Schizophrenia
Dec 24, 2015
Schizophrenia
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
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 functioningCOGNITIONEMOTIONINTERPERSONAL RELATIONSHIPSDebilitating: 25-60% live with relatives•10-20% are homeless -
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
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
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
SchizophreniaA. 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
Schizophrenia (con’t)
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 symptomsEpisodic with No Interepisode Residual Symptoms - continuous (prominent psychotic symptoms) - with prominent negative symptomsSingle Episode in Partial Remission - with prominent negative symptomsSingle Episode in Full RemissionOther or Unspecified Pattern
Differential Diagnosis of Psychosis
• Mood Disorder with Psychotic features
• Prolonged Substance Abuse
• Brain Damage
• Infections
• Neurohereditary Disorders
• Nutritional Abnormalities
Positive Symptoms
Positive Symptoms
Hallucinations Delusions
Auditory Visual Somatic Olfactory
Thought withdrawal Thought insertion Thought broadcasting Persecutory Grandiose Religious Somatic Reference Being controlled Mind reading Guilt or sin
Disorganized Symptoms
Disorganized Symptoms
Thinking & Speech Behavior
Derailment Tangentiality Incoherence Circumstantiality Pressure of speech
Distractible speech Clanging Illogicality
Clothing & Appearance Social & Sexual Aggressive & Agitated Ritualistic or Stereotyped
Negative Symptoms
Negative Symptoms
Primary Secondary
Alogia
Affective blunting/flattening
Avolition
Anhedonia
Attentional impairment
Side effects of neuroleptic drugs
Demoralization and depression
Chronic institutionalization
lack of stimulation - withdrawal & apathy
Withdrawal as a response to delusions and/or hallucinations
Schizophrenia Subtypes
• Can change over the course of the illness
• Catatonic Type
• Disorganized Type
• Paranoid Type
• Undifferentiated Type
• Residual Type
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
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
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
Undifferentiated Type
Type of Schizophrenia where symptoms:
(1) Meet Criterion A
(2 Are not met for the Paranoid, Disorganized or Catatonic type
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
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
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
Delusional DisorderA. 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
Delusional Disorder (con’t)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
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
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
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
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
ETIOLOGY
Biological
• Genetics
• Linkage Analysis
• Genetic Markers
• Heritability
• Twin Studies
• Adoption Studies
Brain Abnormalities
• Enlarged Ventricles
• Frontal Lobe
• Hypofrontality
• Temporal Lobe
• Neurochemical
Brain Abnormalities
Structural Brain Abnormalities Functional Brain
Abnormalites
CT and MRI image brain anatomy in living subjects.
Enlarged ventricles suggest brain tissue volume is reduced.
Reduced brain volume and cortical grey matter volume
Reduction of thalamus
Enlargement of the basal ganglia
SPECT and PET image brain physiology in living subjects.
Hypofrontality
Brain circuitry involved in hallucinations
Inactivity of cingulate cortex while performing a language task
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
Diathesis/Personality/Stress: Schizophrenia
DiathesisHeterogeneity 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
PersonalityPsychoticism 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
Stressor
> 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