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Fundamentals of Schizophrenia

Fundamentals of Schizophrenia

Schizophrenia occurs in fewer than 1% of the population; however, the mental disorder has a huge impact on patients’ lives. Learn more about the prevalence, pathophysiology, diagnosis, and management of schizophrenia here.

Schizophrenia occurs in fewer than 1% of the population; however, the mental disorder has a huge impact on patients’ lives. Learn more about the prevalence, pathophysiology, diagnosis, and management of schizophrenia here.

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Introduction to Schizophrenia

What Is Schizophrenia?

Schizophrenia is a chronic psychiatric disease that severely impacts the quality of life of patients as well as their caregivers.1-3 It is a disorder of brain function that affects a person’s thoughts, feelings, and behavior.3 Symptoms can vary from one patient to another.3 In some cases, symptoms of schizophrenia can develop progressively, while in others they appear abruptly.3 Because of the complexity of schizophrenia, there can be common misconceptions about the disease.

Relationship between negative symptoms, positive symptoms, neurocognitive deficits, and impaired social cognition in schizophrenia and how the symptoms are connected to other comorbid mental health disorders. Adapted with permission from Millan MJ et al. [4]

The core symptoms of schizophrenia are categorized into 4 main categories: positive symptoms, negative symptoms, neurocognitive deficits, and impaired social cognition. Positive symptoms are the most familiar symptoms of schizophrenia, but the relationship between all symptoms represent the overall impact that schizophrenia can have on a patient’s life. These symptoms also can be associated with additional comorbid mental health disorders, such as depression and anxiety.4


Positive Symptoms

The positive symptoms of schizophrenia are considered the most characteristic of the disease.5 These include hallucinations, which are most commonly auditory but can occur through any senses; delusions, which are fixed beliefs that cannot be changed in light of conflicting evidence; and a loss of contact with reality.6,32

Negative Symptoms

Negative symptoms of schizophrenia, including reduced emotional expression, motivation, and pleasure,32 can be the most difficult to manage.7 A significantly greater functional impairment has been associated with prominent negative symptoms versus prominent positive symptoms.8

Reduced Emotional Expression.9 Patients with schizophrenia can experience a decrease in the expression of emotion and reactivity to events, as observed during the spontaneous or elicited expression of emotion (facial and vocal expression and expressive gestures).10 This is also known as a blunted affect.10 Alogia, which is a reduction in quantity of words spoken and in spontaneous elaboration (ie, amount of information spontaneously given beyond what is needed to answer a question), can also appear.10

Reduced Motivation and Pleasure. Patients with schizophrenia experiencing reduced motivation and pleasure can exhibit avolition, which is a reduced initiation and persistence of goal-directed activity due to reduced motivation.10 Another common symptom in patients with reduced motivation and pleasure is anhedonia, or reduced experience of pleasure for a variety of activities or events, during the activity or event (consummatory anhedonia) and for future anticipated activities or events (anticipatory anhedonia).10 Finally, asociality is also exhibited by those who have a reduced level of motivation and pleasure. Asociality causes reduced social interactions and initiation due to decreased motivation for, and interest in, forming and maintaining relationships with others.10

Neurocognitive Deficits

Cognitive dysfunction is a cardinal feature of schizophrenia, present in about 70% of patients.11 Symptoms can include lack of attention, lack of declarative memory, impairments in higher-order problem solving, effects on speed of processing, social cognition, and executive function.3 The effects of schizophrenia on memory can be both semantic and explicit and can include changes to working and long-term memory function.5

Impaired Social Cognition

Functional or social impairment can be a result of cognitive impairment.3 This can manifest as a lack of social behaviors, such as emotional withdrawal and reduction of interpersonal interaction.3


Course of Illness

Schizophrenia is divided into phases—prodromal, progressive or active, and recovery or residual—that tend to occur in order and cycle through the course of illness.12

Progression of schizophrenia over time in relation to severity of illness. Adapted with permission from Correll CU. [12]

Relapse is common in schizophrenia.13 Approximately 82% of patients with a first episode of schizophrenia experience a relapse within 5 years when they don’t receive proper medical care.13

What Is the Burden of Schizophrenia?

