SCHIZOPHRENIA

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SCHIZOPHRENIA

• a chronic, debilitating mental disorder
  characterized by periods of loss of touch with
  reality (psychosis), however 7-15 have only one
  episode and full remission
• usually involves repeated psychotic episodes and
  a chronic, downhill course over years
• persistent disturbances of thought, behavior,
  appearance, and speech
• abnormal affect
• social withdrawal.
• often stabilizes in midlife.

General characteristics
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SCHIZOPHRENIA
General characteristics
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SYMPTOMS OF SCHIZOPHRENIA

• Positive - things additional to expected behavior
  and include delusions, hallucinations, agitation,
  and talkativeness.
• Negative - things missing from expected behavior
  and include lack of motivation, social
  withdrawal, flattened affect, cognitive
  disturbances, poor grooming, and poor (i.e.,
  impoverished) speech content.

General characteristics
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PSYCHOSIS

• Is associated with abnormal functioning of
  frontal systems, temporal lobes, and dopaminergic
  projections to this areas.
• All individuals are at risk for its developing.
  Contributing factors include
• genetic predispositions
• environmental factors
• damage sustained through trauma, disease,
  substance abuse
• effects of experience on neuronal structures and
  neurochemical release
• neuronal and biochemical changes during normal
  human development
• Psychosis will develop when a threshold of damage
  or changes to frontal system, temporal structures
  and dopaminergic projections is attained

Framework for developing psychosis (Fujii, Ahmed,
2002)
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DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA

• A. Two (or more) of the following symptoms, each
  present for a significant portion of time during
  a 1-month period (or less if successfully
  treated)
• 1. Delusions
• 2. Hallucinations
• 3. Disorganized speech (e.g., frequent derailment
  or incoherence)
• 4. Grossly disorganized or catatonic behavior
• 5. Negative symptoms, i.e., affective flattening,
  alogia, or avolition
• Note Only one Criterion A symptom is required if
  delusions arce bizzare or hallucinations consist
  of a voice keeping up a running commentary on the
  person's behavior or thoughts, or two or more
  voices conversing with each other.

DSM-IV
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DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA

• C. Duration Continuous signs of the disturbance
  persist for at least 6 months. This 6-month
  period most include at least 1 months of symptoms
  (or less if successfully treated) that meet
  Criterion A (i.e., active-phase symptoms) and may
  include periods of prodromal or residual
  symptoms.
• During these prodromal or residual periods, the
  signs of the disturbance may he manifested by
  only negative symptoms or two or more symptoms
  listed in Criterion A present in an attenuated
  form (e.g., odd beliefs, unusual perceptual
  experiences).
• D. Schizoaffective and Mood Disorder exclusion

DSM-IV
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DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA

• E. Substance/general medical condition exclusion
  The disturbance is not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition.
• F. Relationship to a Pervasive Developmental
  Disorder. If there is a history of Autistic
  Disorder or another Pervasive Developmental
  Disorder, the additional diagnosis of
  Schizophrenia is made only if prominent delusion,
  or hallucinations are also present for at least a
  month (or less if successfully treated).

DSM-IV
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COURSE OF SCHIZOPHRENIA

• These specifiers can he applied only after at
  least 1 year has elapsed since the initial onset
  of active-phase symptoms
• Episodic With Interepisode Residual Symptoms.
• Episodic With No Interepisode Residual Symptoms
• Continuous
• Single Episode In Partial Remission
• Single Episode In Full Remission
• Other or Unspecified Pattern

classification
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STAGES OF SCHIZOPHRENIA (Fenton, McGlashan, 2000)

• 1. Prodromal
• 2. Acute (active)
• 3. Subacute, stabilization
• 4. Moratorium or adaptative plateau
• 5. Changes points with the possibily of
  improvement or decompensation
• 6. Final stage or stable plateau

classification
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SCHIZOPHRENIA

• Epidemiology
• Schizophrenia 1
• Schizoaffective disorder - 0.5-0.8
  
  
  
• Delusional disorder 0.025 0.03

General information
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SCHIZOPHRENIA

• Etiology is not known, certain factors have been
  implicated in its development.
• Occurs in 1 of the population. Persons with a
  close genetic relationship to a patient with
  schizophrenia are more likely than those with a
  more distant relationship to develop the
  disorder.
• Markers on chromosomes 5, 11, 18, 19 and 22 and,
  most recently, 6, 8, and 13 have been associated
  with schizophrenia.

