Transcript No Slide Title

By
Dr. Muhd. Najib Mohd. Alwi
Dept. of Psychiatry
Universiti Sains Malaysia
Schizophrenia
• Definition:
a major psychotic disorder with onset in early
adulthood, characterised by bizarre delusions,
auditory hallucinations, strange behaviour and a
progressive decline in personal, domestic,
social and occupational competence, all
occurring in clear consciousness.
To diagnose, (ICD-10 & DSMIV) require one
or more discrete symptoms to be present for
more than one month or longer
2
History of Schizophrenia
– Benedict Morel (1856):
• “demense precoce”
– Emil Kraepelin (1893):
• “dementia praecox”
– cognitive disorder
(dementia)
– early onset (praecox)
• included hebephrenia,
catatonia, paranoia,
simple schizophrenia
– Bleuler (1911)
• coined “schizophrenia” =
“splitting of the mind”
• Primary / Fundamental
symptoms (4A’s)
– Ambivalence
– Affective abnormalities
(blunting, inappropriate)
– Autism
– Loosening of Association
• Secondary / Accessory
symptoms
– hallucinations, delusions
3
History of Schizophrenia
• Kurt Schnieder (1959)
– First Rank Symptoms :
• thought passivity
– insertion
– broadcast
– withdrawal
• ‘made’ phenomena
– actions
– impulses
– feelings
• auditory hallucinations
– thought echo
– running commentary
– voices arguing
• somatic passivity (delusion of
bodily influence)
• delusional perception
– Second Rank Symptoms:
• all other hallucinations
• secondary delusions
• catatonic behaviour
4
Schneider’s First Rank Symptoms
• Characteristic, not pathognomonic
• 1/5 patients with Schizophrenia have never
had any FRS
• 1/10 non-Schizophrenic patients have
experienced some FRS
5
Timothy Crow (1980)
• Type I Schizophrenia
–
–
–
–
acute onset
positive symptoms
normal ventricles
good response to
medication
– a/w increased
dopaminergic activity
– better prognosis
• Type II Schizophrenia
–
–
–
–
insidious onset
negative symptoms
enlarged ventricles
poor response to
medication
– deteriorating course
– poorer prognosis
6
Nancy Andreasen (1982)
• Positive Symptoms
–
–
–
–
delusions
hallucinations
bizarre behaviour
due to presence of
abnormal brain
mechanisms
– responds to typical (D2
receptor antagonists)
anti-psychotics
• Negative Symptoms
–
–
–
–
–
avolition
anhedonia
affective blunting
loosening of association
due to loss of brain
mechanisms
– may respond to atypical antipsychotic drugs (e.g.
Clozapine)
7
Epidemiology
How common is it?
Schizophrenia
• Incidence and
Prevalence
– occurs in all cultures
– prevalence is
geographically stable
– Incidence:
• 2 to 4 per 10 000 per
year!
– Lifetime risk:
• 1%
• Age and sex
– equal for both sexes
– peak incidence:
• men: 15-25
• women: 25-35
• In Malaysia
– 100 000 - 500 000
Schizophrenia sufferers
at any one time (could
be underestimation!)
9
Aetiological Theories
Think
Bio
Psycho
Social
Biological Theories
• Genetics
– at least 30% of patients
will have an affected
relative (Gottesman
1991)
– Lifetime Risk
•
•
•
•
•
13% DZ, 48% MZ
10% siblings
5% for parents
13% if one parent
46% if both parents
– 70% of heretability is
genetic
• only 10% of adoptedaway children (of
affected parents)
• only 1% of adoptedinto (affected parent)
– polygenic /
multifactorial threshold
genetic menchanism
– Current view:
• gene/environment
interaction model
11
Biological Theories
• Dopamine Hypothesis
– Opposing facts:
• amphetamine do not produce
negative symptoms
• anti-psychotics are also
effective in other psychotic
conditions
• blockade of D2 within hours
but efficacy within days or
weeks
– Schizophrenia is caused by
excess dopamine activity
within the mesolimbicmesocortical systems
– Supporting facts:
• amphetamine releases
dopamine and causes
positive symptoms
• More recent theories:
• all effective antipsychotics are D2 receptor
– Serotonin overactivity
antagonists
• atypical affinity to 5HT2A/2C
• anti-psychotic efficacy
– Insufficient Excitatory Amino
correlates with D2
Acid Hypothesis (glutamate)
12
occupancy
Biological Theories
– Neurodevelopmental theory
• abnormalities seen in the brain of Schizophrenic patients from
neuroimaging and neuropathological studies:
– limbic system:  size of amygdala, hippocampus,
parahippocampus
– basal ganglia:  D2 receptors in caudate nucleus
• Imaging and pathological findings revealed lesions
representing developmental anomalies rather than disease
dating probably from mid-gestation.
• Some supporting findings in epidemiological studies:
– season of birth (winter)
– prenatal influenza
– obstetric complications
13
Psychological Theories
• Attempts to explain the origin of Schizophrenic
symptoms
– over-inclusive thinking (Cameron)
• loss of conceptual boundaries
– concrete thinking (Goldstein)
• impairment of abstract thinking
– filter theories (Frith)
• inadequate filtering of background environmental stimuli
– cognitive defect theory
• impaired ability to perceive, assess and judge cognitive input
14
Social Theories
• Family processes:
– Double Bind Communication (Bateson, 1956)
• parent giving conflicting messages, can not escape or
respond to both => irrational / ambiguous behaviour =>
Schizophrenia
– Skew and Schism (Lidz, 1957)
• caused by shifts in the traditional power roles in a family
– skew: mother dominant, father submissive
– schism: parents hostile towards each other => split psyche in child
=> Schizophrenia
15
Social Theories
• Family processes:
– Life Events
• relapse preceded by an excess
of life events (compared to
Relapse Rates Over 9 Months
normal controls, but not
Low EE High EE
High EE
compared to other psy.
