Diagnosis and Management of Schizophrenia Stephen R. Marder, M.D. Professor and Director, Section on Psychosis Semel Institute for Neuroscience at UCLA VA Desert Pacific Mental Illness Research, Education, and Clinical Center

Diagnosis and Management of Schizophrenia Process for diagnosing schizophrenia Epidemiology Genetics and environment How to access severity Capacity to Work Current and future treatment

DSM-IV criteria for schizophrenia Characteristic Symptoms Social/occupational dysfunction Duration of 6 months Schizoaffective and mood disorder exclusion Substance/general medical exclusion Relationship to pervasive developmental disorder

Diagnostic Process for Schizophrenia Physical and lab exams rule out psychotic disorder due to a medical condition and substance-induced psychosis Imaging (CT, MRI, PET) are seldom helpful in diagnosis The diagnosis is commonly made from history and the mental status exam There are currently no reliable biomarkers for diagnosis or severity

Characteristic Psychotic Symptoms in Schizophrenia Audible thoughts Voices arguing or commenting Thought withdrawal or insertions by outside forces Thought broadcasting Impulses, volitional acts, or feelings imposed by outside forces Delusional perceptions

Symptom dimensions in schizophrenia Psychotic Hallucinations Suspiciousness Delusions Negative Impoverished speech Lack of motivation Asociality Decreased Affect Neurocognitive – Impairments Memory Attention Motor skills Social cognition Executive skills Disorganized speech

Epidemiology of Schizophrenia Lifetime prevalence of about 1% No differences related to culture or race Onset in men is usually earlier (15-24) than in women (25-34)

Global Burden of Disease 2000 (15-Disease-adjusted Life Years (DALYs) Top 10 Causes of DALYS in Adults (15-44 years) Both Sexes % Total Male Female HIV/AIDS 13.0 12.1 HIV AIDS 13.9 Depressive disorders 8.6 Road traffic accidents 7.7 10.6 4.9 6.7 Tuberculosis 3.2 3.9 Alcohol Use Disorders 5.1 Iron deficiency anemia 3.0 4.5 Schizophrenia 2.8 Self-inflicted Injuries 2.7 Violence 3.7 Obstructed labor Iron-deficiency anemia 2.6 Bipolar disorder 2.5 Abortion 2.4 Self-inflicted injuries 2.3 2.1 Maternal sepsis DALY=Sum of years of life lost due to premature mortality and years lost due to disability WHO. The World Health Report 2001. Available at http://www.who.int/whr/2001/en/index.html

Course of Schizophrenia Good Premorbid Progression Stable Relapsing Function Psycho- pathology Poor 15 20 30 40 50 60 70 Age (Years) Sheitman BB, Lieberman JA. The natural history and pathophysiology of treatment-resistant schizophrenia. J Psychiatr Res. 1998(May-Aug);32(3-4):143-150

Severity in Schizophrenia People with schizophrenia have different levels of disability varying from no disability to complete dependence on institutional care The amount and type of disability is related to the symptoms of the individual’s illness and how responsive these symptoms are to treatment

Severity in Schizophrenia The severity of psychotic symptoms are related to How distracting Do they influence behavior – eg, command hallucinations Do they cause suffering Do they impair social functioning – eg, suspiciousness

Severity The severity of negative symptoms are related to Social isolation Apathy Lack of expressiveness The severity of cognitive impairments are related to Poor concentration Poor memory Inability to make simple decisions Inability to interpret social signals Slower pace

Pharmacological Treatment of Acute Schizophrenia Antipsychotic medications are effective for decreasing the severity of psychotic symptoms Nearly all patients on antipsychotic medications will experience some burden from side effects Antipsychotics are relatively ineffective for negative symptoms and cognitive impairment

Long-term treatment of schizophrenia Antipsychotic medications are effective for preventing relapse in stabilized patients Effective nonpharmacological treatments include patient and family education, skills training, supported employment, cognitive behavior therapies, and psychotherapies For most individuals, antipsychotic medications control the symptoms while non-pharmacological treatments address the impairments in social, vocational, and educational functioning

Clinical Challenges Substance use disorders are common in people with schizophrenia Insight can be impaired leading people with schizophrenia to refuse treatment Adherence to treatments can be irregular