General characteristics
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SCHIZOPHRENIA
genetics
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SCHIZOPHRENIA

• Neural pathology
• 1. Anatomy
• a. Abnormalities of the frontal lobes, as
  evidenced by decreased use of glucose in the
  frontal lobes on positron emission tomography
  (PET') scans are seen in the brains of people
  with schizophrenia.
• b. Lateral and third ventricle enlargement,
  abnormal cerebral symmetry, and changes in brain
  density also may be present.
• c. Decreased volume of limbic structures (e.g.,
  amygdala, hippocampus) is also seen.

General characteristics
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SCHIZOPHRENIA

• Neural pathology
• 2. Neurotransmitter abnormalities
• The dopamine hypothesis of schizophrenia states
  that schizophrenia results from excessive
  dopaminergic activity (e.g., excessive number of
  dopamine receptors, excessive concentration of
  dopamine, hypersensitivity of receptors to
  dopamine). As evidence for this hypothesis,
  stimulant drugs that increase dopamine
  availability (e.g., amphetamines and cocaine) can
  cause psychotic symptoms.
• Laboratory tests may show elevated levels
  of homovanillic acid (HVA), a metabolite of
  dopamine, in the body fluids of patients with
  schizophrenia.
• b. Serotonin hyperactivity is implicated in
  schizophrenia because hallucinogens that increase
  serotonin concentrations cause psychotic symptoms
  and because some effective antipsychotics, such
  as clozapin, have anti-serotonergic-2 (5-HT2)
  activity.
• c. Glutamate is implicated in schizophrenia
  because antagonists of the N-methyl-D-aspartate
  (NMDA) subtype of glutamate receptors (e.g.,
  phencyclidine) increase and agonists of NMDA
  receptors alleviate psychotic symptoms.

General characteristic
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SCHIZOPHRENIA

• The season of birth is related to the incidence
  of schizophrenia. More people with schizophrenia
  are born during cold weather months (i.e.,
  January - April in the northern hemisphere and
  July - September in the southern hemisphere). One
  possible explanation for this finding is viral
  infection of the mother during pregnancy, since
  such infections occur seasonally.

General information
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SCHIZOPHRENIA

• No social or environmental factor causes
  schizophrenia.
• However, because patients with schizophrenia
  tend to drift down the socioeconomic scale as a
  result of their social deficits (the "downward
  drift" hypothesis), they are often found in lower
  socioeconomic groups (e.g., homeless people).

General information
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SCHIZOPHRENIA

• Premorbid features - 25-50
• decreased social adjustment and school
  achievements
• decrease emotional reactivity
• social withdrawal
• introversion
• suspiciousness
• impulsive behavior
• abnormal reactions to usual events and situations
• problems with focusing attention for the longer
  time
• delays in the psychomotoric development
• problems with sensorimotoric and motoric
  coordination

course
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SCHIZOPHRENIA

• Onset of illness
• 50 prodromal syndromes worse prognosis than
  those with acute, sudden onset
• The course
• 55 - rather good,
• 45 - rather unfavorable, including 5 with
  definitely unfavorable (15 in the past)
• antipsychotic medications improve the course
  (decreases symptoms) and reduces relapse rate
  (40- 50 of reduction).

