Schizophrenia: causes, symptoms, diagnosis and treatment

By Cristiano Antonino On Jun 1, 2023

Schizophrenia is a severe psychotic disorder: those affected become completely indifferent to what is happening, react absurdly or incoherently to external events, lose touch with reality and isolate themselves in a world of their own, incomprehensible to others

Due to its destructive characteristic of the personality, schizophrenia compromises all aspects of the subject’s life, profoundly upsetting his relational network and, therefore, also involving the family nucleus.

What is schizophrenia

Schizophrenia is a disorder characterized by alteration of thinking, perception, behavior and affectivity.

It manifests with delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms.

Individuals with schizophrenia often exhibit inadequate affect, dysphoric mood (depression, anxiety, anger), and impaired sleep/wake patterns.

Depersonalization, derealization, and somatic concerns may also occur.

Cognitive deficits often include decreased memory, language function, processing speed, and attention.

Some individuals with schizophrenia show deficits in social cognition and often lack awareness of illness (DSM-5, 2013).

Diagnostic framework

The DSM-5 establishes that, in order to make a diagnosis of schizophrenia, the symptoms must persist for at least 6 months.

In addition, at least two of the following symptoms must be present for at least one month, of which at least one of these must be delusions, hallucinations or slurred speech.

The impairment in functioning must be present in one or more of the following areas: work, interpersonal relationships, or self-care.

Finally, the symptomatology must not be better explained by another mental disorder, it must not be attributable to the physiological effects of a substance (drug, medication) or to another medical condition (DSM-5, 2013).

Development and spread of schizophrenia

Schizophrenia appears in adolescence or youth: between 17 and 30 years in men, later (20-40 years) in women.

The onset can be acute, in 5-15% of patients, and is indicative of a more favorable prognosis.

The diffusion of schizophrenia is relatively low, 1% worldwide, and transversal: in fact, it is found in all social classes, without distinction of sex, race, territory.

Causes and risk factors

There are many theories about the possible origins of schizophrenia.

In reality, a certain cause cannot yet be recognized, but we can speak of risk factors, i.e. conditions that predispose an individual to develop the disease more than others.

In decreasing order of importance, these factors are due to: genetic components, complications of childbirth, biological factors, psychological factors.

The genetic component is certainly the most accredited factor regarding the etiopathogenesis of schizophrenia.

Indeed, it is known that family members of patients with schizophrenia have a higher risk of falling ill than the normal population.

Some childhood and adolescent precursors are: delayed psychomotor development, language problems (in the first 5 years), social anxiety and social withdrawal.

Several subtypes are identified in schizophrenia

Paranoid

The subject presents significant delusions or hallucinations in a context of preserved cognitive and affective functions.

Persecutory delusion is dominant: the individual is convinced of being the object of conspiracy, of deception, of being spied on, followed or poisoned.

The world is perceived as hostile and suspicion can in some cases lead to aggressive and violent behavior as a preventive form of defense against any perceived threats.

Disorganized

Subject has disorganized speech and behavior.

Language and behaviors are inconsistent and inadequate with respect to the context, affectivity is also disorganized and dissociation of thought and disinterest in the surrounding world can occur.

Catatonic

The subject presents a significant psychomotor disturbance: mutism, assumption of abnormal postures, detachment from reality, states of immobility or crises of intense agitation.

Finally, schizophrenia can present in the form of the undifferentiated/residual subtype.

Course and prognosis of schizophrenia

Schizophrenia is a serious and disabling disease, which often leads to hospitalization and which must be carefully diagnosed and treated.

Today, however, its prognosis is not as bad as it used to be.

The onset of negative symptoms, decline in cognitive function, and brain abnormalities are concentrated in the prodromal phase and during the first episode and then remain constant.

The prodrome presents negative symptoms such as depression, anxiety, irritability, distractibility, social withdrawal, flattened affect, alogia, avolition and decreased emotional expression.

