Introduction
Schizophrenia is one of the most prolific mental disorders that is characterized by people having an abnormal interpretation of reality. Individuals face some combination and forms of hallucinations, psychosis, delusions, and cognitive impairment which impacts daily functioning and often leads to social exclusion. Although schizophrenia requires lifelong treatment, early identification and management of the condition can have positive effects and improve the long-term outlook.
Background
The term schizophrenia was coined a Swiss psychiatrist Eugen Bleuler in 1908, from a combination of Greek terms schizein (to split) and phrēn (mind) translated as ‘splitting of the mind.’ Descriptions of schizophrenia-like symptoms have been described as early as the 18th century, but it was characterized as either early dementia or manic depression. For a long time, schizophrenia was also associated with split personalities, what is now known as a separate multiple-personality disorder. While earlier Kraepelian dichotomy characterized the condition as a single disease state, Bleuler viewed schizophrenias as different entities with varying underlying causes and prognoses. In 1959, Kurt Schneider also supported a hierarchical system of classification for schizophrenia symptoms, terming the core features of first-rank symptoms. These included: 1) having one’s thoughts spoken out loud; 2) auditory hallucinations commenting on a person’s behavior; 3) withdrawal, insertion, or broadcasting of thoughts; and 4) somatic hallucinations or belief that one’s mind is controlled or influenced by outside forces (Medscape, n.d.).
This categorical approach provided more structure to diagnosing and studying schizophrenia. By the latter 20th century, schizophrenia was included in the U.S. diagnostic model for mental disorders DSM. However, it has been criticized for not being reliable in diagnosing the condition. Unfortunately, schizophrenia has historically had an extremely negative connotation in society and culture, resulting in individuals not getting the necessary treatment while researchers lacked an opportunity to study it on a large scale. Some countries have officially renamed diagnoses of the disorder to reduce stigma. Modern theoretical conceptualizations and studies of a schizophrenic syndrome are based on improved knowledge of neurobiological processes as well as neuroimaging technologies which allow for more complex and comprehensive understanding (Medscape, n.d.).
Epidemiology
Schizophrenia is prevalent worldwide, with an incidence of approximately 1.5 per 10,000 people, or 1.1% of the global population. In the United States, there 3.5 million individuals diagnosed with schizophrenia, being one of the leading causes of disability. The majority of individuals are diagnosed during the age of adolescence between 16-25 years of age, with the disease rarely showing in childhood or adulthood. Slightly more men than women (1.4 to 1) are diagnosed, with women sometimes having the onset of disease later between 25 and 35 years of age, but anecdotal evidence suggests men may have a worse prognosis (Fischer & Buchanan, 2020). Although schizophrenia can affect everyone, racial disparities in the diagnosis are present, with African Americans and Hispanic minorities having a rate 3-4 times higher than Euro-Americans/White individuals. It is unclear whether this remains a biological factor or sociological causes such as clinical bias and differential access to healthcare and mental health services (Schartz & Blankenship, 2014).
Diagnosis
Knowledge of the neurobiology of schizophrenia remains rudimentary despite significant progress in recent years. Schizophrenia has three primary symptoms groups of positive, cognitive, and negative symptoms. Positive symptoms include delusions and hallucinations that are most recognizable during acute psychosis and are linked to aberrant salience. Cognitive symptoms include impairments to memory, attention, and executive function. Meanwhile, negative symptoms are a lack of emotional expression or other blunting effects, avolition, and social withdrawal. One of the biggest challenges is that psychiatric symptoms exist on a continuum from normal to pathological and establishing a threshold for diagnosis in a clinical setting can be difficult. Most often a clinical diagnosis relies on the exemplification of positive symptoms that are associated with a prolonged psychotic episode. While there is a high incidence of delusions and hallucinations (up to 30%), for most patients, these symptoms are transient. Furthermore, psychotic symptoms are can be attributed to various mental disorders. Clinical evidence suggests that presynaptic dopamine dysfunction is the mediator of psychosis in schizophrenia (Kesby et al., 2018).
There is no specific single test for schizophrenia with the disorder usually diagnosed through a range of assessments by a specialist in mental health. A primary care doctor will first use physical and imaging tests as well as bloodwork, to rule out physical illness as the cause of symptoms. If there is suspicion of schizophrenia, a referral will be made. Most commonly, a psychiatrist will carry out an assessment and evaluate symptoms in the context of personal and medical history as well as life circumstances and behaviors. Mental health professionals have psychological evaluation tests to assess a patient’s condition and to help rule out other disorders such as bipolar or dissociative identity disorders. A doctor uses the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to determine if symptoms point to schizophrenia. The standard in DSM-5 is that a diagnosis of schizophrenia can be made if a person demonstrates two or more core symptoms, one of which must be hallucinations, delusions, or disorganized speech for at least one month. Other core symptoms include gross disorganization and diminished emotional expression (Cleveland Clinic, n.d.). Therefore, as of currently, diagnosis of schizophrenia is subjective although psychiatrists attempt to create categorical standards. However, even by DSM-5 criteria, the diagnostic process depends on ruling out physical illness, substance abuse, or other mental disorders. From a clinical standpoint, this can create potential errors in diagnosis.
