Schizophrenia
Schizophrenia | |
---|---|
Antipsychotics[6] | |
Prognosis | 20–28 years shorter life expectancy[12][13] |
Frequency | ~0.32% (1 in 300) of the global population is affected.[14] |
Deaths | ~17,000 (2015)[15] |
Schizophrenia is a
About 0.3% to 0.7% of people are diagnosed with schizophrenia during their lifetime.[18] In 2017, there were an estimated 1.1 million new cases and in 2022 a total of 24 million cases globally.[2][19] Males are more often affected and on average have an earlier onset than females.[2] The causes of schizophrenia may include genetic and environmental factors.[6] Genetic factors include a variety of common and rare genetic variants.[20] Possible environmental factors include being raised in a city, childhood adversity, cannabis use during adolescence, infections, the age of a person's mother or father, and poor nutrition during pregnancy.[6][21]
About half of those diagnosed with schizophrenia will have a significant improvement over the long term with no further relapses, and a small proportion of these will recover completely.
The mainstay of treatment is antipsychotic medication, including olanzapine and risperidone, along with counseling, job training and social rehabilitation.[6] Up to a third of people do not respond to initial antipsychotics, in which case clozapine gained approval by the Food and Drug Administration for treatment-resistant cases.[28] In a network comparative meta-analysis of 15 antipsychotic drugs, clozapine was significantly more effective than all other drugs, although clozapine's heavily multimodal action may cause more significant side effects.[29] In situations where doctors judge that there is a risk of harm to self or others, they may impose short involuntary hospitalization.[30] Long-term hospitalization is used on a small number of people with severe schizophrenia.[31] In some countries where supportive services are limited or unavailable, long-term hospital stays are more common.[32]
Signs and symptoms
Schizophrenia is a
Positive symptoms
Positive symptoms are those symptoms that are not normally experienced, but are present in people during a psychotic episode in schizophrenia. They include
Negative symptoms
Negative symptoms are deficits of normal emotional responses, or of other thought processes. The five recognized domains of negative symptoms are:
Apathy accounts for around 50 percent of the most often found negative symptoms and affects functional outcome and subsequent quality of life. Apathy is related to disrupted cognitive processing affecting memory and planning including goal-directed behaviour.[48] The two subdomains have suggested a need for separate treatment approaches.[49] A lack of distress is another noted negative symptom.[50] A distinction is often made between those negative symptoms that are inherent to schizophrenia, termed primary; and those that result from positive symptoms, from the side effects of antipsychotics, substance use disorder, and social deprivation – termed secondary negative symptoms.[51] Negative symptoms are less responsive to medication and the most difficult to treat.[49] However, if properly assessed, secondary negative symptoms are amenable to treatment.[45]
Scales for specifically assessing the presence of negative symptoms, and for measuring their severity, and their changes have been introduced since the earlier scales such as the
Cognitive symptoms
An estimated 70% of those with schizophrenia have cognitive deficits, and these are most pronounced in early onset and late-onset illness.
The deficits in
Onset
Onset typically occurs between the late teens and early 30s, with the peak incidence occurring in males in the early to mid-twenties, and in females in the late twenties.
Onset may happen suddenly or may occur after the slow and gradual development of a number of signs and symptoms, a period known as the
Risk factors
Schizophrenia is described as a neurodevelopmental disorder with no precise boundary, or single cause, and is thought to develop from gene–environment interactions with involved vulnerability factors.[6][78][79] The interactions of these risk factors are complex, as numerous and diverse insults from conception to adulthood can be involved.[79] A genetic predisposition on its own, without interacting environmental factors, will not give rise to the development of schizophrenia.[79][80] The genetic component means that prenatal brain development is disturbed, and environmental influence affects the postnatal development of the brain.[81] Evidence suggests that genetically susceptible children are more likely to be vulnerable to the effects of environmental risk factors.[81]
Genetic
Estimates of the
Many
The genes
The question of how schizophrenia could be primarily genetically influenced, given that people with schizophrenia have lower fertility rates, is a paradox. It is expected that
A meta-analysis found that oxidative DNA damage was significantly increased in schizophrenia.[95]
Environmental
Environmental factors, each associated with a slight risk of developing schizophrenia in later life include
Living in an
Substance use
About half of those with schizophrenia use
Cannabis use may be a contributory factor in the development of schizophrenia, potentially increasing the risk of the disease in those who are already at risk.[119][120][121] The increased risk may require the presence of certain genes within an individual.[21] Its use is associated with doubling the rate.[122]
Causes
The causes of schizophrenia are not yet known. Several models have been put forward to explain the link between altered brain function and schizophrenia.
