Schizophrenia Understanding the Disease

What is Schizophrenia Schizophrenia is a chronic and disabling brain disorder that has been recognized throughout recorded history. It affects about 1% of the population of the United States. Symptoms usually emerge for men in In females Many people with this disorder have difficulty holding a job or caring for themselves. This creates a great burden for their families and for society.

Epidemiology First degree relatives have 10 time greater risk of developing the disorder. First degree relatives have 10 time greater risk of developing the disorder. Up to 50% have substance abuse and 90% have smoking. Up to 50% have substance abuse and 90% have smoking. More prevalent in low socio Economices. More prevalent in low socio Economices. High frequent hospitalization. High frequent hospitalization.

Suicide in Schizophrenia People with schizophrenia attempt suicide much more often than people in the general population. About 10% (especially young adult males) succeed. It is hard to predict which patients with the disorder are prone to suicide. Listen when they talk about harming themselves. People with schizophrenia attempt suicide much more often than people in the general population. About 10% (especially young adult males) succeed. It is hard to predict which patients with the disorder are prone to suicide. Listen when they talk about harming themselves.

Presentation Those with the disorder may hear voices that others don’t hear. They may believe that others are reading their minds, controlling their thoughts, or plotting to harm them. Those with the disorder may hear voices that others don’t hear. They may believe that others are reading their minds, controlling their thoughts, or plotting to harm them. They may not make sense when they talk or they may seem perfectly fine until they start talking about what they are really thinking. They may not make sense when they talk or they may seem perfectly fine until they start talking about what they are really thinking.

What are the symptoms? The symptoms of schizophrenia fall into three broad categories. The symptoms of schizophrenia fall into three broad categories. Positive Symptoms are unusual thoughts or perceptions, including hallucinations, delusions, thought disorder and disorder of movement. Auditory hallucinations are the most common. Positive Symptoms are unusual thoughts or perceptions, including hallucinations, delusions, thought disorder and disorder of movement. Auditory hallucinations are the most common.

Summary of Positive Symptoms Delusions Delusions Hallucinations Hallucinations Disorganized thinking Disorganized thinking Disorganized behavior Disorganized behavior Catatonic behavior Catatonic behavior Inappropriate responses Inappropriate responses

Symptoms Continued Negative Symptoms refers to reductions in normal emotional and behavioral states such as: Negative Symptoms refers to reductions in normal emotional and behavioral states such as: Flat affect with immobile facial expression, monotonous voice. Flat affect with immobile facial expression, monotonous voice. Lack of pleasure in everyday life. Lack of pleasure in everyday life. Diminished ability to initiate and sustain planned activity. Diminished ability to initiate and sustain planned activity. Speaking infrequently even when forced to interact Speaking infrequently even when forced to interact People with the disorder often neglect basic hygiene and need help with ADL. People with the disorder often neglect basic hygiene and need help with ADL.

Summary of Negative Symptoms Lack of emotion Lack of emotion Low energy Low energy Lack of interest in life Lack of interest in life Affective flattening Affective flattening Alogia Alogia Inappropriate social skills Inappropriate social skills Inability to make friends Inability to make friends Social isolation Social isolation

Symptoms Continued Cognitive Symptoms are subtle and often detected only when neuropsychological test are performed. Cognitive Symptoms are subtle and often detected only when neuropsychological test are performed. Poor executive functioning. (the ability to absorb and interpret information and make decisions based on that information). Poor executive functioning. (the ability to absorb and interpret information and make decisions based on that information). Inability to sustain attention. Inability to sustain attention. Problems with working memory (the ability to keep recently learned information in mind and use it right away). Problems with working memory (the ability to keep recently learned information in mind and use it right away).

Cognitive Symptoms Difficulties in concentration and memory: Difficulties in concentration and memory: Disorganized thinking Disorganized thinking Slow thinking Slow thinking Difficulty understanding Difficulty understanding Poor concentration Poor concentration Poor memory Poor memory Difficulty expressing thoughts Difficulty expressing thoughts Difficulty integrating thoughts, feelings, behaviors Difficulty integrating thoughts, feelings, behaviors

Types of Schizophrenia Paranoid Paranoid Hebephrenic Hebephrenic Catatonic Catatonic Residual Residual Schizoaffective Schizoaffective Undifferentiated Undifferentiated

Paranoid Schizophrenia Persons are very suspicious of others and often have grand schemes of persecution at the root of their behavior. Persons are very suspicious of others and often have grand schemes of persecution at the root of their behavior. During this phase they may have hallucinations and frequent delusions. During this phase they may have hallucinations and frequent delusions.

