Chapter THIRTEEN

1. Chapter THIRTEEN Schizophrenia & Related Disorders

2. Symptoms Differential Diagnosis Epidemiology Etiology & Course Treatments Schizophrenia & Related Disorders

3. Schizophrenia & Related Disorders • Symptoms • Differential Diagnosis • Epidemiology • Etiology & Course • Treatments

4. Schizophrenia Symptom Categories

5. Positive (Psychotic) Symptoms Functions that are present that shouldn’t be • HALLUCINATIONS • heightened sensory (perceptual) experiences that are not due to external stimuli • experienced by 5 senses; most common, auditory • DELUSIONS(when is a belief delusional?) • rigidly held beliefs that are inaccurate or inconsistent with how people experience reality • 5 types: persecutory, referential, grandiose, somatic, religious • can be “bizarre” or “non-bizarre”

6. Negative Symptoms Aspects of normal behavior and social relationships that should be present, but are absent ANHEDONIA lack of pleasure or interest ALOGIA lack of spontaneous speech AVOLITION lack of will power BLUNTED/FLAT AFFECT lack of expressiveness (e.g., facial)

7. Disorganized Symptoms Do not fit characteristics of positive or negative symptoms and reflect bizarre behaviors & thought disturbances DISORGANIZED SPEECH Clips: tangential speech, very difficult to follow conveys little meaning due to poor context maintenance (word salad) GROSSLY DISORGANIZED/BIZARRE BEHAVIORS ranges from child-like silliness to unpredictable agitation CATATONIC MOTOR BEHAVIORS 3 1 2

8. Criteria for Schizophrenia AT LEAST 1 MONTH • In the ACTIVE phase, must have IMPAIRMENT in functioning + TWO or more of the following:  delusions  hallucinations  disorganized speech  negative symptoms  grossly disorganized or catatonic behavior • During the PRODROMAL and RESIDUAL phases, may have only negative symptoms, or other symptoms in less severity (e.g., odd beliefs instead of delusions) Prodromal Active Residual Duration of Entire Disorder AT LEAST 6 MONTHS

9. Schizophrenia Subtypes • PARANOID • One or more delusions OR frequent hallucinations; no prominent disorganized behaviors/speech, catatonic behavior or flat/inappropriate affect • DISORGANIZED • Disorganized speech & behavior, and flat/inappropriate affect • CATATONIC • UNDIFFERENTIATED • Met Criterion A, but does not fit the other subtypes • RESIDUAL • Attenuated symptoms in Criterion A OR presence of Negative Symptoms

10. Schizophrenia & Related Disorders • Symptoms • Differential Diagnosis • Epidemiology • Etiology & Course • Treatments

11. 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

12. Schizophrenia vs.Mood Disorders with psychotic symptoms • SCHIZOPHRENIA with mood symptoms IF depression and maniasymptoms are present, their duration must be brief in relation to the duration of active and residual schizophrenia symptoms. • MOOD DISORDERS with psychotic symptoms the psychotic symptoms only occur during a manic or depressive episode.

13. SCHIZOPHRENIA with mood symptoms MOOD DISORDER with psychotic symptoms

14. Schizophrenia vs. Schizoaffective Disorder • SCHIZOPHRENIA with mood symptoms • length of time that mood symptoms are present is brief in comparison to the duration of psychotic disturbance • SCHIZOAFFECTIVE DISORDER • mood symptoms must be present for a substantial portion of the psychotic disturbance • delusions and hallucinations must be present for at least 2 weeks without prominent mood symptoms.

15. SCHIZOAFFECTIVE DISORDER SCHIZOPHRENIA with mood symptoms

16. Brief Psychotic Disorder vs. Schizophreniform Disorder vs. Schizophrenia

17. Delusional Disorder vs. Schizophrenia DELUSIONAL DISORDER • Non-bizarre delusions are the prominent psychotic symptom. • Other schizophrenic symptoms, such as hallucinations, disorganized and negative symptoms are largely absent.

18. So, What is the Difference … between Mood disorders w/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

19. Symptoms Differential Diagnosis Epidemiology Etiology & Course Treatments Schizophrenia & Related Disorders

20. Prevalence of Schizophrenia across Western and Non-Western Countries Lifetime prevalence rate in general population is around 1%

21. Symptoms Differential Diagnosis Epidemiology Etiology & Course Treatments Schizophrenia & Related Disorders

22. Etiology of Schizophrenia • Before birth: • Genes • Maternal exposure to virus • Complications/illness during pregnancy • During birth: • Complications during delivery • At various times during development: • Brain abnormalities • During childhood & adolescence: • Socioeconomic status (SES) • Family factors

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

24. Socioeconomic Status (SES) • Highest prevalence of Schizophrenia found in those with lower SES…Why? • Hypothesis 1: “Social Causation” negative factors related to low SES lead to development of illness • Hypothesis 2: “Social Selection” cognitive/social impairments associated with the illness lead individuals to drift to a lower SES

