Objectives

At the end of the lecture discussion, the graduate students taking up Masters of Arts in Nursing

in advanced psychiatric nursing will be able to:

1. Understand the concept of schizophrenia by enumerating the clinical signs and

symptoms which includes the positive and negative manifestation of the disease

condition.

2. Differentiate the genetic factors, both behavioral and molecular in the etiology of

schizophrenia.

3. Discuss how the brain has been implicated in schizophrenia.

4. Discuss the role of stress and other psychosocial factors in the etiology and relapsed

of schizophrenia.

5. Distinguish the treatment of schizophrenia by listing various medical and

psychological treatment of schizophrenia.

6. Share experiences about psychiatric encounter that can contribute to the discussion of

the topic – schizophrenia

7. Utilize the nursing process by presenting current nursing article or journal that will

update health care providers with regards to the latest trends in health care setting

especially in psychiatric health.

Introduction

According to National Institute of mental health, Schizophrenia is a chronic, severe, and

disabling brain disease. Approximately 1 percent of the population develops schizophrenia

during their lifetime – more than 2 million Americans suffer from the illness in a given year.

Although schizophrenia affects men and women with equal frequency, the disorder often appears

earlier in men, usually in the late teens or early twenties, than in women, who are generally

affected in the twenties to early thirties. People with schizophrenia often suffer terrifying

symptoms such as hearing internal voices not heard by others, or believing that other people are

reading their minds, controlling their thoughts, or plotting to harm them. These symptoms may

leave them fearful and withdrawn. Their speech and behavior can be so disorganized that they

may be incomprehensible or frightening to others. Available treatments can relieve many

symptoms, but most people with schizophrenia continue to suffer some symptoms throughout

their lives; it has been estimated that no more than one in five individuals recovers completely.

This is a time of hope for people with schizophrenia and their families. Research is gradually

leading to new and safer medications and unraveling the complex causes of the disease.

Scientists are using many approaches from the study of molecular genetics to the study of

populations to learn about schizophrenia. Methods of imaging the brain’s structure and function

hold the promise of new insights into the disorder.

Incidence and Prevalence

In men, schizophrenia symptoms typically start in the early to mid-20s. In women, symptoms

typically begin in the late 20s. It's uncommon for children to be diagnosed with schizophrenia

and rare for those older than 45. In relation to sex ratio, according to Hanafi (2010) an author of

slideshare presentation, there is 60 % man cases with schizophrenia. Moreover, with regards to

the socioeconomic status, there is high prevalence to those who belong to low socio economic

status.

Moreover, according to Nations for Mental Health the distribution of a disorder in a given

population is measured in terms of incidence and prevalence. Incidence refers to the proportion

of new cases per unit of time (usually one year), while prevalence refers to the proportion of

existing cases (both old and new). Three types of prevalence rate can be used: point prevalence,

which is a measure of the number of cases at a specific point in time; period prevalence ,

showing the number of cases over a defined period of time (usually six months or one year); and

lifetime prevalence, reflecting the proportion of individuals who have been affected by a disorder

at any time during their lives. Incidence studies of relatively rare disorders, such as

schizophrenia, are difficult to carry out. Surveys have been carried out in various countries,

however, and almost all show incidence rates per year of schizophrenia in adults within a quite

narrow range between 0.1 and 0.4 per 1000 population. This has been the main finding from the

WHO 10-country study (Jablensky et al., 1992).

As presented by Hanafi (2010) an author of Slideshare

presentation includes the prevalence of the developing

schizophrenia. Putting the highest percentage was on the

monozygotic twins which compromises for about 48%

and the lowest is Spouses with distant relation and in the

general population

Taking into account differences in diagnostic assessment, case-finding methods and definition of

adulthood, we can say that the incidence of schizophrenia is remarkably similar in different

geographical areas (Warner and de Girolamo,1995). Exceptionally high rates that emerged from

the Epidemiologic Catchment Area Study in the United States (Tien and Eaton, 1992) may be

due to biased assessment. Although few data are available on incidence in developing countries,

early assumptions on consistently lower rates outside the western industrialized countries have

not been confirmed by recent thorough investigations in Asian countries (Lin et al., 1989;

Jablensky et al., 1992; Rajkumar etal., 1991).High incidence figures have recently been reported

in some disadvantaged social groups – especially ethnic minorities in western Europe, such as

AfroCaribbean communities in the United Kingdom and immigrants from Surinamin the

Netherlands (King et al., 1994; Selten and Sijben, 1994). Such findings, plagued by uncertainties

about the actual size and age distribution of the populations at risk, still await convincing

explanations. In the last 15 years a variety of reports from several countries have suggested a

declining trend in the number of people presenting for treatment of schizophrenia (Der et al.,

1990). However, changes in diagnostic practices and patterns of care or more rigorous

definitions of new cases as a result of improved recording systems, have not been ruled out as an

explanation. So far, the case for a true decrease in incidence is suggestive but not

proven(Jablensky, 1995)

According to Mental Health Initiative, there are 3 phases of the disease condition:

1. Prodromal phase

Schizophrenia usually starts with this phase, when symptoms are vague and easy to miss. They

are often the same as symptoms of other mental health problems, such as depression or other

anxiety disorders. They may not seem unusual for teens or young adults. In fact, schizophrenia is

rarely diagnosed at this time.

Symptoms are sometimes triggered by stress or changes, such as going away to school, starting

to use drugs or alcohol, or going through a severe illness or a death in the family.

These first symptoms often include being withdrawn, outbursts of anger, or odd behavior.

2. Psychotic phase (Acute)

At some point a patient may start to have symptoms such as hallucinations, delusions, or

confusing thoughts and speech. These symptoms may appear suddenly or slowly over time. They

can be severe and can cause a psychotic episode, which means you can't tell the difference

between what is real and what isn't real. a patient may need to go to the hospital accompanied by

the support system. this phase usually lasts 4 to 8 weeks. This is when schizophrenia usually is

diagnosed.

3. Remission and Residual phase (chronic)

After an active phase, symptoms get better, especially with treatment, and life may be more

"normal." This is called remission. But symptoms may get worse again, which is called a

residual. A patient may have this cycle of symptoms that get severe and then improve.

In each cycle, symptoms such as hallucinations and delusions may become less intense. A patient

may have few or many cycles before they are able to stay in remission.

Within 5 to 10 years, a patient may develop a unique pattern of illness that often stays the same

throughout their life. It also is possible that they will have fewer relapses as they get older and

may even not have symptoms at all.

