Psychopathology III: Schizophrenia and Common Psychotic Disorders

1. Psychopathology III: Schizophrenia and Common Psychotic Disorders Michael Wilson, PhD University of Illinois Department of Psychology and University of Illinois College of Medicine

2. A clinical vignette… A 28 year-old male who lives in a group home is brought to the ED for agitation. He says that his roommates are spying on him by listening to him through the TV set. For this reason, he has changed roommates a number of times over the past 5 years. He has poor grooming and seems preoccupied when you talk to him. He reports that he is having trouble listening to the doctor’s questions because “I am listening to Abraham Lincoln in my head.” Testing is most likely to reveal: • lack of orientation to time • lack of orientation to person • mental retardation • frontal lobe dysfunction • lack of orientation to place

3. Outline • Defining schizophrenia • Symptoms & diagnosis • Other psychotic disorders • Treatment modalities

4. What is schizophrenia? • Schizophrenia, lit “split mind” • coined by German psychiatrist Eugen Beuler • Mixture of characteristic symptoms that have been present for significant portion of time • no single symptom indicates schizophrenia • must recognize a constellation of signs/symptoms

5. Symptoms of Schizophrenia • Positive symptoms • includes disorganized symptoms • Negative symptoms

6. Positive symptoms • “Positive symptoms” = something present which should not be there • usually an excess or distortion of normal functions • delusions • fixed false beliefs that cannot be argued out of • are not shared by other members of culture • may involve a variety of themes: persecutory, referential, somatic, grandiose • may be bizarre or non-bizarre

7. Positive symptoms • Hallucinations • may occur in any sensory modality • auditory are most common • usually experienced as voices • may be familiar or unfamiliar • isolated experiences such as hearing one’s name or humming in one’s heard are not schizophrenic

8. Positive symptoms • Disorganized thinking • sometimes argued to be single most important feature • difficult to precisely define • disorganized speech often used instead • person may “slip off the track” from one topic to another (derailment, loose associations) • answers to questions may be obliquely related (tangentiality) • speech may simply be incomprehensible (incoherence or word salad)

9. Positive symptoms • Disorganized behavior • may present in variety of ways • behavior may range from childlike silliness to unpredictable agitation • may be completely inappropriate • may note problems in any goal-directed behavior • grooming is usually poor • usually unable to prepare meals

10. Negative Symptoms • “Negative symptoms” = something missing which should be there • affective flattening • especially common • person’s face is immobile & unresponsive • alogia • poverty of speech • brief empty replies to questions • must not simply be unwilling to speak

11. Negative symptoms • avolition • inability to initiate & persist in goal-directed activities • person may sit for long periods of time, shows little interest in work/social activities • anhedonia • loss of interest or pleasure

12. Negative symptoms • Often difficult to evaluate • occur on a continuum with normality • relatively nonspecific • may occur for a variety of reasons other than schizophrenia (medications, depression, etc.)

13. DSM-IV Diagnosis of Schizophrenia A. Characteristic symptoms: > 2 of the following symptoms: • delusions • hallucinations • disorganized speech • grossly disorganized or catatonic behavior • negative symptoms, i.e., affective flattening, alogia, or avolition Note: Only one symptom is required if delusions are bizarre or voices keep up a running commentary on person’s thoughts or behavior, or two or more voices are conversing with each other.

14. Diagnosis of Schizophrenia B. The patient must have substantial social/occupational dysfunction. C. Disturbance persists for at least 6 months. This 6-month period must include at least 1 month of symptoms that meet Criterion A and may include periods of prodromal or residual symptoms. D. Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out.

15. Diagnosis of Schizophrenia E. Cannot be better explained by a substance or a general medical condition. F. If developmental disorder present, additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations.

16. Catatonic Immobile behavior dominates, less common now Disorganized Disorganized speech, behavior, and flat affect Paranoid Delusions and/or auditory hallucinations Not limited to persecutory themes Undifferentiated not above, but Criterion A still met Residual Criterion A no longer met, “burned out.” DSM-IV Subtypes

17. Epidemiology - I • Lifetime prevalence ~1% • male = female • All cultures have similar frequency • typically between late teens to mid-30s • earlier for males • rare prior to adolescence & after 55 • may also begin > 45 years (much more common in women) • Increased mortality rate from accidents and natural causes • life span shortened by ~ decade • under-diagnosis of other medical illness

18. Epidemiology - II • 10-15% suicide • ~50% attempt • Illness seems concentrated in lower socioeconomic classes. • “downward drift” vs. social causation • Increased use vs. abuse vs. dependence • ~1/3 or more of homeless population • Disabling (over 50% unemployed) • 50% of all inpatient psychiatry beds

19. Epidemiology - III • Highest prevalence of Schizophrenia found in those with lower SES…Why? • Hypothesis 1: “Social Causation” Negative factors related to low SES (e.g., stressful life events, social isolation, poor nutrition) lead to development of illness • Hypothesis 2: “Social Selection” Due to cognitive/social impairments in those who develop the illness, they are less able to progress to college or high-paying jobs so they drift to a lower SES

20. Are Schizophrenic People Violent? • Most schizophrenics are far more likely to be victims • despite Hollywood portrayal • However, elevated risk in some patients • Best predictors are history of previous violence, dangerous behavior while hospitalized, hallucinations or delusions involving violence Brennan PA, Mednick SA, Hodgins S. Major mental disorders and criminal violence in a Danish birth cohort. Arch Gen Psychiatry. 2000 May;57(5):494-500.

