Schizophrenia Overview

Schizophrenia is the most severe and debilitating mental illness in psychiatry and is a brain disorder

History Bleuiler 1) Autism 2) Ambivalence 3) Affect 4) Association

Diagnosis of Schizophrenia A. Characteristic symptoms -Delusions -Hallucinations -Disorganized speech -Grossly disorganized or catatonic behavior -Negative symptoms B. Social/occupational dysfunction C. Overall duration > 6 months D. Exclude mood disorders, drugs, pervasive developmental disorders

Positive Symptoms Additions to normal function Delusions Hallucinations Distorted language/communication Disorganised speech / behaviour Catatonic behaviour Agitation

Negative Symptoms Losses of normal function -Affective flattening -Alogia -Avolition -Anhedonia -Attentional impairment Blunted affect, emotional withdrawal, poor rapport, passivity, apathetic, social withdrawal

Cognitive Symptoms Thought disorder Odd use of language incoherence, loose associations, neologisms Impaired attention / cognition reduced verbal fluency learning/memory executive functions

Subtypes of schizophrenia Paranoid Disorganized Catatonic Undifferentiated Residual

Childhood onset schizophrenia Onset before 12 years Increased developmental abnormalities Lower IQ 1 in Increased heritability Decreased gray matter

Epidemiology 1% prevalence worldwide Most begin in late adolescence to 20’s M=F Females age of onset is generally later – better outcome Downward drift social-economically Die younger – 10% suicide

Etiology of schizophrenia Genetic Structural brain changes Functional brain changes Dopamine hypothesis

Risk Factors Genetic Canabis Infection & Birth Season

prognosis Age of onset Function level before onset IQ Drug response Family support sex

Structural changes in brain Larger ventricles Subgroup: inverse correlation between ventricle size and response to drugs

Structural changes in brain Increased loss of gray matter in adolescence

Dopamine hypothesis Amphetamine (very high doses)  paranoia, delusions, auditory hallucination Amphetamines worsen schizophrenia symptoms Effects blocked by dopamine antagonist chlorpromazine (Thorazine) Typical antipsychotics block D2 receptors and alleviate positive symptoms.

A 20th-century artist, Louis Wain, who was fascinated by cats, painted these pictures over a period of time in which he developed schizophrenia. The pictures mark progressive stages in the illness and exemplify what it does to the victim's perception.

Treatment of Schizophrenia

Medications for schizophrenia Conventional antipsychotics - Haldol, Thorazine, Mellaril, etc. Second generation antipsychotics -Risperidone, Zyprexa, Seroquel, Geodon, Abilify, Clozaril Medications are better for positive symptoms than negative symptoms

First generation antipsychotic side-effects Extrapyramidal side-effects – Parkinson symptoms, dystonia, restlessness Sedation Weight gain Dry mouth, constipation Cardiac toxicity Postural hypotension

Second generation antipsychotic side-effects Weight gain Increase blood sugar – diabetes Increased lipids Sedation

Non-pharmacologic treatments for schizophrenia Psychotherapy – supportive Social skills training Family Therapy – expressed emotion Psychosocial rehabilitation

Future Directions in the Treatment of Schizophrenia More optimistic view of outcome Much stronger focus on early intervention and prevention e.g. early psychosis clinics and prodromal studies Increased understanding of neurobiological basis beyond dopamine hypothesis with non-dopamine treatments Renewed emphasis on rehabilitation, supported employment etc.