Brief History

The word "schizophrenia" is more than 100 years old. However the disease was first

identified as a discrete mental illness by Dr. Emile Kraepelin in the 1887 and the illness itself is

generally believed to have accompanied mankind through its history. He was one of the first to

classify the mental disorders into different categories. He used the term "dementia praecox" for

individuals who had symptoms that we now associate with schizophrenia. He was the first to

make a distinction in the psychotic disorders between what he called dementia praecox and

manic depression. Kraepelin believed that dementia praecox was primarily a disease of the brain,

and particularly a form of dementia. Kraepelin named the disorder 'dementia praecox' (early

dementia) to distinguish it from other forms of dementia (such as Alzheimer's disease) which

typically occur late in life. He used this term because his studies focused on young adults with

dementia.

Eugen Bleuler, who first coined the term “schizophrenia”, took exception to the Kraepelinian

notion that schizophrenia almost invariantly involved both a deteriorating course and early onset.

He viewed "the schizophrenias" as being composed of several different entities rather than a

single disease state as Kraepelin conceptualized. He argued that the schizophrenias had varying

underlying causes as well as prognosis. Despite the clinical diversity posited by Bleuler, he

asserted that there were 4 cardinal features almost invariably present in schizophrenic patients.

These have been termed the "four As": 

Blunted Affect  

Loosening of Associations  

Ambivalence  

Autism

Both Bleuler and Kraepelin subdivided schizophrenia into categories, based on prominent

symptoms and prognoses. Over the years, those working in this field have continued to attempt

to classify types of schizophrenia. Five types were delineated in the DSM-III: disorganized,

catatonic, paranoid, residual, and undifferentiated. The first three categories were originally

proposed by Kraepelin. These classifications, while still employed in DSM-IV, have not shown

to be helpful in predicting outcome of the disorder, and the types are not reliably diagnosed.

Many researchers are using other systems to classify types of the disorder, based on the

preponderance of "positive" vs "negative" symptoms, the progression of the disorder in terms of

type and severity of symptoms over time, and the co-occurrence of other mental disorders and

syndromes. It is hoped that differentiating types of schizophrenia based on clinical symptoms

will help to determine different etiologies or causes of the disorder.

Kurt Schneider, a German psychiatrist and a pupil of Karl Jaspers, pointed out certain symptoms

as being characteristic of schizophrenia and therefore exhibiting a “first-rank” status in the

hierarchy of potentially diagnostic symptoms. The “first-rank” symptoms (FRS) have played an

extremely important role in the recent diagnostic systems: in the International Statistical

Classification of Diseases, tenth Revision (ICD-10) as well as in Diagnostic and Statistical

Manual of Mental Disorder, Third and Fourth Edition(DSM-III-IV), the presence of one FRS is

symptomatically sufficient for the schizophrenia diagnosis. At the same time, critics regularly

claim that FRS may also be encountered in the non-schizophrenic conditions, and therefore, they

are not specific or diagnostic for schizophrenia.

He enumerated “first” and “second” rank symptoms :

First Rank :

1. Audible Thoughts

2. Hallucinated voices of two or more individuals arguing or conversing

3. Hallucinated voices commenting on the patient's actions

4. Thought Broadcasting

5. Thought Withdrawal

6. Thought Insertion

7. (Somatic) Passivity

8. Delusional Perception

And, the Second Rank those who belongs to other hallucinations such as :

1. Feelings of emotional impoverishment

2. Depressive and euphoric mood changes

3. Perplexity

4. Sudden delusional ideas

Other individual that gave their inputs about schizophrenia includes:

Karl Jaspers - existential psychoanalysis - trying to understand the psychological meaning of

schizophrenic signs and symptoms such as delusions and hallucinations.

Ernst Kretschmer - “ schizophrenia occurred more often among persons with asthenic (i.e.,

slender, lightly muscled physiques), athletic, or dysplastic body types rather than among persons

with pyknic (i.e., short, stocky physiques) body types.

And, Adolf Meyer - founder of psychobiology in which he highlighted the reaction to stress of

the schizophrenic patients.

Clinical manifestation

The symptoms of schizophrenia fall into three broad categories: positive, negative, and cognitive

symptoms.

1. Positive Symptoms

Positive symptoms are psychotic behaviors not generally seen in healthy people. People with

positive symptoms may “lose touch” with some aspects of reality. For some people, these

symptoms come and go. For others, they stay stable over time. Sometimes they are severe, and at

other times hardly noticeable. The severity of positive symptoms may depend on whether the

individual is receiving treatment. Positive symptoms include the following:

Hallucinations are sensory experiences that occur in the absence of a stimulus. These can occur

in any of the five senses (vision, hearing, smell, taste, or touch). “Voices” (auditory

hallucinations) are the most common type of hallucination in schizophrenia. Many people with

the disorder hear voices. The voices can either be internal, seeming to come from within one’s

own mind, or they can be external, in which case they can seem to be as real as another person

speaking. The voices may talk to the person about his or her behavior, command the person to do

things, or warn the person of danger. Sometimes the voices talk to each other, and sometimes

people with schizophrenia talk to the voices that they hear. People with schizophrenia may hear

voices for a long time before family and friends notice the problem.

Other types of hallucinations include seeing people or objects that are not there, smelling odors

that no one else detects, and feeling things like invisible fingers touching their bodies when no

one is near.

Delusions are strongly held false beliefs that are not consistent with the person’s culture.

Delusions persist even when there is evidence that the beliefs are not true or logical. People with

schizophrenia can have delusions that seem bizarre, such as believing that neighbors can control

their behavior with magnetic waves. They may also believe that people on television are

directing special messages to them, or that radio stations are broadcasting their thoughts aloud to

others. These are called “delusions of reference.”

Sometimes they believe they are someone else, such as a famous historical figure. They may

have paranoid delusions and believe that others are trying to harm them, such as by cheating,

harassing, poisoning, spying on, or plotting against them or the people they care about. These

beliefs are called “persecutory delusions.”

Thought disorders are unusual or dysfunctional ways of thinking. One form is called

“disorganized thinking.” This is when a person has trouble organizing his or her thoughts or

connecting them logically. He or she may talk in a garbled way that is hard to understand. This is

often called “word salad.” Another form is called “thought blocking.” This is when a person

stops speaking abruptly in the middle of a thought. When asked why he or she stopped talking,

the person may say that it felt as if the thought had been taken out of his or her head. Finally, a

person with a thought disorder might make up meaningless words, or “neologisms.”

