Transcript Schizophrenia Lecture

Schizophrenia
Overview
• Often a severe and enduring psychiatric
illness
• Comprises a significant proportion of the
consumers of mental health services
• Require long-term treatment using a range
of modalities and services
• Associated with significant psychiatric and
physical morbidity, as well as mortality
Clinical Presentation
• Presentation may vary from acute to insidious
• A severe psychotic illness characterised by
delusions, hallucinations (usually auditory),
thought disorder and behavioural disturbance
• Often deterioration in social, occupational and
cognitive function
• Clear consciousness – ie to be distinguished from
delirium
First Rank Symptoms
• Thought insertion/broadcast/withdrawal
• Made feelings/impulses/actions/somatic sensations
(a type of delusion)
• Third person auditory hallucinations (running
commentary or arguments)
• Delusional perception
• Thought echo (echo de la pensee or
gendankenlautwerden) – a type of hallucination
First Rank Symptoms contd.
• 58% of patients with a diagnosis of
schizophrenia show at least one FRS
• 20% never show FRS
• 10% of patients who do not have
schizophrenia show FRS
Classification
• Crow Type I and II
– Type I – positive symptoms, good response to treatment
– Type II – negative symptoms, poorer response to treatment
Classification contd.
• Andreasen – positive and negative symptoms
• Positive symptoms – hallucinations, delusions,
bizarre behaviour, formal thought disorder,
inappropriate affect
• Negative symptoms – affective flattening, poverty
of speech/thought, avolition – apathy, anhedonia,
social withdrawal, inattentiveness
Epidemiology
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Lifetime risk – 1%
Incidence – 20/100 000 per year
Low rates in some areas eg Hutterites in US
High rates in some parts of Sweden, Ireland
Epidemiology contd
• Equal prevalence in males and females
• Males diagnosed earlier than women (males
age 15-25 years, females age 25 – 35 years)
Etiological Theories
• Biological, psychological and social
theories proposed
• Biological – biochemical, genetic and
neurodevelopmental
Genetics
• Greatest risk factor is having a relative with
SCZ
• 70% of the heritability of schizophrenia is
genetic
• MZ twin – 48% risk; DZ twin 17%
• Child of one parent with SCZ – 13%
• Child of two parents with SCZ – 46%
Genetics
• Adoption studies indicate that heritability
rates are similar even if adopted away
• Probably polygenic/multifactorial model
• No clear gene responsible although interest
in various genes
Neurodevelopmental Theories
• Hypothesis states that impaired fetal or
neonatal brain development may sow the
seeds of the onset of psychotic symptoms in
later life
• Patients with SCZ have lower than average
IQ, often subtle psychomotor, behavioral,
and social abnormalities
Neurodevelopmental Theories
• Patients with SCZ have more
developmental structural brain
abnormalities
• Soft neurological signs
• Increase in craniofacial and dermatoglyphic
abnormalities
• More obstetric complications recorded
• Exposure to influenza virus?
Clinical Presentation
• May present with a florid, rapidly evolving
psychosis, or a more insidious onset
• May be preceded by a prodromal period
• Some seem to have had difficulties from
ealry childhood eg preferring solitary play,
anxious and asocial, lack social confidence
Acute Schizophrenia
• May develop acutely or be preceded by
days/weeks of delusional mood, bizarre
behavior, social withdrawal, poor self-care
• Anxiety, depression and euphoria may be
seen
• Increased risk of suicide and violence
• May lack insight
• Often need hospitalization
Chronic Schizophrenia
• Characterized by a volition, depression,
social withdrawal, and poverty of
thought/speech
• May need encouragement in basic self-care
• Occupational and social activity diminished
• Insight often very poor
• Some will require long-tern residential care
Diagnosis and Investigation
• Diagnosis – presence of typical symptoms
• Exclusion of other disorder eg organic
causes
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CVA
Drug-induced eg cannabis, speed, steroids
Alcoholic hallucinosis
dementia
Investigations
• No diagnostic test
• Screen for drugs of abuse (urine)
• Bloods for biochemistry, blood glucose,
TFTs, TPHA and VDRL
• EEG
• ECG
• CT and MRI brain
Treatment
• May require admission if acutely disturbed
or present a risk to self or others
• Admission may be useful in assessment
• Essential to assess suicide risk as there is a
mortality of about 10% from suicide in SCZ
• May require involuntary detention in some
cases
Treatment contd.
• Antipsychotic drugs are mainstay of
treatment
• Generally a typicals are first-line treatment
eg olanzapine, respiridone, amisulpiride
• May require depot injection
• Side effects of typicals can be stigmatising
• Side effects of a typicals – screen for DM
Treatment contd.
• A typicals have fewer extra-pyramidal side
effects and tend to be better for negative
symptoms that typicals
• Initial management may include use of
sedative medication such as lorazepam
• IM medication may be required in a very
disturbed, involuntary patient
Treatment contd.
• Maintenance treatment – generally
maintenance on one medication
• Compliance may be a significant problem
because of long-term nature of treatment
and lack of insight
Treatment contd.
• Psychosocial treatment
» Education of patient and carers
» Reduction of high expressed emotion – shown to
affect relapse rates
» Cognitive behavioural therapy – controversial
» Rehabilitation
» Self –help – Schizophrenia Ireland
Prognosis
• 22% have one episode and no residual
impairment
• 35% have recurrent episodes and no
residual impairment
• 8% have recurrent epsiodes and develop
significant non-progressive impairment
• 35% have recurrent episodes and develop
significant progressive impairment
Prognosis contd.
• The majority therefore do not recover fully
• Suicide rate is up to 13%
• Little evidence that anitpsychotic have
altered the course of illness for most
patients
• However, evidence that prolonged
psychosis which is untreated has a bad
prognosis
Prognosis contd.
• Good outcome is associated with:
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Female
Older age of onset
Married
Higher SEG
Living in a developing (as opposed to developed) country
Good premorbid personality
No previous psych history
Good education and employment record
Acute onset, affective symptoms, good compliance with
meds
Prognosis contd.
• Some of the predictors of outcome are the
consequence of a less severe illness
• Predicting risk of suicide
» Acute exacerbation of psychosis
» Depressive symptoms
» History of attempted suicide