7. Schizophrenic patients with prominent depressive symptoms who have made repeated suicide attempts pose an exceptionally difficult problem. They were referred to in the past as schizothymic and to this day it is not certain whether they have schizophrenia, a chronic depressive illness (dysthymia), or both (“schizoaffective”). When in remission, patients with affective disorders are usually normal, whereas those with schizophrenia are not.
8. One should always be hesitant to make the diagnosis of schizophrenia during childhood, although such a diagnosis has been entertained in children who have a variety of developmental and adjustment problems and who at some time become psychotic, that is, they become excited, depressed, or hallucinatory and express bizarre ideas. There is no evidence that such children go on to have schizophrenia later in life. And although what are thought to be “schizoid” traits may be recognized in childhood, a frank psychosis is hardly ever recorded at this age. Of particular importance in such children is to exclude the presence of metabolic errors, mental retardation, or an early-onset depressive illness. Similarly, childhood autism and particularly its milder forms, such as Asperger syndrome discussed in Chap. 38, should not be confused with schizophrenia. That the incidence of schizophrenia is not increased in the families of autistic children supports the idea that the 2 are separate diseases.
9. The special problem of mania that manifests for the first time as a confusional-encephalopathic state was discussed in Chap. 48.
The aims of treatment are to suppress psychotic symptoms, ameliorate the disorder of thinking and the apathetic state, prevent relapse, and optimize social adjustment. It is often possible, once the diagnosis of schizophrenia is established and the optimal regimen of medication decided upon, for a general physician to share the responsibility for following the patient with a psychiatric social worker or nurse. The physician soon becomes accustomed to the particular pattern of the patient’s psychotic behavior and can help support the patient and his family during difficult periods. Relapse with psychotic decompensation demands drug therapy, and if there is a hazard of injury or suicide or difficulty in management at home, hospitalization becomes necessary. Many general hospitals and specialized psychiatric institutions have facilities for the management of such patients; state hospitals and other institutions are able to provide long-term treatment. The aim of hospitalization is to protect the patient, relieve the family of the need for constant vigilance and supervision, and ensure the administration of drugs until the exacerbation spends itself. Later, instead of mere custodial care, the patient needs a supervised program of planned activities, vocational and milieu therapy, often in a “halfway house,” which involves the patient as a contributing member during the more chronic phases of the disease. If medication is successful in preventing progressive decompensation, the patient can many times return to the family and community. It is invaluable to have a competent social worker or nurse maintain frequent contact with the patient and his family and ensure continuity of medication.
In recent years a trend of early intervention with a first psychotic episode has gained favor. This includes a more thorough medical evaluation than had been typically conducted in the past and a team approach to reorienting the patient by providing straightforward cognitive behavioral or psychotherapy and family counseling. In some systems, this has seemingly reduced the incidence of relapse.
The modern era of treatment of schizophrenia began in 1952, with the incidental demonstration by the French surgeon Henri Laborit of the antipsychosis properties of chlorpromazine. Subsequently, a large number of other phenothiazines have been used to treat chronic and acute psychosis. Treatment consists essentially of the administration of one of several similar antipsychotic medications. The various classes of antipsychotic drugs, their mode of action, and neurologic (“neuroleptic”) side effects are discussed in Chap. 41.