SCHIZOPHRENIA
Krenz Harvey L. Talattad
INTRODUCTION
● comprises a group of disorders with heterogeneous
etiologies, and it includes patients whose clinical
presentations, treatment response, and courses of
illness vary. Signs and symptoms are variable and
include changes in perception, emotion, cognition,
thinking, and behavior
HISTORY
● Benedict Morel (1809-1 873), a French psychiatrist, had used the
term demence precoce to describe deteriorated patients whose
illnesses began in adolescence
● Kraepelin translated Morel's demence precoce into dementia
precox, a term that emphasized the change in cognition (dementia)
and early onset (precox) of the disorder. Patients with dementia
precox were described as having a long term deteriorating course
and the clinical symptoms of hallucinations and delusions.
HISTORY: EUGENE BLEULER
● Bleuler coined the term schizophrenia
● Bleuler stressed that, schizophrenia need not have a
deteriorating course
● The FOUR A’s: develop his theory about the internal mental
schisms of patients. These symptoms included associational
disturbances of thought, especially looseness, affective
disturbances, autism, and ambivalence, summarized as the four
A’s
EPIDEMIOLOGY
● about one person in 100 will develop schizophrenia during
their lifetime
Gender and Age
● Schizophrenia is equally prevalent in men and women
● Onset is earlier in men than in women: The peak ages of
onset are 10 to 25 years for men and 25 to 35 years for women
Reproductive Factors
● First degree biological relatives of persons with
schizophrenia have a ten times greater risk for developing
the disease than the general population
EPIDEMIOLOGY
Medical Illness
● Persons with schizophrenia have a higher mortality rate from
accidents and natural causes than the general population.
● Several studies have shown that up to 80 percent of all schizophrenia
patients have significant concurrent medical illnesses and that up to
50 percent of these conditions may be undiagnosed.
Infection and Birth Season
● Persons who develop schizophrenia are more likely to have been born
in the winter and early spring
● Northern Hemisphere: January to April
● Southern Hemisphere: July to September
EPIDEMIOLOGY
Substance Abuse
● Substance abuse is common in schizophrenia. The lifetime prevalence of any
drug abuse (other than tobacco) is often greater than 50 percent.
● abuse is associated with poorer function
● Nicotine. Apart from smoking-associated mortality, nicotine decreases the
blood concentrations of some antipsychotics. Nicotine administration
appears to improve some cognitive impairments and parkinsonism in
schizophrenia, possibly because of nicotine-dependent activation of
dopamine neurons.
Socioeconomic and Cultural Factors
● Economics. Makes heavy demands for hospital care; and requires ongoing
clinical care, rehabilitation, and support services.
● Hospitalization. Patients with schizophrenia occupy about 50 percent of
all mental hospital beds and account for about 16 percent of all
psychiatric patients who receive any treatment.
ETIOLOGY
Genetic Factors
● The likelihood of a person having schizophrenia is correlated with
the closeness of the relationship to an affected relative (e.g.,
first or second-degree relative)
● those born from fathers older than the age of 60 years were
vulnerable to developing the disorder.
ETIOLOGY
Biochemical Factors
● Dopamine Hypothesis. The simplest formulation of the dopamine hypothesis of
schizophrenia posits that schizophrenia results from too much dopaminergic
activity.
● Serotonin. Current hypotheses posit serotonin excess as a cause of both
positive and negative symptoms in schizophrenia.
● Norepinephrine. A selective neuronal degeneration within the norepinephrine
reward neural system could account for this aspect of schizophrenic
symptomatology (ANHEDONIA).
● GABA. GABA has a regulatory effect on dopamine activity, and the loss of
inhibitory GABAergic neurons could lead to the hyperactivity of dopaminergic
neurons.
● Acetylcholine and Nicotine. Postmortem studies in schizophrenia have
demonstrated decreased muscarinic and nicotinic receptors in the
caudate-putamen, hippocampus, and selected regions of the prefrontal cortex.
These receptors play a role in the regulation of neurotransmitter systems
involved in cognition, which is impaired in schizophrenia.
