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Introduction   

Schizophrenia is a serious chronic mental disease which is highly debilitating that causes changes in an individual’s thinking, behavior, and how they process information due to experiencing delusions, hallucinations, and disorganized speech. This condition affects approximately 1% of the world’s population (20 million) people worldwide but is not as common as most other common mental (1).

This condition causes tremendous burden on the health, social, and economic status not only for patients but for their families, caregivers, and society. Health care professionals have seen the revolving door when it comes to treating schizophrenic patients and that can sometimes turn into fatigue by the health care professional because they may feel the patient does not want to get better but that is far from the truth.  

Treating a patient experiencing schizophrenic symptoms is an extraordinarily complex task and it can sometimes take years before the patient responds to the therapy. Schizophrenia is more prevalent in men than in women and each experience different types and symptoms, but the effects are equal.

People with schizophrenia are two to three times more likely to die early than the general population because they will not seek medical treatment for preventable physical diseases such as cardiovascular diseases, infections, or metabolic diseases (1). People with schizophrenia require lifelong treatment and the care they receive is essential to their recovery. 

Case Studies

Case Study #1

Stephanie is a 56-year-old mother of four and recently widowed. She started experiencing psychotic symptoms in her early 20s and has lived with them for over 30 years. Stephanie first started experiencing delusions and hallucinatory voices after her second child’s birth and the death of her parents, who died in a car crash. Her mother suffered from major depression after years of drug abuse and her father suffered from PTSD. Stephanie has been treated as an inpatient in treatment facilities for her psychiatric symptoms as well as outpatient facilities.  

She is experiencing a relapse of her psychiatric symptoms because of her husband of 32 year’s recent passing. Stephanie described her husband as a loving, kind, gentle spirit that would do anything for anyone in need, however, her symptoms resurfaced in the form of hallucinatory voices of him calling her an abusive mother and promiscuous. The voices tell her to harm her children in various ways and seek a relationship with married men. Stephanie is a devout Catholic and is very disturbed by the commands of the voices.  

Over time, Stephanie was able to gain control of the hallucinatory voices with medication and her family’s help. Although the voices have fluctuated and stayed with her, she has worked hard at keeping them under control. Her husband‘s death has caused her to have an increase in positive symptoms as well as negative symptoms. Stephanie’s family has decided to have her committed against her will because of recent suicidal ideations. The medications that she is taking have not had the desired effect on her positive symptoms but have also increased her negative symptoms. Her psychotic symptoms have gained dominance over her abilities as a mother, wife, and individual.  

Case Study #2 

Larry is a young man that was diagnosed with learning disabilities at age 6. He was sent to a special school for people with learning disabilities and was told he was quite different from the rest of his family. Larry’s uncle was diagnosed with manic depressive disorder, and his mother has always been very demanding and controlling of everyone in the household.  

As Larry transitioned into his teen years, he started experimenting with marijuana, opiates, alcohol, and other mind-altering drugs. He participated in a work program for adults with learning disabilities that helps them transition into every day, sustainable living. From there, he moved into a shared home that housed other adults with learning disabilities and began to experience florid psychotic symptoms. Larry began to believe that everyone there was trying to poison him because they thought he was a murderer. His family tried to help him, but his mental experiences became more frequent and to the point of him needing full inpatient admission.  

While in the hospital, he was sitting up all night because he believed he had to protect everyone from the outside world. Larry’s paranoia was heightened when he learned that the facility he was in was over 100 miles away from his family. When his family came to visit, he would appear frightened and informed them that his roommates were stealing from him and physically abusing him; they removed him from the facility. Larry’s family had his services transferred to their general practitioner, who then referred him to a primary care mental health service.  

Despite all efforts, Larry has not responded to any type of therapy, and spends his days drinking alcohol and watching television. He refuses to take any medication because of his suspicions and continues to stay up all night trying to protect his family from gangsters. Larry feels as though there is no help for him and his mental health. 

Throughout the course, please refer to the case studies above to answer the exercise questions.  

