Schizophrenia SARAH D. HOLDER, DO, Baylor Family Medicine Residency at Garland, Garland, Texas AMELIA WAYHS, MD, MPH, Dallas, Texas Schizophrenia is the most common psychotic disease, with a global prevalence of less than 1%. It affects all ethnicities and is slightly more common in men. Patients with schizophrenia commonly experience debilitating social and occu- pational impairments, but some are able to function well with proper treatment. Symptom onset is generally between late adolescence and the mid-30s. There are two categories of symptoms: positive and negative. Hallucinations, delu- sions, and disorganized speech are examples of positive symptoms, whereas decreased emotional expression and lack of motivation are negative symptoms. Antipsychotic medications can treat some symptoms of schizophrenia but are associated with multiple adverse effects, including extrapyramidal symptoms and metabolic changes. Patients receiv- ing antipsychotic medications, especially second-generation (or atypical) antipsychotics, should be monitored regu- larly for metabolic changes and cardiovascular risk factors. Persons with schizophrenia who undergo psychosocial therapy in addition to medical therapy have better outcomes. Patients diagnosed with schizophrenia have a higher overall mortality rate than the general public, partly because of the increased suicide risk associated with schizophre- nia. (Am Fam Physician. 2014;90(11):775-782. Copyright © 2014 American Academy of Family Physicians.) CME This clinical content chizophrenia is a pervasive, chronic been identified. Relatives of persons with conforms to AAFP criteria mental disorder with a global preva- schizophrenia are also at risk of schizoaffec- for continuing medical 1 education (CME). See lence of 0.3% to 0.7%. Although tive disorder, schizotypal personality disor- CME Quiz Questions on there is no significant difference der, bipolar disorder, depression, and autism page 760. Sbetween sexes, a slight predominance is spectrum disorder.1,5 1,2 1 Author disclosure: No rel- noted in men. Schizophrenia affects per- Environmental factors may have a role. evant financial affiliations. sons in all ethnicities. However, a recent Possible environmental factors include being study confirmed that in the United States, born and raised in an urban area, cannabis blacks are diagnosed with schizophrenia at use, infection with Toxoplasma gondii,2,6,7 a disproportionately higher rate compared obstetric complications, central nervous with non-Hispanic whites.3 This finding system infection in early childhood, and could point to a racial or ethnic bias in the advanced paternal age (older than 55 years).1 diagnosis of schizophrenia in black persons who present with psychosis.3 Clinical Presentation Schizophrenia is the most common psy- The symptoms of schizophrenia usually chotic disease.4 Therefore, family physicians begin between late adolescence and the mid- should have an overall knowledge of the dis- 30s. Cases involving children as young as ease, including the initial presentation, treat- five years have been reported, but these are ment and its challenges, and how to address rare. In men, the symptoms tend to present comorbidities. Whenever possible, family between 18 and 25 years of age. In women, physicians should educate patients and their the onset of symptoms has two peaks, the families about medication reactions and the first between 25 years of age and the mid- importance of compliance with treatment. 30s, and the second after 40 years of age.1 Referral to a psychiatrist is appropriate for Patients may have symptoms during a pro- patients presenting with psychosis. dromal phase before they become psychotic. These symptoms include social withdrawal, Etiology and Risk Factors loss of interest in work or school, deteriora- Genetics have an important role in the eti- tion of hygiene, angry outbursts, and behav- ology of schizophrenia, even though most ior that is out of character.1 This phase may patients diagnosed with the disease have be mistaken for depression or other mood no family history of psychosis. The genetic disorders. The patient will eventually exhibit variation responsible for the disease has not active-phase symptoms of the disorder.1 DecemberDownloaded 1, from 2014 the ◆ AmericanVolume Family90, Number Physician 11 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2014 American Academy of FamilyAmerican Physicians. Family For the Physician private, noncom 775- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Schizophrenia Diagnosis in the range and intensity of expressed emotions (i.e., Criteria for schizophrenia include signs and symptoms affective flattening) and a diminished initiation of of at least six months’ duration, including at least one goal-directed activities (i.e., avolition). month of active-phase positive and negative symptoms (Table 1).1 Delusions, hallucinations, disorganized DIFFERENTIAL DIAGNOSIS speech, and disorganized behavior are examples of pos- Other organic and psychiatric diagnoses can pres- itive symptoms. Negative symptoms include a decrease ent with symptoms of psychosis (Table 2).1 Initially, SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Patients who have been diagnosed with psychosis and/or schizophrenia should be urgently referred C 8 for psychiatric evaluation. Antipsychotic drugs should be initiated as soon as possible after schizophrenia is diagnosed. A 1, 8, 10, 11, 13-15, 21, 25 All patients receiving second-generation antipsychotic medications should be monitored at least C 10, 28-30 annually for metabolic changes and cardiovascular risk factors. Patients with schizophrenia should be offered psychosocial therapies, including cognitive behavior B 8-10, 13 therapy, family interventions, and social skills training, in addition to medical treatment. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. Table 1. Diagnostic Criteria for Schizophrenia A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (i.e., diminished emotional expression or avolition) B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning) C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences) D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either: (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated) Reprinted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013:99. 776 American Family Physician www.aafp.org/afp Volume 90, Number 11 ◆ December 1, 2014 Table 2. Differential Diagnosis of Schizophrenia Diagnosis Distinguishing features Laboratory/imaging findings Psychiatric conditions Brief psychotic disorder Delusions, hallucinations, and disorganized speech or NA behavior lasting for at least one day but less than one month Major depressive or bipolar Psychotic symptoms occur exclusively during periods NA disorder with psychotic or of mood disturbance catatonic features Posttraumatic stress disorder Traumatic inciting event; symptoms relate to reliving or NA reacting to the event Obsessive-compulsive Prominent obsessions, compulsions, and NA disorder and body preoccupations with appearance or body odor, dysmorphic disorder hoarding, or body-focused repetitive behaviors Schizotypal personality Subthreshold symptoms