Schizophrenia symptoms typically begin in early adulthood and may be preceded by years of ill-differentiated symptoms, from feelings of vague suspiciousness about others, trouble concentrating, mood swings, and a decline in self-care, to more characteristic features of psychosis including delusions and hallucinations.
Initially, patients are usually referred by family members or friends. As the illness progresses, community mental health workers or law enforcement officers tend to be involved.
Antipsychotic medications and psychosocial interventions are effective for most patients, but to varying degrees.
Suicidal ideation is one of the most dangerous complications. Suicide prevention is therefore a key aspect of management and should include monitoring for depressive symptoms and risk factors of suicide.
Schizophrenia is an illness characterized by a co-occurrence of at least two of the following symptoms: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, or negative symptoms (i.e., diminished emotional expression or avolition) occurring for a significant period of at least 1 month and associated with continuous problems over at least 6 months. At least one of the symptoms should be a positive symptom (i.e., delusions, hallucinations, disorganized speech). The duration of the active phase might be shorter than 1 month if symptoms are successfully managed. For a diagnosis of schizophrenia, symptoms must not only occur concomitantly with substance use or a mood-disorder episode. Affective episodes may occur during the course of illness; however, their total duration must be present for a minority of the total duration of the active and continuous phase periods.
This topic focuses on the diagnosis and management of schizophrenia in adults; the management of schizophrenia in children is beyond the scope of this topic.
History and exam
Key diagnostic factors
- auditory hallucinations
- asocial behavior
- affective blunting
- cognitive deficits
Other diagnostic factors
- lack of insight (anosognosia)
- bizarre or disorganized behavior
- tangentiality and looseness of association (derailment)
- pressured speech
- distractible speech
- incongruent affect
- word salad
- nonauditory hallucinations
- stilted goal-directed behaviors
- catatonic symptoms
- "soft" neurologic deficits
- family history of schizophrenia
- increasing paternal age
- obstetric complications
- cannabis use
- low IQ
- motor dysfunction
- psychological stress
- childhood abuse
- migrant status
1st investigations to order
- clinical diagnosis
Investigations to consider
- MRI/CT head
- serum HIV enzyme-linked immunosorbent assay
- serum rapid plasma reagin (RPR) test
- CBC including absolute neutrophil count (ANC)
- drug toxicology screen
- BUN and electrolytes
- liver function tests
- thyroid-stimulating hormone
- pregnancy test
- genetic testing
at risk of developing psychosis
acute psychotic episode
- Schizoaffective disorder
- Schizophreniform disorder and brief psychotic disorder
- Substance-induced psychotic disorder
- Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5-TR)
- Evidence-based guidelines for the pharmacological treatment of schizophrenia
Schizophrenia: what is it?
Schizophrenia: what treatments work?More Patient leaflets
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