Schizophrenia and other psychotic disorders

Symptoms, models, course, epidemiology

Lucie Bankovská Motlová

Psychotic Disorder

– Psychotic: loss of contact with reality, inability to distinguish reality from fantasy, impaired reality testing, with the creation of a new reality

– Characteristics:» disorganized and delusional thinking» disturbed perceptions» inappropriate emotions and actions

schizoaffective disorder

schizophrenia

brief psychotic disorder

schizophreniformdisorder

substance-inducedpsychotic disorder

PSYCHOSES

Psychotic Disorders: Classification

Diagnostic and Statistical Manual of Mental Disorders

DSM-IV• Schizophrenia• Schizophreniform disorder• Schizoaffective disorder• Delusional disorder• Brief psychotic disorder• Shared psychotic disorder• Psychotic disorder due to a

general medical condition• Substance-induced

psychotic disorder

International Classification of Diseases and Related Health Problems

ICD-10• Schizophrenia• Schizotypal disorder• Persistent delusional

disorders• Acute and transient

psychotic disorders• Induced delusional disorder• Schizoaffective disorders

Schizophrenia

John Nash

Symptoms

• Positive

• Negative

• Cognitive

Positive Symptoms

Symptom

Hallucinations

Disorganized Speech

Bizarre/catatonic behavior

Delusions

Function Distorted

Perception

Thought/Language

Behavioral monitoring

Inferential thinking

Auditory, Visual,Tactile,Olfactory

Persecutory, Paranoid, Grandiose, Religious, Jealous, Somatic

April 1991

Bryan Charnley 1949-1991

Stefan M., Travis M. and Murray R., An Atlas of Schizophrenia, 2002

May 1991

Stefan M., Travis M. and Murray R., An Atlas of Schizophrenia, 2002

June 1991

Stefan M., Travis M. and Murray R., An Atlas of Schizophrenia, 2002

DOPAMIN

• Endogenous dopaminergic sensitization: PET

• Amphetamines intake = ↑↑↑ endogenous dopamin in schizophrenia patients in the acute phase, in comparison with healthy persons

• Relapse of schizophrenia = recurrence of hyperdopaminergic state in subcortical structures

• IMPLICATIONS FOR TREATMENT Chronic blockade of D2 receptors: blocking of sensitization processes

Laurelle 1999

Neurochemical sensitization in mesolimbic dopaminergic system

(studies in schizophrenia)

Negative Symptoms

Symptom

Alogia

Affective blunting

Avolition

Anhedonia

Function Diminished

Fluency of speech/thought

Emotional expression

Volition and drive

Hedonic capacity

Impair ability to function in daily lifeHolding a job

Attending schoolForming friendships

Having intimate family relationships

Cognitive Symptoms

Symptom• forgetfullness• distractibility• reasoning/problem

solving

Function Diminished• working memory • Attention span

• "set-shifting", i.e. the ability to display flexibility in the face of changing schedules of reinforcement

Learning difficultiesInability to read

Problems with planning

Historical Concepts

• Emil Kraepelin

• Eugen Bleuler

• Kurt Schneider

Video: 1942

Emil Kraepelin (1856-1926) Dementia Praecox

“Dementia praecox consists of a series of states, the common characteristic of which is a peculiar destruction of internal connections of the psychic personality....the majority of the clinical pictures are the expression of a single morbid process, though outwardly they often diverge very far from one another.”

Eugen Bleuler (1857-1939): Group of Schizophrenias

“Of the thousands of associative threads that guide our thinking, this disease seems to interrupt, quite haphazardly, sometimes single threads, sometimes a whole group, and sometimes whole segments of them.”

Bleuler’s Fundamental Symptoms: 4 „A“

• Associations

• Affective Blunting

• Autism

• Ambivalence

Kurt Schneider (1887-1967)

First-Rank Symptoms

First-Rank Symptoms of Kurt Schneider

• Audible thoughts• Voices arguing or discussing• Voices commenting on patient´s actions• Somatic passivity• Thought withdrawal• Thought broadcasting• Made feelings• Made impulses or drives• Made volitional acts• Delusional perception

Syndromes, models, classification systems

John Hughlins Jackson

Timothy Crow

ICD -10, DSM IV

John Hughlins Jackson (1835-1911)Positive and negative symptoms

Positive•Delusions, hallucinations•Pathological disinhibition of cortical functions•Absent in normal „psyche“Negative•Flat affect, apathy, lack of motivation•Generalized loss of functions•Normal „psyche“ lost them

Timothy CrowSchizophrenia type I and II

I•Positive symptoms•Normal size of brain ventricules•Better prognosis•Better treatment responseII•Negative symptoms•Brain ventricules enlargement•Worse prognosis•Worse treatment response

ClassificationICD-10 Europe; DSM-IV-USA

• General criteria 1st rank symptoms

according to Schneider

• Long-term course types

• Clinical subtypes

Traditional clinical Subtypes• Paranoid• Disorganized (Hebephrenic)• Catatonic• Simplex

• Undifferentiated• Residual

Out of the Shadow

What symptoms of schizophrenia have you identified?

Course and prognosisof schizophrenia

Long-term course: Attack, Relapse, Remission

20 30 40 50 60 70roky

M E D I K A C E

The natural history of schizophrenia: a 5-year follow-up.

EarlyWarning

Signs

Early Warning

Signs

Early Warning Symptoms of RelapsePatient

1. Troubles with sleep.

2. Decreased appetite.

3. Difficulty concentrating on reading or watching television.

4. Fear, anxiety or annoying feelings from other people.

5. Restlessness, irritability or quick temperedness.

6. Feeling that something unusual and incomprehensible is about to happen around me.

7. Loss of energy or interests.

8. Decreased capacity to cope with everyday problems.

9. Experience of hearing people's voices speaking when nobody seems to be around.

10. Have you noticed any of your individual warning signs since last evaluation?

Family member

1. Troubles with sleep.

2. Marked behavioral changes.

3. Social withdrawal.

4. Decline in daily activities.

5. Decline in personal hygiene.

6. Loss of initiative, motivation.

7. Preoccupation with peculiar ideas and

thoughts.

8. Marked poverty of speech or content of

speech.

9. Irritability, quick temperedness or aggression.

10. Have you noticed any of warning signs

individual for your relative since last

evaluation?

10

20

30

40

50

60

70

(%)

1 year 2 years 5 years 15 years

80

30-50% 40-60% 80% 80%

(Shepherd et al , 1989, Hogarty et al 1993, Möller et al., 1995, Wieden a Olfson 1995, Mason et al, WHO studie, 1996, Doering et al.,1998, Wiersma et al. 1998, Robinson et al. 1999, Ohmori et al . 1999, Rabinowitz et al. 2001, Gaebel 2002, Schooler et al., 2003)

Relapse rates

Epidemiology

Onset and Prevalence of Schizophrenia worldwideAbout 0.2% to 1.5% (or about 1% population)Often develops in early adulthoodCan emerge at any time

Schizophrenia Is Generally ChronicMost suffer with moderate-to-severe lifetime impairment Life expectancy is less than average

Schizophrenia Affects Males and Females About Equally

Females tend to have a better long-term prognosisOnset differs between males and females

Schizophrenia has a Strong Genetic Component