Movement disorders may appear as agitated body movements. A person with a movement

disorder may repeat certain motions over and over. In the other extreme, a person may become

catatonic. Catatonia is a state in which a person does not move and does not respond to others.

Catatonia is rare today, but it was more common when treatment for schizophrenia was not

available.

2. Negative Symptoms

Negative symptoms are associated with disruptions to normal emotions and behaviors. These

symptoms are harder to recognize as part of the disorder and can be mistaken for depression or

other conditions. These symptoms include the following:

“Flat affect” (reduced expression of emotions via facial expression or voice tone)

Reduced feelings of pleasure in everyday life

Difficulty beginning and sustaining activities

Reduced speaking

People with negative symptoms may need help with everyday tasks. They may neglect basic

personal hygiene.

This may make them seem lazy or unwilling to help themselves, but the problems are symptoms

caused by schizophrenia.

3. Cognitive Symptoms

For some people, the cognitive symptoms of schizophrenia are subtle, but for others, they are

more severe and patients may notice changes in their memory or other aspects of thinking.

Similar to negative symptoms, cognitive symptoms may be difficult to recognize as part of the

disorder. Often, they are detected only when specific tests are performed. Cognitive symptoms

include the following:

1. Poor “executive functioning” (the ability to understand information and use it to make

decisions)

2. Trouble focusing or paying attention

3. Problems with “working memory” (the ability to use information immediately after

learning it)

Poor cognition is related to worse employment and social outcomes and can be distressing to

individuals with schizophrenia.

The relationship of schizophrenia and violence

Most people with schizophrenia are not violent. In fact, most violent crimes are not committed

by people with schizophrenia. People with schizophrenia are much more likely to harm

themselves than others. Substance abuse may increase the chance a person will become violent.

The risk of violence is greatest when psychosis is untreated and decreases substantially when

treatment is in place.

The relationship of schizophrenia and suicide

Suicidal thoughts and behaviors are very common among people with schizophrenia. People

with schizophrenia die earlier than people without a mental illness, partly because of the

increased suicide risk.

It is hard to predict which people with schizophrenia are more likely to die by suicide, but

actively treating any co-existing depressive symptoms and substance abuse may reduce suicide

risk. People who take their antipsychotic medications as prescribed are less likely to attempt

suicide than those who do not. If someone you know is talking about or has attempted suicide,

help him or her find professional help right away or call 911.

The relationship of schizophrenia and Substance abuser

Substance use disorders occur when frequent use of alcohol and/or drugs interferes with a

person’s health, family, work, school, and social life. Substance use is the most common co-

occurring disorder in people with schizophrenia, and the complex relationships between

substance use disorders and schizophrenia have been extensively studied. Substance use

disorders can make treatment for schizophrenia less effective, and individuals are also less likely

to engage in treatment for their mental illness if they are abusing substances. It is commonly

believed that people with schizophrenia who also abuse substances are trying to “self-medicate”

their symptoms, but there is little evidence that people begin to abuse substances in response to

symptoms or that abusing substances reduces symptoms.

Nicotine is the most common drug abused by people with schizophrenia. People with

schizophrenia are much more likely to smoke than people without a mental illness, and

researchers are exploring whether there is a biological basis for this. There is some evidence that

nicotine may temporarily alleviate a subset of the cognitive deficits commonly observed in

schizophrenia, but these benefits are outweighed by the detrimental effects of smoking on other

aspects of cognition and general health. Bupropion has been found to be effective for smoking

cessation in people with schizophrenia. Most studies find that reducing or stopping smoking does

not make schizophrenia symptoms worse.

Cannabis (marijuana) is also frequently abused by people with schizophrenia, which can worsen

health outcomes. Heavy cannabis use is associated with more severe and earlier onset of

schizophrenia symptoms, but research has not yet definitively determined whether cannabis

directly causes schizophrenia.

Drug abuse can increase rates of other medical illnesses (such as hepatitis, heart disease, and

infectious disease) as well as suicide, trauma, and homelessness in people with schizophrenia.

It is generally understood that schizophrenia and substance use disorders have strong genetic risk

factors. While substance use disorder and a family history of psychosis have individually been

identified as risk factors for schizophrenia, it is less well understood if and how these factors are

related.

When people have both schizophrenia and a substance abuse disorder, their best chance for

recovery is a treatment program that integrates the schizophrenia and substance abuse treatment.

Causes

The main cause of the disease condition is not known but several risk factors were enumerated

that links to the development of Schizophrenia.

A. Theoretically, According to:

1. Sigmund Freud - postulated that schizophrenia resulted from developmental fixations that

occurred earlier than those culminating in the development of neuroses.

2. Margaret Mahler - there are distortions in the reciprocal relationship between the infant and

the mother.

3. Paul Federn - the defect in ego functions permits intense hostility and aggression to distort the

mother-infant relationship, which leads to eventual personality disorganization and vulnerability

to stress.

4. Harry Stack Sullivan - schizophrenia is an adaptive method used to avoid panic, terror, and

disintegration of the sense of self.

Another aspect that many researchers consider is the Family Dynamics:

1. Double Bind - children receive conflicting parental messages about their behavior, attitudes,

and feelings. In Bateson's hypothesis, children withdraw into a psychotic state to escape the

unsolvable confusion of the double bind.

2. Schisms and Skewed Families - In one family type, with a prominent schism between the

parents, one parent is overly close to a child of the opposite gender. In the other family type, a

skewed relationship between a child and one parent involves a power struggle between the

parents and the resulting dominance of one parent.

3. Pseudomutual and Pseudohostile Families - suppress emotional expression by consistently

using pseudomutual or pseudohostile verbal communication.

4. Expressed Emotion - families with high levels of expressed emotion, the relapse rate for

schizophrenia is high.

B. Genes and Environment

Scientists have long known that schizophrenia sometimes runs in families. The illness occurs in

less than 1 percent of the general population, but it occurs in 10 percent of people who have a

first-degree relative with the disorder, such as a parent, brother, or sister. People who have

second-degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop

schizophrenia more often than the general population. The risk is highest for an identical twin of

a person with schizophrenia. He or she has a 40 to 65 percent chance of developing the disorder.

Although these genetic relationships are strong, there are many people who have schizophrenia

who don’t have a family member with the disorder and, conversely, many people with one or

more family members with the disorder who do not develop it themselves.

