SCHIZOPHRENIASCHIZOPHRENIA

HistoryHistoryEmil Kraeplin - dementia precoxEugen Bleuler - schizophrenia

4A’s : associational disturbances

affective disturbances

ambivalence

autism

- Secondary Symptoms: hallucinations & delusions

Emil Kraeplin - dementia precoxEugen Bleuler - schizophrenia

4A’s : associational disturbances

affective disturbances

ambivalence

autism

- Secondary Symptoms: hallucinations & delusions

Other Theorists:Adolf Meyer - founder of psychobiology;

schizophrenic reactionHarry Stack Sullivan - founder of

interpersonal psychoanalytic school; social isolation

Gabriel Langfeldt - 2 groups: with true schizophrenia & schizophreniform psychosis

Kurt Schneider - first rank symptoms

Other Theorists:Adolf Meyer - founder of psychobiology;

schizophrenic reactionHarry Stack Sullivan - founder of

interpersonal psychoanalytic school; social isolation

Gabriel Langfeldt - 2 groups: with true schizophrenia & schizophreniform psychosis

Kurt Schneider - first rank symptoms

EpidemiologyEpidemiology Lifetime prevalence (US) = 0.6 - 1.9% Annual incidence of 0.5 - 5.0 per

10,000

1. Age & Sex: M=F• M: early onset (15-25 yrs), > (-) sxs• F: peak onset=25-35 yrs, better outcome• 90% of cases - between 15-55 years old• Onset before 10yrs & after 50 yrs=rare

Lifetime prevalence (US) = 0.6 - 1.9% Annual incidence of 0.5 - 5.0 per

10,000

1. Age & Sex: M=F• M: early onset (15-25 yrs), > (-) sxs• F: peak onset=25-35 yrs, better outcome• 90% of cases - between 15-55 years old• Onset before 10yrs & after 50 yrs=rare

2. Medical Illness• Have higher mortality rate from accidents

and natural causes• 80% - have significant concurrent

medical illness

2. Medical Illness• Have higher mortality rate from accidents

and natural causes• 80% - have significant concurrent

medical illness

3. Suicide - 50% attempt suicide

50% attempt suicide

10-15% die by suicide

M=F, likelihood to commit suicide

Major risk factors: (+) depressive sxs, young age, high levels of premorbid functioning

3. Suicide - 50% attempt suicide

50% attempt suicide

10-15% die by suicide

M=F, likelihood to commit suicide

Major risk factors: (+) depressive sxs, young age, high levels of premorbid functioning

4. Associated Substance Use & Abuse

cigarette smoking

substance abuse

5. Cultural and Socioeconomic Consideration

a. Downward Drift Hypothesis

b. Social Causation Hypothesis

4. Associated Substance Use & Abuse

cigarette smoking

substance abuse

5. Cultural and Socioeconomic Consideration

a. Downward Drift Hypothesis

b. Social Causation Hypothesis

EtiologyEtiology1. Stress-Diathesis Model

2. Biological Factors - limbic system, basal ganglia, frontal cortex• Dopamine Hypothesis - too much

dopaminergic activity• Other Neurotransmitters

• 5HT• NE• Amino Acids

1. Stress-Diathesis Model

2. Biological Factors - limbic system, basal ganglia, frontal cortex• Dopamine Hypothesis - too much

dopaminergic activity• Other Neurotransmitters

• 5HT• NE• Amino Acids

NeuropathologyLimbic systemBasal ganglia

Brain Imaging - CT scan, MRIEEG

NeuropathologyLimbic systemBasal ganglia

Brain Imaging - CT scan, MRIEEG

3. Genetics

4. Psychosocial Factors

a. Psychoanalytic theories

b. Psychodynamic theories

c. Expressed emotions (EE)

5. Social Theories

3. Genetics

4. Psychosocial Factors

a. Psychoanalytic theories

b. Psychodynamic theories

c. Expressed emotions (EE)