Definition 

Although Kraepelin from the late 19th century was the first individual to distinguish schizophrenia from other forms of psychosis in 1887, but the oldest available description of an illness closely resembling schizophrenia was found in Ebers’s papyrus dating back to Egypt of 1550 BCE. There have been some archaeological finds from the Stone Age with skulls with burr holes drilled into them presumably to release evil spirits, those finds tends to lead to the speculation that schizophrenia is as old as human mankind (5).

Over a century ago there have been large public institutions for serious mental illness patients, leprosy. and tuberculosis. Today we still have facilities for mental illness patients especially people suffering from schizophrenia, and not much has changed in the prevalence and disability of schizophrenia (5). In the past schizophrenia was determined to be a psychotic reaction a fragmented ego due to rejection or ambivalent mother or evil spirits that have invaded the individual body (5).

The Swiss psychiatrist Paul Eugene Bleuler from the early 20th century in 1908 coined the term schizophrenia from the Greek word schizo (split) and phren (mind). He intended the term to mean a losing of thoughts and feelings, but the public took it to mean split personality (5).  Contrary to most belief, schizophrenia is not a split or multiple personality disorder (5).  

Neither Kraepelin nor Bleuler considered psychosis as the core symptoms of what we now call schizophrenia, neither defined schizophrenia based on it. Kraepelin delineated the illness on the cognitive decline preceding the onset of psychosis which he therefore named dementia praecox (5).

Bleuler viewed delusions and hallucinations as accessory symptoms. According to Bleuler, the basis of the illness was determined by disturbance in affect, cognitive, social interaction, and volition (5). Focusing on psychosis instead of the defining phenotype of schizophrenia, may well be the reason the field has made little material progress in improving its outcome. 

Consequently, psychiatry students are taught that schizophrenia debuts in early adulthood because that is when first signs of psychosis usually present itself to the healthcare professionals (5).

There have been many retrospective and prospective studies that show the first signs of the illness precedes the onset of psychosis by at least a decade. This is consistent with Kraepelin’s first observations that schizophrenia does not debut with psychosis but with much more subtle deviations of the norm, expressed in motor, social and cognitive behavior (5). 

Schizophrenia is a chronic severe mental disorder that affects the way a person thinks, expresses emotions, perceive reality, and how they relate to others (2). People with schizophrenia often have problems blending in with society, at work, at school or in in relationships. They feel frightened, withdrawn, and can appear to have lost touch with reality.

Schizophrenia involves a psychosis which is a type of mental illness in which a person cannot tell what is real from what is imagined (2). People with schizophrenia lose touch with reality and the world appears like a jumble of emotions, thoughts, images, and sounds. Research has shown that schizophrenia affects men and women equally but may have an earlier onset in males.

Men often experience initial symptoms in their late teens or early 20s while women tend to show first size of the illness in their 20s and early 30s. Early more subtle signs may be present which include troubled relationships, reduce motivation, and poor school performance (2).  

The severity of schizophrenia varies from person to person. Individuals may have one episode while others have multiple lifetime episodes but tend to lead a normal life in between the episodes. Schizophrenia symptoms can get worse or improve in cycles and this is known as relapse and remissions. 

Symptoms 

Schizophrenia is characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behaviors, decreased participation in daily activities. Although the exact signs and symptoms can vary with everyone, most symptoms in people with schizophrenia can be categorized into subsections including behavioral, cognitive, mood, psychological, speech, and miscellaneous (3). 

Behavioral

These symptoms include disorganized behavior, aggression, compulsive behavior, repetitive movements, agitation, social isolation, lack of restraint, hostility, and excitability (3). 

Cognitive

These symptoms include thought disorder, delusions, amnesia, mental confusion, false belief of superiority, disorientation, slow in performing activities, belief that their thoughts are someone else’s thoughts, belief that every day events have special meanings behind them (3). 

Mood

Their symptoms include anger, anxiety, apathy, feeling detached from self, elevated mood or inappropriate emotional response, lack of interest or pleasure in any activities, and general discontent (3). 

