Schizophrenia

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Schizophrenia
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Overview

• Most debilitating and costly of all adult
  psychiatric illnesses
• 25 of all psychiatric beds are occupied by
  persons with schizophrenia
• 2002 fiscal costs of schizophrenia was 62.7
  billion
• Greatest burden is lost productivity

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Schizophrenia

• Multisystem disease
• Often difficult to describe and understand
• No single feature is pathogonomic of
  Schizophrenia
• Associated with a constellation of signs and
  symptoms
• A disease that affects many domains of human
  functioning
• COGNITION
• EMOTION
• INTERPERSONAL RELATIONSHIPS
• Debilitating 25-60 live with relatives
• 10-20 are homeless
• -

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Epidemiology

• 2.2 million people have schizophrenia at any
  given time
• One year prevalence rates are 1-4.6
• Prevalence rates are roughly stable across a
  range of populations and cultures
• Persons with schizophrenia in developing
  countries may have a better course and prognosis
• Persons with schizophrenia are less likely to
  marry (particularly males) and less likely to
  complete higher education
• Between 14-20 of those with schizophrenia are
  employed competitively

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Onset and Course of Illness

• Onset typical in late adolescence or early
  adulthood
• Prodromal period or changes in mood and behavior
  prior to first break may last up to five years
• Early versus late onset illness
• Early signs date back to childhood
• Deficits in verbal memory
• Deficits in attentional vigilance
• Deficits in gross motor skills
• May be additional interpersonal difficulties or
  other difficulties in functioning
• Early conduct disorder may also be prodromal
• Early signs may be subtle, irregular, and
  graduate and more apparent in adolscence

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Factors Assoc. with Better Prognosis

• Good premorbid adjustment
• Acute onset
• Later afe at onset
• Being female
• Precipitating event
• Associated mood disturbance
• Brief duration of active phase symptoms
• Good interepisode functioning
• Minimum residual symptoms
• Absence of structural brain abnormalities
• No family history of schizophrenia

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Schizophrenia
A. Two or more of the following during 1- month
period (or less if successfully treated)
(1) delusions (2) hallucinations
(3) disorganized speech (frequent derailment or
incoherence) (4) grossly disorganized or
catatonic behaviour (5) negative symptoms
(affective flattening, alogia, avolition) B.
Social Occupational Dysfunction C. Duration at
least 6 months, with 1 month of active phase
symptoms (or less if successfully treated)
May include Prodromal/Residual periods
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Schizophrenia (cont)
D. Schizoaffective and Mood Disorder
exclusion C. Substance/general medical
condition exclusion E. Relationship to a
Pervasive Developmental Disorder
Specify course Episodic with Interepisode
Residual Symptoms - with prominent negative
symptoms Episodic with No Interepisode Residual
Symptoms - continuous (prominent psychotic
symptoms) - with prominent negative
symptoms Single Episode in Partial Remission
- with prominent negative symptoms Single Episode
in Full Remission Other or Unspecified Pattern
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Differential Diagnosis of Psychosis

• Mood Disorder with Psychotic features

• Prolonged Substance Abuse

• Brain Damage

• Infections

• Neurohereditary Disorders

• Nutritional Abnormalities

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Positive Symptoms
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Disorganized Symptoms
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Negative Symptoms
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Schizophrenia Subtypes

• Can change over the course of the illness

• Catatonic Type

• Disorganized Type

• Paranoid Type

• Undifferentiated Type

• Residual Type

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Catatonic Type
Clinical Picture is dominated by at least two of
the following (1) motoric immobility as
evidenced by catalepsy (2) excessive motor
activity (3) extreme negativism (4)
peculiarities of voluntary movement (5)
echolalia or echopraxia
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Disorganized Type
Following criteria are met A. All of the
following are prominent (1) disorganized
speech (2) disorganized behaviour
(3) flat or inappropriate affect B. The
criteria are not met for Catatonic Type
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Paranoid Type
Following criteria are met A. Preoccupation
with one or more delusions or frequent
auditory hallucinations B. None of the
following is prominent disorganized
speech disorganized or catatonic behaviour
flat or inappropriate affect
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Undifferentiated Type
Type of Schizophrenia where symptoms (1) Meet
Criterion A (2 Are not met for the Paranoid,
Disorganized or Catatonic type
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Residual Type
Following criteria are met A. Do not fit into
an other categories B. Evidence of a
disturbance as indicated by presence of
negative symptoms or two or more symptoms
listed in Criterion A
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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) lasts at least 1 month
  but less than 6
• months.
• Provisional when without recovery
• Specify if Without Good Prognostic Features
• With Good Prognostic Features