Hebephrenic Schizophrenia AKA disorganized schizophrenia; characterized by emotionless, incongruous, or silly behavior, intellectual deterioration, frequently beginning insidiously during adolescence. AKA disorganized schizophrenia; characterized by emotionless, incongruous, or silly behavior, intellectual deterioration, frequently beginning insidiously during adolescence. May be verbally incoherent and may have moods and emotions that are not appropriate to the situation. May be verbally incoherent and may have moods and emotions that are not appropriate to the situation. Hallucinations not usually present. Hallucinations not usually present.

Catatonic Schizophrenia Person is extremely withdrawn, negative and isolated. Person is extremely withdrawn, negative and isolated. May have marked psychomotor disturbances. May have marked psychomotor disturbances.

Residual Schizophrenia Lacks motivation and interest in day-to- day living. Lacks motivation and interest in day-to- day living. Person is not usually having delusions, hallucinations or disorganized speech. Person is not usually having delusions, hallucinations or disorganized speech.

Undifferentiated Schizophrenia Conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the previous types. Conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the previous types. Exhibits more than one of the previous types without a clear dominance of one. Exhibits more than one of the previous types without a clear dominance of one.

Causes The disorder is believed to result from a combination of environmental and genetic factors. It is well known that the disease runs in families, and is seen in 10% of people with a first degree relative. The disorder is believed to result from a combination of environmental and genetic factors. It is well known that the disease runs in families, and is seen in 10% of people with a first degree relative. Identical twins have 50% chance of developing the disorder. Identical twins have 50% chance of developing the disorder. Child of one parent schizophrenia 12 and two parent 40%. Child of one parent schizophrenia 12 and two parent 40%. Age of the father at conception time. Age of the father at conception time.

Cause Although there is a genetic risk for schizophrenia, it is not likely that genes alone are sufficient to cause the disorder. Interactions between genes and the environment are thought to be necessary for the disorder to develop. Although there is a genetic risk for schizophrenia, it is not likely that genes alone are sufficient to cause the disorder. Interactions between genes and the environment are thought to be necessary for the disorder to develop. Many risk factors have been identified such as exposure to viruses or malnutrition in the womb, problems during birth, and psychosocial factors such as stressful environmental conditions. Many risk factors have been identified such as exposure to viruses or malnutrition in the womb, problems during birth, and psychosocial factors such as stressful environmental conditions.

Brain Function: Neurotransmission Dysfunction Dopamine Pathway. Dopamine Pathway. Serotonin pathway. Serotonin pathway. Norepinephrine pathway. Norepinephrine pathway. GABAergic system. GABAergic system. Neuropeptide (substance P, neurotensine). Neuropeptide (substance P, neurotensine). Glutamate( Glutamate antagonist-PCP and psychosis ). Glutamate( Glutamate antagonist-PCP and psychosis ). Acetylcholine and Nicotine(cognition regulation) Acetylcholine and Nicotine(cognition regulation)

Brain Function: Neuropathology Cortex & Cerebral ventricles. Cortex & Cerebral ventricles. Reduced symmetry. Reduced symmetry. Limbic system:( amigdala, hypocumpus,…) decreased size. Limbic system:( amigdala, hypocumpus,…) decreased size. Prefrontal cortex. Prefrontal cortex. Thalamic nuclei. Thalamic nuclei. Basal ganglia and cerebellum(movement disorders and psychosis). Basal ganglia and cerebellum(movement disorders and psychosis). Neural circuits. Neural circuits.

Brain function: Brain metabolism. Brain metabolism. Applied electrophysiology. Applied electrophysiology. Complex partial seizure and psychosis. Complex partial seizure and psychosis. Evoked potential and delayed transmission velocity. Evoked potential and delayed transmission velocity. Eye movement Dysfunction. Eye movement Dysfunction.

Psychoneuroimmunology Decreased T-cell interlukin-2 production. Decreased T-cell interlukin-2 production. Abnormal cellular reactivity to neurons. Abnormal cellular reactivity to neurons. Presence of antibrain antibody. Presence of antibrain antibody. =Neurotoxic viral infectin? Or endogenous autoimmune disorders.