Psychological

These symptoms include hallucinations, paranoia, hearing voices, depression, fear, persecutory delusions, or religious delusions (3). 

Speech

These symptoms are categorized by circumstantial speech, incoherent speech, rapid and frenzied speech, or speech disorder (3). 

Miscellaneous

These symptoms can include fatigue, impaired motor function, lack of emotional response, or memory loss (3). 

Following, the DSM–5 categorizes the symptoms of people with schizophrenia as positive or negative. 

Positive Symptoms

When dealing with mental health symptoms, the word positive does not mean something good. It refers to increased thoughts or actions that are not based (4). Positive symptoms in people with schizophrenia are related to over-stimulation of interval timing, an understanding that their time perception may be associated with psychosis (5). Positive symptoms can include the following: 

Delusions

Mixed strange false beliefs that are not based, and the person refuses to give up those beliefs when shown true facts (4). 

Hallucinations

Involve various sensations that are not real. The most common hallucination that people experience is hearing auditory voices. Those voices will sometimes comment on the person’s behavior, say things that insult them, or give commands. Some people with schizophrenia may experience visual hallucinations, but it is less common. Additionally, they may also experience smelling strange orders, verbalize having a funny taste in their mouth, or a feeling of sensation on their skin, although nothing is visibly touching them (4). 

Catatonia

This a condition in which the person may stop speaking and their body may be fixed in a single position for an exceptionally long time (4). 

Disorganized

This symptom showcases that a person cannot think clearly or respond as expected. Usually, this is due to the person using nonsense words, shifting quickly from one thought to another without any logical connection, moving slowly, unable to make decisions, writing excessively but without any meaning, forgetting, losing things frequently, repeated movements or gestures, having problems making sense of everyday sounds, feelings, or sight (4). 

When a patient is experiencing positive symptoms, they have trouble understanding information or making decisions, focusing, paying attention, using their information immediately after learning, or recognizing that they have any of these problems. 

Negative Symptoms

When dealing with mental health symptoms, the word negative does not mean bad. Negative just means that there is an absence of normal behaviors in people with schizophrenia. The person experiencing negative symptoms will have a lack of emotion or a limited range of emotions, less energy, loss of pleasure or interest in life, poor hygiene and grooming habits, less speaking, and an obvious withdrawal from family friends and social activities (4). 

Causes and Risk Factors of Schizophrenia  

Although the actual cause of schizophrenia remains unclear, physicians know that the etiology of schizophrenia is multifactorial and has genetic and environmental factors. The most significant risk factors for having schizophrenia is having a first degree relative with schizophrenia. Various studies have concluded that the interaction of genetic risk (parent with schizophrenia) with environmental risk (a mother experiencing depression along with another mental disorder) significantly increases the likelihood by least 9 times that the individual will have schizophrenia (6).  

Maternal depression during pregnancy significantly increases the risk of schizophrenia in offspring’s if one of the parents has a psychotic disorder (6). It is believed that the genetic risk of schizophrenia is presents itself in two ways. The first is the polygenetic interaction of multiple common variants of thousands of genes and the second is rare but included highly penetrant genetic events such as deletions or duplications of several variations (6). Researchers believe that hormones and physical changes in the body can be a factor leading to schizophrenia because the symptoms of the disorder usually begin in young adults during a time of major change; puberty going into adulthood, for example (6). 

Traditionally the pathophysiology of schizophrenia has been associated with abnormalities in dopamine (DA) transmissions which in turn have been linked to the speed of the internal clock. Several studies have demonstrated dopamine receptors agonist accelerate the internal clock while antagonist decelerate it (6). Schizophrenia currently is thought to be a very subtle neurodevelopmental disorder of brain connectivity. It is likely an abnormal developmental trajectory of synapse and circuit formation that ultimately leads to the brain being mis wired and clinical symptoms (6).  

