Schizophrenia

Definition/Description

Schizophrenia is "a chronic, more or less debilitating illness characterized by perturbations in cognition, affect, and behavior, all of which have a bizzare affect. "[1]


Image:Schizophrenia_graphic_high_contrast1.jpg

Prevalence

  • Schizophrenia affects approximately 1% of the general population. [1] [2]
  • It affects both males and females at an equal rate.[1]
  • Average onset is in the late teens/early adult years. Males tend to start between the ages of 17-20. Women are generally diagnosed a little later in their twenties. [2]
  • Childhood onset, before age 12, and late adulthood onset are not as common. [3]

Characteristics/Clinical Presentation

     Diagnostic Criteria for Schizophrenia[2]:

        1.  Two or more of the following symptoms during a 1 month period of time:

  • Delusions: almost a universal symptom among schizophrenics. These delusions the person has are often gradiose ideas, thoughts of persecution, and the feeling that their thoughts are being broadcasted to the rest of the world and that everyone can hear what they are thinking. [1]
  • Hallucinations: auditory hallucinations are the most common type of hallucination. 80% of children with schizophrenia present with auditory hallucinations. [3] People can also experience visual, touch, taste, or smell hallucinations. These hallucinations are never comforting, but are very demanding of the person hallucinating. [1]
  • Disorganized speech: This is also called "word salad." When the person speaks, their words make no sense at all and are in a very illogical order[1]. The average IQ of a person with schizophrenia is around 80-85 and it declines with aging. [4]
  • Catatonic behavior: A state in which the person may give automatic obedience. They may also have increased muscle tension, hold their bodies in strange postures, and mimic the behaviors of others around them. [1]
  • Negative symtpoms: decreased speech production, decreased goal oriented behaviors, lack of emotion, lack of motivation, unable to find pleasure in activities, and has a blunted personality. [4]

    2. Social or occupational dysfunction (ex. at work, in public, etc)

    3. A duration of continuous symptoms for at least 6 months.

    4. Rule out differential diagnoses such as autism, mood disorder, depression, borderline personality disorder, bipolar disorder, alcoholism, etc. [5]

    Clinical Presentation
  • The person's symptoms are not always continuous; they may come and go at certain points in their life. 
  • Exacerbation of symptoms can be brough on by life stresses, such as, marriage, work, school, and other major lifechanging events. [1]
  • There are 5 types of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual. Any person may be diagnosed with one or multiple types of schizophrenia. [4]
  • People with schizophrenia will experience a decrease in mental and physical function over time, which is part of the disease. [6]

Associated Co-morbidities

  • Depression. [1]
  • Suicide risk. 50% of people with schizophrenia attempt suicide. [1]
  • Diabetes Mellitus (as a result of the medication). [7]
  • Attention Deficit Hyperactive Disoder with childhood onset. [3]

Medications

Typical Antipsychotics [4] [8]

Drug Name             Brand Name          Side Effects

  • Chlorpromazine (Thorazine)          Nausea, dizziness, jitteriness, dry mouth, loss of appetite
  • Haloperidol       (Haldol)               Trouble sleeping, dry mouth, GI upset, constipation
  • Loxapine          (Loxitane)            Weight loss/gain, blurred vision, dry mouth, dizziness, trouble sleeping
  • Molindone        (Moban)               Increased saliva production, restlessness, dry mouth, constipation
  • Perphenazine   (Trilafon)               Nasal congestion, sleeplessness, tired feeling, vomiting, confusion
  • Thiothixene       (Navane)              Lightheaded, tired, diarrhea, headache, dry mouth, changes in appetite
  • Trifluperazine     (Stelazine)           Mild agitation, trouble sleeping, headache, loss of appetite


Atypical Antipsychotics [4] [8]

Drug Name          Brand Name          Side Effects

  • Aripiprazole      (Abilify)               Dizziness, drowsiness, headache, vomitting
  • Clozapine        (Clozaril)              Shortness of air, stiff muscles, numbness, seizure, chest pain, nausea
  • Olanzapine      (Zyprexi               Weakness, pain, redness, swelling at injection site, dizziness, drowsiness
  • Paliperidone     (Invega)               Sore throat, weakness, redness, swelling, weight gain, dizziness
  • Quetiapine       (Seroquel)           Stomach pain, nasal congestion, constipation, dizziness, weight gain
  • Risperidone     (Risperal)             Tremor, fever, stiff muscles, restlessness, trouble swallowing, fainting
  • Ziprasidone      (Geodon)             Anxiety, pain at injection site, runny nose, constipation, restlessness

Diagnostic Tests/Lab Tests/Lab Values

There are no diagnostic tests or labs that will diagnose or help medically manage schizophrenia.

