Schizophrenia l Kraepelin-dementia precox l Bleuler-schism between thought, emotion and behavior in affected patients l 4 A’s –ambivalence –associations –affect –autism

Schizophrenia and DSM l Disturbance of 6 months or more that includes one month of 2 or more* of the following active-phase symptoms –Delusions –Hallucinations some point) –Disorganized Speech –Grossly disorganized or catatonic behavior –Negative symptoms

Positive & Negative Sx. l Delusions l Hallucinations l Disorganized thinking l Misperceptions l Blunted affect l Poor initiation & planning with tasks l Poverty of speech l Anhedonia

Delusions l Grandeur l Guilt l Jealousy l Passivity l Persecution l Poverty l Reference

Other Symptoms of Schizophrenia l Cognitive Dysfunction l Dysphoria l Absence of Insight l Sleep disturbance l Suicide l Illusions l Echopraxia

Why accurate Dx is important? l Frequency-1% l Chronicity –Schizophrenic patients die younger l Males 5.1 greater mortality l Suicide rate 10-13% higher overall l 2x MVAs; More disease & homelessness l Severity l Management* –80% vs. 30% relapse 1 year

Epidemiology l Gender vs l Comorbid with substance abuse l Deinstitutionalization (>2/3) l Dx has increased with the onset of neuroliptics

Etiology l Many different problems that converge on the same syndrome, not just a single disease l >50% of Sx appear to be associated with brain abnormalities (especially + Sx). l Stress Diathesis Model l Dopamine Hypothesis

Genetics

Factors related to good prognosis in Schizophrenia l Late onset l Obvious precipitating factors l Acute onset l Good premorbid social, sexual, and work history l Married l Family/Personal history of mood disorders l Good support systems l Positive symptoms

Factors related to poor prognosis in Schizophrenia l Young and insidious onset l No precipitating factors l Poor premorbid social, sexual, and work histories l Withdrawn, autistic behavior; assaultive history l Single, divorced or widowed l Neurological signs and symptoms/prenatal trauma l Family history of schizophrenia l No remission in 3 years; many relapses

Medication Issues l Chlorpromazine (Thorazine); Fluphenazine (Prolixin); Haloperidol (Haldol); Thiothixene (Navane); Thioridazine (Mellaril) & Perphenazine (Trilafon) l Benzodiazepines –Valium (diazepam) –Librium (chordiazepoxide) l Tardive dyskenesia l Newer drugs (Risperdal, Clozaril & Zyprexa) l Tablet or liquid form with “depot formulations”

Common antipsychotic medication side effects l Dry mouth l Constipation l Blurred vision l Drowsiness

Less common antipsychotic medication side effects l Decreased sexual desire l Menstrual changes l Stiff muscles on one side of the neck or jaw

Serious antipsychotic medication side effects l Restlessness l Muscle stiffness l Slurred speech l Extremity tremors l Agranulocytosis

Ethnicity and Antipsychotic medication efficacy (Frackiewicz, et al., 1997) l Asians responded to lowest dosages l Limited AfA results, with differences apparently due to prescribing practices l Authors highlight the problem of this line of cross-cultural research where Western ethnic groups are seen as homogenous l AfA are diagnosed significantly more with Scz than EA and less with depression l Satcher (2001) AfAs and Latinos… l AfA more likely to receive medication and less likely to be referred for therapy (Richardson, 2001)

Work Behavior Strengths l Minimal physical limitations l Generally have at least average IQ l Medications provide good control over symptoms for most l If onset in late 20s, the consumer may have a work history of > HS education

Work Behavior Limitations l Difficulty multitasking l Difficulty interacting with co-workers l Difficulty accepting criticism or supervision l May have difficulty with customer service or customer contact l Cyclic symptoms lead to inconsistent perf. l Needs work space with limited stimulation

Common types of work accommodations l Flexible schedule to allow time off during times when symptoms exacerbate or need “treatment” l Loss stress, low stimulation work environment l Training and education staff l Modifying simple job tasks l Developing on site services (e.g. EAP)

Comorbidity l 91% with accompanying substance abuse or mental health disorders (Judd, 1989) l Strongest relationship with mood disorders –81.4% with comorbid mood disorder –59% with comorbid unipolar depression –22% with comorbid bipolar depression –38% with comorbid mood disorder made at least one suicide attempt – 28.9% suicide attempts in pts. with comorbid bipolar disorder

Cultural variants l Women are less vulnerable to cognitive deficits than men (particularly verbal processing) Goldstein, et al., 1998 l Sx. Expression on the BSI were significantly higher in HA compared to EA Coelho, et al., 1998 l Cognitive differences must be covaried by premorbid language functioning

Catatonic Schizophrenia l Meets basic criteria for Schizophrenia l At least 2 catatonic symptoms predominate: –Stupor or motor immobility (catalepsy or waxy flexibility) –Hyperactivity w/o apparent purpose or not influenced by external stimulation –Mutism or marked negativism –Peculiar posturing, stereotypes, or mannerisms –Echolalia or echopraxia

Disorganized Schizophrenia l Meets all of the basic criteria for Schizophrenia plus l Disorganized behavior l Disorganized speech l Affect is flat or inappropriate l Not meet criteria for Catatonic Schz.

Undifferentiated Schizophrenia l Meets basic criteria for Schizophrenia but not Paranoid, Disorganized or Catatonic types l Diagnosis of exclusion..what is left

Residual Type l At one time met criteria for Schizophrenia, Catatonic, Disorganized, or Undifferentiated Type l No longer has pronounced catatonic behavior, delusions, hallucinations, or disorganized speech or behavior l Still ill as indicated by either –Negative symptoms –Attenuated form of at least 2 symptoms of Schz

Paranoid Schizophrenia l Meets basic criteria for Schizophrenia l Preoccupied with delusions or frequent auditory hallucinations l None of these symptoms is prominent: –Disorganized speech –Disorganized behavior –Inappropriate of flat affect –Catatonic behavior

Schizophreniform Disorder l “A” criteria symptoms for at least a month l Delusions (only 1 required, if bizarre) l Hallucination(s)* l Incoherent, derailed, or disorganized speech l Severely disorganized or catatonic behavior l Negative symptom l From prodromal to active and residual, symptoms last at least one month but no longer than six months

Factors related to good prognosis of Schizophreniform Disorder l Actual psychotic features begin within 4 weeks of the 1st noticeable change in the patient’s functioning or behavior l Pt. confused or perplexed when psychotic l Good premorbid social or job functioning l Affect is neither blunt nor flattened