Schizophrenia

1. Schizophrenia

2. History of Schizophrenia Diagnosis Emil Kraepelin (1856-1926): dementia praecox Eugen Bleuler (1857-1939): schizophrenia The Broadened U.S. Concept Increased frequency of diagnosis Process-reactive dimension Other U.S. diagnostic practices Diagnose schizophrenia whenever delusions or hallucinations were present Patients having a personality disorder were also diagnosed as schizophrenic Emil Kraepelin - Dementia Praecox included several diagnostic concepts - dementia paranoides, catatonia, and hebephrenia - that had been regarded as distinct entities by clinicians in the previous few decades. Although these disorders were symptomatically diverse, Kraepelin believed they shared a common core - an early onset (praecox) and a deteriorating course marked by a progressive intellectual deterioration (dementia). Among the major symptoms Kraepelin saw in dementia praecox were hallucinations, delusions, negativism, attentional difficulties, stereotyped behavior, and emotional dysfunction. Bleuler broke with Kraepelin on two major points: he believed that the disorder did not necessarily have an early onset, and he believed that it did not inevitably progress toward dementia. In 1908 Bleuler proposed his own term, schizophrenia, from the Greek words schizein meaning �to split� and phren, meaning �mind,� to capture what he believed was the essential nature of the condition. The common property of schizophrenia, according to Bleuler, was the �breaking of the associative threads� (i.e., threads which joined words and thoughts). Thus, goal directed, efficient thinking and communication were possible only when these hypothetical structures were intact. In the US, psychiatrists followed Bleuler and began to diagnose more and more patients with schizophrenia. The reason for the expansion was the expansion of the term schizophrenia. In the 60�s and 70�s, the process-reactive dimension was another key means of maintaining the broad concept of schizophrenia. In process schizophrenia, the symptoms came on gradually, whereas in reactive schizophrenia the symptoms came on suddenly following a stressor. People with good premorbid functioning (i.e., reactives) had good prognosis. Hallucinations and delusions are present in a number of disorders (e.g., mood disorders). Emil Kraepelin - Dementia Praecox included several diagnostic concepts - dementia paranoides, catatonia, and hebephrenia - that had been regarded as distinct entities by clinicians in the previous few decades. Although these disorders were symptomatically diverse, Kraepelin believed they shared a common core - an early onset (praecox) and a deteriorating course marked by a progressive intellectual deterioration (dementia). Among the major symptoms Kraepelin saw in dementia praecox were hallucinations, delusions, negativism, attentional difficulties, stereotyped behavior, and emotional dysfunction. Bleuler broke with Kraepelin on two major points: he believed that the disorder did not necessarily have an early onset, and he believed that it did not inevitably progress toward dementia. In 1908 Bleuler proposed his own term, schizophrenia, from the Greek words schizein meaning �to split� and phren, meaning �mind,� to capture what he believed was the essential nature of the condition. The common property of schizophrenia, according to Bleuler, was the �breaking of the associative threads� (i.e., threads which joined words and thoughts). Thus, goal directed, efficient thinking and communication were possible only when these hypothetical structures were intact. In the US, psychiatrists followed Bleuler and began to diagnose more and more patients with schizophrenia. The reason for the expansion was the expansion of the term schizophrenia. In the 60�s and 70�s, the process-reactive dimension was another key means of maintaining the broad concept of schizophrenia. In process schizophrenia, the symptoms came on gradually, whereas in reactive schizophrenia the symptoms came on suddenly following a stressor. People with good premorbid functioning (i.e., reactives) had good prognosis. Hallucinations and delusions are present in a number of disorders (e.g., mood disorders).

3. DSM-IV Diagnosis Schizophrenia Symptoms > 6 months Schizophreniform disorder Symptoms 1 month - 6 months Brief psychotic disorder Symptoms 1 day - 1 month

4. Prevalence of Schizophrenia 1-2% of U.S. population 2 million diagnosed in U.S. Primary diagnosis in 40% state/county hospital admissions Low SES 3-8x higher prevalence

5. Prevalence of Schizophrenia Median age at diagnosis = mid-20�s Men = Women prevalence Men earlier diagnosis Worse premorbid history Worse prognosis

6. Prognosis of Schizophrenia 10% continuous hospitalization < 30% recovery = symptom-free for 5 years 60% continued problems in living/episodic periods