Prevalence

It is difficult to estimate the precise prevalence of schizophrenia due to the complexity of the schizophrenia diagnosis and its overlap with other disorders.1 In the United States, it is estimated that between 0.25% and 0.64% of the population have diagnoses of schizophrenia and related psychotic disorders.14-16 Onset of schizophrenia typically occurs in adolescence or early adulthood, with an age of onset between 15 and 35 years.17 Schizophrenia may emerge earlier in men (late adolescence to early twenties) than in women (early twenties to early thirties).1 Subtle changes in cognition and social relationships may precede the actual diagnosis of schizophrenia, often by years.1

Disability

Schizophrenia is ranked as the 19th leading cause of disability world-wide across all age groups18 and is ranked 5th among young adults (ages 20 to 24).19 The disability caused by schizophrenia can have a significant impact on employment; the excess rate of unemployment among patients with schizophrenia is 58%.20

Mortality

An average of 14.5 years of potential life (15.8 years and 13.0 years for men and women, respectively) are lost due to schizophrenia.21 Individuals with schizophrenia have an average life expectancy of 64.7 years.21 The average life expectancy for men with schizophrenia is lower, at about 59.3 years, compared to women at 66.8 years.21

Suicidality

An estimated 4.9% of people with schizophrenia will commit suicide during their lifetime, with the highest risk being in the early stages of illness.22 Patients with schizophrenia are about 13 times more likely to die by suicide than the general population.23


Quality of Life

Reliability of self-reporting in patients with schizophrenia makes it difficult to accurately measure the quality of life burden of the disease.2,3

The following factors may be predictive of whether patients with schizophrenia are more or less likely to experience a worse quality of life when compared to the general population and other physically ill patients:2

Impaired Quality of Life More Likely: Impaired Quality of Life Less Likely:
  • Longer length of schizophrenia illness
  • Being younger, a woman, married, and with a low level of education
  • Psychopathology, especially negative and depressive syndromes
  • Experiencing fewer side effects from medications
  • Weight gain and sexual dysfunction
  • Combination of psychopharmacological and psychotherapeutic treatment

  • Patients integrated in community support programs compared to those who are institutionalized

Caregiver Burden

Schizophrenia affects the psychological, emotional, physical, social, and financial life of caregivers as well.3 The majority of caregivers for patients with schizophrenia are parents or stepparents (68%); siblings (12%), spouses or significant others (7%), and children or grandchildren (7%) represent most of the rest of the caregivers.24

For individuals caring for a person with schizophrenia, factors associated with an increased burden of care include25:

  • Treatment-resistant schizophrenia
  • Longer duration of care
  • Increased number of hospital admissions
  • Presence of disability
  • High expressed emotion and criticism between caregivers and individuals with schizophrenia
  • Financial burden
  • Challenging symptoms: 
            -Paranoia
            -Disorganized Speech
            -Delusions
            -Aggression

In a survey by the National Alliance on Mental Illness (NAMI), caregivers of individuals with schizophrenia were asked to describe the primary challenges they faced.24

Reported Challenges of Caregivers Surveyed Chart

2008 survey on challenges reported by caregivers of individuals with schizophrenia. [24]

In another study, face-to-face interviews with 12 parents caring for adult children with schizophrenia were conducted to gather their experiences.26 The caregivers identified 4 main areas of burden: psychological and emotional burden, physical burden, social burden, and financial burden.3,26

Factors that can reduce caregiver burden include25:

  • Stress management programs improve caregivers’ mental status, coping with stress attitude, and feelings of burden
  • Improved access to medication, psychiatric care, and crisis care
  • Assertive community treatment, a team-based model for community mental health care delivery
  • Peer support groups of caregivers

Pathophysiology of Schizophrenia

What Do We Know About the Causes?

