Schizophrenia: Diagnosis and Treatment

Diagnosis

The history will clarify acute symptoms, and physical examination may help rule out other causes of psychosis. The diagnostic criteria of the American Psychiatric Association call for 2 or more of the following, each present for a significant portion of time during a 1–month period:

• Delusions.
• Hallucinations.
• Disorganized speech.
• Grossly disorganized or catatonic behavior.
• Negative symptoms: affective flattening, reduced productivity of thought or speech, or reduced goal–directed behavior.

To establish the diagnosis, the patient must also demonstrate marked social or occupational dysfunction, signs of illness must be present for at least 6 months, and the condition cannot be attributable to substance abuse, a medical condition, or other mental health problems, such as depression and bipolar disorder.

Schizophrenia cannot be diagnosed through laboratory tests or imaging. However, some brain–imaging studies reveal increased ventricular and decreased frontal lobe volume.

Treatment

Treatment for schizophrenia is lifelong and multidisciplinary, aiming to reduce symptoms, maximize functioning, and prevent relapse. This is often challenging, because affected individuals may not recognize their illness or seek treatment, and may stop treatment because of undesirable side effects, limited financial resources, or lack of access to mental health services.

Ideally, a person can maintain a fairly normal lifestyle once properly treated. Emotional and physical support is an important component of treatment, and patients often have superior outcomes when direct family or community support is a part of their overall treatment plan.

Pharmacologic Therapy

Medications are the most effective treatment. Discontinuing medication will typically lead to recurrence of symptoms. However, relapse is common even with continuous treatment. The disease is characterized by a waxing and waning of symptoms, necessitating close follow–up and continued support.

First–generation antipsychotics, such as haloperidol or chlorpromazine, can be very effective, but they carry greater risk of tardive dyskinesia and other undesirable side effects, compared with newer drugs.

Second–generation (atypical) antipsychotics, such as risperidone, olanzapine, ziprasidone, aripiprazole, and quetiapine, generally carry less risk of tardive dyskinesia and neuroleptic malignant syndrome, and may be more effective than first–generation drugs at preventing relapse. Olanzapine often results in significant weight gain (on the order of 20–30 pounds) as well as the development of metabolic syndrome and its accompanying health consequences. Aripiprazole and ziprasidone are the least likely to cause weight gain and sedation. Risperidone now carries a black box warning for increased risk of cerebrovascular events. Sedation is often a side effect of risperidone, quetiapine, and olanzapine, although it subsides with continued use.

Clozapine may be used for refractory cases. It also helps treat suicidal ideation, an important consideration given that as many as 40% of persons with schizophrenia will attempt suicide. Physicians need special authorization to use clozapine. Clozapine has several serious potential adverse effects, including life–threatening agranulocytosis, making weekly blood draws mandatory. Additional adverse effects include weight gain, anticholinergic effects, and increased risk of seizures.

Nonpharmacologic Therapy

Cognitive–behavioral therapy and family therapy are intended to help the patient and family identify warning signs of relapse and its consequences and improve treatment adherence. Family therapy has been shown to reduce relapse and rehospitalization.⁵

Group therapy, job training, and social skills training may improve quality of life and social functioning.^6,7