25. Family Factor: Expressed Emotions (EE) EE = family members’ negative, critical & hostile attitudes & behavior towards patient AND/OR emotional over-involvement & intrusiveness of family Families can be classified as high or low on EE Patients who return to live with families are more likely to relapse if at least one relative was high in EE Relapse is defined as return of positive symptoms, increase in medication dosage, OR re-hospitalization It is also possible that families exhibit high EE following a relapse

26. Relapse Rate for EE and Level of Contact High EE families close contact risk of relapse Low EE families close contact risk of relapse

27. Gender Differences in Schizophrenia Age of onset (younger for men) Premorbid social functioning (better for women) Typical symptoms (men have more negative symptoms) Course of illness & Response to tx (men more chronic and poorer response to treatment)

28. Multiple Pathways to Schizophrenia Schizophrenia combined liability adolescence young adult middle age Time Hints of psychosis

29. Schizophrenia & Related Disorders • Symptoms • Differential Diagnosis • Epidemiology • Etiology & Course • Treatments

30. Treatment: Older Antipsychotic Medications • Target dopamine receptors • Work well for positive symptoms (somewhat effective for 75% of patients) • 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. Treatment: Newer Antipsychotics • Better at treating negative symptoms • Also have side effects (Clozapine has 1% chance of lethal blood condition) • Affect other neurotransmitters like serotonin and norepinephrine • Relapse rates are high if medication stops, some relapse even if medication is continued

32. Treatment: Psychosocial • Psychosocial treatments focus on long-term strategies to improve aspects of patient’s life other than the reduction of psychotic symptoms such as improving social competence, housing stability, employment, etc. • Types of psychosocial treatment include: • Family therapy • Social skills training • Vocational rehabilitation • Assertive community treatment (ACT)

33. Treatment: Family Therapy • Most effective if the family is high in expressed emotion • Some psychosocial treatments aim to improve family coping skills and reduce relapse. • Eliminating unrealistic expectations for the patient • Improving communication and problem-solving skills of family members

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 is available 24/7, and contact with clients is frequent • Good outcomes

35. Cognitive Behavioral Therapy for Psychosis • Goals • decrease conviction of delusional beliefs • promote more effective coping strategies • reduce distress • Teaches skills to challenge & modify beliefs • experimental reality testing • Effectiveness • superior to control condition in clinical studies • significantly decreases positive symptoms • continued improvement at 6-month follow-up

36. Chapter THIRTEEN Schizophrenia & Related Disorders OPTIONAL SLIDES & I-CLICKER ACTIVITY

37. Vulnerability Marker • is a sign or an evidence that a person is more vulnerable to developing a disorder than someone else. • importance: can provide clues about who is at risk for developing a disorder • specific measure or test useful in identifying people vulnerable to a disorder • e.g., we can localize a marker to a gene on a specific chromosome

38. Vulnerability Markers: Characteristics • Must have sensitivity 1. Should see marker as a stable trait in all people with schizophrenia 2. Should be more common among 1st degree relatives than general population 3. Should predict future episodes of schizophrenia among those who have the marker, but have not experienced a psychotic episode • Must have specificity • distinguish those with schizophrenia from other groups

39. Example: Eye-Tracking Dysfunction • Difficulty with smooth-pursuit eye movements when tracking the motion of a pendulum or similar oscillating stimulus • Individuals with schizophrenia typically exhibit rapid eye movements Target Non-Sz subject Sz subject • Is it a vulnerability marker for Schizophrenia?

40. Chapter THIRTEEN Schizophrenia & Related Disorders I-CLICKER ACTIVITY Differential Diagnoses

41. Did psychotic symptoms occur at times other than during mood episodes? No Yes Has duration of mood episodes been brief relative to duration of schizophrenia symptoms (including negative symptoms and odd beliefs)? No Yes Has duration of schizophrenia symptoms been 6 months or longer? No Yes Has the duration of schizophrenia symptoms been at least 1 month? No Yes 1 2 3 5 4

42. Which disorder should go on box #1 Schizophrenia Schizoaffective Disorder Schizophreniform Disorder Mood Disorder with Psychosis Brief Psychotic Disorder

43. Which disorder should go on box #2 Schizophrenia Schizoaffective Disorder Schizophreniform Disorder Mood Disorder with Psychosis Brief Psychotic Disorder

44. Which disorder should go on box #3 Schizophrenia Schizoaffective Disorder Schizophreniform Disorder Mood Disorder with Psychosis Brief Psychotic Disorder

45. Which disorder should go on box #4 Schizophrenia Schizoaffective Disorder Schizophreniform Disorder Mood Disorder with Psychosis Brief Psychotic Disorder

46. Which disorder should go on box #5 Schizophrenia Schizoaffective Disorder Schizophreniform Disorder Mood Disorder with Psychosis Brief Psychotic Disorder