Schizophrenia is a psychiatric illness representing a heterogeneous syndrome of disorganized and bizarre thoughts, delusions, hallucinations, inappropriate affect, and impaired psychosocial function. The etiology of schizophrenia is unknown, but genetics and alteration of neurotransmitters, such as dopamine, have a significant role in the development of schizophrenia.
A common misconception is that schizophrenia means split personalities or multiple personalities. Schizophrenia is an illness associated with various types of symptoms and is not a split personality disorder. Positive, negative, and cognitive symptoms are the different types of symptoms associated with schizophrenia. Positive symptoms are an excess of normal functions or are added to normal functions. Delusions, defined as false, fixed beliefs and hallucinations, defined as real perception of senses in the absence of external stimuli, are examples of positive symptoms. Hallucinations may affect all five senses and are primarily categorized as visual, auditory, olfactory, tactile, and gustatory depending on the sensation alteration. Other positive symptoms may also include: disorganized speech, tangentiality, disorganized behavior, and catatonic behavior. Negative symptoms are loss of normal functions or qualities that subtract from an individual’s personality. Examples of negative symptoms include alogia, avolition, and anhedonia. Negative symptoms are difficult to assess as compared to positive symptoms, because they are also associated with other psychiatric disorders. Examples of cognitive symptoms are impaired attention or memory. Additionally, individuals with schizophrenia may present with social and occupational dysfunction. For example, patients may have difficulty with self-care, maintaining employment, or maintaining relationships.
No objective measures exist to confirm the diagnosis of schizophrenia. Schizophrenia is diagnosed by evaluating the patient and the patient’s symptoms. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) is a diagnostic reference that provides criteria for schizophrenia diagnosis. Characteristic symptoms, social and occupational dysfunction, duration and the ruling out of other disorders are key components of the DSM-5 criteria for schizophrenia.
The goal is to develop a treatment plan that decreases symptoms, improves quality of life, improves patient functioning, and minimizes medication side effects. Treatment options for schizophrenia include nonpharmacologic therapy and pharmacologic therapy, and both are beneficial for the treatment of schizophrenia. Nonpharmacologic therapy includes psychosocial support groups and programs that focus on enhancing patient functioning, though these are utilized in conjunction to pharmacologic therapy. Antipsychotics are the mainstay of treatment for schizophrenia. There are two classes of antipsychotics: first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs), also known as typical and atypical antipsychotics, respectively. Both antipsychotic classes are effective for improving positive symptoms; however, SGAs are more likely to control negative symptoms when compared to FGAs. Tables 56-1, 56-2, 56-3 provide a list of FGAs and SGAs including formulations and dosing.
TABLE 56-1Antipsychotic Medications Classified by Generation