The etiology of schizophrenia is complex. While the primary causes of schizophrenia are unknown, a variety of factors are thought to be involved.27


Brain Structure and Function

Altered brain structures, including decreased gray matter volume and enlarged ventricles, have been hypothesized as an underlying cause of schizophrenia.27-29 Patients with schizophrenia have been observed to have changes in cortical thickness. Magnetic resonance imaging over a 5-year longitudinal study showed the brains of individuals with schizophrenia had excessive thinning of the cortex over time.30 This thinning occurred across widespread areas of the cortex, starting in the prefrontal and temporal areas where it was most pronounced, and then progressing across other areas over the course of the illness.30

Biochemical

Altered neurotransmitter systems are also thought to be involved in the pathophysiology of schizophrenia.27-29 There are 4 main neurotransmitter systems implicated (dopamine, glutamine, serotonin, and gamma aminobutyric acid [GABA]), but all are hypothesized to involve increased glutamate transmission in those with schizophrenia.31

Neuronal Circuits (adapted with permission)

Neuronal circuits that may be involved in schizophrenia. Adapted with permission from Freedman R. [31] ACH = acetylcholine, DA = dopamine, GABA = g-aminobutyric acid, GLU = glutamate, NE = norepinephrine, 5-HT = serotonin.



Neurodevelopmental

During the course of neurodevelopment (both fetal and during childhood), there are multiple factors that have been demonstrated to impact an individual’s chances for developing schizophrenia.27-29 During gestation, maternal infection has been linked to schizophrenia diagnosis.27,29 Research has demonstrated that the risk rate for developing schizophrenia is higher in individuals born following a flu epidemic or exposure to rubella.29 This is called the “season-of-birth” effect, as several studies have demonstrated that more schizophrenic patients are born during the winter. Exposure to viral pathogens is most common in the late fall and early winter, thus exposing mothers during their second trimesters.29

Maternal stress during gestation also can impact the fetus and increase the risk for developing schizophrenia. In mothers who had a spouse die or who experienced military invasion during the pregnancy, children were more likely to develop schizophrenia.29

Obstetric complications have been tied to adverse effects on the development of the fetal brain, which can lead to schizophrenia. Several studies have demonstrated a correlation between schizophrenia diagnosis and a history of obstetric complications including toxemia, preeclampsia, and labor and delivery complications.29 One of the most common labor and delivery complications linked to the development of schizophrenia is hypoxia.29

Genetic

Schizophrenia has a substantial genetic component, with multiple susceptibility genes identified.27-29 The specific genetics of schizophrenia are not yet fully understood, as susceptibility genes are thought to act in combination with epigenetic and environmental factors.27 Heritability is high in schizophrenia, with genetic factors contributing to about 80% of liability for the illness.28 While two-thirds of schizophrenia diagnoses are sporadic, there is an increased risk if an individual has a family history of schizophrenia, and the level of risk is correlated with the degree of genetic distance to the affected family member.28 One of the more recent genetic discoveries is the association between deletion of the 22q11 gene and development of schizophrenia.29 Approximately 25% of individuals with this deletion meet diagnostic criteria for schizophrenia; however, only 2% of patients with schizophrenia have a 22q11 deletion.29

Environmental

Environmental factors, particularly sociodemographic, have demonstrated an association with an increased risk of schizophrenia.27 Stressful environmental conditions are a risk factor, with individuals living in poverty and those of lower social class being more likely to develop the disorder.27 Living in an urban setting during childhood also can increase the risk for schizophrenia diagnosis.28 Childhood trauma and abuse, as well as separation from parents or parental death during childhood and the early teen years, are additional risk factors.28 Ultimately, stress exposure within a child’s home environment may trigger underlying genetic predisposition for schizophrenia.27-29

Diagnosis

DSM-5 Diagnostic Criteria

The Diagnostic and Statistical Manual, 5th Edition (DSM-5), developed by the American Psychiatric Association (APA), provides resources on the symptoms, diagnostic features, risk factors, and comorbidities associated with schizophrenia.32 While the criteria listed within the DSM-5 are used to distinguish schizophrenia, there is no single symptom that is specifically characteristic to schizophrenia.32 Every patient will differ on how clinical symptoms present.32

In order to diagnose a patient with schizophrenia, there must be continuous signs of disturbance that persist for at least 6 months and include at least 1 months of key clinical features, including 2 or more of the following:32

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behavior
  • Negative symptoms

This may include prodromal or residual phases, during which only negative symptoms or attenuated symptoms are seen.32 Level of functioning in 1 or more major areas, such as work, interpersonal relations, or self-care is markedly diminished.32

Schizoaffective disorder and depressive or bipolar disorder with psychotic features must be ruled out, using the following criteria32:

  • No major depressive or manic episodes occurring at the same time as active-phase symptoms; or
  • If mood episodes occur at the same time as active-phase symptoms, they are present for a minority of the active and residual periods of illness

