Theresa B.

Arambulo
San Beda College
Group 1 4-CAN

Schizophrenia
(pronounced /ˌskɪtsɵˈfrɛniə/ or /ˌskɪtsɵˈfriːniə/) is a mental disorder characterized by a disintegration of
the process of thinking and of emotional responsiveness. It most commonly manifests as auditory
hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is generally
accompanied by significant social or occupational dysfunction. Onset of symptoms typically occurs in
young adulthood, with a global lifetime prevalence of around 1.5%. Diagnosis is based on the patient's
self-reported experiences and observed behavior. No laboratory test for schizophrenia exists.
Genetics, early environment, neurobiology, psychological and social processes appear to be important
contributory factors; some recreational and prescription drugs appear to cause or worsen symptoms.
Current psychiatric research is focused on the role of neurobiology, but this inquiry has not isolated a
single organic cause. As a result of the many possible combinations of symptoms, there is debate about
whether the diagnosis represents a single disorder or a number of discrete syndromes. Despite the
etymology of the term from the Greek roots skhizein (σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-;
"mind"), schizophrenia does not imply a "split mind" and it is not the same as dissociative identity
disorder—also known as "multiple personality disorder" or "split personality"—a condition with which it
is often confused in public perception.
Unusually high dopamine activity in the mesolimbic pathway of the brain has been found in people with
schizophrenia. The mainstay of treatment is antipsychotic medication; this type of drug primarily works
by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the early
decades of their use. Psychotherapy, and vocational and social rehabilitation, are also important. In
more serious cases—where there is risk to self and others—involuntary hospitalization may be
necessary, although hospital stays are shorter and less frequent than they were in previous times.
The disorder is thought mainly to affect cognition, but it also usually contributes to chronic problems
with behavior and emotion. People with schizophrenia are likely to have additional ( comorbid)
conditions, including major depression and anxiety disorders; the lifetime occurrence of substance
abuse is around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are
common. Furthermore, the average life expectancy of people with the disorder is 10 to 12 years less
than those without, due to increased physical health problems and a higher suicide rate (about 5%).

Signs and symptoms

A person diagnosed with schizophrenia may experience:

 hallucinations (most commonly hearing voices)
 delusions (often bizarre or persecutory in nature)
 disorganized thinking and speech.

The latter may range from loss of train of thought, to sentences only loosely connected in meaning, to
incoherence known as word salad in severe cases. There is often an observable pattern of emotional
difficulty, for example lack of responsiveness or motivation. Impairment in social cognition is associated
with schizophrenia, as are symptoms of paranoia, and social isolation commonly occurs. In one
uncommon subtype, the person may be largely mute, remain motionless in bizarre postures, or exhibit
purposeless agitation; these are signs of catatonia.

Late adolescence and early adulthood are peak years for the onset of schizophrenia. In 40% of men and
23% of women diagnosed with schizophrenia, the condition arose before the age of 19. These are
critical periods in a young adult's social and vocational development. To minimize the developmental
disruption associated with schizophrenia, much work has recently been done to identify and treat the
prodromal (pre-onset) phase of the illness, which has been detected up to 30 months before the onset
of symptoms, but may be present longer. Those who go on to develop schizophrenia may experience
the non-specific symptoms of social withdrawal, irritability and dysphoria in the prodromal period, and
transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes
apparent.

Schneiderian classification

The psychiatrist Kurt Schneider (1887–1967) listed the forms of psychotic symptoms that he thought
distinguished schizophrenia from other psychotic disorders. These are called first-rank symptoms or
Schneider's first-rank symptoms, and they include delusions of being controlled by an external force; the
belief that thoughts are being inserted into or withdrawn from one's conscious mind; the belief that
one's thoughts are being broadcast to other people; and hearing hallucinatory voices that comment on
one's thoughts or actions or that have a conversation with other hallucinated voices. Although they
have significantly contributed to the current diagnostic criteria, the specificity of first-rank symptoms
has been questioned. A review of the diagnostic studies conducted between 1970 and 2005 found that
these studies allow neither a reconfirmation nor a rejection of Schneider's claims, and suggested that
first-rank symptoms be de-emphasized in future revisions of diagnostic systems.

