- Clinical science
Schizophrenia is a severe psychiatric disorder characterized by chronic or recurrent psychosis. The majority of patients with schizophrenia initially experience symptoms in their 20s. The exact mechanism is unknown, but it is thought to be related to increased dopaminergic activity in the mesolimbic neuronal pathway and decreased dopaminergic activity in the prefrontal cortical pathway. Clinical features include positive psychotic symptoms, negative psychotic symptoms, cognitive impairment, catatonia, and mood symptoms. The mainstay of treatment is psychoeducation and antipsychotic therapy with dopamine antagonists.
- < 1%
- Lifetime risk: ♂ = ♀
Age of onset: young adults aged 18–35
- Men: typically early 20s
- Women: typically late 20s
Epidemiological data refers to the US, unless otherwise specified.
- Multiple factors
- Risk factors
Schizophrenia tends to present initially with a prodrome of negative symptoms (classically social withdrawal) that precedes the positive psychotic symptoms (i.e., hallucinations and bizarre behaviors).
|Positive symptoms of psychosis|| |
|Negative symptoms of psychosis|| |
|Cognitive symptoms|| |
|Mood symptoms and anxiety|| |
Positive symptoms are usually an exaggeration of normal thoughts, speech, and/or behavior, while negative symptoms involve a deficit or absence of these normal processes..
Schizophrenia is a clinical diagnosis. Diagnostic criteria include (according to DSM-5):
- A) ≥ 2 of the following symptoms for ≥ 1 month (at least one of the symptoms must be from the group that is bolded)
- B) Symptoms must cause social, occupational, or personal functional impairment.
- C) Some sign of illness must persist for at least 6 months.
- D) Schizoaffective disorder and mood disorder with psychotic features have been ruled out.
- E) Symptoms must not be due to a medical or substance use disorder.
- F) If there is a history of autism spectrum disorder or other communication disorder beginning in childhood, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).
Brain imaging of schizophrenia patients often shows cortical atrophy and enlargement of the cerebral ventricles.
|Brief psychotic disorder|| |
|Schizophreniform disorder|| |
|Delusional disorder|| |
|Delusional symptoms in partner of individual with delusional disorder|
|Mood disorder with psychotic features|
|Please note: Personality disorders should not be diagnosed if there is an underlying general medical condition or substance use disorder that can better explain the symptoms.|
The differential diagnoses listed here are not exhaustive.
- Hospitalization if acutely psychotic
- General approach: Establish therapeutic alliance when taking care of patients with delusions
Antipsychotic treatment: see for more details
- Acute psychotic episodes: short-acting antipsychotics (e.g., olanzapine ) +/- mood stabilizer for acute mania (e.g., lithium, valproate, carbamazepine), if present
- First-line treatment: (; e.g., olanzapine, risperidone, quetiapine), which are especially effective at treating positive psychotic symptoms
- Alternatively, fluphenazine, haloperidol, chlorpromazine) ( ) in depot form for those at risk of poor adherence (e.g.,
- Clozapine for treatment-resistant schizophrenia: persistent positive symptoms (i.e., delusions, hallucinations, and/or disorganized speech) despite trials of ≥ 6 weeks of 2 different antipsychotics at their maximum doses
- Treatment during pregnancy: See .
Psychoeducation (used as an adjunct to avoid relapse)
- Patient, family, and group psychosocial therapy and education
- Cognitive behavioral therapy
- Supportive social measures
Long-acting injectable antipsychotics should be considered for patients struggling with compliance and frequent relapses!
Schizophrenia is a progressive disease that causes significant disability, with > 30% of patients presenting with psychosocial dysfunction.
Predictive factors for an unfavorable course of the illness
- Family history
- Earlier onset of disease
- Poor network of social support
- Being male
- Slow onset of illness
- More negative symptoms
- Concomitant substance use disorder
Predictive factors for a favorable course of the illness
- Later onset of disease
- Being female
- Mood symptoms
- Good network of social support
- Acute onset of illness
- More positive symptoms