Schizophrenia

Schizophrenia is a chronic severe psychiatric disorder characterized by disturbances in thought processes, perception, emotions, behaviour, cognition, and reality testing. The illness commonly results in impaired social and occupational functioning and varying degrees of disability.

Patients experience episodes of psychosis, including hallucinations, delusions, disorganized thinking, emotional blunting, and withdrawal from reality. Symptoms fluctuate over time, often following a relapsing and remitting course requiring long-term treatment.

Epidemiology

• Lifetime prevalence: approximately 1% worldwide

• Usual onset:

  • Males: late adolescence to early 20s

  • Females: late 20s to early 30s

• Slight male predominance in early onset

• Major contributor to global psychiatric disability

Risk Factors

Genetic Factors

• Strong familial association

• First-degree relatives have 5–10× increased risk

• Polygenic inheritance

NeurodevelopmentalFactors

• Prenatal infections

• Obstetric complications

• Low birth weight

• Maternal malnutrition

Neurobiological Factors

• Dopamine dysregulation (mesolimbic hyperactivity)

• Glutamate dysfunction

• Structural brain abnormalities

Environmental Factors

• Urban upbringing

• Psychosocial stress

• Cannabis and substance misuse

• Childhood trauma

Pathophysiology

Schizophrenia involves dysfunction in multiple neural circuits:

• Increased dopamine activity → positive symptoms

• Reduced dopamine activity in prefrontal cortex → negative symptoms

• Impaired synaptic connectivity

• Neurodevelopmental abnormalities

• Cognitive processing deficits

Clinical Phases

1. Prodromal Phase

   • Social withdrawal

   • Decline in functioning

   • Suspiciousness

2. Active (Psychotic) Phase

   • Hallucinations

   • Delusions

   • Disorganized behaviour

3. Residual Phase

   • Negative symptoms predominate

Signs and Symptoms

Positive Symptoms

(Excess or distortion of normal function)

• Delusions

• Hallucinations (commonly auditory)

• Disorganized speech

• Thought disorder

• Agitation

• Bizarre behaviour

Negative Symptoms

(Loss of normal function)

• Flattened affect

• Reduced emotional expression

• Social withdrawal

• Poverty of speech

• Lack of motivation (avolition)

• Anhedonia

Cognitive Symptoms

• Poor attention

• Memory impairment

• Executive dysfunction

• Poor insight

Diagnostic Criteria

Diagnosis is clinical (DSM-5 / ICD-11 based).

Characteristic features include:

• Bizarre appearance

• Reduced motor activity

• Social withdrawal

• Flattened affect

• Delusions

• Hallucinations

• Disorganized thinking or behaviour

Symptoms must:

• Persist ≥6 months

• Include ≥1 month of active psychotic symptoms

• Cause functional impairment

• Not be attributable to substance or medical illness

Differential Diagnosis

• Schizoaffective disorder

• Bipolar disorder with psychosis

• Major depressive disorder with psychotic features

• Substance-induced psychosis

• Delirium

• Temporal lobe epilepsy

• Brain tumours

Investigations

Purpose

• Exclude organic causes

• Establish baseline before antipsychotic therapy

Recommended Tests

• Full blood count

• Electrolytes

• Liver function tests

• Renal function tests

• Thyroid function tests

• Blood glucose

• Lipid profile

• Urine toxicology screen

• HIV and syphilis screening (where indicated)

Additional Investigations

• CT or MRI brain (first episode psychosis)

• ECG before antipsychotics

• Weight and BMI monitoring

Management

Management requires long-term multidisciplinary care.

Non-Pharmacological Management

Psychoeducation

• Patient and family education

• Illness awareness

• Medication adherence counselling

Psychological Therapy

• Cognitive Behavioural Therapy (CBT)

• Social skills training

• Reality orientation therapy

Psychosocial Rehabilitation

• Occupational therapy

• Vocational rehabilitation

• Supported employment

• Community reintegration programmes

Community-Based Care

• Assertive community treatment

• Supported housing

• Case management services

Pharmacological Management

1. Acute Psychotic Episode

Manage agitation and behavioural disturbance according to aggressive disruptive behaviour protocols.

Goals:

• Control psychosis

• Reduce agitation

• Prevent harm

2. Maintenance Treatment

Use only ONE antipsychotic at a time

First-Generation Antipsychotics

Haloperidol

• 3–4.5 mg PO every 12 hours

OR

Chlorpromazine

• 100–600 mg/day PO in divided doses

Second-Generation (Atypical) Antipsychotics**

Preferred due to better effect on negative symptoms.

Olanzapine

• 5–10 mg daily

• Maximum 25 mg/day

OR

Risperidone

• Start 1 mg every 12 hours

• Increase gradually every 2–3 days

• Usual dose 2–3 mg every 12 hours

• Maximum 16 mg/day

3. Long-Acting Injectable Therapy

(For poor adherence)

Fluphenazine Decanoate

• 12.5–50 mg IM every 4 weeks

OR

Flupenthixol Decanoate

• 20–40 mg IM every 4 weeks

Adjunct Treatment

Used only if extrapyramidal side effects (EPS) occur.

Antiparkinsonian Drugs

Benzhexol

• 5 mg once–twice daily

• Last dose before 14:00 hrs

OR

Procyclidine

• 10 mg twice daily

• Last dose before 14:00 hrs

Monitoring During Treatment

• Weight and metabolic profile

• Blood glucose and lipids

• Movement disorders

• Sedation

• Prolactin effects

• Medication adherence

Complications

• Suicide (≈5–10%)

• Substance abuse

• Homelessness

• Cognitive decline

• Social isolation

• Metabolic syndrome

• Medication adverse effects

Special Populations

First Episode Psychosis

• Use lowest effective dose

• Early treatment improves prognosis

Elderly

• Increased sensitivity to side effects

• Start low, go slow

Substance Use

• Integrated dual-diagnosis management required

Prognosis

Better outcomes associated with:

• Early intervention

• Good family support

• Treatment adherence

• Short duration of untreated psychosis

Poor prognostic factors:

• Early onset

• Prominent negative symptoms

• Substance misuse

• Poor adherence

Prevention

Although primary prevention is limited:

• Early detection programs

• Continuous maintenance therapy

• Relapse prevention plans

• Substance abuse avoidance

• Family education

• Regular psychiatric follow-up

Patient & Family Education

Patients and caregivers should understand:

• Schizophrenia is treatable but chronic

• Medication must be continued long-term

• Relapse commonly follows treatment interruption

• Early warning signs require urgent review

• Social support improves recovery