Transcript Good Prognosis Poor Prognosis


Schizophrenia -major, serious psychotic
disorder characterized by wide range of
features affecting thought process (main),
perception, speech, affect and cognition










– 1% of population
Begins before age 25
Persists throughout life
Clinical presentations – may vary
Treatment response – may vary
Courses of illness – may vary
No laboratory test - diagnosis
History - diagnosis
MSE - diagnosis
Cause unknown, developmental, cure not
known`



Neuroimaging and neuropathologic
techniques (advances and refinement –
frontal lobe, amygdale, hippocampus,
parahippocampal gyrus, cerebellum
Introduction of atypical antipsychotic like
clozapine (drugs effective in reducing
negative symptoms)
Increased interest in the psychosocial factors
affecting schizophrenia








Morel - “demence precoce” (deteriorated patients, illness began
in adolescence)
Kraeplin – “dementia precox” (longterm deteriorating
course/hallucination/delusions) vs manic-depressive psychosis
Bleuler – “schizophrenia” (presence of schisms between thought,
emotion and behavior) (split mind)
Not split personality (called dissociative indentity disorder)
4 A’s (associational disturbance, affective disturbance, autism,
ambivalence) (association, affect, autism, ambivalence)
Langfeldt – 2 groups: true schizophrenia (insidious,
derealization, depersonalization, autism, emotional, blunting) vs.
schizophrenia like psychosis
Other names: nuclear/ process / non-remitting schizophrenia
Schneider – first rank symptoms for schizophrenia














Prevalence rate – 1% / 1/100 (will develop schizophrenia during their
lifetime
Annual incidence range – 0.5 – 5.0 / 10,000
Equal prevalence in men and women, earlier onset in men
Peak ages of onset late teens – mid twenties (10-25 for men) (25-35 for
women)
Men- more likely with negative symptoms
Women – better social functioning vs men, prior to disease onset
Outcome for female schizophrenia is better vs. male
Reproductive factors, medical illness, suicide risk, substance use,
population density
Socioeconomic factors: downward drift hypothesis
: social causation hypothesis
Stress of immigration – abrupt culture change as a stress
Schizophregenic cultures and families
Impact on economics
Hospitalization and homelessness



Stress – Diathesis Model: integration of
biological, psychosocial, environmental
factors – specific volurability (diathesis)
When acted on by STRESS – schizophrenia
symptoms develop
Either biological on environmental or both





Neurobiology – cause of schizophrenia is
unknown
- limbic system, frontal cortex, cerebellum and
basal ganglia – involved, interconnected (limbic
system: potential site for primary pathologic
process)
- basis for brain abnormality: abnormal
development vs. degeneration of neuron after
development
- nature-nurture theory always in mind
- studies on factors regulating gene expression






Dopamine hypothesis:
Too much dopamine activity, hyperdopaminergia 
positive symptoms
2 observations – antipsychotic drugs (dopamine
receptor antagonist)
Drugs that increase dopamine activity amphetamine /
psychomimetic (either much release of dopamine, too
many dop receptors, hypersensitivity of dop receptor
or combination)
Mesocortical / mesolimbic tracts are implied
Positive correlation between high pretreatment
concentration of homovanillic acid (dop metabolic);
decline of HA in symptoms improvement in some
patient





Serotonin – maybe involved in negative
symptoms
Noradrenalin / Norepinephrine – modulates
dopamine (predisposes a patient to relapse
frequently)
GABA – loss of inhibitory GABAergic neurons lead
to hyperactivity of dopamine receptors
Glutamine – related to hyperactivity glutamate
induced neurotoxicity (phencyclidine – PCP, a
glutamate antagonist  symptoms of
schizophrenia)
Neuropeptides – cholecystokinin and neurotensin
involvement








Limbic system and basal ganglia
Cerebral cortex, thalamus and brainstem
Reduced density of the axons, dendrites and
synapses – loss of brain volume (in schizophrenia)
Theory: excessive pruning of synapses during
adolescence
Limbic system – emotion control, decreased size of
amygdale, hippocampus and para hippocampal gyrus
Basal ganglia – movement control, cell loss, reduced
volume of globus pallidus and substancia nigra
Limbic system and basal ganglia problem account for
negative symptoms
Frontal lobe – cognition – hypofrontality in PET scans







