Schizophrenia

Radovan Přikryl, Hana Kučerová

Department of Psychiatry Medical Faculty Masaryk Univerzity Brno

2004

Definition of schizophrenia

Schizophrenia is a disorder of unknown causes.It is characterized by psychotic symptoms that significantly impair functioning and that involve disturbances in feeling, thinking and behaviour.Disorder is chronic and generally has a prodromal phase, an active phase with delusions, hallucinations, or both, and a residual phase in which the diorder may be in remission.

History

1852: schizophrenia was first formally described by Belgian psychiatrist Benedict Morel, who called it „demence precoce“1896: Emil Kraepelin, a German psychiatrist, applied the term „dementia praecox“ to a group of illnesses that began in adolescence and ended in dementia1911: Swiss psychiatrist Eugen Bleuler introduced the term „schizophrenia“, he postulated the cluster of symptoms pivotal for schizophrenia, there are called 4A: association, ambivalence, anhedonia, autizmus

Diagnosis

Diagnosis is based on observation and description of the patients

DSM IV diagnostic criteria for schizophrenia

DSM IV diagnostic criteria for schizophrenia

A. characteristic symptoms: two or more of the following, each present for a significant portion of time during a 1 month period Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behaviour Negative symptoms (affective flattening, alogia, avolition)

B. social or occupational dysfunctionC. duration of B at least for 6 monthD. schizoaffective and mood disorder exclusionE. Substance/ general medical condition exclusion

Symptoms of schizophreniaImpaired overall functioning The level of patients functioning declines or fails to

achieve the expected level

Abnormal content of thought For example delusions, ideas of reference, poverty of

content

Illogical form of thought Loosening of associations, incoherence, tangentiality,

neologism, blocking, echolalia

Distorted perception Hallucinations: visual, olfactory, tactile, and most

frequently auditory

Symptoms of schizophreniaChanged affect Flat, blunted, labile, inappropriate

Impaired sense of self Loss of ego boundaries, gender confusion, inability to distiquish

internal from external reality

Altered volition Inadequate motivation or marked ambivalence

Impaired interpersonal functioning Social withdrawal and emotional detachment, aggressiveness,

sexual inappropriateness

Change of psychomotor behaviour Agitation, withdrawal, grimacing, posturing, rituals, catatonia

Types

ParanoidPreoccupation with systematized delusions

or with frequent auditory hallucinations

Disorganized Incoherence, marked loosening of

associations or grossly disorganizes behavior

Flat or grossly inappropriate affect

Types

CatatonicStupor or mutismNegativismRigidityExcitementPosturingEcholalia or echopraxia

TypesUndifferentiated type Prominent delusions, hallucinations, incoherence or grossly

disorganized behavior Does not meet the criteria for paranoidm catatonic or

disorganized type

Residual type Absence of prominent delusions, hallucinations, incoherence

or grossly disorganized behavior Continuing evidence of the disturbance through two or more

residual symptoms

Simple schizophrenia Primary symptom is the withdrawal of the patient from social

and work related situations

The division of schizophrenia into the positive and the negative symptoms

according to Nancy Andreasen

Positive symptoms of schizophrenia: the presence of abnormal behaviourHallucinationsDelusionsDisorganised speech and/or thinkingGrossly disorganised behaviourCatatonic behaviour

Negative symptoms of schizophrenia: the absence of normal behaviourSocial withdrawalIsolationPoor self careBlunted mood and facial expressionLack of spontaneous thinking

Epidemiology

Prevalence Approximately 1-1,5%

Sex ratio The male to female ratio is 1:1

Age of onset Most common between ages 15 and 35

Cost in USA approximately 100 bilion dolars a year

Dopamine hypothesis

Schizophrenic symptoms are in part a result of hypersensitive dopamine receptors or increased dopamine activityAntipsychotics bind dopamine D2 receptors and cause functional decrease in dopamine activityThe mesocortical and mesolimbic CNS dopamine tracts ate rhose most implicated in schizophreniaDrugs that increase dopamine worsen or trigger psychosis

Brain imaging

MRI Cortical atrophy in 10-35% Enlargement of the lateral or third ventricle in 10-

50% Findings may correlate with the presence of

negative symptoms

PET Decreased frontal and pariental lobe metabolism Abnormal laterality Increased temporolimbic metabolism

Neuropsychology I.A neuropsychological evaluation is recommended for any case in which brain-based impairment in cognitive function or behavior is suspected.

Typical referrals are made to diagnose or rule out the following conditions, and to describe their impact on a person's cognitive functioning:

Traumatic brain injury; Strokes; Developmental learning disabilities; Attention deficit disorders; Psychiatric or neuropsychiatric disorders; Seizure disorders; Medical illness or treatments; Effects of toxic chemicals or chronic substance abuse; Dementing conditions (e.g., Alzheimer's Disease)

Neuropsychology II.

A neuropsychological evaluation is particularly useful for tracking progress in rehabilitation after brain injury or other neurological disease.

