Transcript Schizophrenia - Terri L. Weaver, Ph.D.

Schizophrenia
Overview
• Most debilitating and costly of all adult
psychiatric illnesses
• ~25% of all psychiatric beds are occupied
by persons with schizophrenia
• 2002 fiscal costs of schizophrenia was 62.7
billion
• Greatest burden is lost productivity
Schizophrenia
• Multisystem disease
• Often difficult to describe and understand
• No single feature is pathogonomic of Schizophrenia
• Associated with a constellation of signs and symptoms
• A disease that affects many domains of human functioning
COGNITION
EMOTION
INTERPERSONAL RELATIONSHIPS
Debilitating: 25-60% live with relatives
•10-20% are homeless
Epidemiology
• 2.2 million people have schizophrenia at any given time
• One year prevalence rates are 1-4.6%
• Prevalence rates are roughly stable across a range of
populations and cultures
• Persons with schizophrenia in developing countries may
have a better course and prognosis
• Persons with schizophrenia are less likely to marry
(particularly males) and less likely to complete higher
education
• Between 14-20% of those with schizophrenia are
employed competitively
Onset and Course of Illness
• Onset typical in late adolescence or early adulthood
• Prodromal period or changes in mood and behavior prior to first break
may last up to five years
• Early versus late onset illness
• Early signs date back to childhood
– Deficits in verbal memory
– Deficits in attentional vigilance
– Deficits in gross motor skills
– May be additional interpersonal difficulties or other difficulties in
functioning
– Early conduct disorder may also be prodromal
– Early signs may be subtle, irregular, and graduate and more
apparent in adolscence
Factors Assoc. with Better
Prognosis
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Good premorbid adjustment
Acute onset
Later afe at onset
Being female
Precipitating event
Associated mood disturbance
Brief duration of active phase symptoms
Good interepisode functioning
Minimum residual symptoms
Absence of structural brain abnormalities
No family history of schizophrenia
Schizophrenia
A. Two or more of the following during 1- month period (or
less if successfully treated):
(1) delusions*
(2) hallucinations*
(3) disorganized speech (frequent derailment or incoherence)
(4) grossly disorganized or catatonic behaviour
(5) negative symptoms (affective flattening, alogia, avolition)
B. Social Occupational Dysfunction
C. Duration: at least 6 months, with 1 month of active phase
symptoms (or less if successfully treated)
May include Prodromal/Residual periods
Schizophrenia (con’t)
D. Schizoaffective and Mood Disorder exclusion
C. Substance/general medical condition exclusion
E. Relationship to a Pervasive Developmental Disorder
Specify course:
Episodic with Interepisode Residual Symptoms
- with prominent negative symptoms
Episodic with No Interepisode Residual Symptoms
- continuous (prominent psychotic symptoms)
- with prominent negative symptoms
Single Episode in Partial Remission
- with prominent negative symptoms
Single Episode in Full Remission
Other or Unspecified Pattern
Differential Diagnosis
of Psychosis
• Mood Disorder with Psychotic features
• Prolonged Substance Abuse
• Brain Damage
• Infections
• Neurohereditary Disorders
• Nutritional Abnormalities
Positive Symptoms
Positive Symptoms
Hallucinations
Auditory
Visual
Somatic
Olfactory
Delusions
Thought withdrawal
Thought insertion
Thought broadcasting
Persecutory
Grandiose
Religious
Somatic
Reference
Being controlled
Mind reading
Guilt or sin
Disorganized Symptoms
Disorganized Symptoms
Thinking & Speech
Derailment
Tangentiality
Incoherence
Circumstantiality
Pressure of speech
Distractible speech
Clanging
Illogicality
Behavior
Clothing & Appearance
Social & Sexual
Aggressive & Agitated
Ritualistic or Stereotyped
Negative Symptoms
Negative Symptoms
Primary
Alogia
Secondary
Side effects of neuroleptic drugs
Affective blunting/flattening Demoralization and depression
Avolition
Chronic institutionalization
Anhedonia
lack of stimulation - withdrawal & apathy
Attentional impairment
Withdrawal as a response to delusions and/or
hallucinations
Schizophrenia Subtypes
• Can change over the course of the illness
• Catatonic Type
• Disorganized Type
• Paranoid Type
• Undifferentiated Type
• Residual Type
Catatonic Type
Clinical Picture is dominated by at least two of the following:
(1) motoric immobility as evidenced by catalepsy
(2) excessive motor activity
(3) extreme negativism
(4) peculiarities of voluntary movement
(5) echolalia or echopraxia
Disorganized Type
Following criteria are met:
A. All of the following are prominent:
(1) disorganized speech
(2) disorganized behaviour
(3) flat or inappropriate affect
B. The criteria are not met for Catatonic Type
Paranoid Type
Following criteria are met:
A. Preoccupation with one or more delusions or frequent
auditory hallucinations
B. None of the following is prominent:
disorganized speech
disorganized or catatonic behaviour
flat or inappropriate affect
Undifferentiated Type
Type of Schizophrenia where symptoms:
(1) Meet Criterion A
(2 Are not met for the Paranoid, Disorganized or
Catatonic type
Residual Type
Following criteria are met:
A. Do not fit into an other categories
B. Evidence of a disturbance as indicated by:
presence of negative symptoms or
two or more symptoms listed in Criterion A
Schizophreniform Disorder
• Criteria A, D, and E of Schizophrenia are met
• An episode of the disorder (including prodromal, active
and residual phases) lasts at least 1 month but less than 6
months.