Computed tomography scans – enlarged lateral third ventricles
(related to negative symptoms) abnormal cerebral asymmetry,
reduction cortical volume, brain density changes
Magnetic resonance imaging – enlarged cerebral ventricles (in
twin studies 40-50% of other twin even without symptoms)
Functional MRI – difference in sensorimotor cortex activation and
decreased blood flow to occipital lobes vs. normal control
subjects
Magnetic resonance spectroscopy - measures specific molecules
(high levels of ATP – low activity of the brain)
Position emission tomography – decreased blood flow to the
dorsolateral prefrontal cortex during tasks.
Imaging suggest neuropathologic theory of schizophrenia
Implications: electrophysiology, eye movement dysfunction,
psychoneuroimmunology psycho



Literature: potentially heterogenous genetic
basis
- Table of prevalence of schizophrenia in
specific population (show this)
- Adoption studies – genetic implications


Controversial: Nature-nurture
: brain disease expressed with psychosocial
factors influence




Freud (fixations, regression in response to
frustration and conflict, ego defect, ego
disintegration)
Mahler – separation individuation problem
Never achieves object constancy
Sullivan – disturbance in interpersonal
relatedness


Learning theories – poor models for learning
Children who later have schizophrenia learn
irrational reaction and thinking by imitating
parents who have their own problem





Double bind theories conflicting messages
Schisms and skeud families
Pseudomutual and pseudo hostile families –
suppress emotional expression
Expressed emotion – high EE
Social theories – industrialization and
urbanization impact on cause of
schizophrenia






DSM IV TR
ICD 10
The presence of hallucinations or delusions
not necessary for a diagnosis of
schizophrenia
IMPAIRED functioning, although not
DETERIORATION, may be present during the
active phase of the illness
Symptoms persist for at least 6 months
Absent diagnosis for Schizoaffective and
mood disorders





-Paranoid
- Disorganized
- Catatonic
- Undifferentiated
- Residual


Psychological Testing Findings – poor
performance
- vigilance , memory
and
concept for
motion
are affected




Intelligence Tests – tend to score lower
- intelligence MAY continue to
deteriorate with progression
of the
illness



Projective and Personality tests
Rorschach and thematic apperception test
(TAT) – bizarre ideations
Personality tests – may show associated
personality traits (schizoid,
schizotyped,
paranoid)









Stages of Schizophrenia
A. Prodromal
- insidious onset, subtle changes in social, school,
job activities / (negative symptoms)
- schizoid at first, withdrawn/ not sociable/
unproductive, suspicions/ strange ideas/ bothered by
what people think
B. Active
- psychotic features set in (positive symptoms)
- mumbling, hallucinations, delusions, telling to self
C. Residual
- symptoms subside, return to premorbid / normal
functioning is difficult (negative symptoms persist)




Remission and exacerbations
Observe first 5 years since diagnosis –
determine course
School, occupation and social relationshipsdifficulty getting back
Many don’t marry, 10-15% suicide, 50%
attempt suicide








Type I, Type II patients
- High Positive Symptom:
Hallucination – usually auditory
Delusions – persistency, bizarre
Looseness of association
Disorganized thinking and behavior
Irrelevant speech
Neologisms





