Treating paranoid schizophrenia

Schizophrenia is defined as a heterogeneous cluster of psychotic conditions characterised by positive and negative symptoms, disorganised speech and behaviour, as well as mood and cognitive impairments.

Positive symptoms include delusions, hallucinations, disorganisation and catatonia, while negative symptoms include affective flattening (a loss or lack of emotional expressiveness), anhedonia, alogia, avolition and social withdrawal.

Mood disorders include depression, feelings of hopelessness, suicidality, anxiety, agitation and hostility. Cognitive impairments include concentration, memory and executive functioning problems.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) a diagnosis of schizophrenia should only be considered if a patient has experienced at least two of the following symptoms for a month:

  • Delusion
  • Hallucinations
  • Disorganised speech.
  • Disorganised or catatonic behaviour.
  • Negative symptoms.

DSM-5 further states that the disorder must cause social and/or occupational dysfunction that cannot be better accounted for by:

  • Schizoaffective or mood disorders.
  • Substance-related disorders.
  • General medical conditions.

Paranoid schizophrenia

Paranoid schizophrenia is the most common type of schizophrenia in most parts of the world. Paranoia includes intense anxious or fearful feelings and thoughts often related to persecution, threat or conspiracy.

Paranoia can become delusions, when irrational thoughts and beliefs become so fixed that nothing (including contrary evidence) can convince a person that what they think or feel is not true.

When a person has paranoia or delusions, but no other symptoms (like hearing or seeing things that aren’t there), they might have what is called a delusional disorder.  Because only thoughts are impacted, a person with delusional disorder can usually work and function in everyday life, however, their lives may be limited and isolated.

Assessment

In 2013 Stahl et al published the so-called ‘meta-guidelines for the management of patients with schizophrenia’. In terms of assessment, they recommend the following:

  1. Evaluate the causes for a psychotic episode.
  2. Interview people close to the patient if possible.
  3. Complete psychiatric and general medical conditions.
  4. Identify comorbid psychiatric and medical conditions including substance use and possible infectious diseases (e.g. syphilis, HIV).
  5. Evaluate suicide risk.
  6. Assess baseline values that may be affected by antipsychotic treatment e.g. vital signs, diabetes risk factors, hyperprolactinemia and lipid panel.
  7. Consider brain imaging for patients with a new onset of psychosis or atypical clinical presentation.
  8. Engage in therapeutic alliance with the patient as well as other service providers.

Causes

Although the cause of schizophrenia has not yet been identified, recent research suggests that the disorder may be linked to abnormalities of brain chemistry and brain structure.

The brain changes in some cases are suspected to date to childhood. Brain-imaging technology has demonstrated that schizophrenia is as much an organic brain disorder as is multiple sclerosis, Parkinson’s or Alzheimer’s disease.

Genes play some role, but the magnitude of that role remains to be ascertained. Abnormalities of neurotransmitters (e.g. dopamine, serotonin) and viruses also are under investigation.

Risks

Individuals with schizophrenia die at a younger age than do healthy people. Males have a 5.1 greater than expected early mortality rate than the general population, and females have a 5.6 greater risk of early death. Suicide is the single largest contributor to this excess mortality rate, which is 10% to 13% higher in schizophrenia than the general population.

The extreme depression and psychoses that can result due to lack of treatment are the usual culprits. These suicide rates can be compared to the general population, which is somewhere around 0.01%. Other contributors to excess mortality include:

Accidents:

Although individuals with schizophrenia do not drive as much as other people, studies have shown that they have double the rate of motor vehicle accidents per mile driven. A significant but unknown number of individuals with schizophrenia are also killed as pedestrians by motor vehicles.

Diseases:

There is some evidence that individuals with schizophrenia have more infections, heart disease, type 2 diabetes mellitus and female breast cancer. Individuals with schizophrenia who become sick are less able to explain their symptoms to medical personnel, and medical personnel are more likely to disregard their complaints and assume that they are simply part of the illness. There also is evidence that some persons with schizophrenia have an elevated pain threshold so they may not complain of symptoms until the disease has progressed too far to be treatable.

Homelessness:

Although it has not been well studied to date, it appears that homelessness increases the mortality rate of individuals with schizophrenia by making them even more susceptible to accidents and diseases.

Treatment 

While there is no cure for schizophrenia, it is a highly treatable disorder. In fact, according to the US National Advisory Mental Health Council, the treatment success rate for schizophrenia is comparable to the treatment success rate for heart disease.

It is important to diagnose and treat schizophrenia as early as possible to help people avoid or reduce frequent relapses and rehospitalisations. Several promising, large-scale studies suggest early intervention may forestall the worst long-term outcomes of this devastating brain disorder.

People who experience acute symptoms of schizophrenia may require intensive treatment, sometimes including hospitalisation. Hospitalisation is necessary to treat severe delusions or hallucinations, serious suicidal inclinations, inability to care for oneself, or severe problems with drugs or alcohol.