A schizophrenia diagnosis also requires ruling out that the disturbance can be attributed to the effects of a substance or another medical condition.32

In individuals with a history or autism spectrum disorder or a communication disorder with an onset in childhood, a diagnosis of schizophrenia can only be made if prominent delusions or hallucinations are present for at least 1 month (or less if successfully treated), in addition to the other required symptoms.32

Diagnostic and Screening Tools

While there are no psychometric tools recognized by the DSM-5 for the diagnosis of schizophrenia, there are several scales and instruments that have been developed to aid in research, screening, and monitoring a patient’s illness over time.32,33

The following scales are in-depth, reliable, and validated assessments that are typically used in a research setting. Due to the length of these scales and the associated required training, they might be more difficult to use in a clinical practice.33

Scales for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms (SANS and SAPS)

These are the original standardized scales for positive and negative symptoms.33 Developed in the 1980s, these assessment tools help providers measure the severity of both positive and negative symptoms.33 The SANS tool is a 25-item, 6-point scale, and the SAPS tool is a 34-item, 6-point scale.33-35

The Positive and Negative Symptom Scale (PANSS)

The PANSS is the gold standard in research and for measuring symptom improvement. It is comprised of 30 items divided into 3 subscales.33,36 The subscales are independent of one another and focus on positive symptoms, negative symptoms, and general psychopathology.33,36

Negative Symptoms Assessment 16 (NSA-16)

The NSA-16 is an updated scale for monitoring negative symptoms, in particular. The NSA-16 was developed in 1989 and then adapted to the NSA-4 in 1993.33 The NSA-16 analyzes the presence, severity, and range of negative symptoms.33,37 The tool is a 16-item questionnaire that focuses on 5 factors: (1) communication, (2) emotion/affect, (3) social involvement, (4) motivation, and (5) retardation.33,37

The following scales are shorter and therefore more clinically friendly assessments.

Negative Symptoms Assessment 4 (NSA-4)

The NSA-4 was created by modifying the NSA-16 in 1993.33 This assessment tool only focuses on 4 items from the original NSA-16 and is considered nearly as reliable as the much lengthier NSA-16.33

The Clinical Global Impression-Schizophrenia Scale (CGI-SCH)

The CGI-SCH is a reliable, short assessment tool that is most appropriate for use in observational studies and routine clinical practice, but it is less reliable than other tools for the depression rating.33 The CGI-SCH tool assesses positive, negative, depressive, and cognitive symptoms as well as overall severity of schizophrenia.33,38 This questionnaire has 2 categories: severity of illness and degree of change.33,38

The Prodromal Questionnaire – Brief Version (PQ-B)

This assessment tool is a self-reported questionnaire used to identify prodromal phase symptoms or patients that are at ultra-high-risk for developing psychosis.39 The PQ-B is adapted from the original Prodromal Questionnaire, which is a 92-item self-report tool.39

The Clinical Assessment Interview for Negative Symptoms and Brief Negative Symptom Scale (CAINS and BNSS)

The CAINS and BNSS were developed by the National Institute of Mental Health in 2005.33 Both tests use 13 items to assess for negative symptoms of schizophrenia.33,40,41


Potential Differential Diagnoses

Schizophrenia has symptoms that overlap with other mental health disorders, and it can also be comorbid with many of these disorders, making it difficult to diagnose.32 For example, patients with delusional disorder experience delusions just like those with schizophrenia.32 However, delusional disorder can be distinguished from schizophrenia through the absence of other symptoms of schizophrenia such as negative symptoms and disorganized speech.32 Due to the overlap in symptoms with multiple other conditions, careful evaluation of the patient and their history is important for proper diagnosis.