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Schizoaffective Disorder

• Uninterrupted period of illness where there is
  either
• Major Depressive Episode, Manic or Mixed
  concurrent
• with symptoms meeting Criterion A for
  Schizophrenia
• Major depressive episode must meet A1
  criterion
• During illness, two week period of delusions or
• hallucinations in absence of prominent mood
  symptoms
• Symptoms meeting criteria for mood episode
  present for
• substantial period of the total duration of
  illness
• Not better accounted for substance use or
  general medical
• condition
• Specify Bipolar or Depressive Type

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Delusional Disorder
A. Nonbizarre delusions of at least 1 months
duration B. Criterion A for Schizophrenia has
never been met C. Functioning is not markedly
impaired or bizarre D. If there are mood
episodes concurrent with delusions, their
total duration is brief relative to periods of
delusional periods. E. Not due to effects
of substance or a general medical condition
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Delusional Disorder (cont)

• Specify type
• Erotomanic Type another person, usually of
  higher status
• in love with
  the person
• Grandiose Type inflated worth, power,
  knowledge, identity
• Jealous Type unfaithful theme
• Persecutory Type Conspiracy theme
• Somatic Type Physical defect theme
• Mixed Type more than one of the above
• Unspecified Type cannot be determined

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Comorbidity

• Depression is very common with a comorbidity rate
  of 45
• Approximately 10 of those with schizophrenia die
  from the illness though more recent estimates
  have lowered this to 4-5.6
• Suicide risk is greater with mood and substance
  use disorders
• Anxiety disorders have a high rate of comorbidity
  (43) and may prompt the formation and
  maintenance of persecutory delusions and
  hallucinations
• Lifetime comorbidity for substance use disorders
  is 50
• Associated symptoms also include anger,
  hostility, and social avoidance

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Violence and Associated Issues

• Rates of violence for persons with schizophrenia
  are lower than rates for persons with depression
  or bipolar disorder
• If violence occurs it is typically a result of
  the co-occuring substance use
• Rates of victimization risk can be very high
• 34-54 report childhood sexual or physical abuse
• 43-81 report some type of lifetime victimization

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Sex differences in Illness Course

• Women have later age at onset
• Women have better premorbid histories
• Women express more affective symptomatology
• Women exhibit more benign course in terms of
• hospitalizations and social functioning
• Women appear to have less structural brain
  damage
• Males appear to have a higher incidence of the
  illness

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Importance of Estrogen

• Pregnancy confers protective advantage
• Postpartum increased risk for psychotic symptoms
• Psychotic symptoms increase when estrogen levels
• are lowest during menstrual cycle
• Hormone supplements appear to offset psychotic
• symptoms during the menstrual cycle

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ETIOLOGY
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Biological

• Genetics

• Linkage Analysis

• Genetic Markers

• Heritability

• Twin Studies

• Adoption Studies

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Brain Abnormalities

• Enlarged Ventricles

• Frontal Lobe

• Hypofrontality

• Temporal Lobe

• Neurochemical

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Brain Abnormalities
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Psychological Factors

• Expressed Emotion Jill Hooley
• -Concerns the degree to which family members are
  either critical of a recently hospitalized
  patient, hostile, or express overinvolved and
  overprotective attitudes toward the patient.
  This construct is thought to reflect disturbances
  in the organization, emotional climate, and
  transactional patterns of the entire family
  system
• Assessed in the Camberwell Family Interview and
  usually takes 1-2 hours
• Most important element of EE is criticism
• EE is a reliable risk factor for relapse in
  schizophrenia

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Diathesis/Personality/Stress Schizophrenia

• Stressor
• gt Family based communication deviance
• Expressed emotion assoc with increased risk of
  relapse critical and overinvolved (effect size
  .31)
• Severe prolonged stressors studied
• High rates of criterion A stressors

• Diathesis
• Heterogeneity within the etiology
• DA involvement but complex DA receptor
  sensitivity?
• Enlargement of Ventricles, particularly for males
• Polygenic vulnerability
• Hypofrontality, particularly for negative
  symptoms
• Severe birth complications
• Viral infections

• Personality
• Psychoticism historically but New data on
  Neuroticism
• Schizotypal personality
• In childhood lower scores on intelligence and ach
• In childhood less responsive in social situations
• In childhood more diff with motor dev
• Escalating adjustment diff, dep, social
  withdrawal, irritability, noncompliance