Section G - Schizophrenia
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Schizophrenia defines a group of disorders, characterized by a continuum of signs, the most prominent of which are distorted thought and perception. An individual with the most common type - paranoid schizophrenia - presents with various hallucinatory experiences and delusional thinking, either due to the hallucinations or to the wrong interpretation of real stimuli.130 The group of so-called negative signs always develops in schizophrenia patients – flattened affect, lack of emotions and volition/will, etc.131 In most cases, the individual has difficulty thinking clearly and making decisions, managing and expressing emotions, and relating to others; therefore, a substantial part of them is socially withdrawn. Depending on the presence of certain predominant symptoms, diagnosis can be one of five types: catatonic, paranoid, disorganized, undifferentiated, or residual schizophrenia.7 This section will describe the functional limitations associated with each subtype. Although the course of the disease may be variable, with some individuals experiencing exacerbations and remissions, the health states discussed here refer to those individuals in which the disease and disturbances of the disease remain chronic.
Schizophrenia affects approximately 1% of the population132 and is observed worldwide. Onset is usually between the late teens and the mid-30s;1 late-onset cases (after age 45) have been reported but onset before adolescence is rare. Men and women are affected equally, but onset is earlier in men (between ages 18 and 25) than in women (between ages 25 and 35); late-onset cases are more common in women.1,7,133 Although the onset of schizophrenia may be sudden, most cases display a variety of signs and symptoms gradually. In general, symptoms characteristic of schizophrenia involve dysfunctions in both the cognitive and emotional domains: perception, inferential thinking, attention, language and communication, affect, fluency, thought and speech production, behavioural monitoring, volition and drive.
Though there are some instrumental methods for evaluation of the level of structural and functional brain dysfunction in patients with schizophrenia, diagnosis is made based on clinical signs, case and family history.130 The DSM-IV clinically diagnoses schizophrenia if two or more of the following symptoms are present for a significant portion of time during a one-month period: delusions, hallucinations, disorganized speech, disorganized or catatonic behaviour, or negative symptoms including affective flattening (restricted emotional expression), alogia (restricted thought and speech), or abulia (restricted initiation of goal-directed behaviour). Furthermore, since onset, the symptoms result in social or occupational dysfunction. There must also be continuous signs of the disturbance that persist for at least six months. Finally, a diagnosis of schizoaffective disorder or mood disorder with psychotic features has been ruled out, and the symptoms/disturbance is not due to the physiological effects of a substance or a general medical condition.7 Diagnostic criteria for each subtype are described in the health states presented below.
The cause of schizophrenia is unknown, but there is some evidence that genetics are a factor: first degree biological relatives of individuals with schizophrenia are about 10 times more likely than the general population to develop it.7,133,134 Environmental factors that occur during development, such as a viral infection (e.g., prenatal exposure to the flu) or hormonal and physical changes during puberty may also trigger the disorder. Functional abnormalities in the brain may be a cause or a consequence of schizophrenia.1
In spite of the number of antipsychotic agents implemented into clinical practice, prognosis of schizophrenia is still relatively poor: only a quarter of patients show full psychopathological remission and 56% show social remission.130 In 2004, schizophrenia was one of the top ten leading causes of disability (measured in years lost to disability) globally.3 Approximately 1/3rd of people diagnosed with schizophrenia require institutionalization for the rest of their lives,135 and about 40% of individuals will attempt suicide over the course of the disease (approximately 10% will successfully complete suicide)1,7,136 due to psychosis and/or depression. However, with early diagnosis and effective treatment, individuals with schizophrenia can prevent further symptoms and increase the likelihood of recovery. Treatment generally consists of pharmacological interventions and psychotherapy, either in isolation or more effectively, in combination. Hospitalization may be required to treat delusions or hallucinations, particularly if the individual is having suicidal thoughts, is unable to care for themselves, or has severe problems with drugs or alcohol. Antipsychotic medications help to reduce some symptoms of schizophrenia but have considerable side effects, resulting in a high potential for noncompliance.
Schizophrenia, regardless of subtype, has many implications for an individual's health state. Social withdrawal is apparent early in the disease process, therefore most have limited social contacts and the majority (60% to 70%) do not marry.7 Academic performance is typically impaired; consequently, many are unable to finish school. Occupational functioning is also limited: reported employment rates vary significantly but are generally between 10% and 40%.130,137,138 Emotional and financial losses result, as do reduced self-esteem, hopelessness and isolation. Most importantly, there is a stigma associated with schizophrenia that leads to embarrassment due to lack of public understanding of the disease.
Although it is not infrequent for individuals to have symptoms characteristic of more than one subtype, diagnosis is based on the most prominent symptoms, in this order: Catatonic type is designated when the prominent symptoms are catatonic (a state of muscular rigidity and/or mental stupor), regardless of the presence of other symptoms; Disorganized type is assigned whenever disorganized speech, disorganized behaviour and flat or inappropriate affect are prominent (unless Catatonic type is present); Paranoid type is designated whenever delusions or hallucinations are frequent and prominent (unless Catatonic or Disorganized type is present); Undifferentiated type is assigned whenever there are prominent, active-phase symptoms that do not meet the criteria for Catatonic, Disorganized, or Paranoid types; and finally, Residual type is designated when there is continuous evidence of the disorder but active-phase symptoms are not present.7
The following health states describe an individual diagnosed with each subtype of schizophrenia during which time the disturbances and symptoms of the disease are active and chronic. The descriptions do not capture the individual while undergoing treatment.