Other diagnoses that should be considered prior to making a diagnosis of schizophrenia include the following.32

Major Depressive Disorder or Bipolar Disorder With Psychotic or Catatonic Features:

The distinction between these 2 disorders can be made based on the time between the mood disturbance and psychosis, as well as the severity of the depressive or manic symptoms. If delusions and/or hallucinations occur exclusively during the major depressive or manic episodes, the diagnosis would not be schizophrenia.32

Schizoaffective Disorder:

A diagnosis of schizoaffective disorder might be appropriate if a major depressive or manic episode occurs at the same time as active phase symptoms, along with the presence of mood symptoms for most of the active periods.32

Schizophreniform Disorder or Brief Psychotic Disorder:

Schizophreniform or brief psychotic disorder do not last the duration required for schizophrenia. Schizophreniform disorder is a disturbance of less than 6 months, and a brief psychotic disorder lasts less than 1 month (but at least 1 day).32

Delusional Disorder:

Other than the presence of delusions, delusional disorder does not have any other symptoms that are characteristic of schizophrenia.32

Schizotypal Personality Disorder:

Schizotypal personality disorder can be differentiated by milder symptoms and associated persistent personality features.32

Obsessive-Compulsive Disorder and Body Dysmorphic Disorder:

Although individuals with obsessive compulsive disorder and body dysmorphic disorder may present with poor or absent insight, and the preoccupations associated with these disorders may reach the level of delusions, the disorders can be distinguished from schizophrenia by the presence of prominent obsessions, compulsions, preoccupation with appearance or body odor, hoarding, or body-focused repetitive behaviors.32

Posttraumatic Stress Disorder:

While both disorders may include hallucinations or paranoia, a posttraumatic stress disorder diagnosis requires a traumatic event and symptom features related to reliving or reacting to the traumatic event.32

Autism Spectrum Disorder or Other Communication Disorders:

Autism spectrum and communication disorders can have symptoms resembling a psychotic episode but are differentiated by social interaction deficits, repetitive and restricted behaviors, and other cognitive and communication deficits.32


Comorbidities

Depression in Patients With Schizophrenia

In the US Schizophrenia Care and Assessment Program (US-SCAP), a 3-year study including 2,327 patients with schizophrenia between July 1997 and September 2003, researchers found that 39.4% of schizophrenia patients were depressed at enrollment.42 Depression was classified as a score of ≥ 16 on the Montgomery-Asberg Depression Rating Scale (MADRS). The assessment was performed at enrollment and at 12-month intervals.42

Overall, when adjusted for age, gender, and ethnicity, depressed patients with schizophrenia were significantly more likely than non-depressed patients with schizophrenia to experience the following:42

  • Use relapse-related mental health services
  • Be of greater safety concern in the community
  • Have more substance-related problems
  • Have poorer social and family relationships
  • Have poorer quality of life

Substance Use and Schizophrenia

Substance Abuse

In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, which analyzed the baseline prevalence of depression in 1,460 patients with schizophrenia, approximately 37% of patients had a current substance use disorder.43

Smoking Prevalence

Between 70% to 80% of patients with schizophrenia are smokers, in contrast to 20% to 30% in the general population.44

Alcohol Use Disorder

Among individuals living with schizophrenia, approximately 1 in 4 will develop alcohol use disorder in their lifetime.45

Other Comorbid Diseases in Schizophrenia

Aside from mental health and substance use disorders, schizophrenia is associated with multiple other medical comorbidities, including cardiovascular complications, obesity, thyroid dysfunction, and HIV.42,43,46

Body Weight Gain and Schizophrenia

Accumulation of excess body weight among patients with schizophrenia is multi-factorial and can be caused by a combination of unhealthy dietary choices, sedentary lifestyle, a lack of access to appropriate food and physical activity sources, and possible genetic or intrinsic disease-state vulnerability for abdominal adiposity.47

Psychotropic medication, in particular the second-generation antipsychotics, have been associated with weight gain.47 Agents differ in their propensity for weight gain. Switching from one agent to another, when clinically feasible, may help ameliorate weight gain.47


Treatment Guidelines

The treatment guidelines listed below were selected using an objective and systematic, but not exhaustive, process (see below for the methodology used). These guidelines are for educational use only. AbbVie Inc was not involved in the development of the guidelines listed below and does not endorse the use of any specific guidelines. As NP Psych Navigator is a resource for US healthcare providers, we have only included guidelines from US-based organizations. They are provided here for your convenience in alphabetical order. Healthcare providers should use their clinical judgement to determine which guidelines are appropriate for use in their clinical practice.