The common dopamine and glutamate models proposed are not mutually exclusive; each is seen to have a role in the neurobiology of schizophrenia.[125] The most common model put forward was the dopamine hypothesis of schizophrenia, which attributes psychosis to the mind's faulty interpretation of the misfiring of dopaminergic neurons.[126] This has been directly related to the symptoms of delusions and hallucinations.[127][128][129] Abnormal dopamine signaling has been implicated in schizophrenia based on the usefulness of medications that affect the dopamine receptor and the observation that dopamine levels are increased during acute psychosis.[130][131] A decrease in D1 receptors in the dorsolateral prefrontal cortex may also be responsible for deficits in working memory.[132][133]
The
Deficits in
Positive symptoms have been linked to cortical thinning in the superior temporal gyrus.[145] The severity of negative symptoms has been linked to reduced thickness in the left medial orbitofrontal cortex.[146] Anhedonia, traditionally defined as a reduced capacity to experience pleasure, is frequently reported in schizophrenia. However, a large body of evidence suggests that hedonic responses are intact in schizophrenia,[147] and that what is reported to be anhedonia is a reflection of dysfunction in other processes related to reward.[148] Overall, a failure of reward prediction is thought to lead to impairment in the generation of cognition and behavior required to obtain rewards, despite normal hedonic responses.[149]
Another theory links abnormal brain lateralization to the development of being left-handed which is significantly more common in those with schizophrenia.[150] This abnormal development of hemispheric asymmetry is noted in schizophrenia.[151] Studies have concluded that the link is a true and verifiable effect that may reflect a genetic link between lateralization and schizophrenia.[150][152]
Diagnosis
Criteria
Schizophrenia is diagnosed based on criteria in either the
DSM-5 states that to be diagnosed with schizophrenia, two diagnostic criteria have to be met over the period of one month, with a significant impact on social or occupational functioning for at least six months. One of the symptoms needs to be either delusions, hallucinations, or disorganized speech. A second symptom could be one of the negative symptoms, or severely disorganized or catatonic behaviour.[9] A different diagnosis of schizophreniform disorder can be made before the six months needed for the diagnosis of schizophrenia.[9]
In Australia, the guideline for diagnosis is for six months or more with symptoms severe enough to affect ordinary functioning.[160] In the UK diagnosis is based on having the symptoms for most of the time for one month, with symptoms that significantly affect the ability to work, study, or carry on ordinary daily living, and with other similar conditions ruled out.[161]
The ICD criteria are typically used in European countries; the DSM criteria are used predominantly in the United States and Canada, and are prevailing in research studies. In practice, agreement between the two systems is high.[162] The current proposal for the ICD-11 criteria for schizophrenia recommends adding self-disorder as a symptom.[40]
A major unresolved difference between the two diagnostic systems is that of the requirement in DSM of an impaired functional outcome. WHO for ICD argues that not all people with schizophrenia have functional deficits and so these are not specific for the diagnosis.[57]
Comorbidities
Many people with schizophrenia may have one or more other mental disorders, such as panic disorder, obsessive–compulsive disorder, or substance use disorder. These are separate disorders that require treatment.[9] When comorbid with schizophrenia, substance use disorder and antisocial personality disorder both increase the risk for violence.[163] Comorbid substance use disorder also increases the risk of suicide.[117]
Schizophrenia is also associated with a number of somatic comorbidities including
Differential diagnosis
To make a diagnosis of schizophrenia other possible causes of psychosis need to be excluded.[170]: 858 Psychotic symptoms lasting less than a month may be diagnosed as brief psychotic disorder, or as schizophreniform disorder. Psychosis is noted in Other specified schizophrenia spectrum and other psychotic disorders as a DSM-5 category. Schizoaffective disorder is diagnosed if symptoms of mood disorder are substantially present alongside psychotic symptoms. Psychosis that results from a general medical condition or substance is termed secondary psychosis.[9]
Psychotic symptoms may be present in several other conditions, including
A more general medical and neurological examination may be needed to rule out medical illnesses which may rarely produce psychotic schizophrenia-like symptoms, such as
Prevention
Prevention of schizophrenia is difficult as there are no reliable markers for the later development of the disorder.[175]
Early intervention programs diagnose and treat patients in the prodromal phase of the illness. There is some evidence that these programs reduce symptoms. Patients tend to prefer early treatment programs to ordinary treatment and are less likely to disengage from them. As of 2020, it is unclear whether the benefits of early treatment persist once the treatment is terminated.[176]
