Schizophrenia

Schizophrenia is a chronic brain disorder characterised by hallucinations, delusions, formal thought and movement disorders, behavioural changes and a lack of motivation. Symptoms are traditionally divided into positive and negative. The diagnosis is made clinically after a full psychiatric history and other causes of psychosis are excluded. The pathophysiology and causes of schizophrenia are multifaceted and extremely complex and there is no full understanding why it occurs. It has a relatively low prevalence affecting less than 1% of people in their lives. However, the burden of disease is high, and it is associated with high comorbidity (e.g. substance misuse). Primary management of schizophrenia is pharmacological, however keeping patients adherent to their medications is a challenge.

Aetiology

Schizophrenia is thought to be caused by an imbalance in multiple neurotransmitters, including serotonin, glutamine, dopamine and GABA signalling pathways. Risk factors can be genetic, environmental and social. The disorder seems to have a strong genetic inheritance with a 40% risk for the children of two people diagnosed with schizophrenia. There are multiple environmental factors including cannabis use and urbanisation, as well as pregnancy and birthing complications. These include pre-eclampsia, gestational diabetes, maternal malnutrition and winter births. Social risk factors include childhood trauma and social isolation.

Diagnosis

The DSM-5 says schizophrenia can only be diagnosed after a full psychiatric history and other causes of psychosis have been excluded. In order to make the diagnosis the patient must have two or more of the listed symptoms lasting at least one month. These are:

• Delusions
• Hallucinations
• Disorganised speech
• Grossly disorganised or catatonic behaviour
• Negative symptoms e.g., anhedonia or a lack of motivation

It is important to take a full neurological, drug and social history as well as there are many other causes of psychosis. These are listed in the table below

Management

Management of schizophrenia involves a combination of approaches with symptom control being achieved using antipsychotics and social interventions once symptom control has been achieved.

Pharmacological

Second generation anti-psychotics are used first-line in the acute phase and include:

• Quetiapine
• Aripiprazole
• Olanzapine
• Risperidone

These are used first-line in preference to first generation anti-psychotics because of their better side-effect profiles and a higher rate of medication adherence. However, they can still be used either first or second line. Examples of first generation anti-psychotics include:

• Haloperidol
• Chlorpromazine
• Fluphenazine

In treatment-resistant of schizophrenia, where two different antipsychotics have been unsuccessfully trialled, clozapine is used. This requires regular blood tests as there is a high risk of agranulocytosis.

Once the acute phase is managed patients are moved to the maintenance phase of management. This includes establishing a minimum effective dose to prevent relapse of the anti-psychotic used to control their symptoms in the acute phase. The maintenance dose can be given orally however a depot injection is usually preferred as it has significantly better rates of medication concordance.

There should also be management of any comorbid conditions. Substance misuse can significantly worsen symptoms so must be managed. Antidepressant and anxiolytics can be used to manage any persistent depressive or anxiety related symptoms.

Psychosocial

Social interventions have a significant role to play in prophylaxis. Rehabilitation into the community is very important as social isolation can worsen the disease. This includes participation of family in the healing process. This has been shown to improve disease outcomes and lower family distress. This can be combined with social skills training has been shown to help giving patients the skills to better communicate and interact with others. Common therapies employed are:

• Family psychoeducation
• Social skills training
• Cognitive training
• Cognitive behavioural therapy