Schizophrenia

Overview Most debilitating and costly of all adult psychiatric illnesses ~25% of all psychiatric beds are occupied by persons with schizophrenia 2002 fiscal costs of schizophrenia was 62.7 billion Greatest burden is lost productivity

Schizophrenia Multisystem disease Often difficult to describe and understand No single feature is pathogonomic of Schizophrenia Associated with a constellation of signs and symptoms A disease that affects many domains of human functioning COGNITION EMOTION INTERPERSONAL RELATIONSHIPS Debilitating: 25-60% live with relatives 10-20% are homeless -

Epidemiology 2.2 million people have schizophrenia at any given time One year prevalence rates are 1-4.6% Prevalence rates are roughly stable across a range of populations and cultures Persons with schizophrenia in developing countries may have a better course and prognosis Persons with schizophrenia are less likely to marry (particularly males) and less likely to complete higher education Between 14-20% of those with schizophrenia are employed competitively

Onset and Course of Illness Onset typical in late adolescence or early adulthood Prodromal period or changes in mood and behavior prior to first break may last up to five years Early versus late onset illness Early signs date back to childhood –Deficits in verbal memory –Deficits in attentional vigilance –Deficits in gross motor skills –May be additional interpersonal difficulties or other difficulties in functioning –Early conduct disorder may also be prodromal –Early signs may be subtle, irregular, and graduate and more apparent in adolscence

Factors Assoc. with Better Prognosis Good premorbid adjustment Acute onset Later afe at onset Being female Precipitating event Associated mood disturbance Brief duration of active phase symptoms Good interepisode functioning Minimum residual symptoms Absence of structural brain abnormalities No family history of schizophrenia

Schizophrenia A. Two or more of the following during 1- month period (or less if successfully treated): (1) delusions* (2) hallucinations* (3) disorganized speech (frequent derailment or incoherence) (4) grossly disorganized or catatonic behaviour (5) negative symptoms (affective flattening, alogia, avolition) B. Social Occupational Dysfunction C. Duration: at least 6 months, with 1 month of active phase symptoms (or less if successfully treated) May include Prodromal/Residual periods

Schizophrenia (con’t) D. Schizoaffective and Mood Disorder exclusion C. Substance/general medical condition exclusion E. Relationship to a Pervasive Developmental Disorder Specify course: Episodic with Interepisode Residual Symptoms - with prominent negative symptoms Episodic with No Interepisode Residual Symptoms - continuous (prominent psychotic symptoms) - with prominent negative symptoms Single Episode in Partial Remission - with prominent negative symptoms Single Episode in Full Remission Other or Unspecified Pattern

Differential Diagnosis of Psychosis Mood Disorder with Psychotic features Prolonged Substance Abuse Brain Damage Infections Neurohereditary Disorders Nutritional Abnormalities

Positive Symptoms

Disorganized Symptoms

Negative Symptoms

Schizophrenia Subtypes Can change over the course of the illness Catatonic Type Disorganized Type Paranoid Type Undifferentiated Type Residual Type

Catatonic Type Clinical Picture is dominated by at least two of the following: (1) motoric immobility as evidenced by catalepsy (2) excessive motor activity (3) extreme negativism (4) peculiarities of voluntary movement (5) echolalia or echopraxia

Disorganized Type Following criteria are met: A. All of the following are prominent: (1) disorganized speech (2) disorganized behaviour (3) flat or inappropriate affect B. The criteria are not met for Catatonic Type

Paranoid Type Following criteria are met: A. Preoccupation with one or more delusions or frequent auditory hallucinations B. None of the following is prominent: disorganized speech disorganized or catatonic behaviour flat or inappropriate affect

Undifferentiated Type Type of Schizophrenia where symptoms: (1) Meet Criterion A (2 Are not met for the Paranoid, Disorganized or Catatonic type

Residual Type Following criteria are met: A. Do not fit into an other categories B. Evidence of a disturbance as indicated by: presence of negative symptoms or two or more symptoms listed in Criterion A