Scientists believe that many different genes contribute to an increased risk of schizophrenia, but

that no single gene causes the disorder by itself. In fact, recent research has found that people

with schizophrenia tend to have higher rates of rare genetic mutations. These genetic differences

involve hundreds of different genes and probably disrupt brain development in diverse and subtle

ways.

Research into various genes that are related to schizophrenia is ongoing, so it is not yet possible

to use genetic information to predict who will develop the disease. Despite this, tests that scan a

person’s genes can be bought without a prescription or a health professional’s advice. Ads for the

tests suggest that with a saliva sample, a company can determine if a client is at risk for

developing specific diseases, including schizophrenia. However, scientists don’t yet know all of

the gene variations that contribute to schizophrenia and those that are known raise the risk only

by very small amounts. Therefore, these “genome scans” are unlikely to provide a complete

picture of a person’s risk for developing a mental disorder like schizophrenia.

In addition, it certainly takes more than genes to cause the disorder. Scientists think that

interactions between genes and aspects of the individual’s environment are necessary for

schizophrenia to develop. Many environmental factors may be involved, such as exposure to

viruses or malnutrition before birth, problems during birth, and other, not yet known,

psychosocial factors.

Different Brain Chemistry and Structure

Scientists think that an imbalance in the complex, interrelated chemical reactions of the brain

involving the neurotransmitters dopamine and glutamate, and possibly others, plays a role in

schizophrenia. Neurotransmitters are substances that brain cells use to communicate with each

other. Scientists are learning more about how brain chemistry is related to schizophrenia.

Dopamine is one of the chemicals that carries messages between brain cells. There is evidence

that too much dopamine may be involved in the development of schizophrenia, but it’s still not

clear how, or whether everyone diagnosed with schizophrenia has too much dopamine.

Also, the brain structures of some people with schizophrenia are slightly different than those of

healthy people. For example, fluid-filled cavities at the center of the brain, called ventricles, are

larger in some people with schizophrenia. The brains of people with the illness also tend to have

less gray matter, and some areas of the brain may have less or more activity.

These differences are observed when brain scans from a group of people with schizophrenia are

compared with those from a group of people without schizophrenia. However, the differences are

not large enough to identify individuals with the disorder and are not currently used to diagnose

schizophrenia.

Studies of brain tissue after death also have revealed differences in the brains of people with

schizophrenia. Scientists have found small changes in the location or structure of brain cells that

are formed before birth. Some experts think problems during brain development before birth may

lead to faulty connections. The problem may not show up in a person until puberty. The brain

undergoes major changes during puberty, and these changes could trigger psychotic symptoms in

people who are vulnerable due to genetics or brain differences. Scientists have learned a lot

about schizophrenia, but more research is needed to help explain how it develops.

Complication during infancy

According to Medical news, Individuals that were subjected to complications before and during

birth have also been observed to be at greater risk of developing schizophrenia. These

complications may include premature labor, low birth weight and asphyxia during birth.

Additionally, exposure to viruses or infections in the womb or early infancy may also have an

effect. The pathophysiology of this link is not known for certain, although it is thought to be a

result of subtle changes in the development of the infant’s brain.

Diagnosis

In the absence of a biological marker, diagnosis of schizophrenia relies on examination of mental

state, usually through a clinical interview, and observation of the patient’s behaviour. Table 1

shows the diagnostic guidelines according to the two major current classification systems. As can

easily be seen, the two systems overlap to a considerable extent, while retaining some

differences.

The ICD classification system appears to offer some advantage over the DSM classification:1.

Firstly, with the symptoms only needing to be present for one month as opposed to six with the

DSM, sufferers do not have so much time in which they may be at risk to themselves and

others.2. They also only have to live without help for one month before receiving diagnosis and

therefore appropriate treatment.

Comparison between the two diagnostic tool

In the DSM, it is multi-axial which considers the individual and the situation rather than merely

the symptoms as it assesses the sufferer’s social functioning such as poverty and physiological

state of health on the contrary, the ICD put emphasis on the first rank symptoms it ignores the

social functioning context of an individual. ICD and the DSM do not entirely agree on the

number of subtypes of Schizophrenia; with the ICD suggest seven different subtypes and the

DSM five. the reliability here is questioned as a sufferer could be diagnosed as one type of

schizophrenic according to the DSM and a different type according to the ICD. Implications:

incorrect treatment. There are some weaknesses enumerated with the use of DSM, Culturally-

biased - created by Americans for Americans. Problem- as behavior in one culture may not be

regarded as a symptom of schizophrenia but according to the DSM it is. For instance, hearing

voices in some cultures is considered to be a message and is regarded as an honor -not a

symptom of a mental disorder. Implication: Incorrect diagnosis- incorrect treatment.

Subtypes of Schizophrenia

The kinds of symptoms that are utilized to make a diagnosis of schizophrenia differ between

affected people and may change from one year to the next within the same person as the disease

progresses. Different subtypes of schizophrenia are defined according to the most significant and

predominant characteristics present in each person at each point in time. The result is that one

person may be diagnosed with different subtypes over the course of his illness.

1. Paranoid type

The defining feature of the paranoid subtype (also known as paranoid schizophrenia) is

the presence of auditory hallucinations or prominent delusional thoughts about persecution or

conspiracy. However, people with this subtype may be more functional in their ability to work

and engage in relationships than people with other subtypes of schizophrenia. The reasons are

not entirely clear, but may partly reflect that people suffering from this subtype often do not

exhibit symptoms until later in life and have achieved a higher level of functioning before the

onset of their illness. People with the paranoid subtype may appear to lead fairly normal lives by

successful management of their disorder.

People diagnosed with the paranoid subtype may not appear odd or unusual and may not

readily discuss the symptoms of their illness. Typically, the hallucinations and delusions revolve

around some characteristic theme, and this theme often remains fairly consistent over time. A

person’s temperaments and general behaviors often are related to the content of the disturbance

of thought. For example, people who believe that they are being persecuted unjustly may be

easily angered and become hostile. Often, paranoid schizophrenics will come to the attention of

mental health professionals only when there has been some major stress in their life that has

caused an increase in their symptoms. At that point, sufferers may recognize the need for outside

help or act in a fashion to bring attention to themselves.

Since there may be no observable features, the evaluation requires sufferers to be

somewhat open to discussing their thoughts. If there is a significant degree of suspiciousness or

paranoia present, people may be very reluctant to discuss these issues with a stranger.

