Schizophrenia and schizophrenia-like disordersm- Schizophrenia and schizophrenia-like disorders Dr: WeiboLiu E-mail:liuweibo1020@163.com ... catatonic behavior, or flat or inappropriate

Schizophrenia and schizophrenia-like disorders

Dr: Weibo Liu E-mail:liuweibo1020@163.com

The Second Affiliated Hospital Zhejiang University

College of Medicine

Category of psychotic disorders

• Schizophrenia (SC)

• Schizoaffective disorder

• Schizophreniform disorder

• Brief psychotic disorder

• Delusional disorder

Introduction

• The definition of schizophrenia

• The symptom of schizophrenia

• Diagnostic criteria of schizophrenia (DSM-IV and ICD-10)

• The therapeutic principle of schizophrenia

• The factors influencing prognosis of schizophrenia

• The concept and diagnostic significance of insight

“Big” Names associated with SC

(1) Kraepelin ---Dementia praecox

(2)Eugen Bleuler-- formal thought

disorder(splitting)

(3)Kurt Schneider-first-rank symptoms

Definition of SC

•Schizophrenia is a disorder characterized by apathy, absence of initiative (avolition), and affective blunting

•Patients have alterations in thoughts, perceptions, mood, and behavior

•Many schizophrenics display delusions, hallucinations and misinterpretations of reality

Epidemiology — gender and age

• SC is equally prevalent in men and women.

• On set is earlier in men (in the teens or 20s) than in women (in the 20s or early 30s).

• It's uncommon for children to be diagnosed with SC and rare for those older than 40.

Moises HW, Zoega T, Gottesman II. The glial growth factors deficiency and synaptic

destabilization hypothesis of schizophrenia. BMC Psychiatry. 2002 Jul 3;2(1):8.

Epigenetic Code

Etiology of SC

• Genetic factors

• Biochemical factors

• Neuropathology

• Neural circuits

• Psychoneuroimmunology

• Psychoneuroendocrinology

• ……

Genetic factors

• A genetic contribution to SC, and a high proportion of the variance in the liability to SC is due to additive genetic effects

• But, Most patients have no family history of SC, is a complex genetic disease – Multiple genes (epistasis) and environmental exposures (interaction)

are involved in risk.

Biochemical factors

• Dopamine hypothesis

• Serotonin

• Glutamate

• Norepinephrine

• GABA

• Neuropeptides

• Acetylcholine and nicotine

Dopamine hypothesis in CNS

Brain Structure & Brain Function

Ventricle Enlargement (MRI)

Hypofrontality (fMRI)

Clinical feature of Schizophrenia

Positive

symptoms

1

Mood

symptoms

3

Cognitive

impairment

42

Negative

symptoms

Positive symptoms

• Hallucinations are most commonly auditory or visual, but hallucinations can occur in any sensory modality

• Delusions--fixed false beliefs that cannot be corrected by reason

• Thought disorder is characterized by loose associations, tangentiality, incoherent thoughts, neologisms, thought blocking, thought insertion, thought broadcasting, and ideas of reference

• Disorganized behavior

Negative symptoms

• Poverty of speech (alogia) or poverty of thought content

• Flat affect

• Loss of motivation (avolition)

Mood symptoms

• Common and severe

• Depression or mood swings

• People with schizophrenia often seem inappropriate and odd, causing others to avoid them, which leads to social isolation

Cognitive impairment

• Exhibit subtle cognitive dysfunction in the domains of attention, executive function, working memory, and episodic memory such as: Problems with making sense of information

Difficulty paying attention

Memory problems

• 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

Classification of schizophrenia

• A – paranoid type schizophrenia

• B – disorganized type schizophrenia

• C – catatonic type schizophrenia

• D – undifferentiated type schizophrenia

• E – residual type schizophrenia

Paranoid type schizophrenia

• Characterized by preoccupation with one or more

delusions or frequent auditory hallucinations

• No prominent disorganized speech, disorganized or

catatonic behavior, or flat or inappropriate affect

• Best prognosis

Disorganized type schizophrenia

• Characterized by prominent disorganized speech,

disorganized behavior, and flat or inappropriate affect

• worse prognosis

Catatonic type schizophrenia

Characterized by at least 2 of the following:

• Motoric immobility

• Excessive motor activity

• Extreme negativism or mutism

• Peculiar voluntary movements such as bizarre posturing

• Echolalia or echopraxia

Undifferentiated type schizophrenia

• Meets criteria for SC, but can not be Characterized by paranoid, disorganized, or catatonic type

Residual type schizophrenia

Characterized by the absence of prominent delusions, disorganized speech and grossly disorganized or catatonic behavior and continued negative symptoms or two or more attenuated positive symptoms

Once a Schizophrenic,

Always a Schizophrenic?

DSM-Ⅳ diagnostic criteria for schizophrenia

A. Two or more of the following symptoms present for one month:

1.Delusions

2.hallucinations

3.disorganized speech

4.grossly disorganized or catatonic behavior

5.negative symptoms (ie,affective flattening,alogia,avolition)

B. Decline in social and/or occupational functioning since the onset of illness

C. Continuous signs of illness for at least six months with at least one month of active symptoms

D. Schizoaffective disorder and mood disorder with psychotic features have been excluded

E. The disturbance is not due to substance abuse or a medical condition

F. If history of autistic disorder or pervasive developmental disorder is present, schizophrenia may be diagnosed only if prominent delusions or hallucinations have been present for one month

DSM-Ⅳ diagnostic criteria for schizophrenia

ICD-10 diagnositic criteria for schizophrenia

1. At least one of the following: • Thought echo, insertion, withdrawal, or broadcasting.

• Delusions of control, influence, or passivity; clearly referred to body or limb movements or specific thoughts, actions, or sensations; and delusional perception.

• Hallucinatory voices giving a running commentary on the patient's behavior or discussing him/her between themselves, or other types of hallucinatory voices coming from some part of the body.

• Persistent delusions of other kinds that are culturally inappropriate or implausible, (e.g. religious/political identity, superhuman powers and ability).

2. Or, at least two of the following: • Persistent hallucinations in any modality, when accompanied by fleeting

or half-formed delusions without clear affective content, persistent over-valued ideas, or occurring every day for weeks or months on end.

• Breaks of interpolations in the train of thought, resulting in incoherence or irrelevant speech or neologisms.

• Catatonic behavior such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor.

• Negative symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses.

• A significant and consistent change in the overall quality of some aspects of personal behavior, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

ICD-10 diagnositic criteria for schizophrenia

A case of SC

What’s the symptoms?

How to make a diagnose?

Differential diagnosis with SC

• Psychotic disorder due to a general medical condition

CNS infections, lupus, multiple strokes, HIV …

• Substance-induced psychotic disorder

Amphetamines, cocaine, phencyclidine(PCP) …

• Mood disorder with psychotic features

Therapeutic approach of SC

• “ UCLA Recovery Criteria ”

Recovery criteria must be met in each of 4 domains

Improvement in each domain must be sustained concurrently for ≥2 y

Level of recovery in these 4 domains is measured by:

－ Symptom remission

－ Appropriate role function

－ Ability to perform day-to-day living tasks without supervision

－ Social interaction

Liberman RP et al. Int Rev Psychiatry. 2002;14;256-272.

Therapeutic goals

• Reduce or eliminate symptoms

• Maximize quality of life and adaptive functioning

• Promote and main