Positive and negative symptoms

Schizophrenia is often described in terms of positive and negative (or deficit) symptoms. The term
positive symptoms refers to symptoms that most individuals do not normally experience but are present
in schizophrenia. They include delusions, auditory hallucinations, and thought disorder, and are typically
regarded as manifestations of psychosis. Negative symptoms are things that are not present in
schizophrenic persons but are normally found in healthy persons, that is, symptoms that reflect the loss
or absence of normal traits or abilities. Common negative symptoms include flat or blunted affect and
emotion, poverty of speech (alogia), inability to experience pleasure (anhedonia), lack of desire to form
relationships (asociality), and lack of motivation (avolition). Research suggests that negative symptoms
contribute more to poor quality of life, functional disability, and the burden on others than do positive
symptoms.

Diagnosis
Diagnosis is based on the self-reported experiences of the person, and abnormalities in behavior
reported by family members, friends or co-workers, followed by a clinical assessment by a psychiatrist,
social worker, clinical psychologist, mental health nurse or other mental health professional. Psychiatric
assessment includes a psychiatric history and some form of mental status examination.

Standardized criteria

The most widely used standardized criteria for diagnosing schizophrenia come from the American
Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, version DSM-IV-TR, and
the World Health Organization's International Statistical Classification of Diseases and Related Health
Problems, the ICD-10. The latter criteria are typically used in European countries, while the DSM criteria
are used in the United States and the rest of the world, as well as prevailing in research studies. The ICD-
10 criteria put more emphasis on Schneiderian first-rank symptoms, although, in practice, agreement
between the two systems is high.[19]

According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria must be met: [5]

1. Characteristic symptoms: Two or more of the following, each present for much of the time
during a one-month period (or less, if symptoms remitted with treatment).
o Delusions
o Hallucinations
o Disorganized speech, which is a manifestation of formal thought disorder
o Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or
catatonic behavior
o Negative symptoms: Blunted affect (lack or decline in emotional response), alogia (lack
or decline in speech), or avolition (lack or decline in motivation)

If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice
participating in a running commentary of the patient's actions or of hearing two or more voices
conversing with each other, only that symptom is required above. The speech disorganization
criterion is only met if it is severe enough to substantially impair communication.

2. Social/occupational dysfunction: For a significant portion of the time since the onset of the
disturbance, one or more major areas of functioning such as work, interpersonal relations, or
self-care, are markedly below the level achieved prior to the onset.
3. Duration: Continuous signs of the disturbance persist for at least six months. This six-month
period must include at least one month of symptoms (or less, if symptoms remitted with
treatment).

If signs of disturbance are present for more than a month but less than six months, the diagnosis of
schizophreniform disorder is applied.[5] Psychotic symptoms lasting less than a month may be diagnosed
as brief psychotic disorder, and various conditions may be classed as psychotic disorder not otherwise
specified. Schizophrenia cannot be diagnosed if symptoms of mood disorder are substantially present
(although schizoaffective disorder could be diagnosed), or if symptoms of pervasive developmental
disorder are present unless prominent delusions or hallucinations are also present, or if the symptoms
are the direct physiological result of a general medical condition or a substance, such as abuse of a drug
or medication.

Subtypes

The DSM-IV-TR contains five sub-classifications of schizophrenia, although the developers of DSM-5 are
recommending they be dropped from the new classification:

 Paranoid type: Where delusions and hallucinations are present but thought disorder,
disorganized behavior, and affective flattening are absent.
 Disorganized type: Named hebephrenic schizophrenia in the ICD. Where thought disorder and
flat affect are present together.
 Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless
movement. Symptoms can include catatonic stupor and waxy flexibility
 Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid,
disorganized, or catatonic types have not been met.
 Residual type: Where positive symptoms are present at a low intensity only.

Management

The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the
most common being the Positive and Negative Syndrome Scale (PANSS).Management of symptoms and
improving function is thought to be more achievable than a cure. Treatment was revolutionized in the
mid-1950s with the development and introduction of chlorpromazine. A recovery model is increasingly
adopted, emphasizing hope, empowerment and social inclusion.

Hospitalization may occur with severe episodes of schizophrenia. This can be voluntary or (if mental
health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient
stays are now less common due to deinstitutionalization, although can still occur. Following (or in lieu
of) a hospital admission, support services available can include drop-in centers, visits from members of a
community mental health team or Assertive Community Treatment team, supported employment and
patient-led support groups.

In many non-Western societies, schizophrenia may only be treated with more informal, community-led
methods. Multiple international surveys by the World Health Organization over several decades have
indicated that the outcome for people diagnosed with schizophrenia in non-Western countries is on
average better there than for people in the West.

Medication

The first line psychiatric treatment for schizophrenia is antipsychotic medication. These can reduce the
positive symptoms of psychosis. Most antipsychotics take around 7–14 days to have their main effect.
Currently available antipsychotics fail, however, to significantly ameliorate the negative symptoms, and
the improvements on cognition may be attributed to the practice effect.