There is a broad spectrum to the nature and severity of symptoms that may be present at

any one time. When symptoms are in a phase of exacerbation or worsening, there may be some

disorganization of the thought processes. At this time, people may have more trouble than usual

remembering recent events, speaking coherently or generally behaving in an organized, rational

manner. While these features are more characteristic of other subtypes, they can be present to

differing degrees in people with the paranoid subtype, depending upon the current state of their

illness. Supportive friends or family members often may be needed at such times to help the

symptomatic person get professional help.

2. Disorganized type

As the name implies, this subtype’s predominant feature is disorganization of the thought

processes. As a rule, hallucinations and delusions are less pronounced, although there may be

some evidence of these symptoms. These people may have significant impairments in their

ability to maintain the activities of daily living. Even the more routine tasks, such as dressing,

bathing or brushing teeth, can be significantly impaired or lost.

Often, there is impairment in the emotional processes of the individual. For example, these

people may appear emotionally unstable, or their emotions may not seem appropriate to the

context of the situation. They may fail to show ordinary emotional responses in situations that

evoke such responses in healthy people. Mental health professionals refer to this particular

symptom as blunted or flat affect. Additionally, these people may have an inappropriately jocular

or giddy appearance, as in the case of a patient who chuckles inappropriately through a funeral

service or other solemn occasion.

People diagnosed with this subtype also may have significant impairment in their ability to

communicate effectively. At times, their speech can become virtually incomprehensible, due to

disorganized thinking. In such cases, speech is characterized by problems with the utilization and

ordering of words in conversational sentences, rather than with difficulties of enunciation or

articulation. In the past, the term hebephrenic has been used to describe this subtype.

3. Catatonic type

The predominant clinical features seen in the catatonic subtype involve disturbances in

movement. Affected people may exhibit a dramatic reduction in activity, to the point that

voluntary movement stops, as in catatonic stupor. Alternatively, activity can dramatically

increase, a state known as catatonic excitement.

Other disturbances of movement can be present with this subtype. Actions that appear relatively

purposeless but are repetitively performed, also known as stereotypic behavior, may occur, often

to the exclusion of involvement in any productive activity.

Patients may exhibit an immobility or resistance to any attempt to change how they appear. They

may maintain a pose in which someone places them, sometimes for extended periods of time.

This symptom sometimes is referred to as waxy flexibility. Some patients show considerable

physical strength in resistance to repositioning attempts, even though they appear to be

uncomfortable to most people.

Affected people may voluntarily assume unusual body positions, or manifest unusual facial

contortions or limb movements. This set of symptoms sometimes is confused with another

disorder called tardive dyskinesia, which mimics some of these same, odd behaviors. Other

symptoms associated with the catatonic subtype include an almost parrot-like repeating of what

another person is saying (echolalia) or mimicking the movements of another person

(echopraxia). Echolalia and echopraxia also are seen in Tourette’s Syndrome.

4. Undifferentiated type

The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are

not sufficiently formed or specific enough to permit classification of the illness into one of the

other subtypes.

The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty

as to the correct subtype classification. Other people will exhibit symptoms that are remarkably

stable over time but still may not fit one of the typical subtype pictures. In either instance,

diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome.

5. Residual type

This subtype is diagnosed when the patient no longer displays prominent symptoms. In

such cases, the schizophrenic symptoms generally have lessened in severity. Hallucinations,

delusions or idiosyncratic behaviors may still be present, but their manifestations are

significantly diminished in comparison to the acute phase of the illness.

Just as the symptoms of schizophrenia are diverse, so are its ramifications. Different kinds of

impairment affect each patient’s life to varying degrees. Some people require custodial care in

state institutions, while others are gainfully employed and can maintain an active family life.

However, the majority of patients are at neither of these extremes. Most will have a waxing and

waning course marked with some hospitalizations and some assistance from outside support

sources.

People having a higher level of functioning before the start of their illness typically have a better

outcome. In general, better outcomes are associated with brief episodes of symptoms worsening

followed by a return to normal functioning. Women have a better prognosis for higher

functioning than men, as do patients with no apparent structural abnormalities of the brain.

In contrast, a poorer prognosis is indicated by a gradual or insidious onset, beginning in

childhood or adolescence; structural brain abnormalities, as seen on imaging studies; and failure

to return to prior levels of functioning after acute episodes.

Treatments

Treatment of schizophrenia requires integration of medical, psychological, and psychosocial

inputs. The bulk of care occurs in an outpatient setting and probably is best carried out by a

multidisciplinary team, including some combination of the following: a psychopharmacologist, a

counselor or therapist, a social worker, a nurse, a vocational counselor, and a case manager.

Clinical pharmacists and internists can be valuable members of the team.

It is important not to neglect the medical care of the person with schizophrenia. Obesity,

diabetes, cardiovascular disease, and lung diseases are prevalent in schizophrenia, and the person

with schizophrenia often does not receive adequate medical care for such conditions.

Antipsychotic medications (also known as neuroleptic medications or major tranquilizers)

diminish the positive symptoms of schizophrenia and prevent relapses. Approximately 80% of

patients relapse within 1 year if antipsychotic medications are stopped, whereas only 20%

relapse if treated. Children, pregnant or breastfeeding women, and elderly patients present

special challenges. In all of these cases, medications must be used with particular caution.

The choice of which drug to use for treatment of a patient with schizophrenia depends on many

issues, including effectiveness, cost, side-effect burden, method of delivery, availability, and

tolerability. Many studies have compared antipsychotic drugs with one another, but no broad

consensus has been reached. In the absence of clinical or pharmacogenetic predictors of

treatment response, the current treatment approach is largely one of trial and error across

sequential medication choices.

Although treatment is primarily provided on an outpatient basis, patients with schizophrenia may

require hospitalization for exacerbation of symptoms caused by noncompliance with

pharmacotherapy, substance abuse, adverse effects or toxicity of medications, medical illness,

psychosocial stress, or the waxing and waning of the illness itself. Hospitalizations are usually

brief and are typically oriented towards crisis management or symptom stabilization.

Treatment of patients with schizophrenia, particularly during a psychotic episode, may raise the

issue of informed consent. Consent is a legal term and should be used with respect to specific

tasks. A person who is delusional in some but not all areas of life may still have the capacity to

make medical and financial decisions.

