Schizophrenia

1. Schizophrenia Presentation for PHO Dr Verity Humberstone

2. Overview • Why prioritize schizophrenia? • Diagnosing Schizophrenia • Treatment of schizophrenia • Atypical Antipsychotic – metabolic monitoring • Clozapine

3. Questions • Which is the most common diagnosis in acute and forensic hospitals? • Which is the most common diagnosis for people requiring residential support? • Are people with schizophrenia at a greater risk of victimisation? • Are people with schizophrenia at a greater risk of perpetrating violence?

4. Maori and Schizophrenia • The psychiatric report 1986 – Maori 10-12% population 67% special patient admissions • Te Puni Kokiri - 1996 rates of admission for schizophrenia 2-3 times greater for Maori than Non Maori / Pacific. Greater first presentations and readmissions. • Hauora: Maori standards of Health IV has identified that between 2003 and 2005 Maori were over 3.5 times more likely to be hospitalized for schizophrenia than non Maori. Maori men had a hospitalization rate for schizophrenia of 416.7 per 100,000 compared with 222.4 for Maori women, 119.7 for non-Maori men and 62.3 per 100,000 for non- Maori women

5. Prevalence Schizophrenia Kake et al

6. Diagnosing schizophrenia

7. Bleuler • “Contrary to the general opinion, the concept of schizophrenia is as precise as is possible for any fact found in nature. There is no room for it to be confused with any other mental disorder”

8. Review of Clinical features Prodrome • Sleep disturbance • Depressed mood • Social withdrawal • Drop off in function e.g. work / study • Irritable / Oversensitive • Odd beliefs / Odd Behavior • Suicidal

9. Positive Symptoms of Schizophrenia • Delusions • Hallucinations • Formal Thought Disorder • Bizarre Behavior

10. Delusions • Bizarre • Non Bizarre • Delusions of reference • Delusions of mind reading • Jealous delusions • Persecutory delusions • Grandiose delusions • Delusions of control • Religious delusions • Nihilistic delusions • Somatic delusions • Erotomanic delusions

11. Negative Symptoms of Schizophrenia • Attention • Alogia • Avolition - Apathy • Anhedonia • Asociality • Affective Disturbance

12. Cognitive Symptoms of Schizophrenia • Verbal memory and learning • Executive function • Attention • Spatial memory

13. Classification

14. Types of schizophrenia • Delusional disorder • Paranoid schizophrenia • Undifferentiated schizophrenia • Disorganized schizophrenia • Catatonic schizophrenia • Schizotypal personality • Schizoaffective disorder (controversial)

15. Clarify Diagnosis • If people have delusions, thought disorder and hallucinations with a euthymic or normal mood the diagnosis is schizophrenia rather than a mood disorder • Look at longitudinal history • Look for medical conditions / drug and alcohol

16. Diagnostic Confusion • Where schizophrenia is diagnosed as bipolar affective disorder • Where schizophrenia is diagnosed as a personality disorder • Where schizophrenia is diagnosed as a substance induced psychosis

17. Schizophrenia diagnosed as Bipolar Affective Disorder • Grandiose delusions, sleep disturbance and elevated mood are often attributed to a manic episode from cross sectional rather than longitudinal analysis • Key distinguishing factor is in schizophrenia the arousal and mood disturbance resolve more quickly than hallucinations, delusions or thought disorder

18. Schizophrenia diagnosed as Bipolar Affective Disorder • Key features relate to affect and function • Analysing cases all have combinations of mood stabilisers and antipsychotics inevitably stabilised on clozapine – controversial usefulness of mood stabilisers

19. Mood changes

20. Schizophrenia treated as depression • Mood changes are very common in schizophrenia and particularly a dysphoric, tormented, anxious mood with sleep disturbance • If there are hallucinations and delusions or any other psychotic symptom treat with antipsychotic medication • SSRIs will be useless

21. Schizophrenia Diagnosed as Substance induced psychosis • Significant substance abuse is common – ending up with recurrent psychotic mental health admissions is very uncommon • Psychosis with substances does not explain disturbances in affect, persistent disorganisation or cognitive dysfunction • Controversy regarding severe prolonged amphetamine use and paranoid schizophrenia

22. Marijuana • Heavy marijuana use prior to age 18 years in prospective studies increases risk of developing schizophrenia by 6-7 times. • NZ Dunedin study 10.3% those using marijuana at age 15 years had schizophrenia by 26 years cf 3% controls

23. Schizophrenia diagnosed as personality disorder • A totally normal social history is not compatible with the diagnosis of personality disorder • Schizophrenia typically has a pattern of a deteriorating social history although this can be complex with early onset schizophrenia