NEUROPATHOLOGY
● The loss of brain volume widely reported in schizophrenic brains
appears to result from reduced density of the axons, dendrites,
and synapses that mediate associative functions of the brain.
Basal Ganglia and Cerebellum.
● The odd movements can include an awkward gait, facial grimacing,
and stereotypies.
Psychoneuroimmunology
● The abnormalities include decreased T-cell interleukin-2
production, reduced number and responsiveness of peripheral
lymphocytes, abnormal cellular and humoral reactivity to neurons,
and the presence of brain directed (antibrain) antibodies.
PSYCHOSOCIAL AND PSYCHOANALYTIC THEORIES
Psychoanalytic Theories.
● Sigmund Freud postulated that schizophrenia resulted from developmental
fixations early in life. Ego disintegration in schizophrenia represents a
return to the time when the ego was not yet developed or had just begun to be
established
● Margaret Mahler, there are distortions in the reciprocal relationship between
the infant and the mother. The child is unable to separate from, and progress
beyond, the closeness and complete dependence that characterize the
mother-child relationship in the oral phase of development. the person's
identity never becomes secure.
● Psychoanalytic theory also postulates that the various symptoms of
schizophrenia have symbolic meaning for individual patients. For example,
fantasies of the world coming to an end may indicate a perception that a
person's internal world has broken down. Feelings of inferiority are replaced
by delusions of grandeur and omnipotence.
● Regardless of the theoretical model, all psychodynamic approaches are founded
on the premise that psychotic symptoms have meaning in schizophrenia.
● Learning Theories. the poor interpersonal relationships of persons with
schizophrenia develop because of poor models for learning during childhood.
FAMILY DYNAMICS
In a study of British 4-year-old children, those who had a poor
mother-child relationship had a sixfold increase in the risk of developing
schizophrenia, and offspring from schizophrenic mothers who were adopted
away at birth were more likely to develop the illness if they were reared
in adverse circumstances compared with those raised in loving homes by
stable adoptive parents.
SUBTYPES
Paranoid Type.
● Classically, the paranoid type of schizophrenia is characterized mainly by the presence of
delusions of persecution or grandeur
● show less regression of their mental faculties, emotional responses, and behavior than do
patients with other types of schizophrenia.
● are typically tense, suspicious, guarded, reserved, and sometimes hostile or aggressive, but
they can occasionally conduct themselves adequately in social situations.
● Their intelligence in areas not invaded by their psychosis tends to remain intact.
Catatonic Type.
● The classic feature of the catatonic type is a marked disturbance in motor function; this
disturbance may involve stupor, negativism, rigidity, excitement, or posturing
● Associated features include stereotypies, mannerisms, and waxy flexibility.
Undifferentiated Type.
● Frequently, patients who clearly have schizophrenia cannot be easily fit into one type or
another.
Residual Type.
● Emotional blunting, social withdrawal, eccentric behavior, illogical thinking, and mild
loosening of associations commonly appear in the residual type.
● When delusions or hallucinations occur, they are neither prominent nor accompanied by strong
affect.
CLINICAL FEATURES
● First, no clinical sign or symptom is pathognomonic for schizophrenia; every
sign or symptom seen in schizophrenia occurs in other psychiatric and
neurological disorders.
● Second, a patient's symptoms change with time. For example, a patient may have
intermittent hallucinations and a varying ability to perform adequately in
social situations, or significant symptoms of a mood disorder may come and go
during the course of schizophrenia.
● Third, clinicians must take into account the patient's educational level,
intellectual ability, and cultural and subcultural membership. An impaired
ability to understand abstract concepts, for example, may reflect either the
patient's education or his or her intelligence.
CLINICAL FEATURES
POSITIVE SYMPTOMS.
● Hallucinations, Delusions, Disorganized thinking or speech
NEGATIVE SYMPTOMS. The five A’s
● Affective flattening
○ Lack of emotional display or not showing facial expressions (“flat
affect”)
● Alogia
○ Impaired thinking that affects speech
● Anhedonia
○ No interest in being with others or doing things that used to be
pleasurable
● Asociality
○ Decreased interest in relationships with others
○ Decreased social interactions
● Avolition
○ Reduced or lack of motivation
○ Difficulty planning, starting, and sustaining activities
Premorbid Signs and Symptoms
● Pre Schizophrenic adolescents may have no close friends and no dates
and may avoid team sports. They may enjoy watching movies and
television, listening to music, or playing computer games to the
exclusion of social activities.