course
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SCHIZOPHRENIA

• Social Functioning
• GAF gt59 (minimal, mild or no difficulty in social
  functioning 38
• Additionally no flare-up requiring treatment
  within two years 38
• Polish data (based on 6000 patients)
• Working in the natural conditions 12.4
• Working in protected conditions 4.1
• Students 6.9
• High school 1.3

course
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SCHIZOPHRENIA

• Suicide is common in patients with schizophrenia.
  More than 50"/o attempt suicide (often during
  post-psychotic depression or when having
  hallucinations "commanding" them to harm
  themselves), and 10 of those die in the attempt.
• The prognosis is better and the suicide risk is
  lower if the patient is older at onset of
  illness, is married, has social relationships, is
  female, has a good employment history, has mood
  symptoms, has few negative symptoms, and has few
  relapses.
• The better course in developing countries

course
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SCHIZOPHRENIA
types
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SCHIZOPHRENIA SUBTYPES

• Paranoid Type
• A. Preoccupation with one or more delusions or
  frequent auditory hallucinations.
• B. None of the following is prominent
  disorganized speech, disorganized or catatonic
  behavior, or flat or inappropriate affect.

DSM-IV
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SCHIZOPHRENIA SUBTYPES

• Disorganized Type
• A. All of the following are prominent
• (1) disorganized speech
• (2) disorganized behavior
• (3) flat or inappropriate affect
• B. The criteria are not met for Catatonic Type

DSM-IV
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SCHIZOPHRENIA SUBTYPES

• Catatonic Type
• The clinical picture is dominated by at least two
  of the following
• (1) motoric immobility as evidenced by catalepsy
  (including waxy flexibility) or stupor
• (2) excessive motor activity (that is apparently
  purposeless and not influenced by external
  stimuli)
• (3) extreme negativism (an apparently motiveless
  resistance to all instructions or maintenance of
  a rigid posture against attempts to be moved) or
  mutism
• (4) peculiarities of voluntary movement as
  evidenced by posturing (voluntary assumption of
  inappropriate or bizarre postures), stereotyped
  movements, prominent mannerisms, or prominent
  grimacing
• (5) echolalia or echopraxia

DSM-IV
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SCHIZOPHRENIA SUBTYPES

• Undifferentiated Type
• A type in which symptoms that meet Criterion A
  are present, but the criteria are not met for the
  paranoid, disorganized, or catatonic type.

DSM-IV
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SCHIZOPHRENIA SUBTYPES

• Residual Type
• A. Absence of prominent delusions,
  hallucinations, disorganized speech, and grossly
  disorganized or catatonic behavior.
• B. There is continuing evidence of the
  disturbance, as indicated by the presence of
  negative symptoms or two or more symptoms listed
  in Criterion A for schizophrenia, present in an
  attenuated form (e.g., odd beliefs, unusual
  perceptual experiences).

DSM-IV
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SCHIZOPHRENIA DIFFERENTIAL DIAGNOSIS

• Medical illnesses that can cause psychotic
  symptoms, and thus mimic schizophrenia (i.e.,
  psychotic disorder caused by a general medical
  condition), include neurological infection,
  neoplasm, trauma, disease (e.g., Huntington
  disease, multiple sclerosis), temporal lobe
  epilepsy, and endocrine disorders (e.g., Cushing
  syndrome, acute intermittent porphyria).

DSM-IV
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SCHIZOPHRENIA DIFFERENTIAL DIAGNOSIS

• Medications that can cause psychotic symptoms
  include analgesics, antibiotics,
  anticholinergics, antihistamines,
  antineoplastics, cardiac glycosides (e.g.,
  digitalis), and steroid hormones.

DSM-IV
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SCHIZOPHRENIA DIFFERENTIAL DIAGNOSIS

• A.Other psychotic disorders - characterized at
  some point during their course by a loss of touch
  with reality. However, the other psychotic
  disorders do not include all of the criteria
  required for the diagnosis of schizophrenia
• brief psychotic disorder
• schizophreniform disorder
• delusional disorder
• shared psychotic disorder
• B. Mood disorders (e.g., the manic phase of
  bipolar disorder, major depression).
• C. Cognitive disorders (e.g., delirium, dementia,
  and amnestic disorder)
• D. Substance-related disorders
• E. Schizotypal, paranoid and borderline
  personality disorders are not characterized by
  frank psychotic symptoms but have other
  characteristics of schizophrenia, (e.g., odd
  behavior, avoidance of social relationships).

