Schizophrenia: definition, overview, types�Third & Fourth chapters

By: Dr. Pegah A.M. Seidi

Email: Pegah.am.seidi@kti.edu.iq

2025 -2026

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Definition

• Schizophrenia is defined in the DSM-5-TR as a chronic psychiatric disorder characterized by disturbances in thought, perception, emotion, and behavior. The essential diagnostic features include the presence of at least two or more Criterion A symptoms for a significant portion of one month, with at least one symptom being delusions, hallucinations, or disorganized speech. The full disturbance must persist for a minimum of six months, including prodromal and residual phases.

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Core Criteria

A. Core Symptoms

Two (or more) of the following, each present for a significant portion of time during 1 month (or less if successfully treated). At least one must be (1), (2), or (3): 1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms (diminished emotional expression or avolition).

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B. Functional Impairment

For a significant portion of the time since onset, level of functioning in one or more major areas (work, interpersonal relations, self-care) is markedly below the level achieved prior to onset. If onset in childhood/adolescence, failure to achieve expected level of functioning.

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C. Duration

Continuous signs of disturbance persist for at least 6 months. This 6-month period must include at least 1 month of active-phase symptoms (Criterion A) and may include prodromal or residual periods (with only negative symptoms or mild forms of Criterion A symptoms).

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D. Schizoaffective and Mood Disorder Exclusion

Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because: – No major mood episodes occurred concurrently with active-phase symptoms, or – If mood episodes occurred, they were present for a minority of the total duration of active and residual periods.

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E. Substance/Medical Exclusion

The disturbance is not attributable to the physiological effects of a substance (e.g., drugs, medication) or another medical condition.

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F. Autism Spectrum/Communication Disorder Rule-out

If history of autism spectrum disorder or communication disorder of childhood onset exists, additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 month.

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Associated Features

• Cognitive deficits (working memory, declarative memory, processing speed).
• Social cognition impairments such as difficulty inferring others’ intentions.
• Poor insight (anosognosia), which strongly predicts nonadherence to treatment and relapse
• Hostility or aggression in specific contexts, though the majority of patients are more often victims than aggressors.

Neurological soft signs (motor sequencing problems, sensory integration issues) and subtle brain structural differences (gray/white matter changes, reduced total brain volume) have also been reported.

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Development and Course

• Age of onset: Typically late teens to mid-30s. Earlier onset (early 20s for men, late 20s for women) is associated with poorer outcomes. Childhood onset is extremely rare but linked to severe negative symptoms and poor prognosis
• Course: Highly heterogeneous. Some individuals experience chronic symptoms and functional decline, while others undergo periods of remission and partial recovery.
• Recovery rates: Meta-analyses suggest a 56% remission rate and a 30% long-term recovery rate for first-episode psychosis
• Late-onset schizophrenia (after age 40) is more common in women and tends to present predominantly with psychotic symptoms but preserved social functioning.

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Risk and Prognostic Factors

DSM-5-TR identifies several influential factors:

• Genetic and physiological: Family history is a strong predictor; abnormalities in neurotransmission and brain structure are implicated.
• Environmental: Higher risk in individuals with migration history, refugee status, urban upbringing, or those exposed to social adversity
• Course predictors: Male sex, poor premorbid adjustment, and long duration of untreated psychosis predict worse outcomes.
• Suicide risk is elevated, with contributing factors including male sex, younger age, high IQ, history of attempts, hopelessness, and poor treatment adherence

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Functional Consequences

Schizophrenia leads to marked impairment across life domains:

• Social functioning: Reduced social contacts, isolation, and difficulty forming relationships.
• Occupational and academic performance: Difficulty sustaining employment, educational decline, and higher likelihood of downward social mobility.
• Daily living: Persistent avolition and cognitive deficits interfere with self-care, leading to reduced independence

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Specifiers

DSM-5-TR no longer uses the old subtypes (paranoid, disorganized, catatonic). Instead, it introduces specifiers:

• With catatonia – if catatonic features are present.
• Course specifiers – e.g., first episode, multiple episodes, continuous, currently in partial or full remission.
• Severity rating – clinicians assess delusions, hallucinations, disorganized speech, abnormal behavior, and negative symptoms on a 0–4 scale

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Differential Diagnosis

Conditions to differentiate from schizophrenia include:

• Mood disorders with psychotic features (psychosis limited to mood episodes).
• Schizoaffective disorder (prominent mood episodes plus psychosis).
• Schizophreniform disorder (similar presentation but duration <6 months).
• Brief psychotic disorder (duration 1 day to <1 month).
• Delusional disorder (isolated delusions without full schizophrenia spectrum symptom).

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Treatment of Schizophrenia

Schizophrenia is a chronic psychiatric disorder that requires long-term, comprehensive treatment. Effective care usually combines pharmacological interventions, psychosocial therapies, and social support. The goals of treatment are to reduce symptoms, prevent relapse, improve quality of life, and promote community integration.

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1. Pharmacological Treatment

• Antipsychotic medications are the cornerstone of treatment.
• First-generation antipsychotics (FGAs) (e.g., haloperidol, chlorpromazine) reduce positive symptoms but are associated with extrapyramidal side effects.
• Second-generation antipsychotics (SGAs) (e.g., risperidone, olanzapine, clozapine) are often preferred because they cause fewer motor side effects and may improve negative symptoms.
• Clozapine is reserved for treatment-resistant schizophrenia.
• Medication adherence is essential; long-acting injectable formulations are useful for patients with poor adherence.

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2. Psychosocial Interventions

• Cognitive Behavioral Therapy (CBT): helps patients manage delusions, hallucinations, and improve coping strategies.
• Psychoeducation: involves patients and families, enhancing understanding of the illness and treatment adherence.
• Social skills training: improves communication, daily functioning, and independence.
• Family interventions: reduce expressed emotion and relapse risk.

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3. Rehabilitation and Community Support

• Case management and community mental health services provide ongoing support for housing, employment, and daily living.
• Vocational rehabilitation programs help patients reintegrate into society and gain meaningful roles.
• Peer support groups reduce isolation and promote recovery.

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4. Nursing Role

Psychiatric nurses play a central role in monitoring medication effects, managing side effects, supporting adherence, providing psychoeducation, and encouraging healthy lifestyle habits. They also act as a bridge between the patient, family, and healthcare team.

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Conclusion

• The DSM-5-TR conceptualizes schizophrenia as a heterogeneous spectrum disorder with complex interplay of genetic, environmental, and neurobiological factors. Diagnosis requires persistent psychotic symptoms and functional decline, while prognosis varies widely. Rather than subtypes, the manual emphasizes specifiers of course and severity to capture clinical diversity.

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References

• Sreevani, R. A Guide to Mental Health and Psychiatric Nursing. 4th ed. New Delhi: Jaypee Brothers Medical Publishers; 2015.
• Varcarolis, E.M. Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care. 5th ed. St. Louis: Elsevier; 2022.
• American Psychiatric Association. DSM-5 Handbook of Differential Diagnosis. Washington, DC: American Psychiatric Publishing; 2013.
• World Health Organization (WHO). Mental health action plan 2013–2030. Geneva: WHO; 2021. Available from: https://www.who.int
• Jahoda, M. Current Concepts of Positive Mental Health. New York: Basic Books; 1958.
• Shorter, E. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: Wiley; 1997.
• Kurdistan Technical Institute – Nursing Department. Coursebook: Psychiatric and Mental Health Nursing (NU230). Sulaimaniyah: KTI; 2025.

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How to use website

• Kticc.kti.edu.iq
• Staff administrative staff
• Pegah seidi Link Lectures

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