Antipsychotics are prescribed following a first-episode psychosis, and following remission, a preventive maintenance use is continued to avoid relapse. However, it is recognized that some people do recover following a single episode and that long-term use of antipsychotics will not be needed but there is no way of identifying this group.[178]
Management
The primary treatment of schizophrenia is the use of
Medication
The first-line treatment for schizophrenia is an antipsychotic. The first-generation antipsychotics, now called
About half of those with schizophrenia will respond favourably to antipsychotics, and have a good return of functioning.[188] However, positive symptoms persist in up to a third of people. Following two trials of different antipsychotics over six weeks, that also prove ineffective, they will be classed as having treatment resistant schizophrenia (TRS), and clozapine will be offered.[189][28] Clozapine is of benefit to around half of this group although it has the potentially serious side effect of agranulocytosis (lowered white blood cell count) in less than 4% of people.[26][85][190]
About 30 to 50 percent of people with schizophrenia do not accept that they have an illness or comply with their recommended treatment.[191] For those who are unwilling or unable to take medication regularly, long-acting injections of antipsychotics may be used,[192] which reduce the risk of relapse to a greater degree than oral medications.[193] When used in combination with psychosocial interventions, they may improve long-term adherence to treatment.[194]
Adverse effects
Extrapyramidal symptoms, including akathisia, are associated with all commercially available antipsychotic to varying degrees.[195]: 566 There is little evidence that second generation antipsychotics have reduced levels of extrapyramidical symptoms compared to typical antipsychotics.[195]: 566 Tardive dyskinesia can occur due to long-term use of antipsychotics, developing after months or years of use.[196] The antipsychotic clozapine is also associated with thromboembolism (including pulmonary embolism), myocarditis, and cardiomyopathy.
Psychosocial interventions
A number of psychosocial interventions that include several types of
Other support services for education, employment, and housing are usually offered. For people with severe schizophrenia, who are discharged from a stay in the hospital, these services are often brought together in an integrated approach to offer support in the community away from the hospital setting. In addition to medicine management, housing, and finances, assistance is given for more routine matters such as help with shopping and using public transport. This approach is known as assertive community treatment (ACT) and has been shown to achieve positive results in symptoms, social functioning and quality of life.[202][203] Another more intense approach is known as intensive care management (ICM). ICM is a stage further than ACT and emphasises support of high intensity in smaller caseloads, (less than twenty). This approach is to provide long-term care in the community. Studies show that ICM improves many of the relevant outcomes including social functioning.[204]
Some studies have shown little evidence for the effectiveness of CBT in either reducing symptoms or preventing relapse.[205][206] However, other studies have found that CBT does improve overall psychotic symptoms (when in use with medication) and it has been recommended in Canada, but has been seen to have no effect on social function, relapse, or quality of life.[207] In the UK it is recommended as an add-on therapy in the treatment of schizophrenia.[183][206] Arts therapies are seen to improve negative symptoms in some people, and are recommended by NICE in the UK.[183] This approach is criticised as having not been well-researched,[208][209] and arts therapies are not recommended in Australian guidelines for example.[210] Peer support, in which people with personal experience of schizophrenia, provide help to each other, is of unclear benefit.[211]
Other
Exercise including aerobic exercise has been shown to improve positive and negative symptoms, cognition, working memory, and improve quality of life.[212][213] Exercise has also been shown to increase the volume of the hippocampus in those with schizophrenia. A decrease in hippocampal volume is one of the factors linked to the development of the disease.[212] However, there still remains the problem of increasing motivation for, and maintaining participation in physical activity.[214] Supervised sessions are recommended.[213] In the UK healthy eating advice is offered alongside exercise programs.[215]
An inadequate diet is often found in schizophrenia, and associated vitamin deficiencies including those of
Prognosis
no data ≤ 185 185–197 197–207 207–218 218–229 229–240 | 240–251 251–262 262–273 273–284 284–295 ≥ 295 |
