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SCHIZOPHRENIA
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History Emil Kraeplin - dementia precox Eugen Bleuler - schizophrenia 4A’s : associational disturbances affective disturbances ambivalence autism - Secondary Symptoms: hallucinations & delusions Emil Kraeplin - dementia precox Eugen Bleuler - schizophrenia 4A’s : associational disturbances affective disturbances ambivalence autism - Secondary Symptoms: hallucinations & delusions
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Other Theorists: Adolf Meyer - founder of psychobiology; schizophrenic reaction Harry Stack Sullivan - founder of interpersonal psychoanalytic school; social isolation Gabriel Langfeldt - 2 groups: with true schizophrenia & schizophreniform psychosis Kurt Schneider - first rank symptoms Other Theorists: Adolf Meyer - founder of psychobiology; schizophrenic reaction Harry Stack Sullivan - founder of interpersonal psychoanalytic school; social isolation Gabriel Langfeldt - 2 groups: with true schizophrenia & schizophreniform psychosis Kurt Schneider - first rank symptoms
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Epidemiology Lifetime prevalence (US) = 0.6 - 1.9% Annual incidence of 0.5 - 5.0 per 10,000 1. Age & Sex: M=F M: early onset (15-25 yrs), > (-) sxs F: peak onset=25-35 yrs, better outcome 90% of cases - between 15-55 years old Onset before 10yrs & after 50 yrs=rare Lifetime prevalence (US) = 0.6 - 1.9% Annual incidence of 0.5 - 5.0 per 10,000 1. Age & Sex: M=F M: early onset (15-25 yrs), > (-) sxs F: peak onset=25-35 yrs, better outcome 90% of cases - between 15-55 years old Onset before 10yrs & after 50 yrs=rare
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2. Medical Illness Have higher mortality rate from accidents and natural causes 80% - have significant concurrent medical illness 2. Medical Illness Have higher mortality rate from accidents and natural causes 80% - have significant concurrent medical illness
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3. Suicide - 50% attempt suicide 50% attempt suicide 10-15% die by suicide M=F, likelihood to commit suicide Major risk factors: (+) depressive sxs, young age, high levels of premorbid functioning 3. Suicide - 50% attempt suicide 50% attempt suicide 10-15% die by suicide M=F, likelihood to commit suicide Major risk factors: (+) depressive sxs, young age, high levels of premorbid functioning
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4. Associated Substance Use & Abuse cigarette smoking substance abuse 5. Cultural and Socioeconomic Consideration a. Downward Drift Hypothesis b. Social Causation Hypothesis 4. Associated Substance Use & Abuse cigarette smoking substance abuse 5. Cultural and Socioeconomic Consideration a. Downward Drift Hypothesis b. Social Causation Hypothesis
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Etiology 1. Stress-Diathesis Model 2. Biological Factors - limbic system, basal ganglia, frontal cortex Dopamine Hypothesis - too much dopaminergic activity Other Neurotransmitters 5HT NE Amino Acids 1. Stress-Diathesis Model 2. Biological Factors - limbic system, basal ganglia, frontal cortex Dopamine Hypothesis - too much dopaminergic activity Other Neurotransmitters 5HT NE Amino Acids
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Neuropathology Limbic system Basal ganglia Brain Imaging - CT scan, MRI EEG Neuropathology Limbic system Basal ganglia Brain Imaging - CT scan, MRI EEG
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3. Genetics 4. Psychosocial Factors a. Psychoanalytic theories b. Psychodynamic theories c. Expressed emotions (EE) 5. Social Theories 3. Genetics 4. Psychosocial Factors a. Psychoanalytic theories b. Psychodynamic theories c. Expressed emotions (EE) 5. Social Theories
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Diagnosis DSM IV SUBTYPES 1. Paranoid type 2. Disorganized/Hebephrenic type 3. Catatonic type 4. Undifferentiated type 5. Residual type Type I : (+) symptoms, N brain structures on CT scan, good response to tx Type II: (-) symptoms, structural brain abN, poor response to tx DSM IV SUBTYPES 1. Paranoid type 2. Disorganized/Hebephrenic type 3. Catatonic type 4. Undifferentiated type 5. Residual type Type I : (+) symptoms, N brain structures on CT scan, good response to tx Type II: (-) symptoms, structural brain abN, poor response to tx
