Schizophrenia Treatment

Famous Louis Wain's paintings, potentially showing the progression of Schizophrenia, during his multiple psychiatric hospitalizations



Defining schizophrenia

Schizophrenia, along with manic-depressive illness, is one of the two main diseases of psychiatry.  Unlike manic-depression, which consists of mood episodes which come and go and hence has periods of normality (or near-normality), schizophrenia is chronic, with constant symptoms of psychosis, which may have exacerbations and reductions, but which are always present to a notable degree.  This constant psychosis is associated with low function: most people are unable to have standard levels of functioning at work and in relationships. 

Schizoaffective disorder

A small percentage, perhaps about 10%, have better function at times, but they usually have manic or depressive episodes, and are not only chronically psychotic without mood episodes, as in classic schizophrenia.  This combination of mood episodes with chronic psychosis is labeled as “schizoaffective illness”, but this label does not likely reflect a completely different disease, but rather a subtype of schizophrenia mixed with a subtype of mood illness (as explained further here). 

 Defining psychosis

Psychosis reflects delusions or hallucinations.  Hallucinations involve hearing voices or seeing things; delusions are abnormal thoughts which are usually false and typically illogical, and often fixed and immovable with logic or reasoning or evidence.  Schizophrenia involves the constant presence of such symptoms.

Flat affect

Typically, except in schizoaffective illness, patients with schizophrenia have “flat affect”, meaning they do not have severe mood episodes like depression or mania.  They also do not have normal affect, meaning a typical range of emotional expressions that are contextually appropriate, from normal sadness to normal happiness.  Such patients seem restricted or constrained, having an apparent “absence” of affect, rather than severe extremes of affect, as in manic-depressive illness.

The original concept

Kraepelin originally defined this illness, and called it “dementia praecox” to describe how it was chronic and worsening (‘dementia”) and that it began in adolescence (“praecox”).  Some patients do not worsen consistently but rather plateau out at a low level of function; others, who are schizoaffective, can improve somewhat in function.  But the illness is chronic, and begins early in life, usually by the teens or twenties.

Schizophrenia Treatment

Treatment involves the use of “antipsychotics”, or dopamine blockers. These drugs provide symptomatic improvement to a moderate degree, but do not lead to complete improvement in the vast majority of patients; in some, with schizoaffective illness, more improvement can be seen. The CATIE trial, sponsored by the NIMH, showed very low continuation rates with one year of schizophrenia treatment (about 30%). Since the illness is chronic, and antipsychotics are not curative, special attention should be paid to side effects of antipsychotics, which can be extensive, as discussed here.  Nonetheless, the illness is typically so severe that the benefits of schizophrenia treatment with antipsychotics outweight the harms, as long as agents used and doses given are as minimal and benign as possible given the individual’s treatment response. 

Pharmacology of antipsychotics

Side effects of antipsychotics

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