<35h/wk
>35h/wk
patients)
Anti12%
15%
53%
– High Expressed Emotion (EE): psychotic
No Anti15%
42%
92%
• relapse risk increasing:
psychotic
– hostility
– emotional over-involvement
– critical comments
• relapse risk reducing:
– positive remarks
– warmth
16
Social Theories
• Socio-economic status
– higher in lower SES, urban areas (industrialized
countries)
• social drift hypothesis:
– effected individuals move to lower SES due to social and
occupational incompetence (parents normally higher SES)
• social causation hypothesis:
– stresses related to SE deprivation causes Schizophrenia
• immigrants:
– Afro-Carribean in UK have higher rates of Schizophrenia
– ? Stresses of leaving own country, adapting to new
environment
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• Prodromal
• Acute
• Chronic
Premorbid and Prodromal Phases
• Premorbid personality:
– subtle motor, linguistic and social deficits in
preschizophrenic children
– increased developmental deviance with age and more
marked cognitive impairment in early adolescence
• Prodromal phase:
– decline in the level of functioning: insiduous and
gradual
– changes in behaviour: odd ideas, eccenteric interests,
changes in affect, unusual speech and bizarre perceptual
experiences
19
Acute Phase
• Common features:
– prominent positive
symptoms: persecutory
ideas, auditory
hallucinations
– gradual social
withdrawal / impaired
work performance
10 most common sx in acute
phase
SYMPTOM
FREQUENCY (%)
Lack of insight
97
Auditory
74
Hallucinations
Ideas of reference
70
Suspiciousness
66
Flatness of affect
66
Voices talking to
65
patient
Delusional mood
64
Persecutory
64
delusion
Thought
52
alienation
20
Thought echo
50
Chronic Phase
• Complete recovery possible
after one ot two acute episodes,
but many patients have a
protracted illness with residual
symptoms persisting between
acute relapses
• Characterized by:
– thought disorder
– negative symptoms
• lack of drive
• underactivity
• social withdrawal
• emotional apathy
• THREE clinical syndromes noted in
chronic schizophrenia:
– psychomotor poverty (negative
symptoms)
• poverty of speech, decreased
spontaneous movement,
catatonia, blunting of affect
– disorganisation
• inappropriate affect,
incoherent speech, poverty of
content of speech
– reality distortion
• delusions, hallucinations
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Diagnosis, Course, Treatment
Important facts to remember….
Diagnosis
• DSM-IV Criteria:
• >= major symptoms during 1 month period
 delusions
 hallucinations
 disorganized speech
 grossly disorganized or catatonic behaviour
 negative symptoms
• social/occupational dysfunction
• continuous signs of disturbance for at least 6
months
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Diagnosis
• DSM-IV Criteria:
• subtypes:
 Paranoid type: delusions, auditory hallucinations
 Disorganized type: disorganized speech and
behaviour, flat/inappropriate affect
 Catatonic type: waxy flexibility, stupor, extreme
negativism, posturing, stereotyped movements,
motor excitement
 Undifferentiated type
 Residual type: negative symptoms in absence of
prominent delusions, hallucinations, disorganized
speech or behaviour or catatonic behaviour
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Catatonic Symptoms
• Stupor: akinetic mutism - immobile, mute, unresponsive
but fully conscious
• Excitement: uncontrolled motor activity, agitation,
uninfluenced by external stimuli
• Waxy flexibility: allowing to be placed in awkward
postures without evidence of distress (a.k.a. catalepsy)
• Negativism: opposing every movement instructed to do
• Pillow sign: sleeping with head raised as if there is a
pillow underneath the head
• Stereotypy: repetitive fixed pattern of purposeless
movements
• Mannerism: habitual seemingly goal directed movements 25
Course
• In most cases there are FOUR patterns:
– single episode only, no residual impairment
(22%)
– several episodes, no or minimal impairment
(35%)
– impairment after 1st episode, subsequent
exacerbation, no return to normality (8%)
– increasing impairment with each episode, no
return to normality (35%)
26
Outcome
• Better in developing country (social rather than
clinical recovery)
– ? better social support
• Life span of schizophrenics is shortened by 10
years
– suicide
• 50% attempted
• 10% commit suicide (commonly early stage): depressive
symptoms, educated, good premorbid adjustment
– common causes of death include accidents and
cardiovascular disease (? complication of medication)
27
Prognosis
• Predictors of good
outcome:
– sociodemographic:
• married, female
– premorbid adjustment:
• no previous psy. history
• good social
relationships
• good work/educational
record
– clinical:
• acute onset
• precipitated by stressful
event
• older age of onset
• short episode
• florid psychotic
symptoms
• good initial response to
medication
• good compliance to
medication
28
Management
• Principles:
– Biological
• antipsychotics: typical / atypical
• Electroconvulsive therapy (ECT)
– Psychological
• psychotherapy: supportive, cognitive therapy, token
economy
– Social
• family intervention, social skills training,
rehabilitation programmes
29
And little by little I can look upon
madness as a disease like any other
Vincent van Gogh