Anxiety disorders include generalised anxiety disorder, which is characterised by continuous and excessive worrying for six months or more. Specific phobias are characterised by anxiety provoked by a feared object/situation, resulting in avoidance. Social phobia is anxiety provoked by social or performance situations, and agoraphobia is anxiety about situations where escape may be difficult or help might not be available. Panic disorder is often the most debilitating anxiety disorder, involving recurring panic attacks which are distinct periods where a person experiences sudden apprehension and fearfulness, where they may present to services with shortness of breath, palpitations, chest pain or choking.

What is the evidence for rates of anxiety disorders in people with schizophrenia?

Moderate quality evidence suggests the rate of any anxiety disorder in people with schizophrenia is high, at around 38% compared to around 18% in the general population. Around 29% of people presenting with a first-episode of psychosis and around 15% of people with mild subclinical symptoms of psychosis also experience anxiety.

Social anxiety disorder was reported in around 21% of patients with schizophrenia, social phobia in around 15% of patients, generalised anxiety disorder in around 11% of patients, panic disorder in around 10% of patients, specific phobias in around 8% of patients, and agoraphobia in around 5% of patients.

June 2020

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Attention deficit hyperactivity disorder (ADHD) is a behavioural disorder characterised by inattention, hyperactivity, and impulsivity. The estimated prevalence of ADHD in children under 18 years in the general population is around 5%. ADHD can persist into adulthood with an estimated prevalence of 2.5% in the adult general population. This topic assesses the prevalence of ADHD in people with schizophrenia.

What is the evidence for rates of ADHD in people with schizophrenia?

Moderate quality evidence suggests the prevalence of ADHD in children with schizophrenia is between 17% and 57%, and in adults with schizophrenia, the prevalence of ADHD ranges between 10% and 47%.

June 2020

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People with schizophrenia may show increased rates of unrelated co-occurring conditions. These may include dysfunction of the auditory system or structural abnormalities of the ear canal.

What is the evidence for comorbid auditory dysfunction?

Moderate to low quality evidence is unclear of the prevalence of auditory system dysfunction in people with schizophrenia.

June 2020

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Autism spectrum disorders are neurodevelopmental conditions characterised by problems in social interaction and communication, and restricted, repetitive behaviours. Symptoms usually appear before three years of age, but can appear later. Autism spectrum disorders are often associated intellectual disability, however average-IQ is frequent.

What is the evidence for comorbid autism spectrum disorders?

Moderate to high quality evidence finds a large effect of more autistic symptoms in people with schizophrenia compared to controls, and a large effect of fewer autistic symptoms in people with schizophrenia compared to people with an autistic spectrum disorder.

The prevalence of schizophrenia spectrum disorders in people with an autism spectrum disorder is around 9.5%. In people with autism and an IQ over 70, the prevalence rate is lower, around 6.4%. The rate of schizophrenia in people with autism is significantly is higher than in people without autism.

June 2020

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People with schizophrenia may show increased rates of co-occurring conditions. Autoimmune diseases are caused by an overactive immune system. Some of the more common autoimmune diseases include; Celiac disease where the immune system reacts to gluten found in wheat and other grains; lupus, which affects skin, muscles, joints, lungs, heart and kidneys; rheumatoid arthritis, where bone and cartilage are damaged; Graves’ disease, where the thyroid gland is overactive; multiple sclerosis, where the nervous system is affected; type 1 diabetes, where the pancreas does not produce enough insulin to manage blood sugar levels.

What is the evidence for autoimmune disease in people with schizophrenia?

Moderate to high quality evidence finds a small increased risk of non-neurological autoimmune disorders in people with schizophrenia, in particular anemia, celiac disease, Graves’ disease, pemphigoid, and psoriasis. Rates of schizophrenia were also increased in people with celiac disease.

Rheumatoid arthritis and ankylosing spondylitis were reduced in people with schizophrenia, and there were no differences in rates of polymyalgia rheumatic, alopecia areata, Crohn’s disease, systemic lupus erythematosus, type 1 diabetes, or ulcerative colitis.