7. Schizophrenia 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): delusions hallucinations disorganized speech (e.g., frequent derailment or incoherence) grossly disorganized or catatonic behavior negative symptoms, i.e., affective flattening, alogia, or avolition Social/occupational dysfunction Continuous signs for 6 months, at least 1 month of symptoms Schizophrenia is a psychotic disorder characterized by major disturbances in thought, emotion, and behavior - disordered thinking in which ideas are not logically related; faculty perception and attention; bizarre disturbances in motor activity; and flat or inappropriate affect. Schizophrenic patients withdraw from people and reality; often into a fantasy life of delusions and hallucinations. NO ESSTENTIAL SYMPTOM must be present for a diagnosis of schizophrenia. Thus schizophrenic patients differ from one another more than do patients with other disorders.Schizophrenia is a psychotic disorder characterized by major disturbances in thought, emotion, and behavior - disordered thinking in which ideas are not logically related; faculty perception and attention; bizarre disturbances in motor activity; and flat or inappropriate affect. Schizophrenic patients withdraw from people and reality; often into a fantasy life of delusions and hallucinations. NO ESSTENTIAL SYMPTOM must be present for a diagnosis of schizophrenia. Thus schizophrenic patients differ from one another more than do patients with other disorders.

8. The DSM-IV Diagnosis DSM narrowed the range of individuals who could be diagnosed with schizophrenia in two ways: Explicit and detailed criteria Excluding other disorders Schizoaffective disorder Schizophreniform disorder Brief psychotic disorder Delusional disorder Schizoaffective disorder - a mixture of symptoms of schizophrenia and mood disorder The DSM-IV requires at least six months of disturbance for the diagnosis. The six month period must include at least 1 month of the active phase. These criteria eliminate people who have a brief psychotic episode, often stress related, and then recover quickly. An acute schizophrenic episode is now called either Schizophreniform disorder or brief psychotic disorder. Schizophreniform disorder has the same symptoms as schizophrenia, but lasts from one to six months. Brief psychotic disorder lasts from one day to one month and is often brought on by extreme stress. Delusion Disorder - the person is troubled by persistent persecutory delusions or by delusional jealousy, the unfounded conviction that a spouse or lover is unfaithful. Other delusions are those of being followed, delusions of erotomania (believing that one is loved by some other person, usually a complete stranger with a higher social status), and somatic delusions (believing that some internal organ is malfunctioning). Unlike paranoid schizophrenia, the person with delusional disorder does not have disorganized speech or hallucinations and his or her delusions are less bizarre.Schizoaffective disorder - a mixture of symptoms of schizophrenia and mood disorder The DSM-IV requires at least six months of disturbance for the diagnosis. The six month period must include at least 1 month of the active phase. These criteria eliminate people who have a brief psychotic episode, often stress related, and then recover quickly. An acute schizophrenic episode is now called either Schizophreniform disorder or brief psychotic disorder. Schizophreniform disorder has the same symptoms as schizophrenia, but lasts from one to six months. Brief psychotic disorder lasts from one day to one month and is often brought on by extreme stress. Delusion Disorder - the person is troubled by persistent persecutory delusions or by delusional jealousy, the unfounded conviction that a spouse or lover is unfaithful. Other delusions are those of being followed, delusions of erotomania (believing that one is loved by some other person, usually a complete stranger with a higher social status), and somatic delusions (believing that some internal organ is malfunctioning). Unlike paranoid schizophrenia, the person with delusional disorder does not have disorganized speech or hallucinations and his or her delusions are less bizarre.

9. Course of Schizophrenia Prodromal phase Active phase Residual phase

10. Symptom Distinction Positive symptoms Deviant behaviors present Negative symptoms Normal behaviors absent Poor premorbid history Poorer prognosis Spouses less satisfied

