Schizophrenia

Related Subjects: |Psychiatric Emergencies |Depression |Mania |Schizophrenia |Suicide |Acute Psychosis |Delusions |General Anxiety Disorder |Obsessive-Compulsive disorder |Wernicke Korsakoff Syndrome |Medically Unexplained symptoms |Postpartum/Postnatal Depression |Postpartum / Postnatal Psychosis |Eating disorders in Children

💡 Schizophrenia is a severe mental illness characterised by distortions in thought, perception, and behaviour. 🎧 Auditory hallucinations are classic, but remember: olfactory & gustatory hallucinations suggest a neurological cause (e.g. temporal lobe epilepsy). ⚠️ Early recognition, antipsychotic therapy, and psychosocial support dramatically improve outcomes.

📊 About

• Prevalence ~1% worldwide; onset usually late teens–early 30s.
• M>F (slightly earlier onset in men, worse prognosis).
• Course: relapsing-remitting, with residual negative symptoms in many patients.

🧬 Aetiology

• 🔬 Neurobiology:
  • Dopamine hypothesis: ↑ mesolimbic activity → positive symptoms; ↓ mesocortical activity → negative symptoms.
  • Structural: enlarged ventricles, reduced temporal + hippocampal volume.
• 🧬 Genetics: Concordance in monozygotic twins ~40–50%.
• 🌍 Environment: Urban living, migration, childhood adversity, cannabis use (esp. high potency THC).
• 🧠 Neurodevelopmental: Obstetric complications, perinatal hypoxia, maternal infection.

➕ Positive Symptoms

• 🎧 Hallucinations: typically auditory (“third-person voices”).
• 🧩 Delusions: persecutory, referential, thought insertion/withdrawal.
• 🗯️ Thought disorder: derailment, neologisms, word salad.
• 🤹 Bizarre behaviour: posturing, agitation, disorganised dress.

➖ Negative Symptoms

• 😐 Blunted affect & monotone speech.
• 🚶 Social withdrawal, self-neglect.
• 📉 Avolition (loss of motivation), anhedonia.
• 🗣️ Alogia (poverty of speech).

🔍 Diagnosis

• ICD-10 / DSM-5: ≥1 month of symptoms, impaired function, exclude organic/affective causes.
• Screen for organic mimics: temporal lobe epilepsy, substance misuse (cocaine, cannabis), brain tumour, thyroid disease.
• Psychiatric assessment: collateral history, mental state exam (MSE), risk assessment.

💊 Management

Medication

• 🎯 First-line: Atypical antipsychotics (NICE CG178):
  • Risperidone 2–6 mg/day.
  • Olanzapine 10–20 mg/day (⚠️ metabolic risk).
  • Quetiapine 300–600 mg/day.
  • Aripiprazole 10–30 mg/day (less weight gain).
• 💊 Typicals (e.g. haloperidol 2–10 mg/day) reserved if atypicals not tolerated.
• 💉 Depot/long-acting injections for adherence problems.
• 🩸 Clozapine → ONLY for treatment-resistant schizophrenia (failed 2 other drugs).
  • Start 12.5 mg BD → titrate to 300–450 mg/day.
  • Monitor FBC weekly (risk: agranulocytosis, seizures, myocarditis).

🧠 Psychosocial & Support

• 🗣️ CBT for psychosis (CBTp): helps manage hallucinations/delusions.
• 👨‍👩‍👦 Family interventions: reduce relapse via psychoeducation & reducing expressed emotion.
• 🏠 Social support: supported housing, benefits advice, occupational rehab.
• 📅 Regular GP review: monitor weight, BP, HbA1c, lipids (antipsychotic SEs).

🏥 Crisis Care

• 🚨 Admission if high suicide risk, danger to others, or unable to care for self.
• Rapid tranquillisation: IM haloperidol 2–5 mg + lorazepam 1–2 mg (NICE guidance). ⚠️ Monitor ECG (QTc), vitals, and airway.

🚨 Status Psychoticus (Refractory Agitation)

• Stepwise escalation: verbal de-escalation → oral meds → IM meds → seclusion as last resort.
• ECT considered in rare, severe catatonia or psychotic depression overlap.

🤰 Schizophrenia in Pregnancy

• ⚖️ Balance maternal stability with foetal safety.
• Olanzapine, quetiapine often used (relative safety data better than others).
• Clozapine → possible neonatal agranulocytosis, sedation: needs senior perinatal psychiatry input.
• Avoid valproate (teratogenic, not for women of childbearing age).

📌 Exam Pearls

• Positive = acute; Negative = chronic.
• Clozapine = gold standard in resistant schizophrenia.
• Always screen for suicide risk (10% lifetime risk).
• Don’t forget metabolic monitoring for all antipsychotics.

🔗 References

• NICE CG178 – Psychosis & Schizophrenia in Adults
• NICE CKS: Schizophrenia
• APA – Schizophrenia

Cases — Schizophrenia

• Case 1 — Positive symptoms 🗣️: A 23-year-old man presents with a 6-month history of hearing voices commenting on his actions and believing neighbours are spying on him through the TV. He has withdrawn from university and stopped socialising. Mental state exam: third-person auditory hallucinations, persecutory delusions. Diagnosis: schizophrenia with prominent positive symptoms. Managed with an antipsychotic (first-line: oral atypical).
• Case 2 — Negative symptoms 😶: A 28-year-old woman is brought by her family for social withdrawal, poor self-care, flat affect, and poverty of speech. She has no hallucinations but is unable to maintain work or relationships. Diagnosis: schizophrenia with predominant negative symptoms. Managed with antipsychotics and psychosocial interventions (CBT, supported employment).
• Case 3 — Relapse with poor adherence 🔄: A 35-year-old man with a 10-year history of schizophrenia presents with recurrence of persecutory delusions after stopping his medication. He has previously responded well to risperidone but struggles with adherence. Diagnosis: schizophrenia relapse due to poor adherence. Managed with long-acting injectable antipsychotic (depot) and community psychiatric support.

Teaching Point 🩺: Schizophrenia is a chronic psychotic disorder with positive symptoms (hallucinations, delusions, thought disorder) and negative symptoms (flattened affect, avolition, social withdrawal). Management combines antipsychotics, CBT for psychosis, family therapy, and community support. Non-adherence is a major cause of relapse.