25. Schizophrenia diagnosed as Borderline Disorder • Distracted by extreme behaviours that evoke powerful emotions within staff • Often an underlying hostility and wish to reject the patient • Behavioural disturbances are a direct manifestation of the psychotic process often the underlying exploration of the causes of behaviour are inadequate and the patient’s explanation is accepted at face value

26. Schizophrenia diagnosed as Borderline Disorder • Often recurrent self harm is equated with borderline disorder when it can be part of a psychotic manifestation either directly in response to undisclosed schizophrenia or as a coping strategy in people with a limited degree of psychological maturity or propensity to externalising behaviours

27. Schizophrenia diagnosed as Antisocial Personality Disorder • Schizophrenia can present through contact with the criminal justice system • Behavioural disturbance in the forms of violence or law breaking can be directly attributable to psychotic symptoms or a secondary manifestation e.g. paranoia and disorganisation leading to homelessness and trespass / burglary

28. Schizophrenia diagnosed as Antisocial Personality Disorder • Two important patterns to distinguish • Absence of conduct disorder and sudden change to criminality and convictions later in life • Premorbid conduct disorder then change in escalating pattern of offending or nature of offending

29. Schizophrenia diagnosed as Antisocial Personality Disorder • Key feature is a careful analysis of causes of offending or violent behaviour • Does it make sense? • What are the motivations? • What are the observations of staff within the criminal justice system?

30. Interviewing Issues • Look and Observe • Understand the different language that people have for perceptual experiences – look for dimensionality and affective investment • “Do you hear voices inside / outside head” – limiting and simplistic

31. Interviewing Issues • For guarded patient use other strategies e.g. proverb analysis with cognitive assessment • “People in glass houses should not throw stones” • Assess negative and cognitive features • Be aware of the tendency to normalise psychosis like completion illusions

32. Being guarded

33. Functional Issues • Developmental arrest • Housing history • Employment pattern – however factor in socioeconomic deprivation • Relationships – shrinking network • Change in habitual behaviour

34. Functional impact

35. Family Interview • Changes in sleep, motivation, self care • Times that they did not make sense • Did you ever hear them talk to themselves and what did they say about it • Anger

36. Management • 1. Engagement • 2. Safety • 3. Clarify the Diagnosis • 4. Biological Management • 5. Psychological Management • 6. Social and Family • 7. Rehabilitation

37. Safety • Assess risk of killing or harming themselves • Assess risk of killing or harming others • Assess sexual risk towards others or of being exploited / abused / pregnant • Assess risk from coexistent medical condition • Assess risk of homelessness • Assess risk of financially exploited

38. Safety • Assess risk of very poor self care e.g. ability to obtain food, manage money • Assess risk from comorbid substance abuse • Assess risk of treatment disengagement • Assess risk from certain symptoms: Command Hallucinations, Delusions of control, Jealous delusions, Persecutory delusions

39. Question • Which features of the mental state are important when assessing risk?

40. Biological Management • Atypical Antipsychotics vs typical • First line treatment can include risperidone, aripiprazole, amisulpride, ziprasidone, quetiapine, olanzapine • Olanzapine has a higher risk of weight gain and metabolic syndrome than the other first line agents and should be only used after prior treatment intolerance and with caution • Clozapine only effective treatment for treatment resistant schizophrenia • Depot antipsychotics require- three months to steady state

41. Antipsychotic prescribing

42. Risperidone • Risperidone – generally first line, can have akathisea, EPSE, or high prolactin. • Available in depot form two weekly (paliperidone monthly)

43. Aripiprazole • No weight gain • Can be activating, can have akathisea • 1.5 : 1 potency to olanzapine

44. Olanzapine • Risks weight gain • Metabolic syndrome • Recent depot preparation – post injection syndrome

45. Quetiapine • Frequently used low dose range off label conditions • Doses required for antipsychotic effect may be too sedating

46. Ziprasidone • Needs to be taken twice daily • Needs to be taken with food • Low metabolic effects

47. Amisulpride • Low does beneficial effects negative symptoms • Higher doses sedating, EPSE

48. Clozapine • Clozapine has revolutionized the treatment of schizophrenia and is simply more effective than other antipsychotic medication for persistent and severe psychotic illness.

49. Clozapine

50. Treatment resistant schizophrenia • Two different antipsychotic agents taken at right doses for sufficient time still not associated with improvement in positive psychotic symptoms • Repeated admissions, suicide attempts, assaults, homelessness, imprisonment, severe coexisting substance abuse