diagnosis

  • Clinical Features: Symptoms persisting for at least six months, with at least one month of active-phase symptoms.
  • DSM-5 Criteria: Requires two or more of the following, with at least one being a positive symptom:
    1. Delusions.
    2. Hallucinations.
    3. Disorganised speech.
    4. Grossly disorganised or catatonic behaviour.
    5. Negative symptoms.
  • Exclusion of Other Conditions: Rule out schizoaffective disorder, bipolar disorder, or substance-induced psychosis.

7. Management Overview

  • Goals: Alleviate symptoms, prevent relapse, and improve functioning and quality of life.
  • Approach: Combination of pharmacological treatment, psychotherapy, and psychosocial interventions.

8. Treatment Options with Cost (USD)

  • First-line Medications:
    • Atypical antipsychotics (e.g., risperidone): ~$30–$150/month.
  • Adjunctive Therapies:
    • Cognitive-behavioural therapy (CBT): ~$100–$250/session.
  • Long-Acting Injectable Antipsychotics: ~$1,000–$2,500/month.

9. Advanced Treatment Options with Cost (USD)

  • Clozapine: For treatment-resistant schizophrenia (~$200–$500/month).
  • Electroconvulsive Therapy (ECT): ~$500–$1,000/session for severe catatonic symptoms.
  • Transcranial Magnetic Stimulation (TMS): ~$5,000–$15,000 per treatment course for cognitive and negative symptoms.

10. Pharmacological Treatment

  • First-line: Atypical antipsychotics such as risperidone, olanzapine, or quetiapine.
  • Second-line: Clozapine for treatment-resistant cases.
  • Adjunctive: Mood stabilisers or antidepressants for co-occurring mood symptoms.

11. Medication Tables

Table 1: Doses and Side Effects

DrugIndicationDoseCommon Side Effects
RisperidoneFirst-line atypical antipsychotic2–6 mg/dayWeight gain, sedation, prolactin elevation
OlanzapineSevere psychotic symptoms10–20 mg/dayMetabolic syndrome, sedation
ClozapineTreatment-resistant schizophrenia100–450 mg/dayAgranulocytosis, weight gain, seizures
AripiprazoleAdjunctive for mood symptoms10–30 mg/dayAkathisia, headache
HaloperidolSevere psychotic episodes5–15 mg/dayExtrapyramidal symptoms, tardive dyskinesia

Table 2: Brand Names and Approximate Costs (USD)

DrugBrand NamesApprox. Cost
RisperidoneRisperdal$30–$150 per month
OlanzapineZyprexa$100–$300 per month
ClozapineClozaril$200–$500 per month
AripiprazoleAbilify$200–$500 per month
HaloperidolHaldol$20–$100 per month

12. Lifestyle Interventions

  • Promote regular physical activity to reduce risk of weight gain and metabolic syndrome.
  • Balanced diet rich in nutrients to counteract medication side effects.
  • Avoid substance use, particularly cannabis, which can worsen symptoms.
  • Maintain a consistent daily routine to improve sleep and reduce stress.

13. Monitoring Parameters

  • Regular monitoring of medication side effects (e.g., metabolic parameters, prolactin levels).
  • Assessment of symptom severity using scales like the Positive and Negative Syndrome Scale (PANSS).
  • Regular blood work for clozapine users to monitor for agranulocytosis.

14. Patient Counseling Points

  • Educate on the chronic nature of schizophrenia and the importance of long-term treatment adherence.
  • Discuss potential side effects of medications and strategies to manage them.
  • Encourage regular follow-ups with healthcare providers to monitor progress.
  • Address stigma and provide resources for support groups or community programs.

15. Special Populations

  • In Adolescents: Monitor closely for early-onset schizophrenia; start with low-dose atypical antipsychotics.
  • In Pregnancy: Avoid teratogenic medications; use safer options like clozapine or olanzapine if necessary.
  • In Elderly: Increased sensitivity to medications; monitor for sedation, cognitive decline, and metabolic effects.

16. Prevention

  • Early intervention in high-risk individuals with prodromal symptoms.
  • Minimise exposure to risk factors such as substance use and chronic stress.
  • Family therapy and psychoeducation to improve social support and reduce relapse.

17. FAQs

  1. What is schizophrenia?
    Answer: A chronic mental illness characterised by hallucinations, delusions, and impaired thinking.
  2. What causes schizophrenia?
    Answer: A combination of genetic, neurobiological, and environmental factors.
  3. How is schizophrenia treated?
    Answer: With antipsychotic medications, psychotherapy, and lifestyle changes.
  4. Can schizophrenia be cured?
    Answer: There is no cure, but symptoms can be managed effectively.
  5. What is clozapine?
    Answer: A medication for treatment-resistant schizophrenia, requiring blood monitoring.
  6. Are antipsychotics safe?
    Answer: Yes, but they have side effects that require monitoring.
  7. Can schizophrenia lead to disability?
    Answer: Without treatment, it can severely impair social and occupational functioning.
  8. Does stress cause schizophrenia?
    Answer: Stress does not cause schizophrenia but can trigger or worsen symptoms.
  9. Is schizophrenia hereditary?
    Answer: Genetic predisposition plays a significant role.
  10. How is schizophrenia diagnosed?
    Answer: Based on clinical symptoms persisting for six months or more.
  11. What is the role of psychotherapy in schizophrenia?
    Answer: It helps improve coping skills, reduce distress, and support recovery.
  12. Can diet and exercise help?
    Answer: Yes, they can reduce medication side effects and improve overall health.
  13. Are there different types of schizophrenia?
    Answer: Schizophrenia subtypes (e.g., paranoid, catatonic) are no longer used but describe symptom variations.
  14. When should I seek help?
    Answer: If you or someone experiences persistent hallucinations, delusions, or impaired functioning.
  15. What is the life expectancy of someone with schizophrenia?
    Answer: It is reduced due to comorbidities, but treatment and lifestyle changes can improve outcomes.