CHAPTER THIRTEEN

1. Schizophrenic Disorders Symptoms Diagnosis Causes Treatment and Management CHAPTER THIRTEEN

2. OVERVIEW • Psychosis - A state of being profoundly out of touch with reality • Most common symptoms: changes in the way a person thinks, feels, and relates to other people and the outside environment. • Involves disruptions of mental functions • No single symptom or specific set of symptoms is characteristic of patients.

3. OVERVIEW • Devastating disorder for both the patients & families. • Among mental disorders, the second leading cause of disease burden.

4. OVERVIEW • Onset typically occurs during adolescence or early adulthood. The period of risk is considered to be between 15 and 35. • The problems of most patients can be divided into three phases of variable and unpredictable duration: • prodromal phase (developing) • active phase (psychotic symptoms) • residual phase (no longer psychotic but still showing signs of schizophrenia)

5. What Schizophrenia Isn’t… • Debunking myths - • Not “splitpersonality” • Not inherently violent or homicidal

6. SYMPTOMS • Positive Symptoms--Type I • Hallucinations • Perceptual disturbances • Can occur in any of the senses • Persistent over time

7. SYMPTOMS • Delusional Beliefs • FALSE Idiosyncratic beliefs that are rigidly held in spite of their preposterous nature. • Subtypes: • Grandeur • Persecution • Reference • Nihilistic • Capgras’ syndrome • Cotard’s syndrome

8. SYMPTOMS • Disorganization • Thinking Disturbances • Involves disorganized speech – say things that do not make sense. • Word salad • Loose associations or derailment • Perserveration

9. Symptoms • Disorganized speech or thought • Neologisms • Clang associations • Echolalia

10. SYMPTOMS • Disorganization • Bizarre Behavior • Catatonia • Stuporous state – reduced responsiveness. • Echopraxia • Disheveled • Childlike Behavior • Inappropriate affect

11. SYMPTOMS • Negative Symptoms--Type II • Lack of initiative, social withdrawal, deficits in emotional responding. • Affective flattening, Blunted affect • Anhedonia – inability to experience pleasure. • Apathy - Socially withdrawn • Both a symptom and coping strategy • Avolition – lack of will, motivation • Alogia – impoverished thinking, poverty of speech.

12. Classifying Schizophrenia: The DSM-IV-TR Criteria • Two or more of the following: • Delusions • Hallucinations • Disorganized speech • Grossly disorganized or catatonic behavior • Negative symptoms • Social/occupational dysfunction and decline • Six month duration of symptoms

13. TABLE 13-1 Diagnosis Criteria for Schizophrenia A. Characteristic Symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): 1. Delusions 2. Hallucinations 3. Disorganized speech (such as frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms, such as affective flattening, alogia, or avolition B. Social/Occupational Dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care is markedly below the level achieved prior to the onset. C. Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms that meet Criterion A (active phase symptoms), and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (such as odd beliefs, unusual perceptual experiences).

14. DIAGNOSIS • Subtypes • Schizophrenia is a heterogeneous disorder with many different clinical manifestations and levels of severity. • Paranoid Type • Disorganized Type • Catatonic Type • Undifferentiated Type • Residual Type

15. DIAGNOSIS • Related Psychotic Disorders • Brief psychotic disorder = symptoms < 1 month • Schizophreniform disorder = symptoms for 1-6 months • “Schizophrenic spectrum” also includes: • Schizoaffective disorder • Delusional disorder • Shared delusional disorder • Paranoid and schizotypal personality disorders

16. FREQUENCY • Gender Differences • ♂: 30 to 40% more likely to develop schizophrenia than ♀. • Differences between ♂ and ♀ onset, symptoms, and course of the disorder.

17. CAUSES • The average concordance rate for MZ twins is 48%, whereas the comparable figure for DZ twins is 17%. • Suggests strong genetic factors. • Also compelling evidence for the importance of environment. • Genain quadruplets • Genetic factors play role in development of the disorder (Heston). TWIN STUDIES ADOPTION STUDIES

18. CAUSES • More likely than the general population to have been exposed to various problems during their mother’s pregnancy and to have suffered birth injuries. • Dietary factors • Somewhat more likely to have been born during the winter/spring when viral infections are more prominent. PREGANANCY AND BIRTH COMPLICATIONS VIRAL INFECTIONS

19. Disorder seems to affect many different regions of the brain. Enlarged lateral ventricles Differences (decreased size) in parts of the limbic system. FIGURE 13-3

20. CAUSES • Biological Components: Immediate Causes • Brain function abnormalities: hypofrontality, neurotransmission, dopamine hypothesis • Brain structure abnormalities • Neuropsychological/neurophysiological abnormalities: impaired cognition, sensory gating, visual tracking

21. CAUSES • Focuses on the function of dopamine in the limbic area of the brain. • Hypothesis grew out of attempts to understand how antipsychotic drugs improve the adjustment of schizophrenic patients. • Current research focuses many neurotransmitters: • Serotonin • GABA • Glutamate The dopamine hypothesis Interactions of multiple neurotransmitters

22. CAUSES • Psychological Factors • Expressed Emotion • The family environment does have a significant impact on the course (as opposed to the etiology) of schizophrenia. • Patients who relapsed seemed to react negatively to some feature of their close relationship with their family. • See Figure 13.5

23. TREATMENT • Antipsychotic Medication • Have a relatively specific effect- reduce psychotic symptoms • Positive symptoms respond better than negative symptoms. • A substantial minority of patients, perhaps 25% do not improve on classical antipsychotic drugs. • See Figure 13.7 relapse rate

24. TREATMENT • Antipsychotic Medication • Motor Side Effects • Extrapyramidal symptoms • Tardivedyskinesia

25. TREATMENT • Antipsychotic Medication • Second-Generation Antipsychotics • Atypical antipsychotics • Work on both serotonin and dopamine • Impact both positive and negative symptoms