Agency for Health Research and Quality (AHRQ): Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations48

  • Supporting Organizations: Agency for Health Research and Quality, the National Institute of Mental Health
  • Published: 2009
  • Description: The Schizophrenia Patient Outcomes Research Team (PORT) created treatment recommendations that are based primarily on empiric data, as opposed to some other clinical guidelines. The PORT treatment guidelines were created with the goal of reducing variations in care and encourage use of treatments that have strong scientific evidence. These treatment guidelines were developed using systemic reviews of literature.

American Psychiatric Association (APA): Practice Guidelines for the Treatment of Patients with Schizophrenia 202049

  • Supporting Organizations: American Psychiatric Association
  • Published: 2020
  • Description: The APA Practice Guidelines aim to improve the quality of care and treatment outcomes for patients with schizophrenia. The guidelines were based on Treatment for Schizophrenia in Adults (McDonagh et al 2017), which was tasked by the AHRQ. The definition of schizophrenia is defined by the criteria listed in the DSM-5 manual. The guidelines focus primarily on treatment, both pharmacological and non-pharmacological, but also address assessment and patient-centered care.
  • Grading: The benefits and harms of the guideline recommendations are determined by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale which rates recommendations by confidence that the benefits outweigh the risks. A rating of 1 indicates a recommendation, while a rating of 2 indicates a suggestion. Additionally, alphabetical ratings are assigned (A-C) to rate the strength of the supporting evidence. A grade of A indicates high strength of evidence, B indicates moderate, and C indicates low.

Texas Medication Algorithm Project (TMAP) Procedural Manual: Schizophrenia Algorithm, 200850

  • Supporting Organizations: Texas Department of State and Health Services
  • Published: 2008
  • Description: The TMAP was developed to aid in clinical decision-making by analyzing current information regarding treatment and research data and condensing it into recommendations made based upon response, long-term safety, tolerability, and symptom remission. The algorithm addresses treatment strategies and treatment tactics. The TMAP was developed with contributions by practitioners, patients, families, and administrators.

Methodology for Guideline Selection

On April 1, 2021, the following search string was entered into the PubMed database:

(schizophrenia[Title/Abstract]) AND (treatment[Title/Abstract]) AND (guideline[Title] OR guidance[Title] OR recommendations[Title] OR algorithm [Title]). The search was limited to PubMed, the most commonly used medical publications database in the world, to ensure that this list can be consistently maintained and updated.

Results were restricted to those publications from the year 2000 to the date of the search, those published in English, and those indexed as article type, “Practice Guideline.” This search returned 20 results. These results were screened in depth according to the following exclusion criteria: articles that were not guidelines for clinical practice, such as research or study results; guidelines that had a published update (ie, only the most recent version of a set of guidelines were included); guidelines from any entity other than an established, professional clinical organization or a group of said organizations; guidelines from any non-US organization; guidelines that did not report their process for grading and evaluating recommendations; guidelines written for the use of a specific pharmacological or nutraceutical treatment; guidelines for schizophrenia secondary to another condition; and guidelines for conditions other than schizophrenia.

Non-Pharmacological Management for Schizophrenia

Non-pharmacological approaches and lifestyle modifications can help patients with schizophrenia better manage their diagnoses, foster better coping skills, and improve social inclusion.51

Psychoeducation

Psychoeducation provides patients with education regarding symptom and side effect management, daily living, and relapse prevention.52 It can aid in recovery, provide resources that help patients maintain a sense of well-being, and help patients develop problem-solving skills.52 Psychoeducation has been shown to reduce mortality in patients experiencing their first episode of psychosis,49 improve global function, increase medication adherence, and improve satisfaction with treatment.49

The most important aspect of psychoeducation is that it should be tailored to the individual.52

Coordinated Specialty Care Programs

The American Psychiatric Association (APA) recommends that a patient experiencing their first episode of psychosis receive treatment at a coordinated specialty care program.49 These programs focus on family and patient education and involvement to develop personalized treatment plans and provide education and employment support.53

Cognitive Behavioral Therapy (CBT) and CBT for Psychosis (CBTp)

The APA recommends the use of CBT in patients with schizophrenia.49 CBT can improve quality of life, improve global, social and occupational function, and reduce core symptoms of illness, particularly positive symptoms.49 CBTp is cognitive behavioral therapy adapted to individuals with psychosis.49 In the setting of CBTp, patients develop their own explanations for the cognitive assumptions they have.49 These explanations are healthier and more realistic than previous assumptions; they do not perpetuate delusions or hallucinations.49

Cognitive Adaptive Training (CAT)

CAT aides in memory, focus, paying attention, and problem-solving abilities.52 This form of training encourages patients to develop lists and schedules to manage daily tasks, with a goal of allowing patients to live more independently.52

What Lifestyle Modifications Help With Schizophrenia?