DSM-IV
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SCHIZOPHRENIA TREATMENT

• Pharmacologic
• traditional antipsychotics dopamine2
  (D2)-receptor antagonists first generation of
  antipsychotic medication
• atypical antipsychotic agents second generation
  of antipsychotic medication
• Because of their better side-effect profiles, the
  atypical agents are now first-line treatments.

DSM-IV
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SCHIZOPHRENIA TREATMENT

• Psychosocial treatments
• Psychotherapy individual, family, and group
• Psychoeducation with activity of patients or
  enhancing motivation to the treatment
• Social support

DSM-IV
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SCHIZOPHRENIA-LIKE DISORDERS
SYMPTOMS
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SCHIZOPHRENIFORM DISORDER

• Criteria A, D, and E of schizophrenia are met
• An episode of the disorder (including prodromal,
  active, and residual phases) lasted at least 1
  month but less than 6 months (when the diagnosis
  must be made without waiting for recovery, it
  should be qualified as provisional).
• Specify if
• Without good prognostic features
• With good prognostic features if evidenced by two
  or more of the following

DSM-IV
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SCHIZOPHRENIFORM DISORDER

• With good prognostic features if evidenced by two
  or more of the following
• onset of prominent psychotic symptoms within 4
  weeks of the first noticeable change in usual
  behavior or functioning
• confusion or perplexity at he height of psychotic
  episode
• good premorbid social functioning
• absence of blunted or flat affect

DSM-IV
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SCHIZOAFFECTIVE DISORDER

• A. An interrupted period of illness during which,
  at some time, there is either a Major Depressive
  Episode, a Manic Episode, or a Mixed Episode
  concurrent with symptoms that meet Criterion A
  for schizophrenia.
• B. During the same period of illness, there have
  been delusions or hallucinations for at least 2
  weeks in the absence of prominent mood symptoms.
• C. Symptoms that meet criteria for a mood episode
  are present for a substantial portion of the
  total duration of the active and residual periods
  of the illness.
• D. The disturbance is not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition.

DSM-IV
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SCHIZOAFFECTIVE DISORDER

• Specify type
• Bipolar Type if the disturbance includes a Manic
  or a Mixed Episode (or a Manic or a Mixed and
  Major Depressive Episodes)
• Depressive Type if the disturbance only includes
  Major Depressive Episodes

DSM-IV
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DELUSIONAL DISORDER (PARANOIA)

• A. Nonbizarre delusions (i.e., involving
  situations that occur in real life, such as being
  followed, poisoned, infected, loved at a
  distance, or deceived by spouse or lover, or
  having a disease) of at least 1 months duration.
• B. Criterion A for Schizophrenia has never been
  met. Note Tactile and olfactory hallucinations
  may he present in Delusional Disorder if they
  are related to the delusional theme.
• C. Apart from the impact of the delusion(s) its
  ramifications, functioning is not markedly
  impaired and behavior is not obviously odd or
  bizarre.
• D. If mood episodes have occurred concurrently
  with delusions, their total duration has been
  brief relative to the duration of the delusional
  periods.
• E. The disturbance is not due to the direct
  physiological effects of a substance (e.g., a
  drag of abuse, a medication) or a general
  medical condition.