Before beginning antipsychotic medications, clinicians should warn patients and their families of

adverse effects, and the slowness of response. The patient may be calmer and less agitated

almost immediately, but alleviation of the psychosis itself often takes several weeks. Some

clinicians routinely perform electrocardiography (ECG) before beginning treatment with

antipsychotic medications and then as often as seems appropriate, for example if doses are

increased or agents change. Because suicide is not uncommon in patients with psychotic

illnesses, clinicians should write prescriptions for the lowest dosage that is consistent with good

clinical care. Patients should be urged to avoid substance abuse. All medications should be given

at lower dosages in children and elderly patients and used with great caution in women who are

pregnant or breastfeeding.

The first antipsychotic medications, chlorpromazine and haloperidol, were dopamine D2

antagonists. These and similar medications are known as first-generation, typical, or

conventional antipsychotics. Other antipsychotics, beginning with clozapine, are known as

second-generation, atypical, or novel antipsychotics.

The conventional antipsychotic agents are available in generic forms and are less expensive than

the newer agents. They are available in a variety of vehicles, including liquid and intramuscular

(IM) preparations. Some of these agents (haloperidol and fluphenazine) are also available as

depot preparations, meaning that a person can be given an injection of a medication every 2-4

weeks. Of the second-generation agents, risperidone is available as a long-acting injection that

uses biodegradable polymers; olanzapine, paliperidone, and aripiprazole are also now available

in long-acting injectable forms.

According to a comprehensive review carried out by the Schizophrenia Patient Outcomes

Research Team (PORT) of the University of Maryland, early treatment with any antipsychotic

medication is associated with significant symptom reduction; first- and second-generation

antipsychotics may have equivalent significant short-term efficacy. However, because of the

adverse adverse-effect profile of clozapine and the significant metabolic risks associated with

olanzapine, PORT advised that neither drug should be considered as a first-line treatment for

first-episode schizophrenia.

There is no clear antipsychotic drug of choice for schizophrenia. Clozapine is the most effective

medication but is not recommended as first-line therapy because it has a high burden of adverse

effects, requires regular blood work, and has not outperformed other medications in first-episode

patients.

Patients tend not to be not adherent to antipsychotic medications, and this may, in part, be due to

their adverse effects. Patients sometimes report they feel less like themselves, or less alert, when

taking these medications. One troubling possibility is that while they are used to combat

psychosis and in that sense to preserve brain functioning, these medications can actually interfere

with the usual processes of the brain. Indeed, some practitioners have gone so far as to call

haloperidol “neurotoxic” and suggest that it not be used. However, there may be adverse

neurological effects with all of the antipsychotic medications, not just the conventional ones.

Nursing interventions

The following are adverse effects typically associated with conventional antipsychotic agents

and with the atypical antipsychotic risperidone at dosages higher than 6 mg/day:

1. Akathisia

2. Dystonia

3. Hyperprolactinemia

4. Neuroleptic malignant syndrome (NMS)

5. Parkinsonism

6. Tardive dyskinesia (TD)

Akathisia is a subjective sense of inner restlessness, mental unease, irritability, and dysphoria. It

can be difficult to distinguish from anxiety or an exacerbation of psychosis.

Dystonia consists of painful and frightening muscle cramps, which affect the head and neck but

may extend to the trunk and limbs. Dystonia usually occurs within 12-48 hours of the beginning

of treatment or an increase in dose. Muscular young men are typically affected.

Hyperprolactinemia is an elevation of the hormone prolactin in the blood, caused by the lowering

of dopamine. (Dopamine inhibits the release of prolactin from the pituitary.) It is associated with

galactorrhea, gynecomastia, and osteoporosis. In women it is associated with amenorrhea, and in

men it is associated with impotence.

NMS is marked by fever, muscular rigidity, altered mental state, and autonomic instability.

Laboratory findings include increased creatine kinase levels and myoglobinuria. Acute kidney

injury may result. Mortality is significant. NMS is thought to be less common in patients taking

clozapine or other atypical antipsychotic agents.

Parkinsonism consists of some combination of tremor, bradykinesia, akinesia, and rigidity.

Tardive dyskinesia (TD) consists of involuntary and repetitive (but not rhythmic) movements of

the mouth and face. Chewing, sucking, grimacing, or pouting movements of the facial muscles

may occur. People may rock back and forth or tap their feet. Occasionally, diaphragmatic

dyskinesia exists, which leads to loud and irregular gasping or “jerky” speech. The patient is

often not aware of these movements. The incidence of TD is as high as 70% in elderly patients

treated with antipsychotic agents. Risk factors for TD include older age, female sex, and negative

symptoms.

Physicians should warn patients, especially those being treated with conventional antipsychotic

agents, about the risk of TD. Regular examinations, using the abnormal involuntary movement

scale (AIMS), should be performed to document the presence or absence of TD.

Anticholinergic side effects occur with most antipsychotics (though risperidone, aripiprazole,

and ziprasidone are relatively free of them). Such effects include the following:

Dry mouth

Acute exacerbation of narrow- or closed-angle glaucoma (if undiagnosed or untreated)

Confusion

Decreased memory

Agitation

Visual hallucinations

Constipation

Weight gain is associated both with psychological problems (eg, decreased self-esteem) and with

medical problems (eg, diabetes, coronary artery disease, and arthritis). Education about nutrition

and exercise should be provided. Cognitive-behavioral therapy can be tried.

All antipsychotic agents may be associated with esophageal dysmotility, thus increasing the risks

of aspiration, choking, and the subsequent risk of pneumonia. Orthostatic hypotension can be

problematic at the beginning of therapy, with dose increases, and in elderly patients. This

problem is related to alpha1 -blockade and seems to be particularly severe with risperidone and

clozapine.

enous thromboembolism may be associated with the use of antipsychotic drugs. Patients treated

with clozapine may be at particular risk for this complication; however, the reasons for this

possible association are not understood.

Regular measurement of blood medication levels in the blood would be helpful in schizophrenia,

for the following reasons:

Patients may not always take their medications, and checking drug levels can detect this

noncompliance

Patients may not always be the best reporters of side effects, and monitoring medication

levels can occasionally help the clinician detect toxicity

Smoking tobacco products induces the liver enzyme CYP1A2 (though nicotine patches,

nicotine inhalers, and chewing tobacco do not); this enzyme metabolizes a number of

antipsychotic drugs, so that, for example, patients who stop smoking while being treated

with clozapine or olanzapine often experience increased antipsychotic levels; a patient

who has stopped smoking may have a variety of complaints, and checking drug levels

can help determine their etiology

Many patients with schizophrenia are treated with other psychotropic medications in addition to

antipsychotic agents. Polypharmacy in schizophrenia is supported by little rigorous evidence but

is widely practiced nonetheless. Medications often used include antidepressants, mood

stabilizers, and anxiolytic agents. Carbamazepine and clozapine should not be used together.

