1. IzBen C. Williams, MD, MPH Instructor

2. Lecture 10 SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

3. Schizophrenia DEFINITION DEFINITION Schizophrenia is a mental disorder, or a group of disorders, which may be chronic and debilitating, and is characterized by: positive symptoms, positive symptoms, and negative symptoms negative symptoms

4. Schizophrenia DEFINITION DEFINITION Positive symptoms are those that are additions to expected behavior Delusions Hallucinations Agitation (Talkativeness)

5. Schizophrenia DEFINITION DEFINITION Negative symptoms: are characterized by things missing from expected behavior and include lack of motivation, social withdrawal, flattened affect, anhedonia cognitive disturbances, Impoverished thought (form, process, content) Impoverished content of speech

6. Schizophrenia This classification of symptoms can be useful in predicting the effects of antipsychotic drugs Positive symptoms: respond well to most traditional and atypical antipsychotic agents Negative symptoms: Respond better to atypical than to traditional antipsychotics

7. Schizophrenia DIAGNOSIS DIAGNOSIS A. A. Two of the following for most of a month: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms Only one of these is required if delusions are bizarre or if hallucinations are running and prominent

8. Schizophrenia DIAGNOSIS DIAGNOSIS A. A. Two of the following for most of a month: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms Only one of these is required if delusions are bizarre or if hallucinations are running and prominent

9. Schizophrenia DIAGNOSIS (cont’d) DIAGNOSIS (cont’d) B. B. Marked social or occupational dysfunction C. C. Duration of at least six months of persistent symptoms (negative or positive) D. D. Symptoms of schizoaffective and mood disorder are ruled out E. E. Substance abuse or medical conditions are ruled out as etiology

10. Schizophrenia SUBTYPES SUBTYPES (first meet the diagnostic criteria, then….) Paranoid: Paranoid: preoccupation with one or more delusions or frequent auditory hallucinations Disorganized: Disorganized: all these are present – disorganized speech and behavior, flat or inappropriate affect Catatonic: Catatonic: at least two of: motoric inability, extreme negativism or mutism, excessive activity, peculiarities of voluntary movement, echolalia or echopraxia Undifferentiated: Undifferentiated: cant differentiate subtypes Residual: Residual: symptoms present in attenuated form

11. Schizophrenia EPIDEMIOLOGY: EPIDEMIOLOGY: : Incidence:.03% to.12% a year for individuals older than 15 years. Greatest rate in industrial nations and among the culturally disrupted Rate: ?occurs equally in men and women? Peak age of onset: 15-25 for men 25-35 for women

12. Schizophrenia EPIDEMIOLOGY: EPIDEMIOLOGY: Prevalence: as with incidence, it is lower in developing countries, as is prognostic expectations Point prevalence: estimated to range from less than.01% to 3.0% Lifetime prevalence: in the US < 1.0%

13. Schizophrenia EPIDEMIOLOGY: EPIDEMIOLOGY: ONSET tends to be earlier in men than women. It usually occurs in late adolescence or early adulthood, although cases continue to appear with decreasing frequency throughout adult life : Patients with early onset tend to have more disorganized features, and worse prognosis for recovery and preservation of function Patients with late onset tend to have more paranoid features and better prognosis and preservation of function

14. Schizophrenia EPIDEMIOLOGY: EPIDEMIOLOGY: COURSE: Schizophrenia has three phases: Prodromal: signs and symptoms occur prior to first psychotic episode (avoidance of social activities, physical complaints, new interest in religion, occult, or philosophy) Psychotic phase: person loses touch with reality; disorders of thought (form, content and process) occur during acute episode Residual phase: (time between psychotic episodes) patient in touch with reality but does not behave normally. Typically characterized by negative symptoms

15. Schizophrenia EPIDEMIOLOGY : EPIDEMIOLOGY : PROGNOSIS: The course and prognosis vary widely depending on a variety of social, economic, and treatment factors as well as the diagnostic criteria used to define the population Social recovery is more common than complete remission of symptoms. Over a period of 15 years or longer more than ⅔ of patients experience complete (or “social”) recovery with adequate treatment Recovery rates are better for those with late onset and those from developing countries,

16. Schizophrenia EPIDEMIOLOGY : EPIDEMIOLOGY : PROGNOSIS: After repeated psychotic episodes, the illness usually stabilizes in midlife Suicide is common in patients with schizophrenia. More than 50% attempt suicide. 10% succeed. The prognosis is better, and suicidality lower, if patient is older at onset, is married, has social relationships, is female, has a good employment history, has mood symptoms, has few negative symptoms, and has few relapses

17. Schizophrenia ETIOLOGIC THEORIES : ETIOLOGIC THEORIES : Despite intensive research, a single causative factor has not been discovered for schizophrenia. Many theories: Genetic theories Biochemical theories Neurophysiologic theories Neurologic & Neuropathologic theories Psychological theories Family Interaction theories

18. Schizophrenia ETIOLOGIC THEORIES : Neural pathology ETIOLOGIC THEORIES : Neural pathology Anatomy: Abnormalities of the frontal lobes Lateral and third ventricle enlargement Decreased volume of limbic structures Neurotransmitter abnormalities Dopamine hypothesis Serotonin hyperactivity Glutamate implicated

19. Schizophrenia ETIOLOGIC THEORIES : ETIOLOGIC THEORIES : Some other etiologic considerations Season of birth Environmental factors Downward drift hypothesis (lower socioeconomic groups, eg homeless Social factors:

20. The Genetics relationship correlated with incidence of Schizophrenia Approximate occurence The general population1% Sibling schizophrenic10% Persons with one parent schizophrenia,12% Dizygotic twin of a person with schizophrenia15% Person who has two parents with schizophrenia40% Monozygotic twin of a person with schizophrenia50%

21. Schizophrenia DIFFERENTIAL DIAGNOSIS: DIFFERENTIAL DIAGNOSIS: Medical illnesses Medications Other psychiatric illnesses (mood, cognitive, substance-related Personality disorders (schizotypal, paranoid, borderline

22. Other Psychotic Disorders Schizophreniform disorder Brief psychotic disorder Atypical psychosis Schizoaffective disorder Postpsychotic depression Delusional Disorder Shared psychotic disorder

23. Treatment Treatment programs for people with Schizophrenia should be individualized and comprehensive, taking into account the Biologic Psychological and Social needs of the patient Attention must also be paid to continuity of care. The care setting should be as non-restrictive as possible and every attempt should be made to reintegrate the patient into the community Hospitalization

24. Treatment Hospitalization (indications, goals, side effects, the changing role, ) Melieu treatment (structure, flexibility, ward community, …….) Group therapy Individual psychotherapy Case management

25. Treatment Psychosocial rehabilitation Consumer movement Illness management Cognitive remidiation Pharmacologic treatment and ECT