Attention must grow the moment suspiciousness appears.

Schizophrenia symptoms

The symptoms of schizophrenia are highly variable both in relation to the stage of the disease (prodromal, onset or long-term) and to the clinical subtype.

They can present themselves in critical moments (episodic) or in a stable and chronic way and are generally divided into two antithetical groups: positive and negative symptoms.

Positive schizophrenia symptoms are new, abnormal manifestations of the illness, whereas negative schizophrenia symptoms result from loss of abilities that were present before the onset of the illness.

The positive symptoms of schizophrenia include

Delusions, understood as beliefs contrary to reality, lasting, firmly supported despite evidence to the contrary, dissonant with respect to the reference context. The most frequent ones are those of persecution, of greatness, of reference, of mind reading.
Hallucinations, i.e. alterations of perception for which the person believes he perceives things that are not actually there. Typical auditory ones, when the person hears voices that insult, threaten, command or comment on her actions.
The disorganization and fragmentation of thought.
The bizarre and disorganized behavior.

The negative symptoms of schizophrenia on the other hand include

Apathy
Emotional flattening
Deficits in productivity and fluency of speech
Loss of initiative
Ideational poverty
Difficulty maintaining attention
Impaired interpersonal relationships, social and occupational functioning.

In practice, the subject does not react to those situations that arouse emotions in others, loses interest and energy and tends to increasingly reduce his social relationships, up to isolation.

These are the symptoms of schizophrenia that are more difficult to interpret clearly, they have a slow and gradual evolution.

At least initially, they may not seem like specific signs of such a serious pathology, but can be confused with depressive symptoms.

Schizophrenia and suicidal risk

Individuals with schizophrenia are more likely to commit suicide: 20% attempt suicide and many have significant suicidal ideation.

Suicidal risk factors for schizophrenia are substance use and depressive symptoms.

Furthermore, the period following a psychotic episode or a hospital discharge are also important suicidal risk factors.

Finally, young males appear to be more at risk of suicide than females of the same age.

Schizophrenia cure

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The treatment of schizophrenia can be summarized in different phases.

In the acute phase, hospitalization may be necessary, but in most cases, intervention is carried out with outpatient therapy or conducted in intermediate structures (day care centre).

Pharmacological therapy

Pharmacological therapy is essential to restore the biochemical balance and the new neuroleptics (clozapine, risperidone, olanzapine, quetiapine, aripiprazole) are considered the first therapeutic option, as they are more tolerable and have a positive effect also on cognitive functions.

In the treatment of schizophrenia drugs that act on delusions and hallucinations are used, such as haloperidol (Serenase) and benperidol (Psicoben) or, if there is considerable agitation, sedative drugs such as chlorpromazine (Largactil) or thioridazine ( Melleril).

For negative symptoms, the most suitable neuroleptics are: pimozide (Orap), bromperidol (Impromen) and levosulpiride (Levopraid).

Cognitive behavioral therapy

Associated with pharmacological therapy, a psychological-rehabilitative intervention with the patient is essential for the treatment of schizophrenia.

Cognitive-behavioral interventions aim at the development of basic skills (for example of personal care such as washing and dressing) and social skills (Social Skills Training) and at the control of problematic behaviors such as aggression, self-harm, hyperactivity, stereotypies.

Psychoeducation and interventions on family members

The cognitive behavioral treatment of schizophrenia also includes psychoeducational interventions for the patient’s family, who need help to deal with the disease and have an important role in caring for the sick family member.

Those suffering from schizophrenia are in fact vulnerable to environmental and family stressors and it is essential that the patient and family members learn to recognize the manifestations of the disease and the signs of a possible relapse.

Family members are allies and co-protagonists in the treatment of schizophrenia, they have no fault or responsibility for the disorder and can be helped to improve management strategies.

Family treatment programs also aim to maximize patient adherence to drug treatment.

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