Causes

1. Genetics

  • 5% of schizophrenics have a first generation family member with schizophrenia as well. [1]
  • In the case of identical twins and schizophrenia, there is a 50% chance that if one twin has schizophrenia, the other twin will have it as well. [1]
  • The image below is a graph that shows the rates of relatives with schizophrenia among people with schizophrenia.[9]
    Schizophrenia.risks.jpg


2. Neurodevelopmental

  • The physical structure of the brain is different in people with schizophrenia. 
  • These particular people have been found to have cortical atrophy, ventricular dilation (particularly the third ventricle), and overall have a smaller brain size. [1][4][2]

Systemic Involvement

Depending upon the specific type of schizophrenia, they can experience muscle tension or spasms throughough the body. [4] Due to the fact that this disorder affect the mind and how a person sees or thinks, it can have varied effects on the rest of the person's body.

Medical Management (current best evidence)

  • For symptom management, using one of the medications listed in the above section is the treatment of choice. [3][1]
  • Psychotherapy combined with medication is very effective in the prevention of deterioration. Therapy is also used to teach social and behavioral skills. With the use of individual sessions, group therapy, and family therapy, certain behaviors are positively reinforced in order to help the person achieve a sense of self worth. [4]
  • Prognosis for people who recieve treatment[4]:
    10% have 1 or 2 episodes and then completely recover
    55% will have chronic symptoms
    35% will have intermittent episodes.

Physical Therapy Management

Physical therapy cannot treat the schizophrenia itself. However, it can help manage any co-morbidities, side effects of medications, or help deal with the physical decline in function. Diabetes affects 6% of people with schizophrenia, and this is an area that physical therapy can contribute.[7] Education on diet, exercise, and skin checks would be very beneficial to these people. Also, people with schizophrenia see a decline in physical function as they age, more so than the average person. They may experience bone/joint disease, fractures, decline in brain function, parkinsonism, cerebrovascular accident, spinal cord disorders, amputations, etc. [6] As previously stated, we cannot treat schizophrenia itself, but we will see patients for other medical reasons who are affected by this disorder. 

Differential Diagnosis

  • Differential diagnoses in children include: ADHD, conduct disorder, asperger's, borderline personality disorder, and childhood depression. [3]
  • Differential diagnoses in adults include: bipolar disorder, depression, borderline personality disorder, mood disorders, schizoaffective disorder, schizofreniform, paranoia, and alcoholism. [4][1]


Resources

Schizophrenia, gluten, and low-carbohydrate, ketogenic diets: a case report and review of the literature


[10]

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders-IV-TR. New York: APA; 2000.
  2. 2.0 2.1 2.2 2.3 Kelly D. Treatment Considerations in Women with Schizophrenia. Journal of Women's Health. 2006; 15(10): 1132-1140.
  3. 3.0 3.1 3.2 3.3 3.4 Foster KA, Swartz L, Jager W. The Clinical Presentation of Childhood Onset Schizophrenia: A Literature Review. South African Journal of Psychology. 2006; 36(2): 299-318.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Roberson C. Schizophrenia. The Alabama Nurse. August 2009: 6-8.
  5. Goodman CC, Fuller KS. Pathology Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders Elsevier; 2009.
  6. 6.0 6.1 Senba H, Imamura Y, Fukuda N, Sekine M, Kikuchi Y, Numao H. Guidelines for Physical Therapy in Physically Disabled Schizophrenic Patients. Journal of Physical Therapy Science. 2002; 14:15-20.
  7. 7.0 7.1 Sernyak MJ, Leslie DL, Alarcon RD, Losonczy MF, Rosenbeck R. Association of Diabetes Mellitus with Use of Atypical Neuroleptics in the Treatment of Schizophrenia. American Journal of Psychiatry. 2002; 159(4): 561-566.
  8. 8.0 8.1 Drugs.com. Drug Information Online. 2010. Available at:http://www.drugs.com/. Accessed on February 27, 2010.
  9. Corocan C, Cadenhead K, Vinogradov S. Schizophrenia Prevention-Risk Reduction Approaches. http://schizophrenia.com. Updated 2004. Accessed February 14, 2010.
  10. Schizophrenia-causes, symptoms, diagnosis, treatment and pathology. Available from: https://www.youtube.com/watch?v=PURvJV2SMso