Alogia – decreased or limited speech
Affective blunting – flat, blank,
constricted/restricted
Avolition – lack of initiative
Anhedonia – lack of pleasure
depression related anhedonia vs.
schizophrenia
Symptoms
Negative symptoms
Affective flattening
Unchanging facial expression
Decreased spontaneous movements
Paucity of expressive gestures
Poor eye contact
Affective nonresponsivity
Inappropriate affect
Lack of vocal inflections
Alogia
Poverty of speech
Poverty of content of speech
Blocking
Increased response latency
Avolition-apathy
Grooming and hygiene
Impersistence at work or school
Physical anergia
Mild or
Moderate
Severe or
Extreme
54
37
34
39
18
29
40
33
14
24
16
18
22
9
20
33
12
17
20
6
3
6
33
13
36
41
74
31
Symptoms
Positive symptoms
Hallucinations
Auditory
Voices commenting
Voices conversing
Somatic-tactile
Olfactory
Visual
Delusions
Persecutory
Jealousy
Guilt, sin
Grandiose
Religious
Somatic
Delusions of
reference
Delusions of being
controlled
Mild or
Moderate
Severe or
Extreme
19
22
27
10
5
16
51
12
12
6
1
15
19
2
16
15
12
11
13
47
1
2
15
11
11
21
25
12
Symptoms
Anhedonia-asociality
Recreational interests, activities
Sexual interest, activity
Intimacy, closeness
Relationship with friends, peers
Attention
Social inattentiveness
Inattentiveness during testing
Mild or
Moderate
38
11
24
25
25
33
Severe or
Extreme
41
23
35
63
32
19
Symptoms
Mild or
Moderate
Severe or
Extreme
Delusions of mind
reading
Thought
broadcasting
Thought insertion
Thought
withdrawal
Bizarre behavior
Clothing,
appearance
Social, sexual
behavior
Aggressive/
agitated behavior
Repetitive/
Stereotyped behavior
Positive formal
thought
disorder
Derailment
Tangentiality
Incoherence
Illogicality
Circumstantiality
Pressure of speech
Distractible speech
Clanging
19
14
11
2
15
11
4
6
8
4
17
7
14
6
7
4
30
28
9
10
14
14
12
1
4
4
1
1
0
0
1
0
Kurt Schneider Criteria
1. First-rank symptoms
a. Audible thoughts
b. Voices arguing or discussing or both
c. Voices commenting
d. Somatic passivity experiences
e. Thought withdrawal and other experiences of influenced thought
f. Thought broadcasting
g. Delusional perceptions
h. All other experiences involving volition, made affects, and made impulses
2. Second-rank symptoms
a. Other disorders of perception
b. Sudden delusional ideas
c. Perplexity
d. Depressive and euphoric mood changes
e. Feelings of emotional impoverishment
f. “…and several others as well”
New Haven Schizophrenia Index
1. a. Delusions: not specified or other-than-depressive
2 points
b. Auditory hallucinations
any one: 2 points
c. Visual hallucinations
d. Other hallucinations
2. a. Bizarre thoughts
any one: 2 points
b. Autism or grossly unrealistic private thoughts
c. Looseness of associations, illogical thinking, overinclusion
d. Blocking
either: 2 points
e. Concreteness
f. Derealization
each: 1 point
g. Depersonalization
3. Inappropriate affect
1 point
4. Confusion
1 point
5. Paranoid ideation (self-referential thinking, suspiciousness)
1 point
6. Catatonic behavior
a. Excitement
b. Stupor
c. Waxy flexibility
any one: 1 point
d. Negativism
e. Mutism
f. Echolalia
g. Stereotyped motor activity
Scoring: To be considered part of the schizophrenic group, the patient must score on Item 1 or Item
2a, 2b, or 2c and must receive a total score of at least 4 points








Auditory Hallucination – multiple voices, running
commentary (usually derogatory in
third person)
- Thought insertion
- Thought blocking
- Thought withdrawal
- Thought echoing
- Thought broadcasting
- Delusion of control (passivity of
feelings)
- Primary delusional perception



auditory hallucinations – most important
(high frequency, reliability and specificity)
- delusion of control – most reliable
- neologisms – most specific (98% from
schizophrenia, 2% from organic problem








Good Outcome:
Acute onset
Short duration
Mood symptoms
Stable pre-morbid
Married (before illness)
No family history
Upper social class
Features weighing towards Good to Poor Prognosis in Schizophrenia
Good Prognosis
Late onset
Obvious precipitating factors
Acute onset
Good premorbid social, sexual,
and work histories
Mood disorder symptoms
(especially depressive
disorders)
Married
Family history of mood
disorders
Good support systems
Positive symptoms
Poor Prognosis
Young onset
No precipitating factors
Insidious onset
Poor premorbid social, sexual,
and work histories
Withdrawn, autistic behavior
Single, divorced, or widowed
Family history of schizophrenia
Poor support systems
Negative symptoms
Neurological signs and
symptoms
History of perinatal trauma
No remissions in 3 years
Many relapses
History of assaultiveness










General Description
(precox feelings)
- Mood, Feelings and Affect
- Perceptual disturbances – hallucinations,
cenesthetic hallucinations, illusions
- Thought Thnking – thought content, form of
thought, thought process
- Impulsiveness, violence, suicide, homicide
- Orientation – usually intact
- Memory – intact, some minor cognitive deficiencies
- Judgement or Insight – lack of or poor insight
- Reliability – no less reliable than any other
psychiatric patient

Neurologic Examination – soft neurologic
signs



Eye Examination – disorders of smooth
pursuit (saccadic movement)
elevated blink rate  hyperdopaminergia