Psychosocial treatment is essential for people with schizophrenia and includes a number of

approaches, such as social skills training, cognitive-behavioral therapy, cognitive remediation,

and social cognition training.

Nurses and other clinicians should assist the Schizophrenic patients in many psychosocial

interventions:

1. Cognitive remediation is a treatment modality derived from principles of neuropsychological

rehabilitation and is based, in part, on the ideas that the brain has some plasticity and that brain

exercises can encourage neurons to grow and can develop the neurocircuitry underlying many

mental activities.

2. Most patients with schizophrenia would like to work; employment can improve income, self-

esteem, and social status. However, few people with the disorder are able to maintain

competitive employment. Supported employment programs currently thought to be most

effective are those that offer individualized, supported, and rapid job assignments and that are

integrated with other services. These programs are associated with higher rates of employment,

but gains in other domains are surprisingly difficult to discern.

3. Family Intervention, schizophrenia affects the person’s whole family, and the family’s

responses can affect the trajectory of the person’s illness. Familial “high expressed emotion”

(hostile overinvolvement and intrusiveness) leads to more frequent relapses. Some studies have

found that family therapy or family interventions may prevent relapse, reduce hospital

admission, and improve medication compliance..

4. Many psychotropic medications can cause weight gain and changes in glucose or lipid

metabolism. Occasionally, a person with schizophrenia develops odd food preferences. Finally,

many persons with schizophrenia have limited funds, do not cook for themselves, and live in

areas where fast food outlets are abundant. Therefore, nutritional counseling is difficult but

important. The role of the clinicians is to help clients to choose the right food and stress the

importance of support group in the management of schizophrenic patients.

Nursing Care Plan

According Matt Vera,RN (2014), the diagnosis is made according to the client’s predominant

symptoms:

Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied

on) or grandiose delusions, hallucinations, and occasionally, excessively religiosity

(delusional focus) or hostile and aggressive behavior.

Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect,

incoherence, loose associations, and extremely disorganized behavior.

Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either

motionless or excessive motor activity. Motor immobility may be manifested by

catalepsy (waxy flexibility) or stupor.

Schizophrenia, undifferentiated type is characterized by mixed schizophrenic symptoms

(of other types) along with disturbances of thought, affect, and behavior.

Schizophrenia, residual type is characterized by at least one previous, though not a

current, episode, social withdrawal, flat affect and looseness of associations.

Basing on the type of schizophrenia, below are the manifestation and guide in individualizing

patient care:

1. Paranoid Schizophrenia

Is characterized by persecutory or grandiose delusional thought content and, possibly,

delusional jealousy.

Some patients also have gender identity problems, such as fears of being thought of as

homosexual or of being approached by homosexuals.

Stress may worsen the patient’s symptoms.

Paranoid schizophrenia may cause only minimal impairment in the patient’s level of

functioning – as long as he doesn’t act on delusional thoughts.

Although patients with paranoid schizophrenia may experience frequent auditory

hallucinations (usually related to a single theme), they typically lack some of the

symptoms of other schizophrenia subtypes – notably, incoherent, loose associations, flat

or grossly inappropriate affect, and catatonic or grossly disorganized behavior.

Tend to be less severely disabled than other schizophrenia.

Those with late onset of disease and good pre-illness functioning (ironically, the very

patients who have the best prognosis) are at the greatest risk for suicide.

1.1 Signs and Symptoms

Persecutory or grandiose delusional thoughts

Auditory hallucinations

Unfocused anxiety

Anger

Tendency to argue

Stilted formality or intensity when interacting with others

Violent behavior

1.2 Diagnosis

Ruling out other causes of the patient’s symptoms.

Meeting the DSM-IV-TR criteria.

1.3 Treatment

Antipsychotic drug therapy.

Psychosocial therapies and rehabilitation, including group and individual psychotherapy.

1.4 Nursing Interventions

Build trust, and be honest and dependable, don’t threaten or make promises you can’t

fulfill.

Be aware that brief patient contacts may be most useful initially.

When the patient is newly admitted, minimize his contact with the staff.

Don’t touch the patient without telling him first exactly what you’re going to be doing

and before obtaining his permission to touch him.

Approach him in a calm, unhurried manner.

Avoid crowding him physically or psychologically; he may strike out to protect himself.

Respond neutrally to his condescending remarks; don’t let him put you on the defensive,

and don’t take his remarks personally.

If he tells you to leave him alone, do leave- but make sure you return soon.

Set limits firmly but without anger, avoid a punitive attitude.

Be flexible, giving the patient as much control as possible.

Consider postponing procedures that require physical contact with hospital personnel if

the patient becomes suspicious or agitated.

If the patient has auditory hallucinations, explore the content of the hallucinations (what

voices are saying to him, whether he thinks he must do what they command) tell him you

don’t hear voices, but you know they’re real to him.

2. Disorganized Schizophrenia

Is marked by incoherent, disorganized speech and behaviors and by blunted or

inappropriate affect.

May have fragmented hallucinations and delusions with no coherent theme.

Usually includes extreme social impairment.

This type of schizophrenia may start early and insidiously, with no significant remissions.

2.1 Signs and Symptoms

Incoherent, disorganized speech, with markedly loose associations.

Grossly disorganized behavior.

Blunted, silly, superficial, or inappropriate affect.

Grimacing

Hypochondriacal complaints.

Extreme social withdrawal.

2.2 Diagnosis

Ruling out other causes of the patients symptoms.

Meeting the DSM-IV-TR criteria.

2.3 Treatment

Treatments described for other types of schizophrenia.

Antipsychotic drugs and psychotherapy.

2.4 Nursing Interventions

Spend time with the patient even if he’s mute and unresponsive, to promote reassurance

and support.

Remember that, despite appearances, the patient is acutely aware of his environment,

assume the patient can hear – speak to him directly and don’t talk about him in his

presence.

Emphasize reality during all patient contacts, to reduce distorted perceptions (for

example, say, “The leaves on the trees are turning colors and the air is cooler, It’s fall”)

Verbalize for the patient the message that his behavior seems to convey, encourage him

to do the same.

Tell the patient directly, specifically, and concisely what needs to be done; don’t give him

choice (for example, say, “It’s time to go for a walk, lets go.”)

Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he

won’t complain of pain or physical symptoms.

Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or

decreased circulation.

Provide range-of-motion exercises.

