Schizophrenia is a mental health disorder characterised by psychosis. Psychosis may be relapsing, or continuous, and includes symptoms of hallucinations, disorders of thought and delusions. 

 

Risk factors for schizophrenia

Schizophrenia is thought to result from a combination of genetic predisposition and environmental triggers. The strongest risk factors in order of risk are:

  • Family history – risk ratio (RR) 8
  • Ethnicity – Afro-Caribbean patients are highest risk – RR 5
  • Migration – RR 3
  • Cannabis use – RR 1.5

 

Clinical Features & Schneider’s first rank symptoms

Schneider’s first rank symptoms are highly suggestive of schizophrenia and include:

  • Auditory hallucinations
    • 2 or more voices, commonly 3rd person
    • May be thought ‘echo’ or commentary 
  • Disorders of thought 
    • Thought insertion – the belief that one’s thoughts have been planted by another
    • Thought withdrawal – the belief that one’s thoughts are being ‘stolen’
    • Thought broadcast – the belief that one’s thoughts are being broadcast to others 
  • Passivity phenomena
    • The feeling that certain actions or feelings are being imposed on the patient, or that bodily sensations are being controlled externally
  • Delusional perceptions 
    • Describes the process where a normal perception is interpreted to have certain delusional meanings.
      • E.g. It is windy today, therefore I will score 100% in the MSRA

Other symptoms of schizophrenia include

  • Social withdrawal and isolation
  • Apathy and loss of emotional response 
  • Catatonic behaviour 

  

Management of schizophrenia

1st Line: Oral 1st or 2nd generation antipsychotics in conjunction with any of the following:

  • Family intervention
  • Individual CBT
  • Art therapy 

Atypical (second generation) antipsychotics are usually first line in schizophrenia due to their lower risk of EPSEs. They include:

  • Olanzapine
  • Risperidone
  • Aripiprazole
  • Quetiapine
  • Clozapine
  • Amisulpride

 

Clozapine is typically reserved until the failure to control symptoms adequately despite the use of 2 or more antipsychotics for 6-8 weeks due to its risk of adverse effects (e.g. agranulocytosis).

 

Specific delusional beliefs

 

Cotard Syndrome

  • The patient believes that they are/or part of their body is dead
  • Typically occurs in severe depression or psychosis

  

De Clerambault Syndrome (ertomania)

  • The patient has a delusion that a celebrity or idol is in love with them

 

Delusional Parasitosis

  • The patient has a fixed, false belief that they are infested by bugs or parasites

 

Othello Syndrome

  • Describes pathological jealousy – the patient is convinced beyond all reason that their partner is having any affair, without any evidence. 

 

Folie a deux 

  • Two individuals share the same psychiatric symptom

 

Capgras delusion

  • The delusion that a friend or family member has been replaced by an identical impostor 

 

Fregoli syndrome

  • The delusion that multiple people are in fact the same person, who is in disguise or has the ability to change appearance at will. 

 

Charles-Bonnet Syndrome

  • A differential diagnosis for those experiening visual or auditory hallucinations.
  • In Charles-Bonnet syndrome, hallucinations occur in clear, lucid consciousness, and patients demonstrate insight. They are aware that the perceptions are hallucinatory.  
  • Causes: CBS occurs in the context of visual impairment – the most common predisposing conditions include ARMD, glaucoma, cataracts

  

References and Further Reading

NICE CKS: Psychosis and Schizophrenia [2021]. Available at URL: https://cks.nice.org.uk/topics/psychosis-schizophrenia/