Schizophrenia

1. Schizophrenia Greg Chick SHO Psychiatry, Royal Manchester Children’s Hospital

2. What do I Really Have to Know? • Prevalence (quoted as 1% worldwide) • Age of onset 20ish, (40ish, 70ish) • Differential Diagnosis • Think ORGANIC! • Drug-induced psychosis, Psychotic depression, mania, (schizoaffective disorder), schizotypal personality disorder • Psychopathology • Define: Delusion, Hallucination

3. WHY do I need to know about Sz? • GP • Front line service • Early detection improves prognosis! • worried relatives asking you to section people • Increased burden • Surgeons / Obs & Gynae – delusional pts insisting on unnecessary operations • A&E – pts present with overdose, bizarre behaviour & complaints • Paediatrics – child protection issues; early onset psychosis • Psychiatry – bread & butter! • frequent LONG admissions

4. Definition of Schizophrenia • a “severe and enduring mental illness” • A clinical syndrome • “a collection of features which tend to occur together” • Refined over last 200 years or so • Recognised pattern of outcome • Same methods of treatment • Biological basis; severe psychosocial consequences • No definitive cause or mechanism yet identified (multifactorial – see Theory Lecture) • Neurochemical imbalance • ‘reality testing’ and ‘theory of mind’ defective • + loss of ‘ego boundaries’ – (what is Me and what is Outside) • BUT there is still no single concise definition!

5. Myths & Misconceptions • ‘Schizophrenia’ does literally mean ‘separated mind’ • Greek – applied by Bleuler in 1911 • BUT is nothing to do with ‘split personality’ • Let alone ‘multiple personality’ (very rare) • HAS to do with the brain’s functions separating • Eg. Hear a voice but don’t recognise it’s come from your own mind

6. Heritable Risk

7. Risks for family members with schizophrenia • Single parent: 10% risk • Both parents: 25% risk • Sibling: 10% risk • Twin: 50% risk • Clear-cut genetic loading proven by adopted away twin studies • Not 100% genetic since risk with identical twins is only 50%. • Multifactorial with multiple genes and environmental factors (viral, toxins, drugs, alcohol, psychological stressors)

8. Clinical features • “Prevalence 1% in all countries” • Gradual onset • Onset at late adolescence/early adulthood • But can occur AT ANY AGE • Smaller peak around 40yrs (late onset) • Even smaller peak around 70yrs! (late late onset) • Progressive decline in function • Deficit symptoms predominate • Family history of schizophrenia

9. Age of Onset – Bimodal Distribution

10. Historical – spotting the patterns, grouping the symptoms • 1900’s Kraepelin and Bleuler • Kraepelin’s ‘Dementia praecox’ • premature loss of mind; inevitable decline (13% recovered) • Bleuler’s 4 A’s: • ‘Autism’ (withdrawal into own fantastic world) • Associations loosened (eg chaotic thinking & speech) • Affect (blunted or incongruous) • Ambivalence (love & hate, want / not want)

11. Historical – spotting the patterns, grouping the symptoms • 1950’s - Schneider’s 1st Rank Symptoms: • Primary Delusion = ‘delusional percept’ • Own thoughts spoken aloud = ‘thought echo’ • Voices arguing or discussing • running commentary voices • thought withdrawal and/or thought block • Thought insertion • thought broadcasting (others are thinking it at the same time as you) • Made to feel… ‘passivity of affect’ • Made to want… ‘passivity of impulse’ • Made to do… ‘passivity of volition’ • Done to my body ‘somatic passivity’ eg probed by aliens • Some may occur in illnesses other than schizophrenia eg mania, dementia, delusional disorder

12. Natural History & Prognosis • Often poor • Commonly leads to social disability • Many long admissions to hospital • Unemployment, reliance on benefits • Homelessness (though not usually ‘on the streets’) • Isolation – loss of contact with friends, not making new ones • stigma • Lack of insight => non-compliance with meds, despite need for life-long treatment in most cases. * psycho-education, relapse prevention, family work • Tardive dyskinesia • Occurs even without drug Rx but seems worse with Dopamine antag’ • (involuntary facial / truncal twitching / writhing movements – essentially untreatable) • Much more physical disease • Also side effects of medication

13. 5 Year Outcome after First Presentation

14. Types of Schizophrenia: ICD-10 • F20 Schizophrenia • F20.0 Paranoid Schizophrenia • F20.1 Hebephrenic Sz • F20.2 Catatonic Sz • F20.3 Undifferentiated Sz • F20.4 Post-Schizophrenic Depression\ • F20.5 Residual Sz • F20.6 Simple Sz

15. Types of Schizophrenia: ICD-10 F20.0 Paranoid Schizophrenia • most common type – hallucinations & delusions • ‘paranoia’ from the Greek – reference to the Self • (it’s ME they’re out to get, not anyone else) • Hebephrenic Sz • Cartoon mad person – laughing inappropriately, crying, chaotic • Only seen in young people • Catatonic Sz • Historical asylum cliché – strange postures / muteness / manerisms • Less commonly seen now, more common in mania or severe depression • Residual Sz – chronic low-grade oddness • Simple Sz – hermit-like retreat from society

16. Prodromal / Early Symptoms • Symptoms one month to one year before psychotic crisis • Person feels something strange or weird is happening to them • Perplexity, “delusional atmosphere” • Misinterprets things in the environment • Feelings of rejection, lack of self-respect, loneliness,hopelessness, isolation, withdrawal, and inability to trust others.

