HOW TO TREAT 37 referred , back to them . For example , the television announcer talks about them , songs have lyrics about them , the internet is always running stories about them . Delusional ideas can become bizarre with people believing they have had computer chips inserted into their brains or that people around them have been replaced with doubles pretending to be parents , loved ones or even the doctor or nurse .
These positive symptoms dominate during periods of acute illness and early in the course of the illness . Along with disorganisation , positive symptoms respond well to antipsychotic medication . For many people with schizophrenia , especially early in the course of their illness , their symptoms represent the reality of their world and treatment is a threat to that . This loss of understanding of the pathological nature of their signs and symptoms and their unwillingness to adopt the advice around treatment is known as a loss of insight .
Disorganisation describes the jumbling of thoughts and behaviours that can make speech difficult to follow and behaviour erratic . This can include aggression , which is more typically seen early in the course of the illness . Positive symptoms and disorganisation respond to antipsychotic medication , however if patients with schizophrenia are neglecting self-care or threatening others , they may require urgent involuntary care .
Negative symptoms refer to the loss of capacity to express emotion , think , engage socially or participate in a motivated and goal directed way . There is a reduction in the ability to experience emotion quite separate from the mood state associated with depression . An alteration in cognition can be subtle with a simplification in the complexity and a slowing of the expression of thought . There is a loss of motivation resulting in the tendency to initiate little , even self-care , and a loss of the importance of socialisation , leading to isolation . Negative symptoms often begin early but tend to dominate late in the disease course . They are less responsive to antipsychotic medication and require a range of psychosocial interventions .
People with schizophrenia are frequently depressed and anxious . A depressed mood is seen in about one quarter of people with schizophrenia at any one time and at least half will experience a major depression over the course of their life . 12 However , this can lead to diagnostic confusion . Unfortunately , about 5 % of people with schizophrenia complete suicide . 13 High levels of anxiety are also common in people with psychosis with up to 30 % of people with schizophrenia experiencing post-traumatic stress disorder and 23 % obsessive compulsive disorder . 12 Other anxiety disorders are also commonly seen in people with schizophrenia . Additional targeted treatment for these symptoms is warranted using antidepressants or cognitive behavioural therapy .
Cognitive deficits are an important sign in schizophrenia and are strongly linked to functional impairment . These deficits are broadly based and can be categorised as either neurocognitive ( difficulties with attention , concentration , memory , planning and speed of processing ), or social cognitive ( with difficulties with emotion processing and recognition , theory of mind , social knowledge and attributional bias ). Cognitive deficits have no effective pharmacological treatments and require psychosocial interventions including cognitive remediation therapy .
DIAGNOSIS
SYMPTOMS are required to persist for at least six months to justify the diagnosis of schizophrenia . It is unusual to have all symptoms for this period ; it is frequently only the negative and cognitive symptoms that relentlessly continue , interspersed with positive symptoms such as auditory hallucinations experienced on an intermittent basis . The diagnosis also requires a deterioration in the level of functioning — a formerly excellent student now struggling to pass or an indifferent student dropping out of education or losing his job .
INVESTIGATIONS
INVESTIGATIONS ( see table 2 ) are performed with a view to identifying brain disorders that can masquerade as schizophrenia and establishing a baseline for the physical health issues that often result from long-term treatment with antipsychotic medications . Recent work has highlighted the need to screen for possible autoimmune aetiologies especially in individuals with other autoimmune disorders . 14 These diagnoses are usually indicated by other clinical features such as the recent onset of seizures , movement disorders , changes in the level of consciousness or autonomic dysfunction .
Brain imaging , preferably with MRI ( see figure 7 ) is also appropriate for the initial workup of someone with their first episode of psychosis . An EEG is indicated in people with symptoms suggestive of complex partial seizures . Other investigations may be indicated by the clinical history and presentation , for example , HIV or syphilis serology is not indicated for all people with their first episode of psychosis in standard Australian practice but may be essential given a relevant clinical history .
MANAGEMENT
SCHIZOPHRENIA is a chronic condition and requires a multidisciplinary team to manage it adequately . Treatment includes pharmacological , psychological , occupational and social interventions . These interventions will change over the course of the illness and must include family or other significant people in the person ’ s life , and extensive social support .
Early identification and treatment are an advantage . 18 However , treatment is too often initiated in hospital after a precipitous admission because the onset of positive symptoms in a young person were ignored or not noticed . Management in this context should aim at the items listed in box 1 .
Pharmacological management
The initial pharmacological management should include use any of the five second-generation antipsychotic ( SGA ) medications with an evidence base for use in first episode psychosis ( see figure 8 ). 16 Doses should be increased slowly with treatment response being measured by reduction in positive symptoms and disorganisation . Sedation or anxiolysis may be needed and can be most flexibly achieved using benzodiazepines such as diazepam 5-10mg up to four times daily ; this dose can be tapered and discontinued over the initial 1-2 weeks . In a community setting the use of a benzodiazepine
Proportion (%)
40 35 30 25 20 15 10 5 0
Figure 3 . Age of onset of psychosis in Australia .
Figure 4 . Many people with schizophrenia are lonely .
Figure 5 . The late British artist Bryan Charnley ’ s self-portrait depicting thought reading and thought broadcasting ( thought to be positive symptoms ).
over a short period is reasonable . A failure to respond to antipsychotic medication after a slow increase in dose to the top of the recommended range should prompt review as around 80 % of first episodes of schizophrenia will respond , though this response
Male
rate decreases with relapse . 19 , 20 Search for factors such as poor treatment adherence or continued substance use . Think of using a long-acting injectable ( LAI ) form of administration even at this early stage to improve treatment adherence . If poor treatment
Female
Under 15 |
15-19 |
20-24 |
25-29 |
30-34 |
35-39 |
40-44 |
45-49 |
50-54 |
55-59 |
60-64 |
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© 2011 The University of Western Australia
Bryan Charnley / bit . ly / 3oxfbCW adherence or substance use is not found , then change to another antipsychotic . If trials of three antipsychotics fail , all having reached the top of the recommended drug range and having been sustained for a least four weeks at that dose with good adherence , then