1. Schizophrenia: A neuro-developmental disorder of social and cognitive decline
Demian Rose, MD, PhD

2. Take Home Point 1
Schizophrenia is associated with three primary symptom domains: positive symptoms, negative symptoms and cognitive symptoms.
Of these, cognitive symptoms are most associated with functional impairment, followed by negative symptoms
Despite this, we have traditionally focused our conceptualization based on positive symptoms

3. Components of the Illness
attention
concentration
memory
Cognitive
Impairment
Psychotic
Symptoms
hallucinations
delusions
Negative
Symptoms
anergia
anhedonia
amotivation

4. Percent of Patients Ever in Recovery (5 Follow-ups Over 15-Years) (Harrow et al., 2005, fig 2)

5. Take Home Point 2
Schizophrenia is a neuro-developmental disorder involving abnormal brain development during adolescence and young adulthood
Multiple brain regions are affected in measurable ways

6. Dysfunction in multiple regions in brain areas implicated in schizophrenia
Schobel, S. A. et al. Arch Gen Psychiatry 2009;66:
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7. Iowa Longitudinal Study of First Episode Schizophrenia (Investigator: Nancy Andreasen, MD)
Hundreds of subjects recruited over 20 years
All adolescents or young adults
Half of all subjects show significant brain tissue loss in the frontal lobes (at least 0.5% per year)
One-third of all subjects lose average of 1% per year
Normal loss is on the order of % per year
Most loss in Schizophrenia occurs in the first few years after diagnosis

8. Take Home Point 3
The cognitive and social dysfunction associated with schizophrenia typically pre-dates the onset of the more easily identified “psychotic” symptoms

9. Potential neurodevelopmental stages of schizophrenia
Insel, T. R. Arch Gen Psychiatry 2009;66:
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10. Cognitive deficits predate psychotic symptoms
FE = first episode schizophrenia, UHR = ultra high risk for developing schizophrenia
BS/PCO = controls
Simon (2007) Schizophrenia Bulletin, vol 33, pg

11. Take Home Point 4
By the time of first diagnosis, a crucial time for successful intervention, abnormal brain development and cognitive deficits are already significant, and many psychosocial supports are already in jeopardy

12. Survival graphs for suicide by psychiatric disorder in people admitted to hospital during for attempted suicide in Sweden and followed to 2003
Tidemalm, D. et al. BMJ 2008;337:a2205
Copyright ©2008 BMJ Publishing Group Ltd.

13. Duration of Untreated Psychosis Matters
Finding is
consistent
across
many
studies
Perkins (2005)
AJP, 162:1785

14. Schizophrenia is defined as much by cognitive deficits as by psychotic symptoms
People with schizophrenia have significant deficits in many measurable domains of cognition (1 to 2 standard deviations below the mean, i.e. as low as 5th percentile) 14

15. Schizophrenia memory impairments
Forbes et al (2009)
Psychological Medicine
Vol 39, pg

16. Impairments affect “real world” activities of daily living
When cooking a meal:
“Sequencing errors, repetitions and omissions were significantly higher [in people with schizophrenia] compared to controls”
Stip (2006) Encephale, vol 3, pg

17. Social deficits can be comparable to Autism in type
People with schizophrenia have deficits in social cognition that are comparable to people with high-functioning autism
Poor emotion perception
Poor ability to accurately guess at the motives of others
Couture (2009) Psychological Medicine vol 12, pg 1-11

18. Cognitive deficits can be comparable to Alzheimer’s in severity
People with schizophrenia have a different pattern of cognitive deficits than people with Alzheimer’s Disease, but are equally or more impaired on measures of:
Naming
Object construction
New learning (encoding)
Davidson (1996) American Journal of Psychiatry vol 153, pg

19. Take Home Point 5
If we are to reduce the lifetime morbidity burden of schizophrenia and work towards functional recovery, we must provide a psychosocial framework that allows for evidence-based recovery strategies
In this context, disability benefits can help ensure recovery, by allowing for a shift from necessary external decision-making to independent living and recovery

20. Cognitive Impairment and Recovery
For persons so seriously impaired in their decision making capacity that they are incapable of determining what is in their best interest, a paternalistic externally reasoned treatment approach seems not only appropriate but also necessary … .However, as these impaired persons begin to benefit from externally initiated interventions the locus of control should increasingly shift from the treatment provider to the person who is recovering
Frese et al (2001), Psychiatric Services, vol 52, pg

21. Supported Employment Works (Cook et al., 2005)
Fig 1. Proportion of subjects employed competitively by month

22. Keeping families involved leads to better outcomes
Average relapse rates across 11 RTC’s (N = 895)
Mean length of treatment = 19.7 months
McFarlane, W. R., Dixon, L., Lukens, E., Lucksted, A.
(2003). Family psychoeducation and schizophrenia: a
review of the literature. Journal of Marital and Family
Therapy, 29(2),
A number of reviews of the research literature on family psychoeducation have been published, all of which support the efficacy of family psychoeducation. There are various ways to divide this research literature, such as comparing different formats of intervention, lengths of intervention. This particular graph represents a summary of relapse rates across 11 RTC’s that included some combination of standard treatment conditions, single family, and multiple family formats. The relapse rates represent total percentage of patients that relapsed during the study period, which ranged from 9 months to 4 years, with a mean length of treatment of 19.7 months.
First, starting with the relapse rates in the “standard treatment” conditions, which typically included medication management and (usually) some form of individual psychosocial services, we see an average relapse rate of 63%. When a SF psychoeducation intervention is added to medication management, we see the relapse rate roughly cut in ½, to slightly below 30%. Mean relapse rates for multiple family groups fall in the same range, slightly below 30%.
TAU = treatment as usual, SF = single family group, MF = multifamily group

23. Cognitive training can enhance back-to-work programs (McGurk et al

24. And all of these evidence-based interventions require:
Adequate, sustained financial and social services support that begins as soon as possible after diagnosis and assumes a timeline of recovery that is from months to years