The newer atypical antipsychotic drugs are usually preferred for initial treatment over the older typical
antipsychotic, although they are expensive and are more likely to induce weight gain and obesity-related
diseases. In 2005–2006, results from a major randomized trial sponsored by the US National Institute of
Mental Health (Clinical Antipsychotic Trials of Intervention Effectiveness, or CATIE) found that a
representative first-generation antipsychotic, perphenazine, was as effective as and more cost-effective
than several newer drugs taken for up to 18 months. The atypical antipsychotic which patients were
willing to continue for the longest, olanzapine, was associated with considerable weight gain and risk of
metabolic syndrome. Clozapine was most effective for people with a poor response to other drugs, but it
had troublesome side effects. Because the trial excluded patients with tardive dyskinesia, its relevance
to these people is unclear.

Because of their reportedly lower risk of side effects that affect mobility, atypical antipsychotics have
been first-line treatment for early-onset schizophrenia for many years before certain drugs in this class
were approved by the Food and Drug Administration for use in children and teenagers with
schizophrenia. This advantage comes at the cost of an increased risk of metabolic syndrome and obesity,
which is of concern in the context of long-term use begun at an early age. Especially in the case of
children and teenagers who have schizophrenia, medication should be used in combination with
individual therapy and family-based interventions.

Recent reviews have refuted the claim that atypical antipsychotics have fewer extrapyramidal side
effects than typical antipsychotics, especially when the latter are used in low doses or when low potency
antipsychotics are chosen. Prolactin elevations have been reported in women with schizophrenia taking
atypical antipsychotics. It remains unclear whether the newer antipsychotics reduce the chances of
developing neuroleptic malignant syndrome, a rare but serious and potentially fatal neurological
disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs.

Response of symptoms to medication is variable: treatment-resistant schizophrenia is a term used for

the failure of symptoms to respond satisfactorily to at least two different antipsychotics. Patients in this
category may be prescribed clozapine, a medication of superior effectiveness but several potentially
lethal side effects including agranulocytosis and myocarditis. For other patients who are unwilling or
unable to take medication regularly, long-acting depot preparations of antipsychotics may be given
every two weeks to achieve control. The United States and Australia are two countries with laws
allowing the forced administration of this type of medication on those who refuse, but are otherwise
stable and living in the community.

Psychological and social interventions

Psychotherapy is also widely recommended and used in the treatment of schizophrenia, although
services may often be confined to pharmacotherapy because of reimbursement problems or lack of
training.

Cognitive behavioral therapy (CBT) is used to target specific symptoms and improve related issues such
as self-esteem, social functioning, and insight. Although the results of early trials were inconclusive [142] as
the therapy advanced from its initial applications in the mid 1990s, CBT has become an effective
treatment to reduce positive and negative symptoms of schizophrenia, as well as improving functioning.
[143][144]
However, in a 2010 article in Psychological Medicine entitled, "Cognitive behavioral therapy for
the major psychiatric disorder: does it really work?", Lynch, Laws & McKenna found that no trial
employing both blinding and psychological placebo has found CBT to be effective in either reducing
symptoms or preventing relapse in schizophrenia.
Another approach is cognitive remediation, a technique aimed at remediating the neurocognitive
deficits sometimes present in schizophrenia. Based on techniques of neuropsychological rehabilitation,
early evidence has shown it to be cognitively effective, with some improvements related to measurable
changes in brain activation as measured by fMRI. A similar approach known as cognitive enhancement
therapy, which focuses on social cognition as well as neurocognition, has shown efficacy.

Family therapy or education, which addresses the whole family system of an individual with a diagnosis
of schizophrenia, has been consistently found to be beneficial, at least if the duration of intervention is
longer-term. Aside from therapy, the effect of schizophrenia on families and the burden on carers has
been recognized, with the increasing availability of self-help books on the subject. There is also some
evidence for benefits from social skills training, although there have also been significant negative
findings. Some studies have explored the possible benefits of music therapy and other creative
therapies.

The Soteria model is alternative to inpatient hospital treatment using a minimal medication approach. It
is described as a milieu-therapeutic recovery method, characterized by its founder as "the 24 hour a day
application of interpersonal phenomenologic interventions by a nonprofessional staff, usually without
neuroleptic drug treatment, in the context of a small, homelike, quiet, supportive, protective, and
tolerant social environment." Although research evidence is limited, a 2008 systematic review found the
programme equally as effective as treatment with medication in people diagnosed with first and second
episode schizophrenia.