Initially, the disease presents as mild personality changes, slight paranoia and increased moodiness. It may then progress to a decreased emotional range, depression, noticeable personality changes, disorganized or ‘rambling’ speech, sudden mood swings usually without any precipitating factors and auditory hallucinations. Tactile hallucinations are rare but can possibly occur. The patient often gets delusional, with a firm, almost to the point of stubborn, belief that what he perceives is real. He/she may also get unnecessarily hostile and aggressive or closeted and withdrawn, depending upon his mental status.

Laboratory tests

The main purpose of laboratory tests is to exclude any systemic or metabolic disease.

• Complete blood count
• Thyroid function tests
• Liver and kidney function tests
• Urinalysis to check substance abuse, heavy metal poisoning and pregnancy

Imaging 

CT scan and MRI of the brain to check for structural abnormalities, signs of trauma and tumors can be conducted.

Test results

Once any sign of preexisting disease has been ruled out and if the history and clinical signs point towards a mental disorder, a tentative diagnosis of schizophrenia can be made. It is confirmed by psychoanalysis.

Pharmacological treatment

Antipsychotic medication is the mainstay of pharmacological treatment. Randomized trials have shown that antipsychotics reduce positive symptoms of schizophrenia, such as hallucinations, delusions, and suspiciousness, compared to placebo [8]. They include drugs like clozapine, amisulpride and risperidone. All antipsychotics have a wide range of adverse effects and close monitoring is generally indicated.

Non-pharmacological treatment

It includes cognitive-behavioral therapy (CBT) and emotional support by family and/or friends. Cognitive training involves structured exercises prescribed and undertaken with the intention of enhancing cognitive abilities such as attention, memory, and problem solving. Thus, cognitive training represents a potentially promising intervention for enhancing cognitive abilities in schizophrenia [9]. Participation in support groups also helps in reducing depression and anxiety of the patient.

Schizophrenia is a chronic, progressive disease with a negative prognosis. Life expectancy is reduced by as much as 10-25 years [7]. Social as well as personal life is severely compromised and the patient becomes a victim of depression. Not surprisingly, patients are estimated to have a 5% increased chance of committing suicide. Early identification and diagnosis followed by adequate treatment can help reduce the severity of symptoms, decrease mortality rate and increase the quality of life.

Various genetic and environmental factors work together to develop this disease. A number of risk factors have been associated with the development of schizophrenia, including living in an urban area [2], immigration, obstetrical complications [3] and advanced paternal age at conception. Childhood trauma or being a victim of bullying, substance abuse and severe emotional trauma can all set the ground work of this disease.

The tendency of schizophrenia to run in families is a clear indicator of genetic involvement. Several likely candidates have been implicated like NOTCH4, zinc finger protein 804A and the histone protein loci. The likelihood of a child having schizophrenia when one parent already suffers from this disease is 13%, and as high as 50% if both parents do.

Incidence

Approximately 1% of the population will be affected by this disease worldwide in its lifetime.

Age

The onset of this disease occurs typically between late teens and mid thirties. Schizophrenia is extremely rare in children.

Sex

Slightly more men are diagnosed with schizophrenia than women (on the order of 1.4:1) [4]. Also, the onset of this disease is later in females than in males, possibly due to the antidopaminergic effect of estrogen in females.

Schizophrenia is a result of several pathways that together act to create the disease. The pathogenesis comprises three main mechanisms.

The first is anatomical abnormalities. A meta-analysis of studies using diffusion tensor imaging (DTI) to examine white matter found that 2 networks of white matter tracts are reduced in schizophrenia [5]. The abnormalities identified included loss of whole-brain volume in both gray and white matter and increases in lateral ventricular volume [6]. The exact cause of these structural anomalies is unclear.

The second is abnormally working dopaminergic pathways. It is known that schizophrenics suffer from a hypodopaminergic state which leads to a decrease in mental capabilities and degeneration of involved neurons.

The third mechanism is a defective or disturbed immune system. Schizophrenia is not a strictly autoimmune condition but due to an infection or some other illness, overactivation of the immune system may occur. This would lead to overproduction of cytokines and other inflammatory mediators that could easily penetrate the blood brain barrier and damage the neurons. This excessive inflammation could be both a direct association to schizophrenia or secondary to metabolic diseases like diabetes.

Cognitive behaviour therapy (CBT) is the primary modality for preventing the onset, and mainly, the progression of schizophrenia. The use of a psychological interventional approach that involved CBT and counselling of family members along with group skills training of the patient delayed the onset of psychosis for at least 2 years, as shown by a German study [10]. Avoiding drugs like cocaine and amphetamines can also help prevent this disease.

Schizophrenia is a mental disorder characterized by a myriad of personality changes, most striking of which are extreme paranoia, auditory and sometimes even tactile hallucinations and delusions. It is among the most disabling and economically catastrophic medical disorders, ranked by the World Health Organization as one of the top ten illnesses contributing to the global burden of disease [1]. Schizophrenia tends to run in families, indicating a genetic predisposition. It mainly affects the ability of a person to think and rationalize, but it is also associated with a number of other conditions and comorbidities.

Definition

Schizophrenia is a mental disorder characterized by personality changes, paranoia and hallucinations. It is a common psychological disorder and tends to run in families.

Cause

Schizophrenia is not due to a specific cause; rather it is a combination of various factors that precipitate the disease. They include genetic factors, environmental factors like severe stress, change in living place, physiological changes like pregnancy, pathological conditions like chronic diseases and emotional and/or physical trauma. 

Signs and symptoms

It begins with mild personality changes and mood swings and is followed by hallucinations, paranoia and delusions. The patient may have disorganized speech, wild ideas and the inability to differentiate between what is real and what is not.

Diagnosis

Diagnosis is made first by excluding any underlying disease and then performing a thorough physical and psychological examination. Input from family and close friends or colleagues can also help pinpoint the changes in behaviour, making the diagnosis somewhat easier.

Treatment

Schizophrenia does not have a cure but it can be appropriately managed with the help of antipsychotic drugs and cognitive behaviour therapy. Regular sessions with a psychiatrist and participating in support groups can also help.

1. Murray CJL, Lopez AD. The Global Burden of Disease, Harvard University Press, Cambridge, MA 1996. p.21 
2. Pedersen CB, Mortensen PB. Evidence of a dose-response relationship between urbanicity during upbringing and schizophrenia risk. Arch Gen Psychiatry 2001; 58:1039.
3. Clarke MC, Harley M, Cannon M. The role of obstetric events in schizophrenia. Schizophr Bull 2006; 32:3.
4. Abel KM, Drake R, Goldstein JM. Sex differences in schizophrenia. Int Rev Psychiatry 2010; 22:417.
5. Ellison-Wright I, Bullmore E. Meta-analysis of diffusion tensor imaging studies in schizophrenia. Schizophr Res. Mar 2009;108(1-3):3-10.
6. Olabi B, Ellison-Wright I, McIntosh AM, et al. Are there progressive brain changes in schizophrenia? A meta-analysis of structural magnetic resonance imaging studies. Biol Psychiatry. Jul 1 2011;70(1):88-96. 
7. Laursen TM, Munk-Olsen T, Vestergaard M. "Life expectancy and cardiovascular mortality in persons with schizophrenia". Current opinion in psychiatry. Mar 2012, 25 (2): 83–8. 
8. Buchanan RW, Kreyenbuhl J, Kelly DL, et al. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull 2010; 36:71.
9. Lawlor-Savage L, Goghari VM. Working memory training in schizophrenia and healthy populations. Behav Sci (Basel). 2014 Sep 3;4(3):301-19. 
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