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• Symptoms of schizophrenia may be:• Positive (eg, unusual thought content, hallucinations, conceptual

disorganization)• Negative (eg, affective flattening, apathy, anhedonia, avolition)• Cognitive (eg, impaired attention, working memory, executive

functioning)

References1. American Psychiatric Association. Diagnostic and Statistical Manual of

Mental Disorders Fifth Edition (DSM 5). Arlington, VA: American Psychiatric Association. 2013.

2. American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, second edition Am J Psychiatry. 2004;161 (2 Suppl):1-56.

3. NIMH Web site. http://www.nimh.nih.gov/health/publications/schizophrenia/index.shtml. Accessed October 3, 2013.

4. Velligan DI, et al. A brief cognitive assessment (BCA) for use with schizophrenia patients in a community clinic. Schizophren Res. 2004;71:273-283.

APA DSM 52013 A

APA Practice Guideline2004 A Velligan

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Note: Not all patients experience this disease course.

• Schizophrenia is characterized by a sequential trajectory that usually involves a premorbid phase (with subtle and nonspecific cognitive, motor, and/or social dysfunction), a prodromal phase (characterized by attenuated positive symptoms or basic symptoms and declining function), the first psychotic episode (which heralds the formal onset of schizophrenia), the first decade (which is often marked with reported psychotic episodes), and a stable phase (when psychotic symptoms are less prominent and negative and cognitive symptoms increasingly predominant).

• Some degree of recovery of function typically occurs after each episode of illness. However, it is important to note that, in some patients, there may be an accumulation of permanent disability after each successive episode.{Tandon 2009 A}

• Goals of treatment are dependent of the phase of the illness (ie, psychotic/acute or stable/maintenance). {APA Guideline A} {Kane 2010 A}

References1. Tandon R, et al. Schizophrenia, “just the facts” 4: clinical features and

conceptualization. Schizophr Res. 2009;110:1-23.2. American Psychiatric Association. Guideline Summary. 2nd edition. 1998. NGC-

3572.3. Kane JM. Maintenance strategies in schizophrenia. CNS Spectr. 2010;15(4 Suppl

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• Goals of acute treatment often include preventing harm, controlling disturbed behavior, reducing the severity of psychosis and associated symptoms, addressing factors that led to the occurrence of the acute episode, helping the patient to return to the best level of functioning, developing an alliance with the patient and family, formulating treatment plans, and connecting the patient with appropriate sources of care in the community.{APA Guideline A}

• Goals of maintenance treatment include consolidate the gains of acute therapy, prevent recurrence of illness (ie, remission}, and maintain symptom reduction (ie, recovery).{Kane 2010 A} {Andreasen 2005 A} {Lieberman 2008 A}

References1. American Psychiatric Association. Guideline Summary. 2nd edition. 1998. NGC-3572.2. Kane JM. Maintenance strategies in schizophrenia. CNS Spectr. 2010;15(4 Suppl 6):12-

14.3. Andreasen NC, Carpenter WT Jr, Kane JM, et al. Remission in schizophrenia: proposed

criteria and rationale for consensus. Am J Psychiatry. 2005;162:441-449. 4. Lieberman JA, et al. Science and recovery in schizophrenia. Psychiatr Serv.

2008;59(5):487-496.

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• Proposed criteria for remission require that patients have symptoms of no greater than “mild” severity on the Positive and Negative Symptom Scale (PANSS), for all 8 symptom items, for at least 6 months.{Andreasen 2005 A}

• Recovery is not consistently defined but may be best defined in terms of specific domains of symptom improvement and functioning. {Lieberman 2008 A}

• Reported recovery rates have varied from 4% to 27% over follow-up periods of 1 to 2 years.{Emsley 2011 A} {Emsley 2011 B} {Emsley 2011 C} {Emsley 2011 D}

References1. Andreasen NC, Carpenter WT Jr, Kane JM, et al. Remission in schizophrenia:

proposed criteria and rationale for consensus. Am J Psychiatry. 2005;162:441-449. 2. Lieberman JA, et al. Science and recovery in schizophrenia. Psychiatr Serv.

2008;59(5):487-496.3. Emsley R, et al. The concepts of remission and recovery in schizophrenia. Curr Opin

Psychiatry. 2011;24:114-121.

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• Recovery usually includes both symptom remission and independent psychosocial functioning. It is common opinion that the patient does not need to be living on their own to meet the latter..{Lieberman 2005 A}

• Recovery is not the same as a cure.• There are several operational definitions of recovery in schizophrenia, with all

including both symptom remission and improved psychosocial functioning.

Reference1. Liberman RP, et al. Recovery from schizophrenia: a concept in search of research. Psychiatr Serv. 2005;56:735-742.

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Note: Not all patients with schizophrenia display these structure and function features.

Brain imaging technologies are making it possible to identify structural and functional abnormalities within the brains of individuals with schizophrenia.

References/Image Sources1. MRI image [upper left]: Yoshida T, et al. A prospective longitudinal volumetric MRI

study of superior temporal gyrus gray matter and amygdala-hippocampal complex in chronic schizophrenia. Schizophr Res. 2009;113:84-94.{Yoshida A}

2. PET image [upper right]: Ragland JD, et al. Prefrontal activation deficits during episodic memory in schizophrenia. Am J Psychiatry. 2009;166(8):863-874.{Ragland 2009 A}

3. MRS image [bottom left]: Ongür D, et al. Elevated gamma-aminobutyric acid levels in chronic schizophrenia. Biol Psychiatry. 2010;68:667-670. {Ongur 2010 A}

4. DTI image [bottom right]: Ellison-Wright I and Bullmore E. Meta-analysis of diffusion tensor imaging studies in schizophrenia. Schizophr Res. 2009;108:3-10.{Ellison-Wright 2009}

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• Potential advances in schizophrenia care include greater emphasis on prevention and early diagnosis, reducing or reversing cognitive impairment, moving toward a more integrated model of care delivery, and eliminating stigma.{Insel 2010 A} {Insel 2010 B} {Insel 2010 C}

• The recognition that there may hundreds of different brain lesions and genetic mutations{Nasrallah 2013 A} that potentially contribute to schizophrenia may lead to new ideas about diagnosis and treatment.{Insel 2010 A} {Insel 2010 B} {Insel 2010 D}

References1. Insel TR. Rethinking schizophrenia. Nature. 2010;468(7321):187-193.2. Nasrallah AH. Pleiotropy of psychiatric disorders will reinvent DSM. Current

Psychiatr. 2013;12:6-7.

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