● Some adolescent patients may show a sudden onset of
obsessive-compulsive behavior as part of the prodromal picture.
● The signs may have started with complaints about somatic symptoms,
such as headache, back and muscle pain, weakness, and digestive
problems.
● Family and friends may eventually notice that the person has changed
and is no longer functioning well in occupational, social, and
personal activities.
● Additional prodromal signs and symptoms can include markedly peculiar
behavior, abnormal affect, unusual speech, bizarre ideas, and strange
perceptual experiences.
Mental Status Examination
General Description.
● The appearance of a patient with schizophrenia can range from that of a
completely disheveled, screaming, agitated person to an obsessively
groomed, completely silent, and immobile person.
● Patients with schizophrenia are often poorly groomed, fail to bathe, and
dress much too warmly for the prevailing temperatures.
PRECOX FEELING.
● Some experienced clinicians report a precox feeling, an intuitive
experience of their inability to establish an emotional rapport with a
patient.
Mood, Feelings, and Affect
● Two common affective symptoms in schizophrenia are reduced emotional
responsiveness, sometimes severe enough to warrant the label of anhedonia, and
overly active and inappropriate emotions such as extremes of rage, happiness,
and anxiety.
Perceptual Disturbances
● The most common hallucinations, however, are auditory, with voices that are
often threatening, obscene, accusatory, or insulting.
● tactile, olfactory, and gustatory hallucinations are unusual
ILLUSIONS.
● illusions are distortions of real images or sensations, hallucinations are not
based on real images or sensations.
Thought.
● THOUGHT CONTENT. Disorders of thought content reflect the patient's ideas,
beliefs, and interpretations of stimuli.
● Delusions, the most obvious example of a disorder of thought content
Impulsiveness, Violence, Suicide, and Homicide.
● Patients with schizophrenia may be agitated and have little impulse
control when ill.
● VIOLENCE. Violent behavior (excluding homicide) is common among
untreated schizophrenia patients. Delusions of a persecutory nature,
previous episodes of violence, and neurological deficits are risk
factors for violent or impulsive behavior.
● SUICIDE. Suicide is the single leading cause of premature death a
mong people with schizophrenia. Suicide attempts are made by 20 to 50
percent of the patients, with long-term rates of suicide estimated to
be 10 to 13 percent.
Sensorium and Cognition
Orientation.
● usually oriented to person, time, and place.
Memory.
● is usually intact, but there can be minor cognitive deficiencies.
Cognitive Impairment.
● exhibit subtle cognitive dysfunction in the domains of attention,
executive function, working memory, and episodic memory.
● The cognitive impairment seems already to be present when patients
have their first episode and appears largely to remain stable over
the course of early illness.
Judgment and Insight.
● When examining schizophrenia patients, clinicians should carefully
define various aspects of insight, such as awareness of symptoms,
trouble getting along with people, and the reasons for these
problems.
Somatic Comorbidity
Neurological Findings.
● Nonlocalizing signs include dysdiadochokinesia, astereognosis, primitive
reflexes, and diminished dexterity.
● The presence of neurological signs and symptoms correlates with increased
severity of illness, affective blunting, and a poor prognosis
Eye Examination.
● In addition to the disorder of smooth ocular pursuit (saccadic movement),
patients with schizophrenia have an elevated blink rate.
● The elevated blink rate is believed to reflect hyperdopaminergic activity
Speech.
● The inability of schizophrenia patients to perceive the prosody of speech
or to inflect their own speech can be seen as a neurological symptom of a
disorder in the nondominant parietal lobe
Other Comorbidity
● Obesity. Patients with schizophrenia appear to be more obese, with
higher body mass indexes (BMis) than age- and gender-matched cohorts
in the general population
● Diabetes Mellitus. Schizophrenia is associated with an increased risk
of type II diabetes mellitus.