Delusional Disorder
Schizophreniform Disorders
Schizoaffective Disorders
Shared Psychotic Disorders
Brief Psychotic Disorders
Psychotic Disorders due to general medical
condition
Substance Induced Psychotic Disorders
Mood Disorders
Personality Disorders
Drug Induced Psychosis
Temporal Lobe Epilepsy




What is delusion?
(1) false belief
(2) fixed or unshakable
(3) unexplainable on the basis of individual
socio, religion, cultural background











Overvalued ideas – can be explained by socio,
religious, cultural background
- Prevalence: 0.025-0.03%; much rarer than
schizophrenia
- Main feature: presence of systematized,
encapsulated, non bizarre delusions
- There is no severe/ bizarre deterioration
- Personality remains to be generally the same
- Types of Delusional Disorder:
- Persecutory
- Erotomania (de Clerembault’s syndrome)
- Jealous (Othello’s syndrome)
- Somatic
- Grandiose
COURSE AND PROGNOSIS
 Identifiable stressor(warrant concern or
suspicion accompanies the onset)
 Sudden onset more common vs insiduous
 Usually among below average intelligence
 Premorbid personality-extroverted,
dominant, hypersensitive
 Concernsuspicionselaborateconsume
much of the person’s attention and finally
Delusional



50% of px-recover after long term ff up
20% of px- decrease in symptoms
30% of px-no change
Good prognosis:high level of occupational,
social & functional adjustments, onset <30
y/o, sudden onset, short duration of illness &
presence of precipitating factors
Persecutory, somatic, erotic delusions are
thought to have better prognosis vs px with
grandiose & jealous delusions
TREATMENT
• Success depends on effective therapeutic
doctor-patient relationship-which is difficult
to establish
• Patients don’t complain about psychiatric
symptoms & often takes medicine against
their will-even psychiatrists may be drawn to
their delusional state
• Psychotherapy-TRUST
• Mark of successful treatmentsatisfactory
social adjustment vs abatement of px’s
delusions
• Hospitalization
COURSE AND PROGNOSIS
 Issue: what happens to person with illness
over time?
◦
◦
◦
◦
60-80%-progress to Schizophrenia
20-40%- not known
Some 2-3 episodesdeteriorate to Schizophrenia
Some single episode continue to Schizophrenia
TREATMENT
 3-6 month anti psychotic medications
 Psychotherapy
 Most
Schizophreniform patients progress to
full blown Schizophrenia despite treatment
COURSE AND PROGNOSIS
 Due to uncertainty and evolving diagnosis of
Schizo-affective disorders, it is difficult to
determine the long term prognosis
 Presumed: schizo features=worse prognosis
affective features= good
prognosis
TREATMENT
 Antipsychotic
+Moodstabilizer/Antidepressant



Patients should be kept apart isolateddifferent units and no conntact
The healthier of the two will give up
delusional belief(sometimes without any
other therapeutic intervention)
The sicker of the two will maintain the false
fixed belief
COURSE AND PROGNOSIS
 Less than 1 month
 50% will later display chronic psychiatric
disordereither Schizophrenia or Mood D/O
 Good prognosis-50-80% have no further
major psychiatric problems.




A. Prominent hallucinations and delusions.
B. There is evidence from histoory, physical examination, or
laboratory findings that the disturbance is the direct
physiological consequence of a general medical condition.
C. The disturbance is not accounted for by another mental
disorder.
D. The disturbance does not occur exclusively during the
course of delirium.






A. Prominent hallucinations and delusions. Note: Do not include
hallucinations if the person has insight that they are substance induced.
B. There is evidence from history, physical examination, or laboratory
findings of either (1) or (2).
(1) the symptoms in criterion A developed during, within a month of
Substance Intoxication or withdrawal
(2) medication used is etiologically related to the disturbance
C. The disturbance is not accounted for by a psychotic disorder that is
not substance induced. Evidence that the symptoms are better
accounted for by a Psychotic Disorder that is not substance use (or
medication use); the symptoms persist for a substantial period of time
(about a month) after the cessation of acute withdrawal or severe
intoxication, or a substantially in excess of what would be expected
given the type or amount of the substance use or the duration of use; or
there is evidence suggests the existence of an independent nonsubstance induced psychotic disorder (e.g., history of recurrent nonsubstance related episodes).
D. The disturbance does not occur exclusively during the course of
delirium.
TREATMENT
 Hospitalization
 Rx-anti psychotic/Mood stabilizers
 Psychotherapy