schizophrenia l kraepelin-dementia precox l bleuler-schism between thought, emotion and behavior in...
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SchizophreniaSchizophrenia Kraepelin-dementia precox Bleuler-schism between thought, emotion
and behavior in affected patients 4 A’s
– ambivalence– associations– affect– autism
Schizophrenia and DSMSchizophrenia and DSM
Disturbance of 6 months or more that includes one month of 2 or more* of the following active-phase symptoms– Delusions– Hallucinations (3/4 @ some point)– Disorganized Speech– Grossly disorganized or catatonic behavior– Negative symptoms
Positive & Negative Sx.Positive & Negative Sx.
Delusions Hallucinations Disorganized thinking Misperceptions
Blunted affect Poor initiation &
planning with tasks Poverty of speech Anhedonia
DelusionsDelusions
Grandeur Guilt Jealousy Passivity Persecution Poverty Reference
Other Symptoms of Other Symptoms of SchizophreniaSchizophrenia
Cognitive Dysfunction Dysphoria Absence of Insight Sleep disturbance Suicide Illusions Echopraxia
Why accurate Dx is important?Why accurate Dx is important? Frequency-1% Chronicity
– Schizophrenic patients die younger Males 5.1 greater mortality Suicide rate 10-13% higher overall 2x MVAs; More disease & homelessness
Severity Management*
– 80% vs. 30% relapse rate @ 1 year
EpidemiologyEpidemiology
Gender-15-25 vs. 25-35 Comorbid with substance abuse Deinstitutionalization (>2/3) Dx has increased with the onset of
neuroliptics
EtiologyEtiology
Many different problems that converge on the same syndrome, not just a single disease
>50% of Sx appear to be associated with brain abnormalities (especially + Sx).
Stress Diathesis Model Dopamine Hypothesis
GeneticsGeneticsGeneral Population 1.0%
Nontwin sib of Schz. pt. 8.0%
Child with 1 Schz. parent 12.0%
Dyzygotic twin of Schz. parent
12.0%
Child of 2 Schz. parents 40.0%
Monozygotic twin of a Schz. parent
47.0%
Factors related to good Factors related to good prognosis in Schizophreniaprognosis in Schizophrenia
Late onset Obvious precipitating factors Acute onset Good premorbid social, sexual, and work history Married Family/Personal history of mood disorders Good support systems Positive symptoms
Factors related to poor Factors related to poor prognosis in Schizophreniaprognosis in Schizophrenia
Young and insidious onset No precipitating factors Poor premorbid social, sexual, and work histories Withdrawn, autistic behavior; assaultive history Single, divorced or widowed Neurological signs and symptoms/prenatal trauma Family history of schizophrenia No remission in 3 years; many relapses
Medication IssuesMedication Issues Chlorpromazine (Thorazine); Fluphenazine
(Prolixin); Haloperidol (Haldol); Thiothixene (Navane); Thioridazine (Mellaril) & Perphenazine (Trilafon)
Benzodiazepines– Valium (diazepam)– Librium (chordiazepoxide)
Tardive dyskenesia Newer drugs (Risperdal, Clozaril & Zyprexa) Tablet or liquid form with “depot formulations”
Common antipsychotic Common antipsychotic medication side effectsmedication side effects
Dry mouth Constipation Blurred vision Drowsiness
Less common antipsychotic Less common antipsychotic medication side effectsmedication side effects
Decreased sexual desire Menstrual changes Stiff muscles on one side of the neck or jaw
Serious antipsychotic Serious antipsychotic medication side effectsmedication side effects
Restlessness Muscle stiffness Slurred speech Extremity tremors Agranulocytosis
Ethnicity and Antipsychotic Ethnicity and Antipsychotic medication efficacy medication efficacy
(Frackiewicz, et al., 1997)(Frackiewicz, et al., 1997) Asians responded to lowest dosages Limited AfA results, with differences apparently due to
prescribing practices Authors highlight the problem of this line of cross-cultural
research where Western ethnic groups are seen as homogenous
AfA are diagnosed significantly more with Scz than EA and less with depression
Satcher (2001) AfAs and Latinos… AfA more likely to receive medication and less likely to be
referred for therapy (Richardson, 2001)
Work Behavior StrengthsWork Behavior Strengths
Minimal physical limitations Generally have at least average IQ Medications provide good control over
symptoms for most If onset in late 20s, the consumer may have
a work history of > HS education
Work Behavior LimitationsWork Behavior Limitations
Difficulty multitasking Difficulty interacting with co-workers Difficulty accepting criticism or supervision May have difficulty with customer service
or customer contact Cyclic symptoms lead to inconsistent perf. Needs work space with limited stimulation
Common types of work Common types of work accommodationsaccommodations
Flexible schedule to allow time off during times when symptoms exacerbate or need “treatment”
Loss stress, low stimulation work environment
Training and education staff Modifying simple job tasks Developing on site services (e.g. EAP)
ComorbidityComorbidity 91% with accompanying substance abuse or
mental health disorders (Judd, 1989)
Strongest relationship with mood disorders– 81.4% with comorbid mood disorder
– 59% with comorbid unipolar depression
– 22% with comorbid bipolar depression
– 38% with comorbid mood disorder made at least one suicide attempt
– 28.9%% suicide attempts in pts. with comorbid bipolar disorder
Cultural variantsCultural variants
Women are less vulnerable to cognitive deficits than men (particularly verbal processing) Goldstein, et al., 1998
Sx. Expression on the BSI were significantly higher in HA compared to EA Coelho, et al., 1998
Cognitive differences must be covaried by premorbid language functioning
Catatonic SchizophreniaCatatonic Schizophrenia Meets basic criteria for Schizophrenia At least 2 catatonic symptoms predominate:
– Stupor or motor immobility (catalepsy or waxy flexibility)
– Hyperactivity w/o apparent purpose or not influenced by external stimulation
– Mutism or marked negativism– Peculiar posturing, stereotypes, or mannerisms– Echolalia or echopraxia
Disorganized SchizophreniaDisorganized Schizophrenia
Meets all of the basic criteria for Schizophrenia plus
Disorganized behavior Disorganized speech Affect is flat or inappropriate Not meet criteria for Catatonic Schz.
Undifferentiated Undifferentiated SchizophreniaSchizophrenia
Meets basic criteria for Schizophrenia but not Paranoid, Disorganized or Catatonic types
Diagnosis of exclusion..what is left
Residual TypeResidual Type
At one time met criteria for Schizophrenia, Catatonic, Disorganized, or Undifferentiated Type
No longer has pronounced catatonic behavior, delusions, hallucinations, or disorganized speech or behavior
Still ill as indicated by either – Negative symptoms– Attenuated form of at least 2 symptoms of Schz
Paranoid SchizophreniaParanoid Schizophrenia Meets basic criteria for Schizophrenia Preoccupied with delusions or frequent
auditory hallucinations None of these symptoms is prominent:
– Disorganized speech– Disorganized behavior– Inappropriate of flat affect– Catatonic behavior
Schizophreniform DisorderSchizophreniform Disorder “A” criteria symptoms for at least a month Delusions (only 1 required, if bizarre) Hallucination(s)* Incoherent, derailed, or disorganized speech Severely disorganized or catatonic behavior Negative symptom From prodromal to active and residual, symptoms
last at least one month but no longer than six months
Factors related to good Factors related to good prognosis of prognosis of
Schizophreniform DisorderSchizophreniform Disorder Actual psychotic features begin within 4
weeks of the 1st noticeable change in the patient’s functioning or behavior
Pt. confused or perplexed when psychotic Good premorbid social or job functioning Affect is neither blunt nor flattened