Schizophrenia has great human and economic costs.[6] It decreases life expectancy by between 20[12] and 28 years.[13] This is primarily because of its association with heart disease,[220] diabetes,[13] obesity, poor diet, a sedentary lifestyle, and smoking, with an increased rate of suicide playing a lesser role.[12][221] Side effects of antipsychotics may also increase the risk.[12]
Almost 40% of those with schizophrenia die from complications of cardiovascular disease which is seen to be increasingly associated.[217] An underlying factor of sudden cardiac death may be Brugada syndrome (BrS) – BrS mutations that overlap with those linked with schizophrenia are the calcium channel mutations.[217] BrS may also be drug-induced from certain antipsychotics and antidepressants.[217] Primary polydipsia, or excessive fluid intake, is relatively common in people with chronic schizophrenia.[222][223] This may lead to hyponatremia which can be life-threatening. Antipsychotics can lead to a dry mouth, but there are several other factors that may contribute to the disorder; it may reduce life expectancy by 13 percent.[223] Barriers to improving the mortality rate in schizophrenia are poverty, overlooking the symptoms of other illnesses, stress, stigma, and medication side effects.[224]
Schizophrenia is a major cause of
There is a higher than average
A strong association between schizophrenia and tobacco smoking has been shown in worldwide studies.[235][236] Smoking is especially high in those diagnosed with schizophrenia, with estimates ranging from 80 to 90% being regular smokers, as compared to 20% of the general population.[236] Those who smoke tend to smoke heavily, and additionally smoke cigarettes with high nicotine content.[39] Some propose that this is in an effort to improve symptoms.[237] Among people with schizophrenia use of cannabis is also common.[117]
Schizophrenia leads to an increased risk of dementia.[238]
Violence
Most people with schizophrenia are not aggressive, and are more likely to be victims of violence rather than perpetrators.[9] People with schizophrenia are commonly exploited and victimized by violent crime as part of a broader dynamic of social exclusion.[24][25] People diagnosed with schizophrenia are also subject to forced drug injections, seclusion, and restraint at high rates.[30][31]
The risk of violence by people with schizophrenia is small. There are minor subgroups where the risk is high.[163] This risk is usually associated with a comorbid disorder such as a substance use disorder – in particular alcohol, or with antisocial personality disorder.[163] Substance use disorder is strongly linked, and other risk factors are linked to deficits in cognition and social cognition including facial perception and insight that are in part included in theory of mind impairments.[239][240] Poor cognitive functioning, decision-making, and facial perception may contribute to making a wrong judgement of a situation that could result in an inappropriate response such as violence.[241] These associated risk factors are also present in antisocial personality disorder which when present as a comorbid disorder greatly increases the risk of violence.[242][243]
Epidemiology
In 2017,[needs update] the Global Burden of Disease Study estimated there were 1.1 million new cases;[19] in 2022 the World Health Organization (WHO) reported a total of 24 million cases globally.[2] Schizophrenia affects around 0.3–0.7% of people at some point in their life.[18][13] In areas of conflict this figure can rise to between 4.0 and 6.5%.[244] It occurs 1.4 times more frequently in males than females and typically appears earlier in men.[85]
Worldwide, schizophrenia is the most common
Schizophrenia causes approximately one percent of worldwide
In 2000,[needs update] WHO found the percentage of people affected and the number of new cases that develop each year is roughly similar around the world, with age-standardized prevalence per 100,000 ranging from 343 in Africa to 544 in Japan and Oceania for men, and from 378 in Africa to 527 in Southeastern Europe for women.[247]
History
Conceptual development
Accounts of a schizophrenia-like
The word schizophrenia translates as 'splitting of the mind' and is
In the early 20th century, the psychiatrist Kurt Schneider categorized the psychotic symptoms of schizophrenia into two groups – hallucinations and delusions. The hallucinations were listed as specific to auditory and the delusions included thought disorders. These were seen as important symptoms, termed first-rank. The most common first-rank symptom was found to belong to thought disorders.[page needed][251][page needed][252] In 2013 the first-rank symptoms were excluded from the DSM-5 criteria;[253] while they may not be useful in diagnosing schizophrenia, they can assist in differential diagnosis.[254]
Subtypes of schizophrenia – classified as paranoid, disorganized, catatonic, undifferentiated, and residual – were difficult to distinguish and are no longer recognized as separate conditions by DSM-5 (2013) or ICD-11.[255][256][257]
Breadth of diagnosis
Before the 1960s, nonviolent petty criminals and women were sometimes diagnosed with schizophrenia, categorizing the latter as ill for not performing their duties within patriarchy as wives and mothers.
