Schizophrenia - Rockhurst University
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Transcript Schizophrenia - Rockhurst University
Schizophrenia
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
DSM-IV Diagnosis
Schizophrenia
– Symptoms > 6 months
Schizophreniform
disorder
– Symptoms 1 month - 6 months
Brief
psychotic disorder
– Symptoms 1 day - 1 month
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
Prevalence of
Schizophrenia
Median
age at diagnosis = mid-20’s
Men = Women prevalence
– Men earlier diagnosis
Worse premorbid history
Worse prognosis
Prognosis of Schizophrenia
10%
continuous hospitalization
< 30% recovery = symptom-free for 5
years
60% continued problems in
living/episodic periods
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
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
Course of Schizophrenia
Prodromal
phase
Active phase
Residual phase
Symptom Distinction
Positive
symptoms
– Deviant behaviors present
Negative
symptoms
– Normal behaviors absent
– Poor premorbid history
– Poorer prognosis
– Spouses less satisfied
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
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
Subtypes of Schizophrenia
Paranoid
– Delusions/Hallucinations have single theme =
Persecution/Grandiosity
– No thought disorder
– Better prognosis
Subtypes of Schizophrenia
Catatonic
– Hallmark = motor behavior
Catatonic stupor
Catatonic excitement
Subtypes of Schizophrenia
Disorganized
(Hebephrenic)
– Grossly disorganized cognition, affect,
behavior
– Poor prognosis
Subtypes of Schizophrenia
Undifferentiated
– Does not meet criteria for other subtypes
Diagnosis in First Episode
(Lieberman et al., 1992)
1% Catatonic
3% Disorganized
19% Paranoid
54% Undifferentiated
Etiology of Schizophrenia
Summary of Family and Twin
Studies
Relation to
Proband
Spouse
Grandchildren
Nieces/nephews
Children
Siblings
DZ twins
MZ twins
Percentage
Schizophrenic
1.00
2.84
2.65
9.35
7.30
12.08
44.30
Biochemical Factors in
Schizophrenia
Problems with biochemical research
Dopamine Activity
– Effects of phenothiazines
– Amphetamine psychosis
Problems with Dopamine Hypothesis
– HVA not found in greater amounts in
schizophrenics
– Phenothiazines rapidly block dopamine receptors,
but effect on symptoms is slow
– Excess or oversensitive dopamine receptors
The Brain and
Schizophrenia
Autopsy studies indicate structural problems in
the limbic areas and the prefrontal cortex
CT scan and MRI studies reveal enlarged
ventricles, suggesting deterioration or atrophy
of brain tissue.
PET scans suggest atrophy in the prefrontal
areas.
The Brain and
Schizophrenia
Evidence supports the hypothesis that a
viral infection occurring during the mid
trimester of fetal development may cause
this brain damage
It has been suggested that this early brain
injury remains silent until the prefrontal
cortex matures, typically in adolescence.
Psychological Stress and
Schizophrenia
Social Class - the highest rates of
schizophrenia are found in central city areas
inhabited by people in having the lowest SES
– Sociogenic hypothesis
– Social-selection theory
Family and Schizophrenia
– Schizophrenogenic mother
– Expressed emotion
– High Risk Studies
Treatment of Schizophrenia
Treatments for
Schizophrenia
Insulin coma, prefrontal lobotomy, and ECT
no longer used.
Neuroleptics - anti-psychotic medications
which are the most effective treatment for
the positive symptoms of schizophrenia.
Family Therapy - aimed at reducing the
expressed emotion which predicts relapse
Behavioral Therapy - social skills training
has been found to improve social adjustment
Treatment Today
Outpatient
and Inpatient Treatment
– 80-90% hospital discharge rate
– 40-50% readmission rate = revolving door
$33
billion direct/indirect costs
2.5% of total health care expenditures
Predictors of Good
Outcome
Good
premorbid adjustment
Acute onset
Notable stressful life events
Positive family environment
More positive than negative symptoms
More affective (vs. flat) symptoms
Medication
Atypical
neuroleptics
– Clozaril, Risperdal
– Block 65% dopamine receptors, but more
selective to frontal and temporal nerve
tracts
– Also increase serotonin
Effectiveness of
Medications
Effective for positive symptoms
– Atypical also effective for negative
symptoms
Decrease
time in hospital
Decrease relapse
– 19% vs. 55% placebo
10-15%
patients not helped by medication
Side Effects of Medications
Autonomic
effects
– Dry mouth
– Drowsiness
– Blurred vision
Side Effects of Medications
Extrapyramidal
Effects
– Tardive Dyskinesia - face, mouth, jaw
movement
15% long-term regimens
some not reversible
can affect respiration