DSM-IV diagnostic criteria A screening test A screening test A screening test A screening test At least two characteristic symptoms for one month(or shorter on treatment): At least two characteristic symptoms for one month(or shorter on treatment): +Delusions * +Delusions * +Hallucinations * +Hallucinations * * Only one symptom required if it is bizarre delusions or continually commenting or conversing auditory hallucinations +Disorganized speech +Disorganized speech +Grossly disorganized or catatonic behavior +Grossly disorganized or catatonic behavior Negative symptoms Negative symptoms

More diagnostic criteria Significantly long-lasting marked impairment of social or occupational functioning or self-care. Significantly long-lasting marked impairment of social or occupational functioning or self-care. Lasts for six continuous months, including at least one month of active phase symptoms Lasts for six continuous months, including at least one month of active phase symptoms No major depressive, manic, or mixed mood episodes No major depressive, manic, or mixed mood episodes

The syndrome duration Total duration must be at least 6 months Total duration must be at least 6 months Prodrome Active Phase Residual Phase Prodrome Active Phase Residual Phase Pro- drome Pro- drome Active Phase Residual Phase The active phase must last at least 1 month

0ther psychotic disorders Schizoaffective disorder. Schizoaffective disorder. Brief psychotic disorder. Brief psychotic disorder. Shizophreniforme disorder. Shizophreniforme disorder. Delusional disorders. Delusional disorders. Substance induced psychotic disorders. Substance induced psychotic disorders.

Schizophrenia vs Schizoaffective Disorder Schizoaffective disorder is characterized by both the psychotic thought problems of schizophrenia and the mood problems of depression or bipolar disorder. Schizoaffective disorder is characterized by both the psychotic thought problems of schizophrenia and the mood problems of depression or bipolar disorder. Two conditions must be meet to qualify as schizoaffective disorder: Two conditions must be meet to qualify as schizoaffective disorder: 1. Psychotic symptoms sufficient for the diagnosis of schizophrenia are present – specifically active hallucinations or delusions present for at least two weeks in a row. 1. Psychotic symptoms sufficient for the diagnosis of schizophrenia are present – specifically active hallucinations or delusions present for at least two weeks in a row.

Schizoaffective Disorder 2. One or more major depressive episodes, manic episodes, or mixed mood episode occur concurrent with the psychotic episode. 2. One or more major depressive episodes, manic episodes, or mixed mood episode occur concurrent with the psychotic episode. Doctors differ on whether it is better to diagnose schizoaffective disorder, or to diagnose a bipolar or major depression and schizophrenia separately. It is not sure at this time if schizoaffective disorder describes a single disease entity or not. Doctors differ on whether it is better to diagnose schizoaffective disorder, or to diagnose a bipolar or major depression and schizophrenia separately. It is not sure at this time if schizoaffective disorder describes a single disease entity or not.

Mechanism of Action of Antipsychotics While the precise mechanism of action that accounts for the effects of antipsychotic medications is still unknown, the dopamine hypothesis is the predominate theory used to explain the action of these drugs. While the precise mechanism of action that accounts for the effects of antipsychotic medications is still unknown, the dopamine hypothesis is the predominate theory used to explain the action of these drugs. Schizophrenia is caused by an excess in dopamine activity in the brain, which is inhibited by blockade of the receptors Schizophrenia is caused by an excess in dopamine activity in the brain, which is inhibited by blockade of the receptors There are two core components to the dopamine theory: (1) psychosis is induced by increased levels of dopamine activity and (2) most antipsychotic drugs block postsynaptic dopamine receptors There are two core components to the dopamine theory: (1) psychosis is induced by increased levels of dopamine activity and (2) most antipsychotic drugs block postsynaptic dopamine receptors

Antipsychotics Antipsychotic medications have been available since the mid 1950’s. These drugs have greatly improved the lives of patients with schizophrenia since their first development, but these medications do not cure the disease. Antipsychotic medications have been available since the mid 1950’s. These drugs have greatly improved the lives of patients with schizophrenia since their first development, but these medications do not cure the disease. The older antipsychotic medications effectively alleviate the positive symptoms of schizophrenia. These which are considered conventional or typical medications produced side effects which made compliance difficult. The older antipsychotic medications effectively alleviate the positive symptoms of schizophrenia. These which are considered conventional or typical medications produced side effects which made compliance difficult.