“Provisional” when without recovery
• Specify if: Without Good Prognostic Features
With Good Prognostic Features
Schizoaffective Disorder
• Uninterrupted period of illness where there is either:
Major Depressive Episode, Manic or Mixed concurrent
with symptoms meeting Criterion A for Schizophrenia
Major depressive episode must meet A1 criterion
• During illness, two week period of delusions or
hallucinations in absence of prominent mood symptoms
• Symptoms meeting criteria for mood episode present for
substantial period of the total duration of illness
• Not better accounted for substance use or general medical
condition
Specify Bipolar or Depressive Type
Delusional Disorder
A. Nonbizarre delusions of at least 1 months duration
B. Criterion A for Schizophrenia has never been met
C. Functioning is not markedly impaired or bizarre
D. If there are mood episodes concurrent with delusions, their
total duration is brief relative to periods of delusional
periods.
E. Not due to effects of substance or a general medical
condition
Delusional Disorder (con’t)
Specify type:
• Erotomanic Type: another person, usually of higher status
in love with the person
• Grandiose Type: inflated worth, power, knowledge, identity
• Jealous Type: unfaithful theme
• Persecutory Type: Conspiracy theme
• Somatic Type: Physical defect theme
• Mixed Type: more than one of the above
• Unspecified Type: cannot be determined
Comorbidity
• Depression is very common with a comorbidity rate of
45%
• Approximately 10% of those with schizophrenia die from
the illness though more recent estimates have lowered this
to 4-5.6%
• Suicide risk is greater with mood and substance use
disorders
• Anxiety disorders have a high rate of comorbidity (43%)
and may prompt the formation and maintenance of
persecutory delusions and hallucinations
• Lifetime comorbidity for substance use disorders is 50%
• Associated symptoms also include anger, hostility, and
social avoidance
Violence and Associated Issues
• Rates of violence for persons with schizophrenia
are lower than rates for persons with depression or
bipolar disorder
• If violence occurs it is typically a result of the cooccuring substance use
• Rates of victimization risk can be very high
• 34%-54% report childhood sexual or physical
abuse
• 43%-81% report some type of lifetime
victimization
Sex differences in Illness Course
• Women have later age at onset
• Women have better premorbid histories
• Women express more affective symptomatology
• Women exhibit more benign course in terms of
hospitalizations and social functioning
• Women appear to have less structural brain damage
• Males appear to have a higher incidence of the illness
Importance of Estrogen
• Pregnancy confers protective advantage
• Postpartum increased risk for psychotic symptoms
• Psychotic symptoms increase when estrogen levels
are lowest during menstrual cycle
• Hormone supplements appear to offset psychotic
symptoms during the menstrual cycle
ETIOLOGY
Biological
• Genetics
• Linkage Analysis
• Genetic Markers
• Heritability
• Twin Studies
• Adoption Studies
Brain Abnormalities
• Enlarged Ventricles
• Frontal Lobe
• Hypofrontality
• Temporal Lobe
• Neurochemical
Brain Abnormalities
Structural Brain Abnormalities
CT and MRI image brain anatomy in
living subjects.
 Enlarged ventricles suggest brain
tissue volume is reduced.
 Reduced brain volume and cortical
grey matter volume
 Reduction of thalamus
 Enlargement of the basal ganglia
Functional Brain
Abnormalites
SPECT and PET image brain
physiology in living subjects.
 Hypofrontality
 Brain circuitry
involved in
hallucinations
 Inactivity of cingulate
cortex while
performing a language
task
Psychological Factors
Expressed Emotion: Jill Hooley
-Concerns the degree to which family members are either
critical of a recently hospitalized patient, hostile, or express
overinvolved and overprotective attitudes toward the patient.
This construct is thought to reflect disturbances in the
organization, emotional climate, and transactional patterns
of the entire family system
-Assessed in the Camberwell Family Interview and usually
takes 1-2 hours
-Most important element of EE is criticism
-EE is a reliable risk factor for relapse in schizophrenia
Diathesis/Personality/Stress:
Schizophrenia
Diathesis
Personality
Heterogeneity within the
etiology
Psychoticism
historically but New data
on Neuroticism
DA involvement but
complex; DA receptor
sensitivity?
Enlargement of
Ventricles, particularly for
males
Polygenic vulnerability
Hypofrontality,
particularly for negative
symptoms
Severe birth
complications
Viral infections
Schizotypal personality
In childhood lower
scores on intelligence and
ach
In childhood less
responsive in social
situations
In childhood more diff
with motor dev
Escalating adjustment
diff, dep, social
withdrawal, irritability,
Stressor
> Family based
communication deviance
Expressed emotion
assoc with increased risk
of relapse; critical and
overinvolved (effect size
.31)
Severe prolonged
stressors studied
High rates of criterion
A stressors