Schizophrenia ...

This section of the NICE Implementation Resource Tool has been designed to provide an overview of current models and perspectives that are most commonly used to understand schizophrenia.

People using Mental Health Services have a right to positive messages about their recovery, to receive effective psychosocial approaches (sometimes called psychosocial interventions or PSI) to help them regain control over their experiences and lead a full and satisfying life.

Within this section there is information on Mental Health Services, an over view of the Mental Health Workforce, examples of assessments used and the sort of questions that may be asked to help understand peoples experiences.

Schizophrenia is characterised by distortions of thinking and perception and is usually accompanied by emotions that are inappropriate or blunted. Typically there is a disturbance of the most basic functions that give a person the feeling of individuality, uniqueness and self-direction. For example, an individual may believe that intimate thoughts are known by others or that supernatural forces are influencing his or her actions in ways that are often bizarre. Additionally, the individual may lack insight and may not appreciate that there is anything wrong with his or her mental state.

Mood is usually shallow, frivolous, or inappropriate for the situation. Social withdrawal and emotional detachment are common. In addition, there is often a disturbance in self-initiated, goal-directed activity with inadequate interests or ability to follow a course of action to its logical conclusion.

Clear consciousness and intellectual capacity are usually maintained, although certain cognitive deficits (such as in memory or concentration) may evolve during the course of time.

Listed below is a summary of common complaints given by individuals or their families:

• Hearing voices when no-one is around
• Strange beliefs
• Disturbances with thinking or concentration
• Managing daily activities
• Managing social interactions, work or studies

Families may ask for help with the individual's:

• Strange, frightening, or annoying behaviour (e.g., irritability, suspiciousness)
• Apathy, withdrawal or poor living skills

There is evidence that genetic factors play a role in the disorder. Psychosocial factors such as stress are likely to be involved in triggering the initial and subsequent episodes in vulnerable people, although other factors may also act as triggers (e.g. substance abuse). Episodes of schizophrenia appear to involve biological disturbances in the brain.

Epidemiology

Approximately 1 in 100 individuals will develop schizophrenia. Most of these individuals will present as young adults between the ages of 15 and 25, however schizophrenia may develop at any age. Men and women from all cultures are equally likely to develop schizophrenia although there is a tendency for men to develop the disorder slightly earlier in their lives than women.

Course

Schizophrenia can be divided into three major phases: the prodromal state, an active phase, and a residual phase.

During the prodromal state it is not uncommon for a number of non-specific symptoms to be present in the weeks or months preceding the first onset of typical symptoms of schizophrenia, particularly in young people. These symptoms include:

• A general loss of interest
• Avoidance of social interactions
• Avoidance of work or study (e.g. dropping out of school, college or university)
• Being irritable and oversensitive
• Odd beliefs (e.g. superstitiousness)
• Odd behaviour (e.g. talking to self in public)

These changes will often be incapacitating for the individual and distressing for the family. Friends or relatives may describe the individual as "no longer the same person". The length of the prodromal phase is extremely variable and prognosis is less favourable when the prodromal phase has had a lengthy course.

During the active phase of the illness, psychotic symptoms such as delusions, odd behaviour and hallucinations are prominent and are often accompanied by strong affect such as distress, anxiety, depression, and fear. If untreated, the active phase may resolve spontaneously or may continue indefinitely. With appropriate treatment (primarily medication) the active phase is usually able to be brought under control. It is during the active phase that most individuals present for treatment, whether it is their first presentation or an exacerbation of their symptoms.

The active phase of the illness is usually followed by a residual phase. The residual phase is similar to the prodromal phase although during the residual phase blunted affect and impairment in role functioning are more common. While psychotic symptoms may persist into the residual phase, the psychotic symptoms are less likely to be accompanied by such strong affect as experienced during the active phase. There is great variation in the severity of the residual phase from one person to the next. Some individuals will function extremely well while others may be considerably more impaired.

The most common course of the disorder generally involves numerous active phases of illness with residual phases of impairment between episodes. The extent of residual impairment often increases between episodes during the initial years of the disorder although may possibly become less severe during the later phases of the illness.

Prognosis

While full remissions from schizophrenia do occur, most people have at least some residual symptoms of varying severity. Generally, 25% of people experience a complete recovery, 40% experience recurrent episodes of psychosis with some degree of social disability and periods of unemployment, while 35% may remain chronically disabled.

Research suggests that, rather than being a deteriorating illness, schizophrenia may in fact be viewed as a progressively ameliorating illness in which the frequency of episodes declines over time. Once again, however, the severity and outcome of the disorder varies greatly from one individual to the next.

As yet there is no accurate method for predicting who will or will not recover from this illness. Individual prognosis is never certain, however, some factors that are associated with a good prognosis include:

• Abrupt onset
• An absence of premorbid disturbance
• Onset in mid-life
• Presence of acute and resolvable life stressors
• A family history of affective disturbance
• Presence of florid symptoms, confusion or perplexity during acute phase
• Appropriate early treatment and care
• A favourable, non-critical attitude from family members
• Absence of blunted or flat affect