Schizophrenia Spectrum Disorders

Essentials of Diagnosis

• Social withdrawal, usually slowly progressive, with decrease in emotional expression and/or motivation

• Deterioration in personal care with disorganized behaviors and/or decreased reactivity to the environment

• Disorganized thinking, often inferred from speech that switches topics oddly or is incoherent

• Auditory hallucinations, often of a derogatory nature

• Delusions, fixed false beliefs despite conflicting evidence, frequently of a persecutory nature

General Considerations

• Schizophrenia is manifested by a massive disruption of thinking, mood, and overall behavior as well as poor filtering of stimuli

• Cause is believed to be multifactorial, with genetic, environmental, and neurotransmitter pathophysiologic components

• The characterization and nomenclature of the disorders are quite arbitrary and are influenced by sociocultural factors and schools of psychiatric thought

• There may or may not be a history of a major disruption in the individual's life (failure, loss, physical illness) before gross psychotic deterioration is evident

• Other psychotic disorders on this spectrum are conditions that are similar to schizophrenia in their acute symptoms but have a less pervasive influence over the long term

Symptoms and Signs

• A history of a major disruption in the individual's life may precede gross psychotic deterioration

• Gradual decompensation usually predates the acute episode

• Positive symptoms

  • Delusions are often paranoid, involving perceived threat from others

  • Hallucinations are typically auditory

  • Hypersensitivity to environmental stimuli, with feelings of enhanced sensory awareness

• Negative symptoms

  • Diminished sociability

  • Restricted affect

  • Impoverished speech

• Appearance: may be bizarre, often with deterioration in personal care, though usually patients are just mildly unkempt

• Motor activity: generally reduced, although a broad spectrum is seen

• Social function: marked withdrawal, disturbed interpersonal relationships

• Speech

  • Neologisms (made-up words or phrases)

  • Echolalia (repetition of others' words)

  • Verbigeration (repetition of senseless words or phrases)

• Affect: flat, occasionally inappropriate

• Mood: depression in most patients, less apparent during acute psychosis, may have rapidly alternating mood shifts irrespective of circumstances

• Thought content

  • Varies from paucity of ideas to rich delusions

  • Concrete thinking with inability to abstract

  • Inappropriate symbolism

Differential Diagnosis

• Schizophrenia should be distinguished from other psychoses

  • Delusional disorders are characterized by persistent delusions with minimal impairment on daily life

  • Schizoaffective disorders fail to fit within the definitions of either schizophrenia or affective disorders

  • Schizophreniform disorders have a duration of less than 6 months, but more than 1 month

  • Brief psychotic disorders result from psychological stress, last less than 1 month, and have a much better prognosis

  • "Other psychotic disorders"

    • Patient usually attains higher levels of functioning than in schizophrenia

    • Acute psychotic episodes tend to be less disruptive of the person's lifestyle, with a fairly quick return to previous levels of functioning

  • Clues are precipitous onset and a good premorbid history

• Manic episodes

• Obsessive-compulsive disorder

• Psychotic depression

• Drug intoxication and abuse

• Thyroid, adrenal, and pituitary disorders

• Complex partial seizures and temporal lobe dysfunction may produce psychotic symptoms

• Drug toxicities, particularly overdoses of typical antipsychotics, can produce catatonia

Laboratory Tests

• There is no laboratory method for confirming the diagnosis of schizophrenia

Imaging Studies

• Ventricular enlargement and cortical atrophy on CT have been correlated with chronicity, cognitive impairment, and poor response to antipsychotics

• Decreased frontal lobe activity on positron emission tomography scan has been associated with negative symptoms

• MRI can exclude temporal lobe disorders

Medications

• See Tables 25–4 and 25–5

• Typical (first-generation) antipsychotic agents

  • Phenothiazines

  • Thioxanthenes

  • Butyrophenones

  • Dihydroindolones

  • Dibenzoxazepines

  • Benzisoxazoles

• Newer, atypical (second-generation) antipsychotics (clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, asenapine, iloperidone, and lurasidone)

  • Cause less tardive dyskinesia and extrapyramidal symptoms

  • Are more effective than typical agents for managing negative symptoms

• Lurasidone

  • Effective in treating acute decompensation in patients with chronic schizophrenia

  • Has low incidence of weight gain, increased lipids, or prolonged QT interval

  • Side effects include akathisia; elevated prolactin; and in higher doses, somnolence

• Cariprazine

  • FDA approved for treatment of schizophrenia and bipolar disorder

  • Side effects include akathisia, weight gain, and insomnia

  • Less likely to increase prolactin levels than most antipsychotics

• Antidepressant drugs may be used with antipsychotics if significant depression is present

• Resistant cases may require addition of lithium, carbamazepine, or valproate

• Addition of benzodiazepine can resolve catatonic symptoms and allow a lower antipsychotic dose

• There is early evidence that cannabidiol (CBD), at a dose of 1000 mg/day, added to existing antipsychotic treatment, is efficacious in improving psychotic symptoms

Therapeutic Procedures

• Social therapeutic interventions

  • Board and care homes with experienced staff can improve functioning and limit hospitalizations

  • Nonresidential self-help groups (Recovery, Inc.) should be used

  • Vocational rehabilitation and work agencies (Goodwill Industries, Inc.) can provide structured work situations

• Psychotherapy

  • Need for psychotherapy varies markedly with patient status and history

  • Insight-oriented psychotherapy is often counterproductive

  • Cognitive-behavioral therapy with medication management may be efficacious

  • A form of psychotherapy called Acceptance and Commitment Therapy has shown value in helping prevent hospitalizations in schizophrenia

  • Cognitive remediation therapy is another approach that shows promise in helping schizophrenic patients become better able to focus their disorganized thinking

  • Family therapy may alleviate the patient's stress and assist relatives in coping

• Behavioral intervention

  • Music from portable players with headphones can divert attention from auditory hallucinations

Follow-Up

• Clozapine

  • 1.6% risk of agranulocytosis

  • Weekly white blood cell counts (WBCs) for 6 months, then every other week thereafter

  • Weekly WBCs for 1 month after discontinuation of clozapine

• Ziprasidone

  • Can cause QT prolongation

  • Pretreatment ECG and cardiac risk factor screen are necessary

• Quetiapine

  • Associated with cataracts

  • Ophthalmologic examination at initiation and biannually

  • May cause QT prolongation particularly when prescribed with other medications that effect the QT interval and in overdose

• Asenapine and paliperidone

  • Increase the risk of QT interval prolongation

  • Should be avoided in patients with risk factors for this ECG finding

• Asenapine carries a warning of possible serious allergic reaction (even after the first dose) including anaphylaxis, low blood pressure, and difficulty breathing

Complications

• Antipsychotic malignant syndrome is an uncommon but serious side effect of antipsychotics

• Tardive dyskinesia may occur after long-term use of antipsychotics

• Anticholinergic and adrenergic side effects are more frequent with low-potency antipsychotics

• Extrapyramidal symptoms are seen with high-potency antipsychotics

• Olanzapine has been associated with significant weight gain

• Clozapine may cause adynamic ileus, a rare side effect that can be fatal

• The risk of diabetes mellitus is increased in patients taking clozapine and olanzapine

Prognosis

• After removal of positive symptoms, prognosis is good in most patients

• Negative symptoms are more difficult to treat

• Prognosis is guarded when psychosis is associated with a history of serious drug abuse, owing to likely CNS damage

• Life expectancy is 20% shorter in schizophrenics, mostly because of higher mortality rates among young patients

When to Admit

• Gross disorganization

• Risk of self-harm or harm to others