Understanding Schizophrenia: Symptoms, Subtypes, and Treatment Options

1. Chapter 13 - Schizophrenia • Criteria 1. Symptoms (2 of 5 for 1 month) Content of thought: a. Delusions - belief with no basis in reality b. Hallucinations – perception in absence of stimuli

2. Form of thought ** c. Disorganized, incoherent Behavior d. Disorganized, agitated, or catatonic

3. Emotion e. Flat or inappropriate affect - withdrawal, poverty of speech Positive vs. Negative Symptoms - Positive = excess or distortion - Negative = loss of normal behavior

4. 2. Social/Occupational dysfunction - work, relationships, hygiene - loss of identity 3. Duration > 6 months (Sxs in #1 at least 1 month)

5. 4. Exclusions - not from drugs, medical problems, or mood disorder • INDIVIDUAL DIFFERENCES

6. Course • Onset - late teens to mid-30s - rarely before adolescence - either acute or gradual (most are gradual)

7. Phases a. Prodromal - slow development of negative symptoms - often misinterpreted

8. b. Acute - appearance of positive, psychotic symptoms c. Residual - positive sxs remit, negative sxs remain - return to prodromal

9. d. Remission - never recovered -> labeled for life vs. Third world

10. Progression = variable - chronic - vs. gradually deteriorating - vs. swings between better & worse - vs. remission

11. Subtypes • Paranoid Type - Thematic delusions (eg, paranoid or grandiose) Or frequent auditory hallucinations - Often intact cognition & affect - Stilted, aloof, superior - Mixed evidence for suicidal or homicidal - Best prognosis (lack of negative sxs)

12. Disorganized Type - Incoherent speech & behavior - daily chores difficult - disorganized delusions and/or hallucinations - Flat/inappropriate affect - appear silly/immature - Insidious, early onset - Poor prognosis - continuous course without remissions

13. 3. Catatonic Type Psychomotor disturbance - immobility, stupor, odd postures waxy flexibility Or - agitation, purposeless movement Negativism, mutism, resistance Echolalia, echopraxia

14. 4. Undifferentiated Type - schizophrenic sxs - but don’t meet criteria for types 1-3 - catchall dx

15. 5. Residual Type - 1+ episode of acute positive sxs - no positive sxs currently - continuing negative sxs - eccentric, odd beliefs - transition between full-blown episode and remission? - may be present for years

16. Other Psychotic Disorders • Brief Psychotic Disorder Positive sxs - hallucinations, delusions, loose associations, disorganized beh. Follows acute stressor No prodromal or residual phase Lasts < 1 month Return to normal fxing High suicide risk

17. 2. Delusional Disorder - 1 fixed non-bizarre delusion - no other problems

18. 3. Personality Disorders a. Paranoid – suspicious b. Schizoid – withdrawn c. Schizotypal – odd

19. 4. Schizophreniform Disorder - sxs of schizophrenia - lasts < 6 months - most develop schizophrenia or schizoaffective disorder - no decline in fxing

20. 5. Schizoaffective Disorder - schizophrenia & a mood disorder

21. Etiology Genetic Contributions • Clear genetic basis • Increased risk based on relatedness

22. Family Studies • < 1% in population • 17% if parent or parent’s MZ twin Twin Studies • MZ twins = 50% • DZ = ~ 15%

23. Adoption Studies • Biological risk = 10-17% • Environmental risk = < 1% Unknowns • Means of transmission • One or more genes (polygenetic would explain spectrum)

24. Neurobiology & Neuroanotomy 1. Excess of Dopamine (DA) - some antipsychotics are DA antagonists (block use of DA) - side effects (tardive dyskinesia: TD) similar to Parkinson’s

25. Parkinson’s = inadequate DA - L-dopa increases DA for Parkinson’s - amphetamines activate DA & can worsen psychotic sxs in people with schizophrenia

26. SUM: Increase DA => increase schizo. & decrease Parkinson’s Decrease DA => decrease schizo. & increase Parkinson’s

27. BUT: 1. Antipsychotics don’t always work 2. Antipsychotics ineffective for negative sxs 3. Decrease in DA in some brain areas (may account for subtype differences)

28. Thus, complex interaction of DA, SE, & possibly other neurotransmitters

29. 2. Brain Structure - neurological damage? a. Behavioral signs - abnormal reflexes - decreased attention

30. b. Atrophy - enlarged ventricles - often, but not always - related to perinatal problems?

31. c. Decreased frontal lobe fx - related to negative sxs - more common in men - associated with worse premorbid adjustment & prognosis

32. Abnormal temporal lobe & limbic system fx - related to auditory hallucinations - disconnection between thought & emotion?

33. Abnormal thalamic fx - incoherence?

34. 3. Viral Infections?

35. Family Contributions NOT "Schizophrenogenic Mother" • Cold, aloof, overprotective • Double-bind communication

36. Family Interaction **Expressed emotion = criticism, hostility, overinvolvement => risk of relapse

37. Diathesis-Stress Model Diatheses: • Genes • Perinatal trauma? • Viral infection?

38. Stressors: • Single caregiver • Lack of support • Family high in expressed emotion • Low SES

39. Treatment • Antipsychotic Medication Neuroleptics • Side effects => noncompliance - grogginess, blurred vision, mouth dryness, loss of voices - TD (tardive dyskinesia)

40. Clozapine (& now Risperdone) • Blocks another DA receptor • Treats positive & negative sxs • Fewer side effects (like TD) • Fatal for 2%

41. Monthly Drug Cost (1997) • Clozapine 317.03 • Haloperidol 1.76

42. 2005 • Clozapine 15.95 • Haloperidol 14.95

43. Behavioral Treatment 1. Token economies 2. Social skills training 3. Therapeutic community – Szasz, Laing • Psychosocial rehabilitation • Family Therapy

44. Predictors of Recovery 1. Good premorbid adjustment 2. A precipitating stressor 3. Sudden onset - acute positive symptoms • Older age of onset • Affective Problems - anxiety/depression are good - hopelessness is bad

45. 6. Type of Schizophrenia Best = Paranoid (with acute onset) Worst = Undifferentiated, chronic & Disorganized (both have more negative sxs) 7. Supportive Family 8. Response to Treatment - to medication, therapy, staff - resigned is worse