The overstimulation of time has been thought to be caused by accelerated time processing which may be linked to the hypervigilance state that has been implicated in positive symptoms of schizophrenia. Hypervigilance is a mental state in which intention to external stimuli is exaggerated. The environmental causes of schizophrenia include infection, depression/stress, exposure to toxins and viruses while the individual is still in the womb, increased activation of the immune system, the use of mind-altering drugs especially during teen and young adult years (6).  

DSM-5 Criteria for Diagnosis of Schizophrenia

Schizophrenia currently is diagnosed from criteria that was published in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).  Signs of schizophrenia usually appear in early adulthood but must persist at least six months for a diagnosis to be made. There have since been new changes with the DSM-5 Criteria. These changes include the removal of Schneiders first rank symptoms. The DSM-5 new criteria include any type of delusions or hallucinations which results in the same value for diagnosis (7).  This change is not expected to have a major impact on diagnosis given that less than 2% of patients were diagnoses with schizophrenia based on first rank symptoms (7). 

Another current change in diagnostic criteria in the DSM-5 is that psychiatric symptoms last at least on month instead of 6 months to make a diagnosis, prodromal or residual symptoms must be present for 6 months (7). The DSM-5 also now uses a criterion of “clinical significance of damage” as a threshold and maintains functional impairment as a diagnostic criterion (7). 

 Before a diagnosis can be made the physician must perform a full medical examination to rule out other neurological or more medical illnesses, they may have symptoms like schizophrenia. It is also important to rule out substance abuse prior to making a diagnosis (9). Kraepelin introduced the subtypes of schizophrenia as paranoid, disorganized, catatonic, and undifferentiated type (3). Some changes included omission of the schizophrenia subtypes and the addition of a new scale to assess the severity of symptom cog dimensions (C-RDPSS) (3). The reason for omitting the subtypes of schizophrenia in the DSM-5 is that the subtypes did not accurately reflect the heterogeneity of schizophrenia, moreover, overtime the subtype stability was low and only some of the subtypes that were used were clinical (7). 

Currently the DSM-5 incorporated a symptom specifier in the assessment of the clinical manifestation of schizophrenia (delusions, hallucinations, abnormal psychomotor behavior, disorganized speech, and negative symptoms). These symptoms have been divided into 8 specifiers which are: hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms, cognitive impairment, depression, and mania which must be assessed on a scale from 0 (absent) to 4 (severe) (7). 

The DSM-5 changes included categories: episodic (with and without residual inter-episodic symptoms), continuous, single episode (partial and complete remission), both unspecified patterns and less than one year from onset of the first active phase (7). 

The DSM-5 changes also include that fact that the patient may have residual symptoms but during the six-month time and only negative symptoms may be present. It must be ruled out that the patient may have bipolar or depressive disorder with psychotic features or schizoaffective disorder before an official diagnosis of schizophrenia can be determined (10). Other symptoms that are taken into consideration include inappropriate effect, dysphonic mood, cognitive and memory deficit, anxiety and phobia, disturbed sleep pattern, behavior deficit such as hostility or aggression suicidal ideations, depersonalization and derealization (10). 

The C-RDPSS focuses on the symptoms because the DSM-5 shifted to symptom dimensions which include reality distortion (delusional, hallucinations) negative symptoms, disorganization, cognitive impairment, motor symptoms (catatonia), and mood symptoms (depression or mania) (7). The C-RDPSS produce a distinctive course patterns of treatment response and prognostic implications although the severity of symptoms differs with each patient and within a patient throughout the course of the illness. By assessing the severity of these dimensions, the clinician can attain a picture of the nature of the disorder in a particular patient and assess the impact of treatment on different aspects of the patient’s illness (7). 

Stages of Schizophrenia

Schizophrenia usually occurs in episodes, where the individual cycles through all three stages in order. It is exceedingly difficult for a person suffering from schizophrenia to break the cycle without any treatment or help from a physician. The stages of schizophrenia are identified as the prodromal phase (beginning), acute phase (active), and recovery phase (residual) (13).  

It is unclear how and why each move through the stages at the pace that they do. Some of the factors such as a combination of chemical or structural changes in the individual’s brain may influence how quickly a person progresses from one phase to another. We will look at each phase in depth. 