● Cardiovascular Disease. Many antipsychotic medications have direct
effects on cardiac electrophysiology
● HIV. Patients with schizophrenia appear to have a risk of HIV
infection that is 1.5 to 2 times that of the general population.
● Chronic Obstructive Pulmonary Disease.
● Rheumatoid Arthritis. Patients with schizophrenia have approximately
one-third the risk of rheumatoid arthritis that is found in the
general population
COURSE AND PROGNOSIS
Course.
● The classic course of schizophrenia is one of
exacerbations and remissions. After the first psychotic
episode, a patient gradually recovers and may then
function relatively normally for a long time.
● Patients usually relapse, however, and the pattern of
illness during the first 5 years after the diagnosis
generally indicates the patient's course. Further
deterioration in the patient's baseline functioning
follows each relapse of the psychosis.
PROGNOSIS
TREATMENT
● can augment the clinical improvement
Hospitalization
● for diagnostic purposes; for stabilization of medications; for patients'
safety because of suicidal or homicidal ideation; and for grossly
disorganized or inappropriate behavior, including the inability to take
care of basic needs such as food, clothing, and shelter.
Pharmacotherapy
● Chlorpromazine was subsequently shown to be effective at reducing
hallucinations and delusions, as well as excitement.
● all share the capacity to antagonize postsynaptic dopamine receptors in
the brain.
● first-generation antipsychotics or dopamine receptor antagonists, and
● the newer drugs, which have been called second-generation antipsychotics
or serotonin dopamine antagonists (SDAs).
PHASES OF TREATMENT IN SCHIZOPHRENIA
Treatment of Acute Psychosis
● Acute psychotic symptoms require immediate attention
● This phase usually lasts from 4 to 8 weeks.
● Acute schizophrenia is typically associated with severe agitation, which
can result from such symptoms as frightening delusions, hallucinations, or
suspiciousness, or from other causes (including stimulant abuse).
Treatment During Stabilization and Maintenance Phase
● The goals during this phase are to prevent psychotic relapse and to assist
patients in improving their level of functioning.
● Noncompliance. Noncompliance with long-term antipsychotic treatment is
very high. An estimated 40 to 50 percent of patients become noncompliant
within 1 or 2 years.
STRATEGIES FOR POOR RESPONDERS
● A 4- to 6-week trial on an adequate dose of an antipsychotic
represents a reasonable trial for most patients
● Changing to another drug is preferable to titrating to a high dose
MANAGING SIDE EFFECTS
Extrapyramidal Side Effects
● reducing the dose of the antipsychotic
● adding an anti-Parkinson medication
● changing the patient to an SDA
● Centrally acting B-blockers, are also often effective for treating
akathisia
Tardive Dyskinesia
preventing and managing tardive dyskinesia include
● using the lowest effective dose of antipsychotic
● prescribing cautiously
● examining patients on a regular basis
● considering alternatives to the antipsychotic being used
● considering a number of options if the tardive dyskinesia worsens
Side Effects of Clozapine
● Most serious: Agranulocytosis
○ weekly blood monitoring for the first 6 months
○ biweekly monitoring for the next 6 months
○ Monthly after 1 year
● higher risk of seizures
○ managed by reducing the dose and adding an anticonvulsant
PSYCHOSOCIAL THERAPIES
● The goal is to enable persons who are severely ill to develop social and
vocational skills for independent living
Social Skills Training
● sometimes referred to as behavioral skills therapy
● use of videotapes of others and of the patient, role playing in therapy, and
homework assignments for the specific skills being practiced
Family-Oriented Therapies
● The therapy should focus on the immediate situation and should include
identifying and avoiding potentially troublesome situations.
● When problems do emerge with the patient in the family, the aim of the therapy
should be to resolve the problem quickly.
Assertive Community Treatment (ACT) program
● Patients are assigned to one multidisciplinary team (e.g., case manager,
psychiatrist, nurse, general physicians).
Group therapy
● reducing social isolation, increasing the sense of cohesiveness, and
improving reality testing
Cognitive behavioral therapy
● improve cognitive distortions, reduce distractibility, and correct errors
in judgment
Individual psychotherapy
● major aim is to convey the idea that the therapist is trustworthy, wants
to understand the patient, and has faith in the patient's potential as a
human
Personal therapy
● Its objective is to enhance personal and social adjustment and to
forestall relapse.