Antipsychotics Most of these older "conventional" antipsychotics differed in the side effects they produced. Side effects such as orthostatic hypotension, sedation, anticholinergic effect and extrapyramidal effects. Most of these older "conventional" antipsychotics differed in the side effects they produced. Side effects such as orthostatic hypotension, sedation, anticholinergic effect and extrapyramidal effects. These conventional antipsychotics include chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). These conventional antipsychotics include chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril) chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril)

Extrapyramidal Effects Extrapyramidal Side Effects are a group of symptoms that can occur in persons taking antipsychotic medications. They are more commonly caused by the typical antipsychotics but can and do occur with all of them. Extrapyramidal Side Effects are a group of symptoms that can occur in persons taking antipsychotic medications. They are more commonly caused by the typical antipsychotics but can and do occur with all of them.typical antipsychoticstypical antipsychotics Extrapyramidal side effects include: Extrapyramidal side effects include: tremor, akathisia, slurred speech, dystonia, bradykinesia, and muscular rigidity tremor, akathisia, slurred speech, dystonia, bradykinesia, and muscular rigidity

Extrapyramidal Effects Akathisia is a movement disorder characterized by inner restlessness and the inability to sit or stand still. Akathisia may appear as a side effect of long-term use of antipsychotic medications, Lithium, and some other psychiatric drugs. Akathisia is a movement disorder characterized by inner restlessness and the inability to sit or stand still. Akathisia may appear as a side effect of long-term use of antipsychotic medications, Lithium, and some other psychiatric drugs. Persons with akathisia typically have restless movements of the arms and legs such as tapping, marching in place, rocking, crossing and uncrossing the legs. They may feel anxious at the thought of sitting down. Persons with akathisia typically have restless movements of the arms and legs such as tapping, marching in place, rocking, crossing and uncrossing the legs. They may feel anxious at the thought of sitting down.

Extrapyramidal Effects Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, which force certain parts of the body into abnormal, sometimes painful, movements or postures. Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, which force certain parts of the body into abnormal, sometimes painful, movements or postures. Acute dystonic reactions are characteristically sustained contraction of the muscles of neck (torticollis), eyes (oculogyric crisis), tongue, jaw and other muscle groups typically occurring within days after initiation of the neuroleptic. Acute dystonic reactions are characteristically sustained contraction of the muscles of neck (torticollis), eyes (oculogyric crisis), tongue, jaw and other muscle groups typically occurring within days after initiation of the neuroleptic.

Extrapyramidal Effects Bradykinesia means "slow movement." Bradykinesia essentially refers to a component of parkinsonism. The full spectrum of parkinsonism is derived from the features of Parkinson's disease, which include bradykinesia, tremor, and rigidity. Bradykinesia means "slow movement." Bradykinesia essentially refers to a component of parkinsonism. The full spectrum of parkinsonism is derived from the features of Parkinson's disease, which include bradykinesia, tremor, and rigidity. Rigidity is defined as hypertonia in which the following are true: Rigidity is defined as hypertonia in which the following are true: The resistance to externally imposed joint movement is present at very low speeds of movement, does not depend on imposed speed, and does not exhibit a speed or angle threshold; The resistance to externally imposed joint movement is present at very low speeds of movement, does not depend on imposed speed, and does not exhibit a speed or angle threshold;

Antipsychotics In the 1990’s, new drugs, called atypical antipychotics, were developed. In the 1990’s, new drugs, called atypical antipychotics, were developed. These medications appear to be equally effective for helping reduce the positive symptoms like hallucinations and delusions - but may be better than the older medications at relieving the negative symptoms of the illness, such as withdrawal, thinking problems, and lack of energy. These medications appear to be equally effective for helping reduce the positive symptoms like hallucinations and delusions - but may be better than the older medications at relieving the negative symptoms of the illness, such as withdrawal, thinking problems, and lack of energy. negative symptoms negative symptoms

Antipsychotics The atypical antipsychotics include aripiprazole (Abilify), risperidone (Risperdal), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). The atypical antipsychotics include aripiprazole (Abilify), risperidone (Risperdal), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon).aripiprazole (Abilify)risperidone (Risperdal)clozapine (Clozaril)olanzapine (Zyprexa)quetiapine (Seroquel)ziprasidone (Geodon)aripiprazole (Abilify)risperidone (Risperdal)clozapine (Clozaril)olanzapine (Zyprexa)quetiapine (Seroquel)ziprasidone (Geodon) Current treatment guidelines recommend using one of the atypical antipsychotics other than clozapine as a first line treatment option for newly diagnosed patients. Current treatment guidelines recommend using one of the atypical antipsychotics other than clozapine as a first line treatment option for newly diagnosed patients.

