# Schizophrenia --- **Schizophrenia** is a severe and complex [[mental illness]] that affects just about under 1% of the population. It's incidence throughout different populations is roughly the same everywhere, and there is evidence that schizophrenia has always been a condition that humans have had. Schizophrenia is not a single disease, but it encompasses a wide range of symptoms. Our understanding has changed throughout the years which drives our definition of what schizophrenia is. However, there are two broadly agreed upon statements about schizophrenia: - it's a spectrum disorder - there's no one treatment ## Causes Schizophrenia has always existed in humans. We have written records of people "overcome with madness" or "possessed by demons". We don't really know what causes schizophrenia. It is almost certainly genetic, though we haven't isolated a specific gene. We do know that it is not caused by the way someone is raised. The incidences are pretty equal throughout different countries so nurture isn't a component--but that idea is definitely shared by a lot of cultures and peoples. If two parents have schizophrenia, the chances of a child having it is 50%. If an identical twin has schizophrenia, the chances of their twin having it is 50%. ### The Dopamine Hypothesis **The Dopamine Hypothesis** is the leading theory for what causes schizophrenia. It suggests that schizophrenia may be caused by an increased level of [[dopamine]]/dopamine-dependent neuronal activity in the brain. There is still a lot of research to be done. Essentially we've worked backwards, after realizing that medicines that take a sledgehammer to the dopamine system helped with patients experiencing psychosis. We can also see in postmortem brain studies that there are an increase in the average number of dopamine receptors in about 2/3s of cases. There are other neurotransmitters that may also have an impact, such as: - [[catecholamines|norepinephrine]] - [[serotonin]] - [[glutamate and aspartate|glutamate]] - [[GABA]] ## Risk Factors Schizophrenia is a genetic condition, but there does seem to be correlation with some things that incite the onset of symptoms. Certain medical conditions trigger acute psychotic episodes, such as: - [[Huntington's disease]] - [[hypothyroidism|hypo-]] or [[hyperthyroidism]] - [[hypoglycemia]] - [[calcium]] imbalances - [[meningitis]] There is also evidence to suggest that childhood [[trauma]] (especially if there are multiple traumas), and stressful life events exacerbate symptoms. These things can also contribute to the severity and course of the condition. There are also some anatomical abnormalities that are found in people with schizophrenia: - [[brain ventricles|cerebral ventricle]] enlargement - this is the most consistent finding - brain volume reduction - may also be a side-effect of antipsychotic medications - reduction in grey matter - reduced symmetry in several lobes - abnormalities in the prefrontal cortex ## Signs & Symptoms The signs and symptoms of schizophrenia can be categorized in three ways: **positive**, **negative** and **cognitive** - **Positive symptoms** are those that are abnormal behaviors or experiences. In other contexts we think of symptoms of illness as alterations of conditions everyone has at baseline. For example, everyone has a body temperature, and a fever is an *elevated* body temp—that is not considered a *positive* symptom. - [[hallucinations]] - The subjective sensation that a person experiences without any physical stimuli in the real world - This can occur in any sense, but most often auditory in schizophrenia, sometimes visual or olfactory, rarely tactile (that's common with meth or other stimulants) - The individual is actually experiencing those sensation...the appropriate parts of the brain will light up in an MRI. They just don't correspond to the environment - **delusions** - fixed false beliefs - everyone has them, really, but for the most part, they're in a cultural context - bizarre vs non bizarre delusions - bizarre things can't be true - non-bizarre delusions *could* be true. For example, that their partner is cheating on them. - **disorganized speech and behavior** - it's so antithetical from how we speak or think - sometimes there are themes to the speech even if it's hard to follow - a common one is seeing someone religiously preoccupied - **Negative symptoms** describe diminished emotional expression or will. Patients with these symptoms are organized, oriented, and don't have delusions or hallucinations. Negative symptoms can appear like [[depression]] but they typically don't respond to antidepressants. It also presents differently. A person with depression will usually *wish* they did feel like going to the park, but someone with negative symptoms wouldn't *rather* do anything else, they're just fine staring at the wall for the whole day. They