21. Excluding Related Disorders Before a diagnosis of schizophrenia can be given, disorders with similar symptoms must be ruled out as a possibility • Mood Disorders with Psychotic Symptoms • Schizoaffective Disorder • Schizophreniform Disorder • Brief Psychotic Disorder • Delusional Disorder

22. Difference between Schizophrenia and Mood Disorders with Psychosis • Schizophrenia: If depression and mania symptoms present, duration of mood symptoms must be brief in comparison to schizophrenia symptoms • Mood disorders: psychotic symptoms only occur during a manic or depressive episode

23. Schizophrenia vs. Schizoaffective Disorder • For schizoaffective disorder: • Delusions and hallucinations must be present for at least 2 weeks without prominent mood symptoms. • Mood symptoms must be present for a substantial portion of the psychotic disturbance • For schizophrenia: • Length of time that mood symptoms are present is brief in comparison to the duration of psychotic disturbance

24. Schizophrenia, Brief Psychotic Disorder, Schizophreniform Disorder Brief psychotic Schizophreniform Schizophrenia 1 day 1 month 6 months

25. Delusional Disorder vs. Schizophrenia • Non-bizarre delusions are the prominent psychotic symptom in delusional disorder • Other schizophrenic symptoms, such as hallucinations, disorganized and negative symptoms are absent in delusional disorder

26. So, what is the Difference… …between Mood disorders + Psychosis, Schizophrenia & Schizoaffective Disorder? THE DURATION OF MOOD SYMPTOMS and PSYCHOTIC SYMPTOMS …between Schizophrenia, Schizophreniform Disorder & Brief Psychotic Disorder? THE DURATION OF ENTIRE DISTURBANCE …between Schizophrenia & Delusional Disorder? TYPE OF DELUSION & PRESENCE/ABSENCE OF OTHER SYMPTOMS

27. Etiology: Genes • Adoption and twin studies indicate a genetic influence • Pairwise concordance rates show: • MZ concordance = 48 percent • DZ concordance = 17 percent • Twin concordance rate also implicate other factors beyond genetics

28. Long-term Clinical Course • Classically, consists of exacerbations and remissions • remissions often will not return patient to “baseline” level of functioning • Progression may plateau about 5 years after initial diagnosis • Antipsychotic medications improve acute and long-term outcome • Long-term prognosis is not totally good or bad: • 1/4 have a good outcome • 1/4 continue to have moderate symptoms • 1/2 remain significantly impaired with current treatment

29. Treatment Modalities • Psychopharmacologic • Classical antipsychotics • “Atypical” antipsychotics • Other agents • Psychosocial • Supportive therapy • Social skills training • Case management • Working with families

30. Treatment: Classical Antipsychotic Medications 1. Target dopamine receptors 2. Work well for positive symptoms (somewhat effective for 75% of patients) 3. Induce side effects resembling Parkinson’s Disease: -Extrapyramidal Symptoms Tremors, agitation, involuntary posturing, motor rigidity and inertia -Tardive Dyskinesia Involuntary movements of mouth and face (lip puckering, chewing) and spasmodic body movements

31. Classical Antipsychotics • Divided into a high potency and a low potency group • Potency = amount of drug to give effect • Example of high potency = haloperidol (Haldol) • Example of low potency = chlorpromazine (Thorazine). • High potency drugs bind D2 receptors more strongly • also worse with extrapyramidal symptom (EPS) side effects • They are inexpensive but have unpleasant side effects

32. Treatment: Atypical Antipsychotics 1. Better for negative symptoms 2. Also have side effects (Clozapine has 1-2% chance of agranulocytosis) 3. Affect other neurotransmitters like serotonin and norepinephrine 4. Relapse rates are high if medication stops

33. Treatment: Psychosocial • Medication does not meet many needs of clients • such as improving social competence, housing stability, employment, etc. • Psychosocial treatments focus on long-term strategies • try to improve patient’s life other than reduction of psychotic symptoms • Types of psychosocial treatment include: • Family therapy • Social skills training • Vocational rehabilitation • Assertive community treatment (ACT)

34. Assertive Community Treatment • A comprehensive team works together to meet the needs of the client including: • Psychiatrists • Nurses • Social workers • Vocational counselors • Recreational counselors • Staff to client ratio is high, staff are is available 24/7, and contact with clients is frequent

35. Brain changes in schizophrenia • Structural changes • lateral ventricles are enlarged • decreased brain volume diffusely • temporal lobe structures particularly affected • hippocampus, amygdala, etc. • Functional changes • functional abnormalities widespread • consistently shows less activity in frontal lobes

36. Dorsolateral Prefrontal Cortex (DLPFC) • manipulating information • behavioral inhibition • selective attention • working memory

37. Social and Family Effects • Better prognosis for patient: • Married • Good social support system • Good premorbid social and other functioning • Low levels of “expressed emotion” (hostile, critical, intrusive over-involvement) • Now discredited theories blamed family, especially mothers • Education still needed to help correct this misconception

38. A clinical vignette… A 28 year-old male who lives in a group home is brought to the ED for agitation. He says that his roommates are spying on him by listening to him through the TV set. For this reason, he has changed roommates a number of times over the past 5 years. He has poor grooming and seems preoccupied when you talk to him. He reports that he is having trouble listening to the doctor’s questions because “I am listening to Abraham Lincoln in my head.” Neuropsych testing is most likely to reveal: • lack of orientation to time • lack of orientation to person • mental retardation • frontal lobe dysfunction • lack of orientation to place

39. Readings • Fadem, BRS: Behavioral Science chapter 11