June 2020

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People with schizophrenia may show increased rates of co-occurring conditions. These can include disorders of the blood, such as leukocytosis (excess leukocytes), hypokalemia (reduced potassium), and neutropenia (low neutrophil levels).

What is the evidence for comorbid blood disorders?

Moderate quality evidence suggests the incidence of mild neutropenia in people taking the antipsychotic clozapine is around 3.8%, and the incidence of severe neutropenia is around 0.9%. Death from neutropenia is rare at around 0.013%.

Moderate to low quality evidence is unclear as to the rates of other blood disorders in people with schizophrenia.

June 2020

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Cancer is a broad group of diseases involving abnormal cell growth, where cells divide and grow forming malignant tumours. Cancer may spread through the lymphatic system or blood stream. Lifestyle, genetic factors and environmental pollutants increase a persons’ risk of developing cancer. People with schizophrenia show increased exposure to risk factors associated with cancer, such as smoking, physical inactivity, poor diet, obesity, substance abuse, diabetes and hepatitis.

What is the evidence for comorbid cancer?

Moderate to high quality evidence finds a small increase in the rate of breast cancer in females with schizophrenia compared to general population rates. Lung cancer may also be increased in females with schizophrenia.

There were small to medium-sized decreases in rates of prostate and colorectal cancers in males with schizophrenia, and a small decrease in malignant melanoma in both males and females with schizophrenia. Decreased incidence of liver cancer was found prior to a diagnosis of schizophrenia in both males and females, and increased incidence of liver cancer was found after a diagnosis of schizophrenia in males only.

There were no differences in rates of brain or stomach cancers.

High quality evidence also finds a small decreased incidence of any cancer in parents and siblings of people with schizophrenia.

Cancer-related mortality in people with schizophrenia was increased by about 40% compared to general population rates.

June 2020

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People with schizophrenia may show increased rates of co-occurring conditions when compared to general population rates. Cerebrovascular disease includes strokes, transient ischemic attacks, aneurysms, and vascular malformations. A stroke happens when blood flow to the brain is interrupted due to a blocked artery (ischaemic stroke) or when an artery bursts (haemorrhagic stroke). A transient ischemic attack is similar to a stroke, but less severe, and an aneurysm involves an enlarged artery caused by weakness in the arterial wall. These can all cause brain damage if cells do not get enough of the oxygen and nutrients that are carried by the blood to the brain.

What is the evidence for comorbid cerebrovascular disease?

Moderate quality evidence suggests a small increase in the rate of cerebrovascular disease, including stroke and death by stroke, in people with schizophrenia, with data adjusted for potential confounding factors that may have accounted for the association.

June 2020

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Symptoms of dementia include memory, language and movement impairment. People with dementia may also be unable to identify objects, people, sound or smell. There is often impaired executive functioning, for example, an inability to think abstractly, plan, initiate or stop actions. Other symptoms include behavioural disturbances, anxiety, apathy, delirium, and mood and sleep disturbances. Schizophrenia is also often associated with cognitive and functional decline; however, people with dementia show greater cognitive impairment.

What is the evidence for comorbid dementia?

Moderate quality evidence finds a medium-sized increased risk of dementia in people with schizophrenia. Studies conducted in non-European countries reported the highest risk. There were no differences in the risk according to differences in study design (prospective or retrospective), study quality, study duration (less than or more than 10 years), participant age (under or over 65 years) or sex. Studies adjusted their results for multiple known risk factors for dementia.

Low quality evidence is unable to determine any benefits of rivastigmine, a cholinergic agent, for people with schizophrenia and dementia.

June 2020

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Oral health is an important part of overall physical health. People with severe mental illness are susceptible to oral disease for a number of reasons which may include poor oral hygiene, concern about dental costs, difficulty in accessing healthcare facilities, and the side-effects of psychiatric drugs such as dry mouth.

What is the evidence for comorbid dental disease?

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