Encourage to ambulate every 2 hours.

During periods of hyperactivity, try to prevent him from experiencing physical

exhaustion and injury.

As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow

orders with respect to nutrition, urinary catheterization, and enema use.

Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for

yourself, the patient, and others.

3. Catatonic Schizophrenia

Is a rare disease form in which the patient tends to remain in a fixed stupor or position for

long periods, periodically yielding to brief spurts of extreme excitement.

Many catatonic schizophrenia have an increased potential for destructive, violent

behavior when agitated.

3.1 Signs and Symptoms

Remaining mute; refusal to move about or tend to personal needs.

Exhibiting bizarre mannerisms, such as facial grimacing and sucking mouth movements.

Rapid swing between stupor and excitement (extreme psychomotor agitation with

excessive, senseless, or incoherent shouting or talking).

Bizarre posture such as holding the body (especially the arms and legs) rigidly in one

position for a long time.

Diminished sensitivity to painful stimuli.

Echolalia (repeating words or phrases spoken by others).

Echopraxia (imitating other’s movements).

3.2 Diagnosis

Ruling out other possible causes of the patient’s symptoms.

Meeting the DSM-IV-TR criteria.

3.3 Treatment

ECT and benzodiazepines (such as diazepam or lorazepam) for catatonic schizophrenia.

Avoiding conventional antipsychotic drugs (they may worsen catatonic symptoms).

Investigating atypical antipsychotic drugs to treat catatonic schizophrenia (requires

further evaluation).

3.4 Nursing Interventions

Spend time with the patient even if he’s mute and unresponsive, to promote reassurance

and support.

Remember that, despite appearances, the patient is acutely aware of his environment,

assume the patient can hear – speak to him directly and don’t talk about him in his

presence.

Emphasize reality during all patient contacts, to reduce distorted perceptions (for

example, say, “The leaves on the trees are changing colors and the air is cooler, It’s fall”)

Verbalize for the patient the message that his behavior seems to convey, encourage him

to do the same.

Tell the patient directly, specifically, and concisely what needs to be done; don’t give him

choices (for example, say, “It’s time to eat, lets go”)

Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he

won’t complain of pain or physical symptoms.

Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or

decreased circulation.

Provide range-of-motion exercises.

Encourage to ambulate every 2 hours.

During periods of hyperactivity, try to prevent him from experiencing physical

exhaustion and injury.

As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow

orders with respect to nutrition, urinary catheterization, and enema use.

Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for

yourself, the patient, and others.

Diagnostic Test

Clinical diagnosis is developed on historical information and thorough mental status

examination.

No laboratory findings have been identified that are diagnostic of schizophrenia.

Routine battery of laboratory test may be useful in ruling out possible organic etiologies,

including CBC, urinalysis, liver function tests, thyroid function test, RPR, HIV test,

serum ceruloplasmin ( rules out an inherited disease, wilson’s disease, in which the body

retains excessive amounts of copper), PET scan, CT scan, and MRI.

Treatments and Medications

Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the

impact of disease depends mainly on early diagnosis and, appropriate pharmacological and

psychosocial treatments. Hospitalization may be required to stabilize ill persons during an acute

episode. The need for hospitalization will depend on the severity of the episode. Mild or

moderate episodes may be appropriately addressed by intense outpatient treatment. A person

with schizophrenia should leave the hospital or outpatient facility with a treatment plan that will

minimize symptoms and maximize quality of life.

A comprehensive treatment program can include:

Antipsychotic medication

Education & support, for both ill individuals and families

Social skills training

Rehabilitation to improve activities of daily living

Vocational and recreational support

Cognitive therapy

Medication is one of the cornerstones of treatment. Once the acute stage of a psychotic episode

has passed, most people with schizophrenia will need to take medicine indefinitely. This is

because vulnerability to psychosis doesn’t go away, even though some or all of the symptoms

do. In North America, atypical or second generation antipsychotic medications are the most

widely used. However, there are many first-generation antipsychotic medications available that

may still be prescribed. A doctor will prescribe the medication that is the most effective for the

ill individual

Another important part of treatment is psychosocial programs and initiatives. Combined with

medication, they can help ill individuals effectively manage their disorder. Talking with your

treatment team will ensure you are aware of all available programs and medications.

In addition, persons living with schizophrenia may have access to or qualify for income support

programs/initiatives, supportive housing, and/or skills development programs, designed to

promote integration and recovery.

Updates on Schizophrenia

1. “Progressive brain tissue loss linked to early cognitive decline among patients with

schizophrenia” by Kubota M, et al. JAMA Psychiatry.(2015)

Results from a case-control longitudinal study indicate progressive brain tissue loss among

patients with schizophrenia is associated with cognitive decline early in the illness.

“Because multiple cognitive domains are affected in schizophrenia and about half the variance

across domains is explained by differences in general cognitive ability, cognitive functioning in

schizophrenia is likely to be reflected by changes in IQ,” Manabu Kubota, MD, PhD, of the

University Medical Center Utrecht in the Netherlands, and colleagues wrote in JAMA

Psychiatry.

To determine if changes in brain volume could be explained by changes in IQ during the course

of schizophrenia, researchers conducted MRI scans and IQ tests at baseline and 3 years later

among 84 patients with schizophrenia and 116 control patients.

During the study period, cerebral gray matter volume (P = .006) and cortical volume (P = .03)

and thickness (P = .02) decreased more in patients with schizophrenia than control patients.

Patients with schizophrenia exhibited additional significant decreases in cortical volume and

thickness of the right supramarginal, posterior superior temporal, left supramarginal, left

postcentral and occipital regions.

All study participants demonstrated similar increased in IQ, though these changes were

negatively associated with changes in lateral ventricular volume (P = .05) and positively

associated with changes in cortical volume (P = .007) and thickness (P = .004) only among

patients with schizophrenia.

Positive correlations between changes in IQ and cortical volume and thickness were found across

the study cohort and in regions across frontal, temporal and parietal cortices.

The study findings were independent of symptoms severity at follow-up, cannabis use at baseline

and use of cumulative antipsychotics during the study period, according to researchers.

“We reported that loss of cortical volume and thinning were significantly related to a relative IQ

decrease across a 3-year interval in relatively young patients with schizophrenia. The effect

might be explained by a subgroup characterized by both cognitive deterioration and brain tissue

loss, which could well be clinically and genetically distinct with implications for diagnosis,

treatment and drug development,” Kubota and colleagues wrote. – by Amanda Oldt

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