17. Categories of Symptoms • Symptoms may be classified as • “Positive” – symptoms i.e. hallucinations, delusions, bizarre behavior, disorganized speech • “Negative” – lack of normal experiences: • apathy, lack of motivation, anhedonia (inability to enjoy normal pleasures) • Cognitive - i.e. difficulty with selective attention, memory, planning and problem solving • Disorganized – i.e. disorganized speech, inappropriate affect

18. Differential diagnosis • THINK ORGANIC first! • Delirium tremens, alcoholic hallucinosis, brain tumor, toxins • Rare metabolic disorders • Huntington’s Disease (psychiatric symptoms predominate!) • Drug induced: cannabis, amphetamines, Cocaine, LSD, PCP • Mania; depression with psychotic features • Schizoaffective disorder (equal proportion of psychotic & affective symptoms)

19. Mental state abnormalities in Sz Thought Behaviour Perception Catatonia Form Content Delusions Hallucinations Illusions Pseudohallucinations Overvalued Ideas Circumstantiality Fusion Knight´s Move Thinking Auditory Derailment Tactile Word Salad Visual Olfactory & Gustatory Thought Block

20. Delusions - definition • “A delusion is a false, unshakeable idea or belief which is out of keeping with the patient’s educational, cultural and social background” – Simms • * we can never understand how they arrived at the belief – defies normal logic * • BUT • Need not be totally unshakeable – cognitive therapy for delusions • Need not be false (eg delusional jealousy then discover partner actually IS unfaithful) • Wrongly ARRIVED at belief • Primary Delusion – ‘out of the blue’ • Secondary Delusion – arises out of eg. hallucination

21. Delusions - examples • I am the son of George W Bush • …by a somali woman. They were on holiday there and left me behind. • I have a microchip in my brain which transmits my thoughts to MI5 • There’s a man living in my loft who’s trying to drive me out of my house. He kills pigeons and eats them. • My family are poisoning my food. It tastes funny

22. Hallucination • A perception, which feels real, but has no real stimulus • Modalities: • Auditory • heard as if coming from outwith your head inc. from another part of the body! • Visual (more indicative of organic pathology!) • Somatic / Sexual • Gustatory • Olfactory • Non-pathological • Hypnagogic (going off to sleep) • Hypnopompic (waking up)

23. When it’s NOT a hallucination • Illusion = misperception of a REAL stimulus • Daydream = imagery • Pseudohallucination • Occurs in inner subjective space • eg voices INSIDE your head • May have quality of your own thoughts • Distressed patients not interested in this distinction!

24. Thought Disorder in Schizophrenia • Circumstantiality (goal eventually reached but tortuously indirect and over-inclusive) • Knight’s Move Thinking • Illogical jumping between ideas. Listener can’t follow train of thought. • “I can’t go to the zoo, no money. Oh... I have a hat - these members make no sense, man… What’s the problem?” • NOT the same as Flight Of Ideas, which you CAN follow • Derailment (just losing the plot – goal of speech not reached) • Fusion (themes recur but in odd order, hard to follow) • Thought Block (‘snapping off’ train of thought. No thoughts left)

25. Case Vignette - 2 • Brian began to be a worry to his parents at the age of 17. After doing quite well in his GCSEs, he seemed to lose interest and his ability to concentrate on his studies. He began to spend more time alone in his room listening to music and when he went out with his friends, he appeared dazed and distant on returning home. • His parents suspected he was taking drugs but he denied this. When his mother went into his bedroom to tidy up one day, she found that he had draped a cloth over the mirror. He explained this by saying that he avoided looking at his face because he had a strange look in his eyes, as though he had become hypnotised. His parents tried to persuade him to visit their GP, but he refused to go. He became very quarrelsome and one day he punched one of his friends without warning. That evening, he removed all the light bulbs from their sockets after complaining that they were emitting dangerous radiation. His parents took him to hospital and he was admitted.

26. Negative Symptoms • Develop over time • May not be detected (masked by positive symptoms Negative symptoms include: poverty of speech content, thought blocking, anergia, anhedonia, affective blunting, and lack of volition.

27. Where can I find out more? • “Symptoms in the Mind” Andrew Simms • (the ‘bible’ for descriptive psychopathology) • NICE guidelines • www.abpi.org.uk/publications/publication_details/targetSchizophrenia-2003/section2.asp • Bryan L. Roth, rothlab, (ppt presentation) • Melinda Hermanns (ppt presentation) • Douglas Ziedonis (ppt presentation)

28. Quiz • 2) Can you diagnose Sz in a patient who has been hearing voices for 2 weeks? • No. Need >= 1 month of symptoms • 3) do drugs cause Sz? • Cannabis use in susceptible individuals increases risk X 6 • Amphetamine, cocaine/crack cause identical syndromes • 4) do pts with Sz smoke more than other people? • 70-90% are addicted to smoking • Neuropsychological basis for this – startle response • Lack of other activities in hospital & outside • 5) Are pts with Sz more violent than the rest of the population? • Essentially not. Paranoia & hallucinations make pts frightened. Restraining people ditto. Sz pts have higher rates of drug & alcohol problems, lower IQ in general • 6) ‘Psychotic’ nowadays refers to the bizarre phenomena described above (eg hallucinations, delusions), the perplexed state and being out of touch with reality. Not about being violent or cruel as per Hollywood usage. • 1) still have other questions?