In the early 1970s in the US, the diagnostic model for schizophrenia was broad and clinically based using
Historical treatment
In the 1930s a number of shock procedures which induced seizures (convulsions) or comas were used to treat schizophrenia.[262] Insulin shock involved injecting large doses of insulin to induce comas, which in turn produced hypoglycemia and convulsions.[262][263] The use of electricity to induce seizures was in use as electroconvulsive therapy (ECT) by 1938.[264]
Psychosurgery, including the lobotomy and frontal lobotomy – carried out from the 1930s until the 1970s in the United States, and until the 1980s in France – are recognized as a human rights abuse.[265][266] In the mid-1950s the first typical antipsychotic, chlorpromazine, was introduced,[267] followed in the 1970s by the first atypical antipsychotic, clozapine.[268]
Political abuse
From the 1960s until 1989, psychiatrists in the USSR and Eastern Bloc diagnosed thousands of people with sluggish schizophrenia,[269][270] without signs of psychosis, based on "the assumption that symptoms would later appear".[271] Now discredited, the diagnosis provided a convenient way to confine political dissidents.[272]
Society and culture
In the United States, the annual cost of schizophrenia – including direct costs (outpatient, inpatient, drugs, and long-term care) and non-healthcare costs (law enforcement, reduced workplace productivity, and unemployment) – was estimated at $62.7 billion for the year 2002.[273][a] In the UK the cost in 2016 was put at £11.8 billion per year with a third of that figure directly attributable to the cost of hospital, social care and treatment.[6]
Stigma
In 2002, the term for schizophrenia in Japan was changed from seishin-bunretsu-byō (精神分裂病, lit. 'mind-split disease') to tōgō-shitchō-shō (統合失調症, lit. 'integration–dysregulation syndrome') to reduce stigma.[276] The new name, also interpreted as "integration disorder", was inspired by the biopsychosocial model.[277] A similar change was made in South Korea in 2012 to attunement disorder.[278]
Cultural depictions
Media coverage, especially movies, reinforce the public perception of an association between schizophrenia and violence.[279] A majority of movies have historically depicted characters with schizophrenia as criminal, dangerous, violent, unpredictable and homicidal, and depicted delusions and hallucinations as the main symptoms of schizophrenic characters, ignoring other common symptoms,[280] furthering stereotypes of schizophrenia including the idea of a split personality.[281]
The book
In the UK guidelines for reporting conditions and award campaigns have shown a reduction in negative reporting since 2013.[282]
In 1964 a case study of three males diagnosed with schizophrenia who each had the delusional belief that they were Jesus Christ was published as The Three Christs of Ypsilanti; a film with the title Three Christs was released in 2020.[283][284]
Research directions
A 2015 Cochrane review found unclear evidence of benefit from brain stimulation techniques to treat the positive symptoms of schizophrenia, in particular auditory verbal hallucinations (AVHs).
The study of potential
Explanatory notes
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External links
- Schizophrenia at Curlie