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Clinical Features History is important Symptoms change with time Premorbid sxs : schizoid or schizotypal personalities Consider px’s educational level, intellectual ability and cultural background History is important Symptoms change with time Premorbid sxs : schizoid or schizotypal personalities Consider px’s educational level, intellectual ability and cultural background
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Mental Status Examination 1. General Description : broad 2. Mood, Feelings, Affect : secondary depression or post-psychotic depression; flat or blunted affect 3. Perceptual disturbances : hallucinations, illusions Mental Status Examination 1. General Description : broad 2. Mood, Feelings, Affect : secondary depression or post-psychotic depression; flat or blunted affect 3. Perceptual disturbances : hallucinations, illusions
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4. Thought : content - delusions form of thought thought process 5. Impulsiveness, suicide, homicide 6. Sensorium & Cognition : intact 7. Judgment & Insight ; poor 8. Reliability : poor 4. Thought : content - delusions form of thought thought process 5. Impulsiveness, suicide, homicide 6. Sensorium & Cognition : intact 7. Judgment & Insight ; poor 8. Reliability : poor
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Differential Diagnosis 1. Secondary & Substance-Induced Pscyhotic Do 2. Malingering & Factitious DO 3. Other Psychotic Dos 4. Mood DO 5. Personality DO 1. Secondary & Substance-Induced Pscyhotic Do 2. Malingering & Factitious DO 3. Other Psychotic Dos 4. Mood DO 5. Personality DO
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Course and Prognosis Course : retrospective recognition of symptoms Each relapse of psychosis is followed by a further deterioration in the px’s baseline functioning Exacerbations and remissions (+) symptoms tend to become less severe with time, (-) symptoms may increase in severity Course : retrospective recognition of symptoms Each relapse of psychosis is followed by a further deterioration in the px’s baseline functioning Exacerbations and remissions (+) symptoms tend to become less severe with time, (-) symptoms may increase in severity
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Prognosis : Study : 10-20% good outcome >50% poor outcome Literature - range of recovery rate= 10- 60% 20-30% lead normal lives 20-30% moderate sxs 40-60% significantly impaired Prognosis : Study : 10-20% good outcome >50% poor outcome Literature - range of recovery rate= 10- 60% 20-30% lead normal lives 20-30% moderate sxs 40-60% significantly impaired
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Treatment CONSIDERATIONS 1. Unique individual, familial, social, psychological profile 2. Environmental and psychological factors 3. Complex disorder CONSIDERATIONS 1. Unique individual, familial, social, psychological profile 2. Environmental and psychological factors 3. Complex disorder
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Hospitalizations Indications: diagnostic purposes stabilization on medications patient safety grossly disorganized or inappropriate behavior Hospitalizations Indications: diagnostic purposes stabilization on medications patient safety grossly disorganized or inappropriate behavior
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Somatic Treatment 1. Antipsychotic/Neuroleptics 1. Dopamine-Receptor antagonist 2. Remoxipride 3. Risperidone 4. Clozapine Somatic Treatment 1. Antipsychotic/Neuroleptics 1. Dopamine-Receptor antagonist 2. Remoxipride 3. Risperidone 4. Clozapine
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Therapeutic Principles 1. Define target symptoms to be treated 2. AP that worked in the past should be used for the patient again 3. Minimum length of an AP trial = 4-6 wks 4. Use of monopharmacology 5. Maintain on lowest possible effective dosage Therapeutic Principles 1. Define target symptoms to be treated 2. AP that worked in the past should be used for the patient again 3. Minimum length of an AP trial = 4-6 wks 4. Use of monopharmacology 5. Maintain on lowest possible effective dosage
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2. Psychosocial Treatment Behavior therapy Family-oriented therapy Group therapy Individual psychotherapy 2. Psychosocial Treatment Behavior therapy Family-oriented therapy Group therapy Individual psychotherapy
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