Treatment

Since the exact pathophysiology of schizophrenia is still not understood, the treatment options for those living with schizophrenia focus on the symptoms of the illness, mainly hallucinations. Antipsychotic medications are the first choice for helping people with schizophrenia deal with their hallucinations. The World Federation of Societies of Biological Psychiatry (WFSBP) has done extensive research on long-term treatments for those living with schizophrenia and has come up with a set of guidelines for treating this illness. The goals for "long-term treatment include maintenance therapy to stabilise [sic] remission, prevent relapse, and provide symptom suppression or even continued symptom improvement."1 Treating the symptoms of schizophrenia is an involved process between the individual and his/her provider. This process includes assessing side effects, effectiveness of the current dose of medication, and the risk of relapse or a relapse if one has occurred.1 I will not go into all the specifics included in long-term treatment of schizophrenia, but if you are interested I strongly suggest reading the article published by the WFSBP, which is included in the reference list below.

Typical Antipsychotics

Antipsychotics can be extremely effective at eliminating the psychotic symptoms of schizophrenia and can give people the opportunity to live a normal life, even with this illness. The first wave of antipsychotics came about in the 1950s, and these include common medications like haloperidol (Haldol), chlorpromazine (Thorazine) and fluphenazine (Prolixin).2 In general this class of antipsychotics are dopamine antagonists. What this means is that the drug will bind to postsynaptic receptor sites prohibiting dopamine from binding to these sites.3 If you remember in the pathophysiology post I explained that one problem people with schizophrenia have is too much dopamine in their brains. Too much dopamine is what causes psychosis. By inhibiting dopamine from binding to receptors, psychotic symptoms are then decreased.

As with any medication, antipsychotics have side effects, which can lead to patient nonadherence if severe enough. Some of the more serious side effects associated with typical antipsychotics are sedation, orthostatic hypotension (feeling dizzy or lightheaded when going from laying/sitting to standing), dry mouth, blurred vision, and extrapyramidal symptoms (EPS).3 EPS includes tremors and other uncontrollable movements, especially of the face, which is known as tardive dyskinesia.

Atypical Antipsychotics

The second generation of antipsychotics was developed during the 1990s and includes drugs such as olanzapine (Zyprexa), aripiprazole (Abilify), and risperidone (Risperdal).2 These medications are both dopamine and serotonin antagonists, and, unlike the typical antipsychotics, these not only help eliminate psychotic symptoms, they also help with the negative symptoms of schizophrenia.3

As far as effectiveness of long-term treatment of schizophrenia, there is not a marked difference between the typical and atypical antipsychotics.1 The differences come in the price tag, atypicals are much more expensive, and the side effects. The atypical antipsychotics have fewer EPS, but can still cause sedation. However, the major disadvantage of this class of drugs is they can cause what is called metabolic syndrome. Metabolic syndrome is uncontrollable weight gain and can lead to diabetes, dyslipidemia (high cholesterol), and even heart problems.3

As with any disease or illness the pros and cons of various medications need to be taken into account when starting medications for treating the symptoms of schizophrenia. An open dialogue needs to be maintained with the provider so he/she is aware of positive or negative changes the patient is experiencing. This is very crucial for long-term treatment of this illness.

If you are interested in further reading on schizophrenia, I suggest this article from The American Scholar titled "Living with Voices" found at this link: https://theamericanscholar.org/living-with-voices/#.VN0ZK-bF91Y

References:

1: Hasan, A., Falkai, P., Wobrock, T., Lieberman, J., Glenthoj, B., Gattaz, W. F., & ... Möller, H. (2013). World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, Part 2: Update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects. The World Journal Of Biological Psychiatry, 14(1), 2-44. doi:10.3109/15622975.2012.739708

2: Schizophrenia. (n.d.). Retrieved February 11, 2015, from http://www.nimh.nih.gov/health/publications/schizophrenia/index.shtml#pub7

3: Stuart, G. (2013). Chapter 20: Neurobiological Responses and Schizophrenia and Psychotic Disorders. In Principles and practice of psychiatric nursing (10th ed., pp. 549-555). Maryland Heights, Mo.: Elsevier Saunders.

Symptoms

Last post I discussed the diagnostic criteria that a person must meet to have a diagnosis of schizophrenia. Criterion A in the DSM-5 includes five types of symptoms people living with schizophrenia can experience for extended periods of time.1 I am going to go through all of these groups of symptoms and better explain what each means.

Delusions:
A delusion is defined as a "personal belief based on an incorrect inference of external reality."2 A person who is delusional may be extremely paranoid, may think that he/she is involved in some complex scheme, or may think that he/she is a god. Delusions occur when the brain cannot properly process what a person is actually experiencing, thus leading the person to form misconceptions about what is happening, or what could happen, in his/her life.

Hallucinations:
Hallucinations can take on many different forms. In general a hallucination is a false perception that has not truly happened, but that the person actually experiences as being real. Auditory hallucinations generally take the form of the person hearing voices and can even involve multiple voices talking about the person experiencing the hallucination. Command auditory hallucinations are when voices tell a person to do something that would bring about harm to his/herself or to others. Visual hallucinations can take many forms from just flashing lights to complex scenes that may be enjoyable or may be extremely terrifying. Olfactory and gustatory hallucinations are when a person either tastes or smells something that is not really there. These are not common with schizophrenia and normally indicate the person has a brain tumor or has had a stroke. Tactile hallucinations are pain or discomfort perceived by a person without any external stimuli causing the sensation. Cenesthetic hallucinations are when someone claims to actually feel bodily functions like blood pumping through the body or urine forming . Finally, kinesthetic hallucinations cause a person to feel like his/her body is moving when in reality it is not.

