Schizophrenic Disorders

SymptomsDiagnosisCauses

Treatment and Management

OVERVIEW Psychosis - A state of being profoundly out of

touch with reality Most common symptoms: changes in the

way a person thinks, feels, and relates to other people and the outside environment.

Involves disruptions of mental functions No single symptom or specific set of

symptoms is characteristic of patients.

OVERVIEW Devastating disorder for both the

patients & families. Among mental disorders, the second

leading cause of disease burden.

OVERVIEW Onset typically occurs during

adolescence or early adulthood. The period of risk is considered to be between 15 and 35.

The problems of most patients can be divided into three phases of variable and unpredictable duration: prodromal phase (developing)active phase (psychotic symptoms)residual phase (no longer psychotic

but still showing signs of schizophrenia)

What Schizophrenia Isn’t… Debunking myths -

Not “split personality”Not inherently violent or homicidal

SYMPTOMS Positive Symptoms--Type I

Hallucinations○ Perceptual disturbances○ Can occur in any of the senses○ Persistent over time

SYMPTOMSDelusional Beliefs

○ FALSE Idiosyncratic beliefs that are rigidly held in spite of their preposterous nature.Subtypes:

- Grandeur- Persecution- Reference- Nihilistic

- Capgras’ syndrome- Cotard’s syndrome

SYMPTOMS Disorganization

Thinking Disturbances○ Involves disorganized speech – say things

that do not make sense.Word saladLoose associations or derailmentPerserveration

Symptoms• Disorganized speech or thought

• Neologisms• Clang associations• Echolalia

SYMPTOMS Disorganization

Bizarre Behavior○ Catatonia

Stuporous state – reduced responsiveness.EchopraxiaDisheveledChildlike Behavior

○ Inappropriate affect

SYMPTOMS Negative Symptoms--Type II

Lack of initiative, social withdrawal, deficits in emotional responding.○ Affective flattening, Blunted affect○ Anhedonia – inability to experience pleasure.○ Apathy - Socially withdrawn

Both a symptom and coping strategy○ Avolition – lack of will, motivation○ Alogia – impoverished thinking, poverty of speech.

Classifying Schizophrenia: The DSM-IV-TR Criteria Two or more of the following:

DelusionsHallucinationsDisorganized speechGrossly disorganized or catatonic

behaviorNegative symptoms

Social/occupational dysfunction and decline

Six month duration of symptoms

TABLE 13-1 Diagnosis Criteria for SchizophreniaA. Characteristic Symptoms: Two (or more) of the following, 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 (such as frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms, such as affective flattening, alogia, or avolition

B. Social/Occupational Dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care is markedly below the level achieved prior to the onset.

C. Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms that meet Criterion A (active phase symptoms), and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (such as odd beliefs, unusual perceptual experiences).

DIAGNOSIS Subtypes

Schizophrenia is a heterogeneous disorder with many different clinical manifestations and levels of severity.○ Paranoid Type○ Disorganized Type○ Catatonic Type○ Undifferentiated Type○ Residual Type

DIAGNOSIS Related Psychotic Disorders

Brief psychotic disorder = symptoms < 1 month Schizophreniform disorder = symptoms for 1-6

months “Schizophrenic spectrum” also includes:

Schizoaffective disorderDelusional disorderShared delusional disorderParanoid and schizotypal personality disorders

FREQUENCY Gender Differences

♂: 30 to 40% more likely to develop schizophrenia than ♀.

Differences between ♂ and ♀ onset, symptoms, and course of the disorder.

CAUSESTWIN STUDIES ADOPTION STUDIES

The average concordance rate for MZ twins is 48%, whereas the comparable figure for DZ twins is 17%.

Suggests strong genetic factors.

Also compelling evidence for the importance of environment.

Genain quadruplets

Genetic factors play role in development of the disorder (Heston).

CAUSESPREGANANCY AND BIRTH COMPLICATIONS

VIRAL INFECTIONS

More likely than the general population to have been exposed to various problems during their mother’s pregnancy and to have suffered birth injuries.

Dietary factors

Somewhat more likely to have been born during the winter/spring when viral infections are more prominent.

FIGURE 13-3

Disorder seems to affect many different regions of the brain.Enlarged lateral ventriclesDifferences (decreased size) in parts of the limbic system.

CAUSES Biological Components: Immediate

CausesBrain function abnormalities: hypofrontality, neurotransmission,

dopamine hypothesisBrain structure abnormalities

Neuropsychological/neurophysiological abnormalities: impaired cognition, sensory gating, visual tracking

CAUSESThe dopamine hypothesis Interactions of multiple

neurotransmitters Focuses on the function

of dopamine in the limbic area of the brain.

Hypothesis grew out of attempts to understand how antipsychotic drugs improve the adjustment of schizophrenic patients.

Current research focuses many neurotransmitters:SerotoninGABA Glutamate

CAUSES Psychological Factors

Expressed Emotion○ The family environment does have a

significant impact on the course (as opposed to the etiology) of schizophrenia.

○ Patients who relapsed seemed to react negatively to some feature of their close relationship with their family.

○ See Figure 13.5

TREATMENT Antipsychotic Medication

Have a relatively specific effect- reduce psychotic symptoms

Positive symptoms respond better than negative symptoms.

A substantial minority of patients, perhaps 25% do not improve on classical antipsychotic drugs.

See Figure 13.7 relapse rate

TREATMENT Antipsychotic Medication

Motor Side Effects

○ Extrapyramidal symptoms

○ Tardive dyskinesia

TREATMENT Antipsychotic Medication

Second-Generation Antipsychotics○ Atypical antipsychotics

○ Work on both serotonin and dopamine○ Impact both positive and negative symptoms