Antipsychotics Clozapine (Clozaril) was the first atypical introduced. It treats psychotic symptoms effectively even in people who do not respond to other medications. Clozapine (Clozaril) was the first atypical introduced. It treats psychotic symptoms effectively even in people who do not respond to other medications. It can produce a serious problem called agranulocytosis. This is a loss of the white blood cells that fight infection in the body. Patients who take clozapine must have their white blood cell count monitored weekly and then monthly for the extent of use. It can produce a serious problem called agranulocytosis. This is a loss of the white blood cells that fight infection in the body. Patients who take clozapine must have their white blood cell count monitored weekly and then monthly for the extent of use. Even with this complication, it is still the drug of choice with those whose symptoms do not respond to the other antipsychotic medications, old or new. Even with this complication, it is still the drug of choice with those whose symptoms do not respond to the other antipsychotic medications, old or new.

Antipsychotics Side Effects – When patients first start to take the atypical antipsychotics, they may become drowsy or experience dizziness when they change positions (orthostatic hypotension). Side Effects – When patients first start to take the atypical antipsychotics, they may become drowsy or experience dizziness when they change positions (orthostatic hypotension). They may have blurred vision, or develop a rapid heartbeat, menstrual problems, a sensitivity to the sun, or skin rashes. They may have blurred vision, or develop a rapid heartbeat, menstrual problems, a sensitivity to the sun, or skin rashes.

Antipsychotics Side Effects Many of these symptoms will go away after the first few days but could last for up to one to two weeks. Advise your patients that if the symptoms do not go away after two to three weeks to notify the practitioner who prescribed the medication. Many of these symptoms will go away after the first few days but could last for up to one to two weeks. Advise your patients that if the symptoms do not go away after two to three weeks to notify the practitioner who prescribed the medication. Also advise them that they should not be driving until they adjust to their new medication. Also advise them that they should not be driving until they adjust to their new medication.

Antipsychotics Side Effects The atypical antipsychotics produce much less extrapyramidal symptoms but they can cause weight gain and metabolic changes associated with an increase risk of diabetes and cardiovascular disease. The atypical antipsychotics produce much less extrapyramidal symptoms but they can cause weight gain and metabolic changes associated with an increase risk of diabetes and cardiovascular disease. When starting these medications a baseline check is made for risk factors for diabetes. When starting these medications a baseline check is made for risk factors for diabetes. Baseline laboratory test: Fasting glucose, HDL, Triglycerides, Blood Pressure. Baseline laboratory test: Fasting glucose, HDL, Triglycerides, Blood Pressure. BMI if older than 27 year old. BMI if older than 27 year old.

Monitoring On monthly visits monitor for things such as over eating, weight gain, polyuria (increase urination), polydipsia (increased thirst). On monthly visits monitor for things such as over eating, weight gain, polyuria (increase urination), polydipsia (increased thirst). When each of you see your clients, if they have recently been put on an antipsychotic, discuss the above symptoms with them. When each of you see your clients, if they have recently been put on an antipsychotic, discuss the above symptoms with them. Have them notify the practitioner if they are having problems with any of these symptoms. Have them notify the practitioner if they are having problems with any of these symptoms.

Summary Relapses occur most often when people with schizophrenia stop taking their antipsychotic medication. Relapses occur most often when people with schizophrenia stop taking their antipsychotic medication. They may feel better, or their side effects or so bad they stop the medication. They may feel better, or their side effects or so bad they stop the medication. At times they don’t feel taking their medication regularly is important. At times they don’t feel taking their medication regularly is important. It is our responsibility to education our patient to be compliant and monitor them to keep them healthy. It is our responsibility to education our patient to be compliant and monitor them to keep them healthy.