11. Positive Symptoms of Schizophrenia Disorganized Speech (thought disorder): problems in the organization of ideas and in speaking so that a listener can understand Delusions: Beliefs contrary to reality, firmly held in spite of evidence to the contrary (themes: control, grandeur, persecution) Hallucinations: sensory experiences in the absence of any stimulation from the environment Positive Symptoms comprise excesses, such as disorganized speech, hallucinations, delusions, and bizarre behavior. Disorganized Speech includes: Incoherence - although the patient may make repeated references to central ideas or a theme, the images and fragments of thought are not connected; it is difficult to understand exactly what the patient is trying to tell the interviewer. Loose Associations (or derailment) - the patient has difficulty sticking to one topic. They drift off on a train of associations evoked by an idea from the past. Disturbances in speech were at one time considered the principal clinical symptom of schizophrenia, and they remain one of the criteria for diagnosis. But evidence indicates that the speech of many schizophrenic patients is not disorganized, and the presence of disorganized speech doe not discriminate well between schizophrenic patients and other psychoses, such as mood disorders. For example, many manic patients exhibit loose associations as much as do schizophrenic patients. Delusions - Lack of insight is common in schizophrenic patients (e.g., they don�t realize that their behavior is bizarre). Some common delusions: Being the unwilling recipient of bodily sensations imposed by an external agency. Having thoughts placed in one�s mind by an external source Having one�s thoughts stolen by an external source Believing that one�s thoughts are being broadcasted or transmitted, so that others know what you are thinking. Hallucinations - are thought to be particularly important diagnostically because they occur more often in schizophrenia than in other psychotic disorders. Some patients report hearing their own thoughts spoken by another voice or hearing voices arguing. Positive Symptoms comprise excesses, such as disorganized speech, hallucinations, delusions, and bizarre behavior. Disorganized Speech includes: Incoherence - although the patient may make repeated references to central ideas or a theme, the images and fragments of thought are not connected; it is difficult to understand exactly what the patient is trying to tell the interviewer. Loose Associations (or derailment) - the patient has difficulty sticking to one topic. They drift off on a train of associations evoked by an idea from the past. Disturbances in speech were at one time considered the principal clinical symptom of schizophrenia, and they remain one of the criteria for diagnosis. But evidence indicates that the speech of many schizophrenic patients is not disorganized, and the presence of disorganized speech doe not discriminate well between schizophrenic patients and other psychoses, such as mood disorders. For example, many manic patients exhibit loose associations as much as do schizophrenic patients. Delusions - Lack of insight is common in schizophrenic patients (e.g., they don�t realize that their behavior is bizarre). Some common delusions: Being the unwilling recipient of bodily sensations imposed by an external agency. Having thoughts placed in one�s mind by an external source Having one�s thoughts stolen by an external source Believing that one�s thoughts are being broadcasted or transmitted, so that others know what you are thinking. Hallucinations - are thought to be particularly important diagnostically because they occur more often in schizophrenia than in other psychotic disorders. Some patients report hearing their own thoughts spoken by another voice or hearing voices arguing.

12. Negative Symptoms of Schizophrenia Avolition: or apathy; a lack of energy and a seeming absence of interest in routine activities Alogia: a negative thought disorder: poverty of speech poverty of content Anhedonia: inability to experience pleasure Flat or Blunted Affect: virtually no stimulus can elicit an emotional response Asociality: severe impairments in social relationships Avolition - Patients may be inattentive to grooming and personal hygiene. They may have difficulty persisting in daily activities, and end up sitting around and doing nothing. In poverty of speech the amount of speech is greatly reduced. In poverty of content the amount of discourse is adequate but it conveys little information and tends to be vague and repetitive. The concept of Flat Affect refers only to the outward expression of emotion and not to the patient�s inner experience, which may not be impoverished at all. Other symptoms: Catatonia - motor abnormalities such as complex sequences of finger, hand, and arm movements; unusual increase in the overall level of activity;or in catatonic immobility, patients abopt unusual postures and maintain them for a long period of time. Waxy flexibility - another person can move the patient�s limbs into strange positions that the patient will maintain for long periods of time. Avolition - Patients may be inattentive to grooming and personal hygiene. They may have difficulty persisting in daily activities, and end up sitting around and doing nothing. In poverty of speech the amount of speech is greatly reduced. In poverty of content the amount of discourse is adequate but it conveys little information and tends to be vague and repetitive. The concept of Flat Affect refers only to the outward expression of emotion and not to the patient�s inner experience, which may not be impoverished at all. Other symptoms: Catatonia - motor abnormalities such as complex sequences of finger, hand, and arm movements; unusual increase in the overall level of activity;or in catatonic immobility, patients abopt unusual postures and maintain them for a long period of time. Waxy flexibility - another person can move the patient�s limbs into strange positions that the patient will maintain for long periods of time.

13. Subtypes of Schizophrenia Paranoid Delusions/Hallucinations have single theme = Persecution/Grandiosity No thought disorder Better prognosis

14. Subtypes of Schizophrenia Catatonic Hallmark = motor behavior Catatonic stupor Catatonic excitement

15. Subtypes of Schizophrenia Disorganized (Hebephrenic) Grossly disorganized cognition, affect, behavior Poor prognosis

16. Subtypes of Schizophrenia Undifferentiated Does not meet criteria for other subtypes

17. Diagnosis in First Episode (Lieberman et al., 1992) 1% Catatonic 3% Disorganized 19% Paranoid 54% Undifferentiated

18. Etiology of Schizophrenia

19. Summary of Family and Twin Studies