Schizophrenia - Causes, Symptoms, Treatment

Schizophrenia’’ is a Latin word which means split personality. The word schizophrenia was coined by swiss psychiatrist EUGEN BLEULER. This disease may lead to psychosis. Schizophrenia is as common as other mental diseases. It occurs in less than 1 percent of general population.

Schizophrenia - Causes, Symptoms, Treatment

It is a mental disorder which has a spectrum of symptoms including Alteration in perception, thought and sense of a self decrease in violation, psychomotor slowing and display of antisocial behavior. People with Schizophrenia require lifelong treatment. Early treatment can get symptoms under control.


The exact cause of this is not yet known, but researchers believe that a combination of genetics, brain chemistry, and environment contributes to development of the disease.

Problems with certain naturally occurring brain chemicals, including neurotransmitters called dopamine and glutamate, may contribute to schizophrenia. Certain factors seem to increase the risk of developing or triggering schizophrenia, including

1. Having a family history of schizophrenia.

2. Some pregnancy and birth complications, such as malnutrition or exposure to toxins or viruses that may impact brain development.

3. Taking mind altering drugs during teen years and young adulthood.


Symptoms of schizophrenia are refereed to as positive or negative.

Positive symptoms are those that are present in someone without schizophreniaor another mental health condition would not experience.This may include:

DELUSIONS-these are fixed false beliefs that don’t make sense in the context of a person’s culture.People with psychotic delusions can’t be convinced that their beliefs aren’t real.

HALLUCINATIONS-these are false sensory experiences that have no basis in external world.Auditory hallucinations(hearing voices) and visual hallucinations are the most common but a person can hallucinate a touch,taste,or smell.

DISORGANISED SPEECH-In psychotically disorganized speech ,words are not linked together based on tne normal rules of language but may be strung together based on sounds,rhyme,puns,or free associations.

DISORGANISED BEHAVIOR-In this behavior are not goal directed and don’t makesense in contextEg;laughing at inappropriate times for no reason .

 Most common positive symptoms of schizophrenia

Lack of insight (97%)

Auditory hallucinations (74%)

Ideas of reference (70%)

Delusions of reference (67%)

Suspiciousness (66%)

Flatness of affect (66%)

Delusional mood (64%)

Delusions of persecution (64%)

Thought alienation (52%)

Thoughts spoken aloud (50%)

Negative symptoms means that the person is experiencing an absence or reduction of certain traits that are often present in healthier individuals.

FLATTENED AFFECT- Peopple with this symptom appear emotionless or have a very limited range of emotions.

ANHEDONIA- Someone with this condition can demonstrate a lack of joy in things that used to bring them pleasure.

REDUCED SPEECH- A negative symptoms of schizophrenia can involve someone speaking noticeblyless than they used to.


The loss of will to do things is a negative symptom of  schizophrenia. Remember that a negative symptom refers to a characteristic that seems to be lessening or disappearing from the person. Loss of motivation and initiative, also known as avolition, is a common negative symptom.

Positive Symptoms



Disorganized Speech

Disorganized Behavior

Negative Symptoms

Flattened Affect


Reduced Speech

Lack of Initiative

Cognitive Symptoms of Schizophrenia

Cognitive symptoms of schizophrenia have to do with the way a person thinks.4 Although cognitive symptoms are not used to diagnose schizophrenia, some are fairly common with the condition, such as:

Difficulty maintaining attention - The inability to maintain focused attention makes people with schizophrenia seem spacey or “out of it.”

Memory problems - Schizophrenia often affects working memory, which is the kind of memory you use to keep things in your head for active processing, like the digits of a phone number you’re about to dial.

Difficulty planning and structuring activities - Caused by reduced executive function. Executive function is a set of mental processes that allows us to identify the steps needed to complete a task and then execute them in a proper order. Executive function also allows us to suppress our response to distractions in order to get something done.

Lack of insight - People with schizophrenia have a specific cognitive blind spot that prevents them from understanding that they are ill. This means that loved ones and caregivers should remain as vigilant as possible to help the patient maintain the routines of treatment in order to control symptoms.