Dialectical Behavior Therapy
● improving interpersonal skills in the presence of an active and empathic
therapist
Vocational Therapy
● help patients regain old skills or develop new ones
Art Therapy
● provides an outlet for their constant bombardment of imagery
Cognitive Training
● Utilizing computer generated exercises, neural networks
● cognition is improved which translates into more effective social
functioning
Schizoaffective
Disorder
INTRODUCTION
● Refer to a disorder with symptoms of both schizophrenia and mood
disorders
● onset of symptoms was sudden and often occurred in adolescence
● Diagnosis is made if they fit into one of the following:
○ patients with schizophrenia who have mood symptoms
○ patients with mood disorder who have symptoms of schizophrenia
○ patients with both mood disorder and schizophrenia
○ patients with a third psychosis unrelated to schizophrenia and mood
disorder
○ patients whose disorder is on a continuum between schizophrenia and mood
disorder
○ patients with some combination of the above
EPIDEMIOLOGY and ETIOLOGY
● <1% lifetime prevalence
● Depressive type may be more common in older persons
● Bipolar type may be more common in young adults
● The age of onset for women is later than that for men
● The cause is unknown
● The most likely possibility is that schizoaffective disorder
is a heterogeneous group of disorders encompassing all of
these possibilities
TREATMENT
● Mood stabilizers
● Antidepressants
● Antipsychotic agents
● Psychosocial Treatment
○ Patients benefit from a combination of family
therapy, social skills training, and cognitive
rehabilitation
Schizophreniform
Disorder
INTRODUCTION
● Gabriel Langfeldt
● a condition with a sudden onset and benign course
associated with mood symptoms and clouding of
consciousness the symptoms last for at least 1 month
but less than 6 months
● Patients return to their baseline level of functioning
after the disorder has resolved
● Most common in adolescents and young adults
● 5x in men than in women
● Cause is not known
Delusional
Disorder and
Shared Psychotic
Disorder
INTRODUCTION
● Delusions are false fixed beliefs not in keeping with the
culture
● The diagnosis of delusional disorder is made when a person
exhibits non-bizarre delusions of at least 1 month's duration
that cannot be attributed to other psychiatric disorders
● Mean age of onset is about 40 years (18 -90 years old)
ETIOLOGY
Paranoid Pseudocommunity
Norman Cameron’s 7 situations that favor the development of delusional
disorders:
● an increased expectation of receiving sadistic treatment
● situations that increase distrust and suspicion
● Situation that increase social isolation
● situations that increase envy and jealousy
● situations that lower self-esteem
● situations that cause persons to see their own defects in others
● situations that increase the potential for rumination over probable
meanings and motivations
SHARED PSYCHOTIC DISORDER
● First described by two French psychiatrists, Lasegue and Falret, in 1877,
who named it Jolie a deux
● In DSM5, this disorder is referred to as "Delusional Symptoms in Partner
of Individual with Delusional Disorder,“
● The disorder is characterized by the transfer of delusions from one
person to another
● Both persons are closely associated for a long time and typically live
together in relative social isolation
TREATMENT
● Delusional disorder was generally regarded as resistant to treatment,
Goals of treatment:
● establish the diagnosis
● decide on appropriate interventions
● manage complications
TREATMENT
Hospitalization
● Patients with delusional disorder can generally be treated as outpatients
1. patients may need a complete medical and neurological evaluation to determine
whether a nonpsychiatric medical condition is causing the delusional symptoms.
2. patients need an assessment of their ability to control violent impulses (e.g.,
to commit suicide or homicide) that may be related to the delusional material
3. patients' behavior about the delusions may have significantly affected their
ability to function within their family or occupational settings
PHARMACOTHERAPY
● A patient's history of medication response is the best guide to choosing a
drug.
● A physician should often start with low doses (e.g., 2 mg of haloperidol
[Haldol] or 2 mg of risperidone [Risperdal]) and increase the dose slowly.