It is critical that people with schizophrenia stay in treatment even after recovering from an acute episode. About 80% of those who stop taking their medications after an acute episode will have a relapse within one year, whereas only 30% of those who continue their medications will experience a relapse in the same time period.

Pharmacotherapy

According to the South African Society of Psychiatrists guideline, the therapeutic goals of treatment are to:

  • Achieve and maintain symptom alleviation.
  • Achieve and maintain treatment adherence.
  • Minimise treatment side effects.
  • Monitor physical health and drug-specific adverse event risks.
  • Manage smoking and substance abuse.
  • Manage the risk of harm to self and others.

Treatment plan

Stahl et al strongly recommend that a comprehensive treatment plan should be formulated in consultation with the patient and his/her caregiver and should promote treatment adherence. The treatment plans should include e.g. psychological therapy.

The plan should identify treatment targets and objective outcome measures to determine the efficacy of treatment, set realistic expectations for what constitutes successful treatment, use objective quantitative rating scales to monitor clinical status (e.g. the Positive and Negative Symptom Scale).

To promote treatment adherence, patients and their caregivers should be educated about the nature of the disorder, signs of relapse and coping strategies. The following should also be taken into consideration:

  • The patient’s individual goals to treatment outcomes.
  • Factors that can affect adherence e.g. side effects, lack of insight, patient’s perception of medication risks and benefits, cultural beliefs, social support and cognitive/memory impairments.

The treatment plan should also include strategies aimed at addressing comorbid conditions such as nicotine dependence and other substance use disorders, advised Stahl et al.

Pharmacological treatment

Pharmacological treatment remains the mainstay of therapy. According to studies, pharmacotherapy improves the long-term prognosis for many people with schizophrenia.

Studies show that after 10 years of treatment, 25% of those with schizophrenia have recovered completely, 25% have improved considerably, and 25% have improved modestly, while 15% have not improved, and 10% are dead.

Antipsychotic drugs are recommended as first line therapy. Antipsychotic drugs can be divided into first generation or typical agents (e.g. haloperidol and chlorpromazine) and second generation or atypical agents (e.g. risperidone and olanzapine).

First and second generation agents have been shown to be equally effective in alleviating psychosis. However, the latter has been shown to be more effective in treating negative symptoms as well as mood and cognitive impairment. In addition, second generation agents have been shown to be more tolerable because they have less severe extrapyramidal side effects (EPS).

Treatment phases

Stahl et al proposed the following treatment with antipsychotics for the different phases of the disorder:

Acute phase: Treatment should be initiated as soon as possible. Risks and benefits should be discussed with the patient and his/her consent should be obtained if possible. The choice of drug should be based on severity of symptoms, prior degree of symptom response, prior side effect experience and profile, dosing convenience, patient preference and the available formulation.

Stabilisation phase: Monitor drug response and dose for the next six months, assess adverse effects and adjust medication as needed, continue psychotherapeutic interventions, educate the patient and caregiver and arrange for continuity of care by assuring linkage of services between hospital and community treatment before patient is discharged from hospital.

Stable phase: Conventional antipsychotics should be administered at a dose close to the EPS threshold. Atypical antipsychotics can usually be administered at doses that are therapeutic without inducing EPS. Weigh the advantages of decreasing the antipsychotic dose against the risk of relapse, differentiate between increasing agitation and akathisia and evaluate negative symptoms.

SA treatment algorithm

South African schizophrenia treatment algorithm

South African schizophrenia treatment algorithm

Fast facts

  • Men and women have equal rates of schizophrenia.
  • Men may manifest symptoms of schizophrenia earlier than women.
  • Usually one to two years pass after the initial symptoms of schizophrenia present before diagnosis.
  • Children and people over 45 rarely get schizophrenia (more on schizophrenia in children).
  • All races show equal incidence of schizophrenia.
  • About 10% of adults with schizophrenia die by suicide.
  • Risk of violence in schizophrenia is very small unless there are additional substance abuse issues.
  • Delusions of persecution may also increase the risk for violence.
  • 75%-90% of people with schizophrenics smoke compared with 25% – 30% of the general population. Researchers are not sure why, but people with schizophrenia seem to be driven to smoke and may have a harder time quitting.
  • 25% of people have experienced recovery.
  • 25% are much improved and living independently.
  • 25% are improved but require constant support.

References:

  1. Tandon R, Gaebel W, Barch DM et al. Definition and description of schizophrenia in the DSM-5. Schizophrenia Research, 2013.
  2. Stahl SM, Morrissette DA, Citrome L et al. Meta-guidelines for the management of patients with schizophrenia. CNS Spectrums, 2013.
  3. The South African Society of Psychiatry. The South African Society of Psychiatrists Treatment Guidelines for Psychiatric Disorders. SAJPsychiatry, 2013.

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