Common subtypes of schizophrenia


Delusions or hallucinations are prominent


Sustained flattened or incongruous affect

Lack of goal directed behaviour

Prominent thought disorder


Sustained evidence over at least two weeks of catatonic behaviour including stupor, excitement, posturing, and rigidity


Considerable loss of personal drive

Progressive deepening of negative symptoms

Pronounced decline in social, academic, or employment performance.

Among all of these types paranoid schizophrenia is the most common type of schizophrenia.

While we often think of schizophrenia as a major departure from normal health, mild symptoms can occur in healthy people and are not associated with illness. This has led to the conclusion that schizophrenia reflects a quantitative rather than qualitative deviation from normality, rather like hypertension or diabetes


Diagnostic criteria for schizophrenia

At least one present most of the time for a month

Thought echo, insertion or withdrawal, or thought broadcast

Delusions of control referred to body parts, actions, or sensations

Delusional perception

Hallucinatory voices giving a running commentary, discussing the patient, or coming from some part of the patient's body

Persistent bizarre or culturally inappropriate delusions 

Or at least two present most of the time for a month

Persistent daily hallucinations accompanied by delusions

Incoherent or irrelevant speech

Catatonic behaviour such as stupor or posturing

Negative symptoms such as marked apathy, blunted or incongruous mood

If the onset of psychosis is suspected, the patient should be rapidly referred to secondary care (box 7). This will be the local early intervention or home treatment team in many parts of the UK, or the generic catchment area community mental health team. The risk that patients pose to themselves and others must be assessed  at this first assessment and this information included in the referral. If the presence of psychotic symptoms is confirmed by a psychiatrist, then after discussion it may be appropriate for the general practitioner to prescribe an antipsychotic.

Current NICE guidelines recommend considering and offering an oral atypical antipsychotic such as amisulpiride, risperidone, quetiapine, or olanzapine in low doses. The need for hospital admission and even the use of the Mental Health Act will depend mainly on the patient's presentation, the risk assessment, and the availability of good community support. General practitioners can contribute greatly to this decision because of their long term relationship with the patient and family.

TREATMENT PLAN:                 

 Importance of early recognition.

Most general practitioners with a couple of thousand patients on their list will see one or two new cases of psychosis each year. The mean duration of untreated psychosis—the time between full symptoms emerging and starting continuous antipsychotic treatment—is currently around one to two years in the UK. A systematic review and meta-analysis have shown that the longer this period, the worse the outcome. The idea that reducing the duration of untreated psychosis will be reflected in improved outcome has led to a recent expansion in first episode services in the UK and other countries. Whether or not this proves to be the case, patients with psychotic symptoms should be identified and treated as quickly as possible.

Summary points

Schizophrenia usually starts in late adolescence or early adulthood

Genetic risk and environmental factors interact to cause the disorder

The most common symptoms are lack of insight, auditory hallucinations, and delusions

Clinicians should suspect the disorder in a young adult presenting with unusual symptoms and altered behaviour

Treatments can alleviate symptoms, reduce distress, and improve functioning

Long term management in primary care

An average general practitioner in the UK will look after about 12 patients with schizophrenia and exclusively manage the care of about six. Once a patient has recovered from an acute episode of schizophrenia, current NICE guidelines recommend that they remain on prophylactic doses of antipsychotic for one to two years and continue to be supervised by specialist services. After that time, if they are well and symptom free, the drug dose can gradually be reduced and the patient carefully monitored to detect any signs of relapse; if such signs occur, then the dose must be increased until they disappear. Such a programme of careful monitoring may best be achieved by collaboration between primary and secondary care.

General practitioners are central to ensuring that patients with schizophrenia receive good quality physical health care . Current NICE guidelines encourage all practices to establish a mental health register and offer regular physical health checks tailored to the needs of the patient. Special attention should be paid to screening for endocrine disorders; hyperglycaemia and hyperprolactinaemia; cardiovascular risk factors such as smoking, hypertension, and hyperlipidaemia; and side effects of medication, particularly neurological, cardiovascular, and sexual ones .