Disorganized Speech:
People with schizophrenia who are actively experiencing psychotic symptoms will have difficulty forming coherent thoughts and difficulty speaking. They may be speaking what to us seems like nonsense, they may be speaking very quickly and in a pressured way, and they may make loose associations causing them to change the conversation rapidly and often.

Grossly Disorganized or Catatonic Behavior:
A person may begin to lose his/her ability to do activities that he/she was able to do before. This maladaptive behavior can include a decline in the person's personal relationships and/or job performance and a deterioration in personal appearance and the loss of ability to perform daily hygiene, which is usually the first observable symptom and a warning sign to family and friends. Catatonia is "a stuporous state in which the patient may require complete physical nursing care, similar to that for a comatose patient, sometimes with unpredictable outbursts of aggressive behavior or strange posturing."2

Negative Symptoms:
Negative symptoms refers to any symptoms of diminished normal behaviors. An example of a negative symptom is having a flat affect. This means the person is not showing any signs of emotions. However, it does not mean the person is not experiencing any emotions, he/she is just unable to express any emotions. Other negative symptoms include apathy, without any interest or concern, and anhedonia, a decreased ability to experience joy or pleasure.

The following video is a great summary of what I have discussed here and in the last post on diagnosing schizophrenia.

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References:

1: Tandon, R., Gaebel, W., Barch, D. M., Bustillo, J., Gur, R. E., Heckers, S., & ... Carpenter, W. (2013). Definition and description of schizophrenia in the DSM-5. Schizophrenia Research, 150(1), 3-10. doi:10.1016/j.schres.2013.05.028

2: Stuart, G. (2013). Chapter 20: Neurobiological Responses and Schizophrenia and Psychotic Disorders. In Principles and practice of psychiatric nursing (10th ed., pp. 344-375). Maryland Heights, Mo.: Elsevier Saunders.

3: Howcast. (2013, August 19). Symptoms & Criteria for Diagnosis | Schizophrenia [Video file]. Retrieved from https://www.youtube.com/watch?v=MfFQvKQUFiY

Diagnosis

The Diagnostic and Statistical Manual

When it comes to diagnosing any disease within the realm of psychiatry, health care providers in the United States use the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is "the standard classification of mental disorders [...] and contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. healthcare system."1 Over the years of psychiatric medicine the DSM has been revised and republished several times by the American Psychiatric Association (APA). The most recent publication, the DSM-5, was released in May of 2013, after over a decade of revisions and meetings. However, with the arrival of the newest edition came a lot of worry about what it would mean for those who may have been misdiagnosed according to the DSM-5. Many worry that it will only make the problems we have here in the USA surrounding mental health worse. Either way, the DSM-5 is here to stay, and the group in the video below have come up with a fun jingle about the APA's newest diagnostic criteria manual.

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Diagnostic Criteria for Schizophrenia

Schizophrenia has a variety of different symptoms that when discovered in a person come together to form the diagnosis of this illness (next week I will be discussing the symptoms of schizophrenia in depth, so here I will only mention which symptoms a person diagnosed with the disease will experience).

Tandon, et al. published an article in 2014 comparing the DSM-4 to the DSM-5. The article does an excellent job highlighting and explaining the major differences between the two diagnostic manuals when it comes specifically to the diagnostic criteria for schizophrenia. Here are the six criteria that a person must meet in order to be diagnosed with schizophrenia: 3

Criterion A: Characteristic Symptoms
The person must have two or more of these symptoms for a significant amount of time, and one of the symptoms must be one of the first three listed:

• delusions

• hallucinations

• disorganized speech

• grossly disorganized or catatonic behavior

• negative symptoms

Criterion B: Social/Occupational Dysfunction
The person must experience some form of dysfunction whether it be with self care, work, personal relationships, etc that is clearly worse than prior to onset.

Criterion C: Duration of Six Months
The person must have ongoing symptoms for at least six months with at least one month with active symptoms from criterion A.

Criterion D: Schizoaffective and Mood Disorder Exclusion
Schizoaffective disorder must have been ruled out along with any mood disorders (major depressive disorder, bipolar disorder) with psychotic features.

Criterion E: Substance/General Mood Condition Exclusion
The illness cannot have been caused by any substance use, such as amphetamines, or by any medical condition, such as a brain tumor.

Criterion F: Relationship to Global Developmental Delay or Autism Spectrum Disorder
If a person has a childhood diagnoses of Autism Spectrum Disorder, or any other childhood communication disorder, an additional diagnosis of schizophrenia will only occur if delusions and hallucinations are present for at least a month.


References:

1: American Psychiatric Association DSM-5 Development. (n.d.). Retrieved January 31, 2015, from http://www.dsm5.org/about/Pages/Default.aspx

2: Neipsychopharm. (2014, March 18). DSM-5! [Video file]. Retrieved from https://www.youtube.com/watch?v=0rm5p3DTyE8

3: Tandon, R., Gaebel, W., Barch, D. M., Bustillo, J., Gur, R. E., Heckers, S., & ... Carpenter, W. (2013). Definition and description of schizophrenia in the DSM-5. Schizophrenia Research, 150(1), 3-10. doi:10.1016/j.schres.2013.05.028