ICD-9: 295.2 ICD-10 – Catatonic schizophrenia F20.2
An individual is diagnosed with catatonic schizophrenia if their symptoms are dominated by at least two of the following: motor immobility or stupor, excessive motor activity, extreme negativism (a state in which people resist efforts to physically move their limbs or themselves), peculiarities of involuntary movement, and echolalia (parrotlike repetition of a word or phrase just spoken by another person) or echopraxia (the repetitive imitation of the movements of another person).7 Onset of this subtype is typically sudden. In general, an individual with catatonic schizophrenia might represent two alternative conditions similar in psychopathological sense: at one end, the individual may be in a catatonic stupor and seem immobile and unresponsive or negativistic, shown in their resistance to instructions (they often do the opposite of what they are asked) or maintenance of a rigid posture if attempted to be moved. On the other hand, they may demonstrate catatonic agitation characterized by uncontrolled excitement and repetitive stereotypic movements. Mimicry in terms of echolalia and echopraxia is common.7
During periods of stupor and immobility, individuals are unable to move around and take care of personal needs, and therefore require help with daily tasks such as getting dressed or eating. The use of hands and fingers are restricted throughout periods of rigidity. During the episodes of excitement, the individual will require supervision in order to avoid harming themselves or others, but they can generally function well. Speech disturbances are common: some individuals may not speak at all, and if they do speak, their speech is generally meaningless or consist of echolalia and repetitive chatter. Individuals with catatonic schizophrenia might experience moderate pain and discomfort, particularly due to maintaining uncomfortable postures for long periods of time; fatigue may also result. Individuals with this subtype often have depression and are socially isolated; memory and thinking is also impaired, particularly during periods of stupor due to lack of concentration.7
ICD-9: 295.1 ICD-10 –Hebephrenic schizophrenia F20.1
The predominant symptoms of an individual diagnosed with disorganized schizophrenia are significantly disorganized speech, disorganized behaviour, and flat or inappropriate affect.7 Delusions or hallucinations may be present but are disconnected and do not revolve around a coherent theme. Language is generally incoherent and may be accompanied by silliness and laughter without an appropriate stimulus (often an individual with disorganized schizophrenia will laugh when experiencing pain or cry when hearing a joke that others find funny). The individual may even make up new words or use words in strange ways. Behaviour is inappropriate and there is a lack of goal orientation, which may lead the individual to disregard bathing, meal preparation and other activities of daily living. Auditory hallucinations often cause limitations in hearing. The individual may display unpredictable agitation (i.e., shouting and swearing) or inappropriate sexual behaviour (i.e., public masturbation). Disturbances in thought are common; the individual will tend to have difficulty organizing ideas, and often do not think rationally or logically. This subtype generally follows a continuous course without periods of remission, and onset is abrupt. Disorganized schizophrenia tends to be the most severe of all subtypes of schizophrenia.7
ICD-9: 295.3 ICD-10 –Paranoid schizophrenia F20.0
An individual is diagnosed with paranoid schizophrenia if their predominant symptoms include delusions or auditory hallucinations which attempt to maintain cognitive functioning and affect, and they do not experience symptoms characteristic of the Disorganized or Catatonic types.7 The delusions are usually organized around a coherent theme, and are often persecutory or grandiose. More specifically, persecutory delusions often center on the belief that others are "out to get them" in some way. Consequently, the individual may develop grandiose delusions in which they are extremely famous, important or powerful and are protecting themselves from the perceived persecutions. Hallucinations generally relate to the delusional theme. Onset of this type tends to be later in life than other subtypes of schizophrenia, but the features are relatively more stable over time. Paranoid schizophrenia tends to be the least severe of all subtypes of schizophrenia.7
Individuals with paranoid schizophrenia have minimal impairment in functioning unless they act upon their delusional thoughts. Overall, they may be depressed, angry and argumentative with moderate levels of anxiety. Hearing is impaired due to auditory hallucinations; also, the individual is often distracted therefore the quality of their hearing (e.g., receiving information) is limited. Emotionally, an individual with paranoid schizophrenia appears deprived of emotions and exhibits flattened affect. Their memory and thinking is impaired with delusions and hallucinations as they are often confused and indecisive about what is real and what is imaginary. Their capacity to sustain social relationships is impaired due to hostile and suspicious behaviour, and often delusional jealousy occurs with the deep belief that their sexual partner is unfaithful. Severe attacks may require hospitalization as persecutory themes may cause the individual to become violent and/or suicidal. Paranoid schizophrenia may have a considerably better prognosis than other types of schizophrenia because the individual is generally able to maintain occupational functioning and independent living.7
ICD-9: 295.8 ICD-10 –Undifferentiated schizophrenia F20.3
An individual is diagnosed with undifferentiated schizophrenia if they experience symptoms that meet the criteria for schizophrenia, but do not meet the criteria for paranoid, disorganized, or catatonic types.7 Typically the individual will have fragments of different symptoms (i.e., delusions, hallucinations, incoherence); although these symptoms may remain over a long period of time, a stable pattern of characteristics may emerge later in life. The functional limitations associated with this subtype of schizophrenia include personal hygiene issues, impaired emotional state (depression), some thought disorders including the inability to concentrate, and social functioning limitations caused by social withdrawal.7
ICD-9: 295.5 ICD-10 –Residual schizophrenia F20.5
An individual is diagnosed with residual schizophrenia if they are exhibiting two or more symptoms that meet the criteria for schizophrenia, but prominent delusions, hallucinations, disorganized speech, and disorganized or catatonic behaviour are absent.7 In general, this diagnosis is made when an individual has experienced at least one episode of schizophrenia but is currently not exhibiting symptoms or the symptoms are relatively minor. Nevertheless, individuals with residual schizophrenia experience a lack of motivation and interest in life, and have considerable impairments in personal hygiene practices. In addition, illogical thinking, social isolation or withdrawal, and some deficiency in speech are common. The course of this subtype may be continuous over many years (possibly involving acute exacerbations).7
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