Prodromal Phase (Beginning)

The prodromal phase of schizophrenia is known as the beginning phase before psychosis. During this phase, the individual begins to have changes in their thought process, including bizarre feelings or ideas, social isolation, and impaired functioning. Friends and family may notice a change in the individual because they may want to be alone most of the time, and focus on certain topics like religion, the government, or public figures more than normal.  

This phase can usually last from weeks to years but some people with schizophrenia never get past this point (13). Studies have shown that individuals with disorganized symptoms were more likely to have negative symptoms and the prodromal phase and individuals with paranoid symptoms were more likely to have positive symptoms in the prodromal phase (13).  

Unfortunately, this phase can go undetected until more severe symptoms develop into the active phase. Symptoms in this phase may include increased anxiety, difficulty concentrating or paying attention, lack of motivation, isolation from family social life, and friends, sleep disturbance, increased irritability, forgetting or neglecting personal hygiene, and major changes in normal routines (14, 15). 

In an (2020) article Ferrarell and Mathalone discussed the importance of broadening the scope of prodromal research beyond transition to psychosis as an implication of treatment planning because prodromal research has made major contributions to advancing our understanding the neurobiological mechanisms underlying the risk for and the development of psychosis while bringing more attention to the importance of early detection, intervention, and possibly even the prevention of schizophrenia and related psychotic disorders (13). 

Acute Phase (Active) 

The acute phase of schizophrenia is the most disturbing because of the active introduction of psychosis. Family and friends may become scared and alarmed because of the individual’s obvious signs of disturbing hallucinations, delusions, disorganized speech, and thoughts.  

The acute phase can come on suddenly without a prodromal phase sometimes but is rare (14). Research has shown that negative symptoms and cognitive defects in this phase are core features of schizophrenia that account for much of the long-term mobility at poor functional outcomes (14, 15). Symptoms in this phase may include paranoid delusions, confused or disorganized thoughts, disorganized speech, lack of eye contact, flat affect, hallucination, or scene things that no one else sees, and useless or excessive movement (14, 15). 

Recovery Phase (Residual) 

The recovery phrase is not a recognized diagnosis by the DSM-5, but this term is still used to describe the time in which the individual with schizophrenia has fewer obvious symptoms, but the symptoms are still present. The clinician will often use this phase to describe the symptoms and the progression of schizophrenia (14).  

During this phase of the illness the individual may experience some elements of the active phase and sometimes relapse between the active phase and residual phase.  

Symptoms in the recovery phase may include lack of motivation, low energy, social withdrawal, eccentric behavior, illogical thinking, conceptual disorganization, lack of emotion, and aggressive vocalization (15). 

Current Treatment

Therapy for schizophrenia has evolved over the last century. Prior therapies included lobotomies, Metrazol therapy, insulin coma therapy, isolation and asylum, bloodletting and purging, trephination, and electroconvulsive therapy (ECT).  

Currently, treatment includes a strict pharmacological regimen, psychosocial therapy (family therapy, individual psychotherapy, cognitive remediation, rehabilitation), electroconvulsive therapy (ECT), coordinated specialty care (CSC), and hospitalization. 

Pharmacological

Antipsychotic drugs have been the mainstay of psych schizophrenia treatment since the introduction of chlorpromazine. Antipsychotics do not cure schizophrenia, but they help relieve the most problematic symptoms including hallucinations, delusions, and disorganized thoughts. Antipsychotics work by affecting the neurotransmitters in the brain, specifically serotonin and dopamine. 

Psychosocial Therapy

Although medication helps to relieve symptoms of schizophrenia, psychosocial treatments help with the behavioral, psychological, social, and occupational problems that go along with the illness. Various therapies under psychosocial therapy are available to help the individual and family members identify early warning signs of relapse and manage a relapse prevention plan (4). 

Family-Based Therapy

Family therapy is based on the system theory which underlies the multifamily treatment approach that includes coping recommendations, problem-solving, crisis intervention, reduction of pathogenic interactions, and psychoeducation which helps the patient and family members be able to identify early warning signs that may show that the individual is at a high-stress level (8). 