don't have a problem, you're the one with the problem, you want them to do something. - flat affect - avolition - this can be confused with apathy, but it is much more intense - anhedonia - the loss of ability to feel pleasure - alogia - poverty of speech, or replying to anything - We often think of the positive symptoms with schizophrenia, but the negative ones are the ones that are very isolating. People don't react right, they feel off or weird, they don't seem like a person. Often times family and friends don't know what to do with that and distance themselves. - **Cognitive** symptoms are those where people's thought processing is affected. They have deficits in: - memory - attention - planning - decision making - [[anosognosia]], or an inability to recognize one has a disorder in the first place ## Diagnostic Criteria Schizophrenia is the most commonly diagnosed psychiatric disorders, but it's a spectrum so there's a lot going on. Remember these are categories we made up to organize our care...these are not distinct disease states, but it's more useful to think of these as broad buckets. - **brief psychotic disorder** and **schizophreniform disorder** - Technically this means that someone has symptoms for less than 6 months, but you are not going to see these in someone charts. They're intended in the DSM as placeholders so someone can get appropriate treatment without jumping to a schizophrenia diagnosis. - **unspecified schizophrenia spectrum disorder** - This is the term that you will see in someone's chart, especially if someone doesn't have a history at a particular location. - It's not always very useful as you can't really tell if someone's high on meth or experiencing an organic manic episode - **schizoaffective disorder** - all the symptoms of schizophrenia also with a [[mood disorder]] (like bipolar) - this is...pretty much anyone with schizophrenia, so it ends up being a distinction without a difference most of the time ## Prognosis The prognosis of someone with schizophrenia is difficult to predict, but it's also quite difficult for individuals to retain their level of function before the onset of symptoms. There are a lot of factors at play, including risk factors and **protective factors**, which aid in a person's [[recovery model|recovery]]. Some of these factors are: - good premorbid function - later age at onset - AFAB people - a rapid resolution of symptoms - minimal residual symptoms - no family history - normal neurological findings - absence of structural abnormalities Although schizophrenia itself is not fatal, the life expectancy for schizophrenia is lower than average, pretty universally across populations. There are several contributing reasons for this: - 20-40% of people with schizophrenia attempt [[suicide]] - Especially with an early diagnosis. When you're in your 20s or 30s and you have two or three hospitalizations does it sink in that this is real and it's not going away and you do not get to have a normal life. That's hard. - Current evidence suggest 5% die by suicide - Medication side effects - weight gain (80 pounds!) - diabetes - people with schizophrenia don't tend to manage their diabetes very well, even compared to the otherwise mentally healthy population who already tend to not manage their diabetes well - [[metabolic syndrome]] (at an even higher rate than what the already mentioned weight gain would account for) - violent situations - accidents, disordered thinking - police - high rates of narcotic uses - A lot of people with schizophrenia have [[substance use disorder]], and it's usually stimulants. Meth, meth and more meth. One thing is that they feel good. Life is stressful in general, and it's *really* stressful when you have schizophrenia. But another thing, is they are used to living with dopamine coming out of their ears, but then they have Haldol in them to control their positive symptoms, which stomps on their pleasure and reward system in their brain. Meth can give that back to them. - low ability to do health maintenance - this is big - *The [[chronic stress]] of living with schizophrenia* is real. Life is hard already, but schizophrenia (and the treatment for it) is even harder. ## Treatment Treatment for schizophrenia consists largely of [[antipsychotics]]. They mostly work by removing dopamine from the system, one way or another, and these improve positive symptoms. They also can make negative symptoms worse. medication side effects: - anticholinergic effects - dry mouth - blurred vision - constipation - [[antipsychotics|extrapyramidal side effects]] - sedation ## Nursing Considerations Care for patients with schizophrenia should be [[recovery model|recovery focused]], [[QSEN competencies|patient-centered]] and include family, friends/roommates, and caregivers. Recovery Focused Patient Centered Include family, caregiver, roommates, friends ___