5. Social Theories

DiagnosisDiagnosis DSM IV SUBTYPES

1. Paranoid type

2. Disorganized/Hebephrenic type

3. Catatonic type

4. Undifferentiated type

5. Residual type

Type I : (+) symptoms, N brain structures on CT scan, good response to tx

Type II: (-) symptoms, structural brain abN, poor response to tx

DSM IV SUBTYPES1. Paranoid type

2. Disorganized/Hebephrenic type

3. Catatonic type

4. Undifferentiated type

5. Residual type

Type I : (+) symptoms, N brain structures on CT scan, good response to tx

Type II: (-) symptoms, structural brain abN, poor response to tx

Clinical FeaturesClinical FeaturesHistory is importantSymptoms change with timePremorbid sxs : schizoid or schizotypal

personalitiesConsider px’s educational level,

intellectual ability and cultural background

History is importantSymptoms change with timePremorbid sxs : schizoid or schizotypal

personalitiesConsider px’s educational level,

intellectual ability and cultural background

Mental Status Examination

1. General Description : broad

2. Mood, Feelings, Affect : secondary depression or post-psychotic depression; flat or blunted affect

3. Perceptual disturbances : hallucinations, illusions

Mental Status Examination

1. General Description : broad

2. Mood, Feelings, Affect : secondary depression or post-psychotic depression; flat or blunted affect

3. Perceptual disturbances : hallucinations, illusions

4. Thought : content - delusions

form of thought

thought process

5. Impulsiveness, suicide, homicide

6. Sensorium & Cognition : intact

7. Judgment & Insight ; poor

8. Reliability : poor

4. Thought : content - delusions

form of thought

thought process

5. Impulsiveness, suicide, homicide

6. Sensorium & Cognition : intact

7. Judgment & Insight ; poor

8. Reliability : poor

Differential DiagnosisDifferential Diagnosis1. Secondary & Substance-Induced

Pscyhotic Do

2. Malingering & Factitious DO

3. Other Psychotic Dos

4. Mood DO

5. Personality DO

1. Secondary & Substance-Induced Pscyhotic Do

2. Malingering & Factitious DO

3. Other Psychotic Dos

4. Mood DO

5. Personality DO

Course and PrognosisCourse and PrognosisCourse : retrospective recognition of

symptomsEach relapse of psychosis is followed by a

further deterioration in the px’s baseline functioning

Exacerbations and remissions(+) symptoms tend to become less severe

with time, (-) symptoms may increase in severity

Course : retrospective recognition of symptomsEach relapse of psychosis is followed by a

further deterioration in the px’s baseline functioning

Exacerbations and remissions(+) symptoms tend to become less severe

with time, (-) symptoms may increase in severity

Prognosis : Study : 10-20% good outcome

>50% poor outcomeLiterature - range of recovery rate= 10-

60% 20-30% lead normal lives 20-30% moderate sxs 40-60% significantly

impaired

Prognosis : Study : 10-20% good outcome

>50% poor outcomeLiterature - range of recovery rate= 10-

60% 20-30% lead normal lives 20-30% moderate sxs 40-60% significantly

impaired

TreatmentTreatment CONSIDERATIONS

1. Unique individual, familial, social, psychological profile

2. Environmental and psychological factors

3. Complex disorder

CONSIDERATIONS1. Unique individual, familial, social,

psychological profile

2. Environmental and psychological factors

3. Complex disorder

HospitalizationsIndications: diagnostic purposes

stabilization on medications

patient safety

grossly disorganized or inappropriate behavior

HospitalizationsIndications: diagnostic purposes

stabilization on medications

patient safety

grossly disorganized or inappropriate behavior

Somatic Treatment1. Antipsychotic/Neuroleptics

1. Dopamine-Receptor antagonist

2. Remoxipride

3. Risperidone

4. Clozapine

Somatic Treatment1. Antipsychotic/Neuroleptics

1. Dopamine-Receptor antagonist

2. Remoxipride

3. Risperidone

4. Clozapine

Therapeutic Principles1. Define target symptoms to be treated

2. AP that worked in the past should be used for the patient again

3. Minimum length of an AP trial = 4-6 wks

4. Use of monopharmacology

5. Maintain on lowest possible effective dosage

Therapeutic Principles1. Define target symptoms to be treated

2. AP that worked in the past should be used for the patient again

3. Minimum length of an AP trial = 4-6 wks

4. Use of monopharmacology

5. Maintain on lowest possible effective dosage

2. Psychosocial Treatment Behavior therapy Family-oriented therapy Group therapy Individual psychotherapy

2. Psychosocial Treatment Behavior therapy Family-oriented therapy Group therapy Individual psychotherapy