Neuropsychological evaluation can assist greatly in planning educational and vocational programs. It can also be invaluable for disability determination or for forensic (legal) purposes.

What is a Neuropsychological Evaluation?

A neuropsychological evaluation is a comprehensive assessment of cognitive and behavioral functions using a set of standardized tests and procedures. Various mental functions are systematically tested, including, but not limited to:

Intelligence; Problem solving and conceptualization; Planning and organization; Attention, memory, and learning; Language; Academic skills; Perceptual and motor abilities; Emotions, behavior, and personality

Course

Prodromal symptomsAnxiety, depression, suspiciousMay be present for months before the

onset of schizophrenia

Acute stage Is generally in the late teens and early 20sPrecipitating events, such as emotional

trauma, drugs, separations, may trigger schizophrenia in predisposed persons

Course

Course of schizophrenia is deteriorating over time with acute exacerbations superimposed on a chronic pictureVulnerability to stress is lifelongPostpsychotic depressive episodes may occur in the residual phaseOver the course, the more florid positive psychotic symptoms tend to diminish in intensity, while the more residual negative symptoms may actually increase

Prognosis

The rule of thirds Approximately one third of patients lead somewhat

normal lives One third continue to experince significant

symptoms but can function within society The remaining one third are markedly impaired

and require frequent hospitalizations Approximately 10% of this final third of patients require

long-term hospitalization

Treatment

Antipsychotic drugs are available to control acute psychosis, but unfortunately many of the older agents are associated with a high rate of undesirable side effectsHowever, this is being improved by the newer antipsychotic drugsEffective treatment of schizophrenia extends well beyond drug therapy and includes psychotherapy and support from family and friendsUp to 20% of people who experience a psychotic episode may not experience any further episodes and will not require lifelong treatment.

TreatmentPeople with schizophrenia have an excess of the neurotransmitters like dopamine and serotoninThe conventional, first-generation antipsychotics are dopamine antagonistsThe newer, atypical, second-generation antipsychotics are dopamine and serotonin antagonists. The first-generation antipsychotics are associated with a high risk of side effects, which can be inconvenient, disabling and dangerous and occur in 40-50% of those treated. Second-generation antipsychotics are generally more widely prescribed to treat schizophrenia, as they cause fewer side effects.

Treatment

Schizophrenia can be characterised by three phases of treatment: AcuteStabilisationMaintenance

Acute treatment

The acute phase of treatment is from the start of the psychotic episode until remission or significant improvement of the psychotic symptomsThis usually takes 4 to 6 weeksDuring this short period, people with schizophrenia are often admitted to psychiatric hospitals or enrolled in a day care hospital programme, and are treated with the optimal dose of antipsychotic medication and may be sedated initially.

Stabilisation

This phase lasts from 6 weeks to 6 months after the onset of an acute episode and during this time, acute psychotic symptoms decrease in severityThe affected individual is discharged from hospital and antipsychotic medication is stabilised at a dose where the side effects are minimised while preventing recurrence of the psychotic symptomsPsychotherapy should be started at this phase.

Maintenance

After 6 months of antipsychotic treatment symptoms should be relatively stable and the psychiatrist should begin to reduce the dose of antipsychotic medication to a level that still prevents the reoccurrence of a psychotic episode

Continued support is needed during this time and psychoeducation and compliance-improving measures are very important.

How long should treatment continue?

minimum of 1 to 2 years maintenance treatment is recommended for people who have experienced one psychotic episodePeople who have experienced multiple psychotic episodes should receive treatment for up to 5 years to prevent further episodesPeople with a history of suicidal or dangerously aggressive behaviour should be treated for longer than 5 years. In severe cases, people should receive life-long treatment.

Psychosocial treatments

Psychosocial treatments are vital forms of therapy and should be implemented alongside medication. Psychosocial treatments include: Psychotherapy - individual and group therapies

that focus on practical life problems associated with schizophrenia, eg life skills training.

Family interventions - programmes that educate families about schizophrenia, provide support and crisis intervention and offer training in communication.

Psychosocial treatments

Psychosocial rehabilitation and skills development - training that teaches people verbal and nonverbal interpersonal skills, such as listening and conversation skills and medication management, to allow them to live successfully in the community.

Coping and self-monitoring - training to enable people to manage distressing symptoms and the effects of their illness.

Vocational rehabilitation - training on employment, self-esteem and personal purpose in life to teach people with schizophrenia the values of employment.

Prevention

Schizophrenia cannot be prevented

However, there are measures that can be taken to prevent schizophrenic relapses

Although antipsychotic medications can provide effective relief from the symptoms of schizophrenia, at least 50% of people with schizophrenia will suffer one or more relapses within one year.

PreventionOne of the major reasons that people relapse is because they stop taking their medicationThis may be because they experience inconvenient and distressing side effects, or because they do not fully understand the importance of their treatmentPeople with schizophrenia, and their families, should be given extensive and well-prepared information to enable them to fully understand the nature of the symptoms of schizophrenia, the course of the disease and the importance of taking their medication