DSM-IV
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DELUSIONAL DISORDER (PARANOIA)

• Specify type (the following types are assigned
  based on the predominant delusional theme)
• Erotomanic delusions that another person,
  usually of higher status, is in love with the
  individual
• Grandiose delusions of inflated worth, power,
  knowledge, identity, or special relationship to a
  deity or famous person
• Jealous delusions that the individual's sexual
  partner is unfaithful
• Persecutory delusions that the person (or
  someone to whom the person is close) is being
  malevolently treated in some way
• Somatic delusions that the person has some
  physical defect or general medical condition
• Mixed Type delusions characteristic of more than
  one of the above types but no one theme
  predominates
• Unspecified Type

DSM-IV
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BRIEF PSYCHOTIC DISORDER

• A. Presence of one (or more) of the following
  symptoms
• (1) delusions
• (2) hallucinations
• (3) disorganized speech (e.g., frequent
  derailment or incoherence)
• (4) grossly disorganized or catatonic behavior
• Note Do not include a symptom if it is a
  culturally sanctioned response pattern.
• B. Duration of an episode of the disturbance is
  at least 1 day but less than 1 month, with
  eventual full return to premorbid level of
  functioning.
• C. The disturbance is not better accounted for b
  a Mood Disorder With Psychotic features,
  Schizoaffective Disorder, or Schizophrenia and is
  not due to the direct physiological effects of a
  substance (e.g., a drug of abuse, a medication)
  or a general medical condition.

DSM-IV
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BRIEF PSYCHOTIC DISORDER

• Specify if
• With Marked Stressor(s) (brief reactive
  psychosis) if symptoms occur shortly after and
  apparently in response to events that, singly or
  together, would be markedly stressful to almost
  anyone in similar circumstances in the person's
  culture
• Without Marked Stressor(s) if psychotic symptoms
  do not occur shortly after, or are not apparently
  in response to events that, singly or together,
  would be markedly stressful to almost anyone in
  similar circumstances in the person's culture.
• With Postpartum Onset if onset is within 4 weeks
  postpartum

DSM-IV
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SCHRED PSYCHOTIC DISORDER

• A. Delusion develops in an individual in the
  context of a close relationship with another
  person(s), who has an already-established
  delusion.
• B. The delusion is similar in content to that of
  the person who already has the established
  delusion
• C. The disturbance is not better accounted for by
  another psychotic disorder (e.g., Schizophrenia)
  or a Mood Disorder with Psychotic Features and is
  not due to the direct physiological effects of a
  substance (e.g., a drag of abuse, a medication)
  or a general medical condition.

DSM-IV
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PSYCHOTIC DISORDER DUE TO (INDICATE THE GENERAL
MEDICAL CONDITION)

• Psychotic Disorder Due to . . . (Indicate the
  General Medical Condition)
• A. Prominent hallucinations or delusions.
• B. There is evidence from the history, physical
  examination, or laboratory findings that the
  disturbance is the direct physiological
  consequence of a general medical condition.
• C. The disturbance is not better accounted for by
  another mental disorder.
• D. The disturbance does not occur exclusively
  during the course of a delirium.

DSM-IV
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SUBSTANCE-INDUCED PSYCHOTIC DISORDER

• A. Prominent hallucinations or delusions.
• B. There is evidence from the history, physical
  examination, or laboratory findings of either (1)
  or (2)
• the symptom in Criterion A developed during, or
  within month of substance intoxication or
  withdrawal
• medication use is etiologically related to the
  disturbance

DSM-IV
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SUBSTANCE-INDUCED PSYCHOTIC DISORDER

• C. The disturbance ins not better accounted for
  psychotic disorder that is not substance induced.
  Evidence that symptoms are better accounted for
  the psychotic disorder the is not substance
  induced may include following
• the symptoms precede the onset of the substance
  use (or medication use)
• the symptoms persist for a substantial period of
  time (e.g., about month) after cessation of acute
  withdrawal or severe intoxication, or are
  substantially in excess of what would be expected
  given the type or amount of the substance used or
  the durations of use or there is other evidence
  that suggest s the existence of an independent
  non-substance-induced psychotic disorder (e.g. a
  history of recurrent non-substance-related
  episodes).

DSM-IV