Personal Therapy 

Personal therapy combines aspects of social skills training (SST)and some other common elements of cognitive behavior therapy. The social skills training is based on a behavioral model that targets the improvement of the person’s ability to function skillfully in social situations and interactions in has been found to improve both positive and negative symptoms.  

This therapy is focused on the area of recovery, and it is a long-term endeavor that has been shown to decrease the probability of relapse (8). 

Cognitive Remediation Therapy (CRT)

Cognitive remediation therapy (CRT) is a computer-based intervention that was originally designed to improve deficits in cognitive abilities in people suffering from traumatic brain injury but has now been a part of treatment for schizophrenia. Cognitive remediation therapy is used in combination with SST, groups, coaching, and problem-solving to help improve the individual’s social cognition attention span, and speed of processing for the individual with schizophrenia. The effects are meaningful, durable, and related to improvement in everyday functional outcomes (11). 

Rehabilitation

This form of therapy focuses on job training and social skills to help the individual function in the community and be able to live an independent life (4). 

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy has been around since 1930. It has been utilized for various stages of schizophrenia. A course of ECT therapy involves two to three treatments per week for several weeks. While the patient goes under general anesthesia the doctors send a small shot to the brain which causes a controlled seizure. Currently, ECT treatment is utilized for medication-resistant schizophrenia and causes improvement in symptoms and cognition (17). 

Coordinated Specialty Care (CSC) 

This type of therapy uses a team approach to treating schizophrenia when the first symptoms appear. there is a combination of medicine and therapy with social services employment and educational intervention the family is utilized as much as possible early treatment is the key to helping the patient lead a normal life (4). 

Hospitalization

Individuals who have severe problems who might want to harm themselves or who cannot take care of themselves at home are treated as inpatients because it is a better option for them and safer until they can be placed in the outpatient clinic setting (4). 

Healthcare and Economic Impact 

Because individuals with schizophrenia tend to cycle through the phases, they are often left with psychiatric deficits which lead to unemployment, homelessness, and incarceration. 

Schizophrenia is now one of the top 15 leading causes of disability worldwide and individuals with schizophrenia have an extremely high risk of premature death at a younger age than the general population (18). In the US, the estimated average of potential early mortality is 28.5 years. There is an estimated 4.9% of people with schizophrenia committing suicide and the rate is far greater than the general population with the highest risk being in the early stages of the illness (2). 

Individuals with schizophrenia have comorbid medical conditions such as liver disease, diabetes, and heart disease, which is a high factor and is usually the contributing factor to early mortality. There are disproportionately high financial costs associated with schizophrenia relative to other chronic mental and physical health conditions (2).  

If schizophrenia is left untreated schizophrenia can result in severe problems that affect every area of life. For example. The amount of healthcare services needed to treat the disorder can be an economic burden on the patient and their families (18). 

While schizophrenia affects only 1% of the population it accounts for 2.5% of total health care expenditures in the United States. The estimated cost of all mental illness care was $103.7 billion with schizophrenia alone accounting for $22.7 billion in 1995 (18). Current studies have concluded the annual cost for schizophrenia in the United States range from $155.7 billion in 2013 and $343.2 billion in 2019 (18). 

Conclusion

Schizophrenia is a complex multi-factor disease that is difficult to control. From the current knowledge that we have it does not seem very probable that all symptoms of the disease can be treated under one modality. Over a century of schizophrenia treatment, we have made significant progress in the treatment of schizophrenia from lobotomy operations through the discovery of chlorpromazine to the current second and third-generation drugs and psychosocial therapy. Despite our best efforts we have a high rate of relapse what schizophrenia patients.  

As healthcare workers, we must continue to integrate the medical and psychological approaches to treatment for our patients. By showing our compassion and understanding of their struggles, we must empower them and include them in their treatment plan. Our biggest asset as healthcare professionals is to be an advocate and coach for these patients.  

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