The process of recovery for individuals with schizophrenia includes helping them to feel empowered to take ownership and control over their own lives.52 This can include adopting certain lifestyle modifications that can help promote and maintain wellness for those living with schizophrenia.52

Medication Adherence Education

Nearly 75% of patients with schizophrenia discontinue medication treatment within 18 months.54 Preventing discontinuation can allow for continual treatment, which is necessary for treatment success.

As every patient is different, there is no universal intervention that will increase patient adherence.55 However, there are strategies for better supporting patients. These can be divided into 4 main categories: (1) patient-related interventions, (2) psychosocial interventions, (3) physician-related interventions, and (4) pharmacological treatment-related interventions.

Patient-Related Interventions55

  • Improving patient understanding of disease state
  • Helping to reduce psychotic symptoms
  • Addressing the stigma associated with medication
  • Helping to improve patient’s cognitive function

Psychosocial Interventions55

  • These work best as family interventions, not just for the patient
  • Developing community support
  • Improving problem solving skills

Physician-Related Interventions55

  • Improving physician awareness of adherence issues
  • Developing relationship between provider and therapist
  • Including the patient in the decision-making process
  • Assessing possible risk factors for non-adherence and making attempts to modify them
  • Continually re-evaluating where the patient is at in their course of illness

Pharmacological Treatment-Related Interventions55

  • Considerations of using pharmacological monotherapy over polytherapy, because of simplicity, less adverse effects, lower risk of drug interactions and easier response evaluation
  • Using treatment schedules as simple as possible, and simplifying instructions on medications as much as possible
  • Avoiding unrealistic expectations by explaining to the patient what they can and cannot achieve with the medication

Healthy Diet

A well-balanced diet can balance health problems associated with schizophrenia.52 Patients who meet nutrition guidelines can have a better perception of body function and are more likely to have a normal weight.56

Sleep Hygiene

Disturbed sleep may put patients with schizophrenia at higher risk for developing psychosis.57 A regular sleep schedule can reduce the occurrence of insomnia in patients with schizophrenia.58

Exercise

Physical activity can create a positive response in the body, which affects both physical and mental health.52 The atypical antipsychotics typically used in treatment of patients with schizophrenia can be associated with increased body weight, BMI, and proportion of weight gained during use.59 Exercise can be helpful to combat weight gain.


Patient Education

Patients incorporate their schizophrenia diagnoses into their lives and identities in different ways. To best prepare a patient for living with a diagnosis of schizophrenia, the APA makes several recommendations.

First, patients should be educated on specific early symptoms of relapse. Proper symptom education allows for early detection prior to or at the beginning of relapse and can help prevent an active episode of psychosis.60 The patient should be educated on the course and outcome of the disease, with particular emphasis placed on the importance of medication adherence to prevent relapse.60

Secondly, not only should the patient receive education, but so too should the patient’s family or support system.60 Of course, this is contingent upon the diagnosis of schizophrenia being shared with the family or loved one. The family should be educated on schizophrenia as a diagnosis to better understand the patient’s symptoms, disease management, and expectations for living with the disease. Additional education surrounding coping mechanism for the patient can help the caregiver aid in prevention of relapses and improving quality of life.60

Both the patient and the family should be made aware of community resources for individuals living with schizophrenia. Setting up services to aid in social function will allow for the patient’s ability to adapt to community life.60

References

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Additional Resources about Schizophrenia

Clinical Article

Cross-cultural Adaptation of the Arabic Positive and Negative Syndrome Scale in Schizophrenia: Qualitative Analysis of a Focus Group

Studies looking at the diagnosis of schizophrenia are often completed in Western countries. Here, we review the process and importance not only of translation but also of cultural adaptation of a psychiatric rating scale, concentrating on the Positive and Negative Syndrome Scale (PANSS) in patients of Arab descent with schizophrenia. The authors explore issues related to interview structure and cultural sensitivity within varied populations.

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