Common side effects of antipsychotic drugs20

First generation antipsychotics

Extrapyramidal effects:




Tardive dyskinesia



Reduced seizure threshold

Postural hypotension

Anticholinergic effects:

Blurred vision

Dry mouth

Urinary retention

Neuroleptic malignant syndrome

Weight gain

Sexual dysfunction

Cardiotoxicity (including prolonged QTc)

Second generation antipsychotics


Weight gain


Glucose intolerance and frank diabetes mellitus





Extrapyramidal side effects at higher doses

Sexual dysfunction




Extrapyramidal effects









Reduced seizure threshold

Hypotension and hypertension



Weight gain

Glucose intolerance and diabetes mellitus

Nocturnal enuresis

Rare serious side effects:

Neutropenia (93%)

Agranulocytosis (0.8%)




Aspiration pneumonia

Some patients will inevitably need to be referred back to secondary care. Guideline criteria for this decision include:

Poor treatment compliance

Poor treatment response

Ongoing substance misuse

Increase in risk profile.

 Treatment a  patient can expect in secondary care


The first line drug for a patient with a first episode of psychosis is an oral atypical antipsychotic, such as risperidone or olanzapine .Drug companies have emphasised the superior side effect profile of these drugs, but in reality the atypicals have different side effects from typical antipsychotics, and they can be just as debilitating. Well conducted randomised controlled trials have shown that, except for clozapine, they are no more effective than the older typical drugs.Thus, patients with established illness who already take a typical antipsychotic, who are clinically well, and who have no troublesome side effects should not change to an atypical.Clinicians should consider changing patients who take typical antipsychotics and have extrapyramidal side effects to an atypical drug.

Intermittent dosing regimens and drug holidays to reduce side effects are not recommended because of the increased risk of relapse. Depot preparations are usually offered to prevent covert non-concordance with treatment and to facilitate dosing regimens. The lowest effective dose of antipsychotic should be used, and the concurrent use of two or more antipsychotics should be limited to specialist services. Anticholinergic drugs should not be routinely prescribed to prevent side effects because of their adverse effects on cognition and memory.

 Meta-analysis has shown that clozapine is the best drug for 20-30% of patients who are resistant to treatment. Treatment resistance is defined as failure to respond to two or more antipsychotics (one of which should be an atypical) when given at an adequate dose for at least six to eight weeks, and once confounding factors such as concordance failure or substance misuse have been excluded. To prevent agranulocytosis, which occurs in less than 1% of patients taking clozapine, a full blood count must be done regularly. Clozapine is the only antipsychotic that can reduce positive and negative symptoms in patients with treatment resistance, and it should be prescribed as soon as treatment resistance is confirmed.


Several psychological treatments can help ameliorate symptoms, improve functioning, and prevent relapse, although their availability is often limited by a lack of trained therapists. Systematic reviews show that cognitive behaviour therapy can reduce persistent symptoms and improve insight; NICE guidelines recommend that it should be provided for at least 10 sessions over three months. Family therapy provides support and education for families. It aims to improve communication between family members, raise awareness in all people involved, and reduce distress. It can help reduce relapse rates, admission rates, symptoms, and the burden on carers, as well as improve compliance with treatment. Systematic reviews have shown that psychoeducation can reduce relapse and readmission rates and is potentially cost efficient. Other treatments with less robustly established evidence include cognitive remediation therapy and social skills training. Psychodynamic psychotherapy may increase the risk of relapse.

What is the prognosis?

The common perception that schizophrenia has a poor prognosis is not true. More than 80% of patients with their first episode of psychosis will recover, although less than 20% will never have another episode. While many patients with schizophrenia have a lifelong vulnerability to recurrent episodes of illness, a large proportion will have few relapses and make a good functional recovery. Poor premorbid adjustment, a slow insidious onset, and a long duration of untreated psychosis—together with prominent negative symptoms—tend to be associated with a worse prognosis. An acute onset, an obvious psychosocial precipitant, and good premorbid adjustment all improve the prognosis.


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Written by

Alokita Barik
Rajasthan Dental College & Hospital
Jaipur, Rajasthan

Guided by Prof CS Bhan

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