● 6-week trial
PROGNOSIS
FACTORS CORRELATE WITH A GOOD PROGNOSIS:
● High levels of occupational, social, and functional adjustments
● Female sex
● Onset before age 30 years
● Sudden onset
● Short duration of illness
● Presence of precipitating factors
Brief Psychotic
Disorder, Other
Psychotic
Disorders, and
Catatonia
OVERVIEW
● A psychotic condition that involves the sudden onset of psychotic
symptoms, which lasts 1 day or more but less than 1 month.
● Remission is full, and the individual returns to the premorbid
level of functioning
● An acute and transient psychotic syndrome
● Occurs more often among younger patients (20s and 30s), more
common in women than in men
● cause of brief psychotic disorder is unknown
CLINICAL
DIAGNOSIS
FEATURES
● symptoms last at least 1 ● Symptoms always include at least one
day but less than 1 major symptom of psychosis, usually
month with an abrupt onset, but do not
always include the entire symptom
3 Subtypes: pattern seen in schizophrenia
➢ the presence of a
stressor ➢ the absence of a
stressor ● Characteristic symptom include
➢ a postpartum onset ○ emotional volatility, strange or
bizarre behavior, screaming or
muteness, and impaired memory of
recent events
COURSE AND
TREATMENT
PROGNOSIS
By definition, the course ● 2 major classes of used are the
of brief psychotic disorder antipsychotic drugs and the
is less than 1 month benzodiazepines
● Psychotherapy is of use in providing
an opportunity to discuss the
stressors and the psychotic episode
PSYCHOTIC DISORDER NOT OTHERWISE SPECIFIED
● A variety of clinical presentations that do not fit within
current diagnostic rubrics
● It includes psychotic symptomatology about which there is
inadequate information to make a specific diagnosis or
about which there is contradictory information
● It also includes disorders with psychotic symptoms that do
not meet the criteria for any specific psychotic disorder.
Autoscopic Psychosis
● Characteristic symptom is a visual hallucination of all or part of the person's
own body
● The hallucinatory perception is called a phantom
● Patients usually respond to anti-anxiety medication
Motility Psychosis
● Akinetic form has a clinical presentation similar to that of catatonic stupor
● Hyperkinetic form can resemble manic or catatonic excitement
Postpartum Psychosis
● sometimes called puerperal psychosis
● characterized by the mother's depression, delusions, and thoughts of harming
either her infant or herself
PSYCHOTIC DISORDERS DUE TO A GENERAL MEDICAL
CONDITION AND SUBSTANCE OR MEDICATION
INDUCED PSYCHOTIC DISORDER
Disorders are most often encountered in patients who abuse alcohol or
other substances on a long-term basis
Diagnosis:
Psychotic Disorder Due to a General Medical Condition
● The diagnosis is defined by specifying the predominant symptoms
Substance- or Medication-Induced Psychotic Disorder
● full diagnosis should include the type of substance or medication
involved, the stage of substance use when the disorder began
PSYCHOTIC DISORDERS DUE TO A GENERAL MEDICAL
CONDITION AND SUBSTANCE OR MEDICATION
INDUCED PSYCHOTIC DISORDER
Treatment
● involves identifying the general medical condition or the
particular substance involved
● Antipsychotic agents may be necessary for immediate and
short-term control of psychotic or aggressive behavior
● Benzodiazepines is be useful for controlling agitation and
anxiety
CATATONIC DISORDER
● Clinical syndrome characterized by striking behavioral
abnormalities that may include motoric immobility or
excitement, profound negativism, or echolalia, or
echopraxia
● Medical conditions that can cause catatonia include
neurological disorders, infections, and metabolic
disturbances
● Medications that can cause catatonia include
corticosteroids, immunosuppressants, and antipsychotic
agents
CATATONIC DISORDER
Course and Treatment
● Requires hospitalization
● The primary treatment modality is identifying and correcting
the underlying medical or pharmacological cause
● Offending substances must be removed or minimized
● Benzodiazepines can provide temporary improvement in symptoms
● ECT is appropriate for catatonia due to a general medical
condition, especially if it is life threatening or has
developed into lethal catatonia
THE END!