Treatment
The complexity of both positive, negative, and cognitive symptoms demonstrated in schizophrenia requires a complex and multifaceted approach. Since patients do not commonly return to a baseline level of adaptive functioning, both pharmacological and nonpharmacological treatments are recommended to improve long-term outcomes. The key to target symptoms, prevent relapse, and help a patient to reintegrate back into society. For most patients, it is challenging to implement rehabilitation initiatives without antipsychotic agents, which are the primary type of medication prescribed. Prompt pharmacological treatment is vital, especially within 5 years of the first acute episode, during which illness-related changes occur in the brain. In the event of acute psychosis, drug therapy must be administered immediately to decrease hostility and return the patient to normal within 7 days. Maintenance treatment is then utilized to prevent relapse. Drug therapy is recommended to continue for at least 12 months after the last psychotic episode. The APA recommends second-generation (atypical) antipsychotics (SGAs) as the first line of treatment for schizophrenia. Clozapine is the only exception due to the risk of agranulocytosis. SGAs are preferred over first-generation (typical) antipsychotics (FGAs) due to fewer associated extrapyramidal symptoms, although SGAs also have potential metabolic side effects (Patel et al., 2014).
Psychotherapy is the most utilized nonpharmacological treatment, in all forms of individual, group, and cognitive behavioral therapy. Psychotherapies such as meta-cognitive training, narrative, and mindfulness therapy have been used. This approach can help fill the gaps in pharmacological treatment, ensuring patients are adherent to treatment plans as well as helping them adjust in terms of mental health and socialization. However, nonpharmacological treatments should only be used as a supplement to medication, not as a substitute. Adherence to medication is challenging to patients with mental disorders due to the effects of symptoms or denial of the disease. Nonadherence rates for schizophrenia range from 37 to 74%, and those who stop taking medication are at an increased risk of relapse. Psychotherapy such as cognitive-behavioral therapy or compliance therapy aims at increasing adherence by educating patients and informing them about the risks of the illness and the effectiveness of treatment (Patel, 2014).
Impact and Outcomes
The outcome of schizophrenia depends largely on the ability to identify it early and receive healthcare. One-third to one-half of homeless adults have schizophrenia and 50% of diagnosed individuals do not receive treatment. Studies indicate that 25% of diagnosed recover completely, 50% improve over a 10-year period, and 25% do not improve (SARDAA, n.d.). Unfortunately, there is a strong social stigma around schizophrenia, fueled by media, and such patients are misunderstood, even by family and friends, perceived as violent and dangerous. However, a minuscule percentage of schizophrenics are violent, and there is a greater danger of people with schizophrenia of harming themselves or committing suicide due to social stigmatization (NHS, n.d.).
If left untreated, which can occur due to lack of access to healthcare or people refusing to acknowledge the mental disorder, the disease can have tragic effects. It is likely that even with treatment, people with schizophrenia will require day-to-day care to ensure adherence to treatment and managing any bouts of psychosis or socially challenging behavior. It is difficult to maintain employment with schizophrenia since the condition decreases motivation and attention span as well as challenges social communication. It is likely that family and romantic relationships face difficulties as well (NHS, n.d.). This results in many schizophrenia patients ending up in tragic life circumstances of being left alone, homeless, or failing to maintain daily functioning.
References
Cleveland Clinic. (n.d.). How is schizophrenia diagnosed?
Fischer, B.A., & Buchanan, R.W. (2020). Schizophrenia in adults: Epidemiology and pathogenesis. Web.
Kesby, J., Eyles, D., McGrath, J., & Scott, J. (2018). Dopamine, psychosis and schizophrenia: The widening gap between basic and clinical neuroscience. Translational Psychiatry, 8(1). (n.d.). Web.
Historical roots of schizophrenia. Web.
Living with schizophrenia. Web.
Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: Overview and treatment options. P&T: A Peer-Reviewed Journal for Managed Care and Hospital Formulary Management, 39(9), 638–645. Web.
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Schwartz, R. C., & Blankenship, D. M. (2014). Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World Journal of Psychiatry, 4(4), 133–140.