Schizophreniform Disorder Criteria A, D, and E of Schizophrenia are met An episode of the disorder (including prodromal, active and residual phases) lasts at least 1 month but less than 6 months. “Provisional” when without recovery Specify if: Without Good Prognostic Features With Good Prognostic Features

Schizoaffective Disorder Uninterrupted period of illness where there is either: Major Depressive Episode, Manic or Mixed concurrent with symptoms meeting Criterion A for Schizophrenia Major depressive episode must meet A1 criterion During illness, two week period of delusions or hallucinations in absence of prominent mood symptoms Symptoms meeting criteria for mood episode present for substantial period of the total duration of illness Not better accounted for substance use or general medical condition Specify Bipolar or Depressive Type

Delusional Disorder A. Nonbizarre delusions of at least 1 months duration B. Criterion A for Schizophrenia has never been met C. Functioning is not markedly impaired or bizarre D. If there are mood episodes concurrent with delusions, their total duration is brief relative to periods of delusional periods. E. Not due to effects of substance or a general medical condition

Delusional Disorder (con’t) Specify type: Erotomanic Type: another person, usually of higher status in love with the person Grandiose Type: inflated worth, power, knowledge, identity Jealous Type: unfaithful theme Persecutory Type: Conspiracy theme Somatic Type: Physical defect theme Mixed Type: more than one of the above Unspecified Type: cannot be determined

Comorbidity Depression is very common with a comorbidity rate of 45% Approximately 10% of those with schizophrenia die from the illness though more recent estimates have lowered this to 4-5.6% Suicide risk is greater with mood and substance use disorders Anxiety disorders have a high rate of comorbidity (43%) and may prompt the formation and maintenance of persecutory delusions and hallucinations Lifetime comorbidity for substance use disorders is 50% Associated symptoms also include anger, hostility, and social avoidance

Violence and Associated Issues Rates of violence for persons with schizophrenia are lower than rates for persons with depression or bipolar disorder If violence occurs it is typically a result of the co- occuring substance use Rates of victimization risk can be very high 34%-54% report childhood sexual or physical abuse 43%-81% report some type of lifetime victimization

Sex differences in Illness Course Women have later age at onset Women have better premorbid histories Women express more affective symptomatology Women exhibit more benign course in terms of hospitalizations and social functioning Women appear to have less structural brain damage Males appear to have a higher incidence of the illness

Importance of Estrogen Pregnancy confers protective advantage Postpartum increased risk for psychotic symptoms Psychotic symptoms increase when estrogen levels are lowest during menstrual cycle Hormone supplements appear to offset psychotic symptoms during the menstrual cycle

ETIOLOGY

Biological Genetics Linkage Analysis Genetic Markers Heritability Twin Studies Adoption Studies

Brain Abnormalities Enlarged Ventricles Frontal Lobe Hypofrontality Temporal Lobe Neurochemical

Brain Abnormalities

Psychological Factors Expressed Emotion: Jill Hooley -Concerns the degree to which family members are either critical of a recently hospitalized patient, hostile, or express overinvolved and overprotective attitudes toward the patient. This construct is thought to reflect disturbances in the organization, emotional climate, and transactional patterns of the entire family system -Assessed in the Camberwell Family Interview and usually takes 1-2 hours -Most important element of EE is criticism -EE is a reliable risk factor for relapse in schizophrenia

Diathesis/Personality/Stress: Schizophrenia Diathesis  Heterogeneity within the etiology  DA involvement but complex; DA receptor sensitivity?  Enlargement of Ventricles, particularly for males  Polygenic vulnerability  Hypofrontality, particularly for negative symptoms  Severe birth complications  Viral infections Personality  Psychoticism historically but New data on Neuroticism  Schizotypal personality  In childhood lower scores on intelligence and ach  In childhood less responsive in social situations  In childhood more diff with motor dev  Escalating adjustment diff, dep, social withdrawal, irritability, noncompliance Stressor > Family based communication deviance  Expressed emotion assoc with increased risk of relapse; critical and overinvolved (effect size.31)  Severe prolonged stressors studied  High rates of criterion A stressors