Schizophrenia

Cancer of Psychiatry

Introduction
Schizophrenia- is a Greek word ~ schizein -"to split ~ phren- "mind ~ is a psychiatric diagnosis ~ disorder is thought to mainly affect cognition ~characterized by abnormalities in the perception or expression of reality. ~also can have additional (comorbid) conditions, including major depression and anxiety disorders, lifetime occurrence of subs abuse is 40% ~~ It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social or occupational dysfunction ~these symptoms occur in clear consciousness

Epidemiology
Schizophrenia is the fourth leading cause of diasbility in the world Males = females typical earlier in men peaking at age 2028 years , 26 32 years for females Onset in childhood,middle- or old age is rare Lifetime prevelence of schizophreniathe proportion of individuals expected to experience the disease at any time in their livesis commonly given at 1% (0.5%1.5%) which is 10 to 12 years less than those without the dz, due to increased physical health problems and a higher suicide rate 2002~lifetime prevalence of 0.55%.

Course: Onset- may be abrupt or insidious, but usually gradual

prepsychotic phase of increasing negative symptoms (e.g., social withdrawal, deterioration in hygiene and grooming, unusual behavior, outbursts of anger, and loss of interest in school or work). these symptoms to predominate in men symptoms are less responsive to antipsychotic meds. A few months or years later, a psychotic phase develops (with delusions, hallucinations, or grossly bizarre/disorganized speech and behavior)-positive symptoms these symptoms tend to predominate in women. These symptoms respond the antipsychotic meds This psychotic phase must last for at least one month (or less if successfully treated).

 If onset of Schizophrenia later in their 20's or 30's often female less evidence of structural brain abnormalities or cognitive impairment better outcome. Disease can persists (continuously or episodically) for a life-time. Some pts can have a relatively stable course, while some show a progressive worsening associated with severe disability. Complete remission -return to full premorbid functioning, is uncommon.

Positive and negative symptoms

Positive symptoms include delusions, auditory hallucinations, and thought disorder, and are typically regarded as manifestations of psychosis. Negative symptoms are so-named because they are considered to be the loss or absence of normal traits or abilities, and include features such as flat or blunted affect and emotion, poverty of speech (alogia), inability to experience pleasure (anhedonia), and lack of motivation (avolition). Despite the appearance of blunted affect, recent studies indicate that there is often a normal or even heightened level of emotionality in schizophrenia, especially in response to stressful or negative events.

Problems encountered!

Prepsychotic (Prodromal) Or Postpsychotic (Residual) Phase Social and/or Occupational Impairment Apathy Lack of Physical Exercise Poor Sexual Interest or Ability Increased Smoking Sad or Depressed Mood Poor Concentration or Attention Poor Memory Impaired Executive Functioning (planning, problem-solving) Lack of Insight Solitary Lifestyle Indifference To Others Lack of Self-Confidence Shyness

Psychotic (Active) Phase Social and/or Occupational Impairment Delusions or Hallucination Disorganized or Bizarre Behaviour Apathy Impaired Communication With Words Impaired Communication With Emotions Lack of Physical Exercise Poor Sexual Interest or Ability Distrust or Suspiciousness Increased Smoking Sad or Depressed Mood Poor Concentration or Attention Generalized Worry Poor Memory

Problems When severe!

Prepsychotic or Postpsychotic Phase When Severe Distrust or Suspiciousness Mistrust of Friends Difficulty Handling Conflict Poor Money Management Risk of Harming Self Impaired Communication With Words Impaired Communication With Emotions Poor Grooming and Hygiene Need for Institutional Care Psychotic Phase When Severe Poor Money Management Physical Violence Obsessive Thinking or Compulsive Rituals Risk of Harming Self Poor Grooming and Hygiene Need for Institutional Care

Comorbidity
Alcoholism and drug abuse worsen the course Are aften associated with it 80% to 90% patients with Schizophrenia are regular cigarette smokers. Anxiety and phobias increased risk of Obsessive-Compulsive Disorder and Panic Disorder.

Subtypes of Schizophrenia The DSM-IV-TR contains five sub-classifications of schizophrenia.

Paranoid schizophrenia - These persons are very suspicious of others and often have grand schemes of persecution at the root of their behavior. Halluciations, and more frequently delusions, are a prominent and common part of the illness. Disorganized schizophrenia - Person is verbally incoherent and may have moods and emotions that are not appropriate to the situation. Hallucinations are not usually present. Catatonic schizophrenia - In this case, the person is extremely withdrawn, negative and isolated, and has marked psychomotor disturbances.

 Residual schizophrenia - In this case the person is not currently suffering from delusions, hallucinations, or disorganized speech and behavior, but lacks motivation and interest in day-to-day living. Undifferentiated Schizophrenia Conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the above subtypes, or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics.

 The ICD-10 defines two additional subtypes. Post-schizophrenic depression: A depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present. Simple schizophrenia: Insidious and progressive development of prominent negative symptoms with no history of psychotic episodes.

Causes
but no single organic cause has been found a PET study suggests that the less the frontal lobes are activated during a working memory task, the greater the increase in abnormal dopamine activity in the mesolimbic pathway of the brain relates to the neurocognitive deficits in schizophrenia.

 Genetic- Familial pattern - first-degree biological relatives are at risk about 10 times greater than that of the general population. Rates are also increased in monozygotic twins than in dizygotic twins. Prenatal Social Drugs-A 2007 meta-analysis estimated that cannabis use is statistically associated with a dose-dependent increase in risk of development of psychotic disorders, including schizophrenia There is some support for the theory that they use drugs to cope with unpleasant states such as depression, anxiety, boredom and loneliness.[61] Psychological Neural

Diagnosis
No laboratory test for schizophrenia currently exists is based on the self-reported experiences of the person, and abnormalities in behavior reported by family members, friends or co-workers, followed by a clinical assessment by a psychiatrist, social worker. Psychiatric assessment includes a psychiatric history and some form of mental status examination.

According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria must be met. 1. Characteristic symptoms: Two or more of the following.
Delusions Hallucinations Disorganized speech, Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior Negative symptomsaffective flattening (lack or decline in emotional response), alogia(lack or decline in speech), or lack or decline in motivation

2. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset. 3. Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment).
Schizophrenia cannot be diagnosed if symptoms of mood disorder or pervasive developmental disorder are present, or the symptoms are the direct result of a general medical condition or a substance, such as abuse of a drug or medication

 However, individuals with Schizophrenia often have a number of (non-diagnostic) neurological abnormalities. They have enlargement of the lateral ventricles, decreased brain tissue, decreased volume of the temporal lobe and thalamus, decreased blood flow and metabolic functioning of the frontal lobes. They also have a number of cognitive deficits on psychological testing (e.g., poor attention, poor memory, difficulty in changing response set, impairment in sensory gating, abnormal smooth pursuit and saccadic eye movements, slowed reaction time

Treatment
The effectiveness of treatment is often assessed using standardized methods, one of the most common being the Positive and Negative Syndrome Scale (PANSS). It should be noted that management of symptoms and improving function is thought to be more achievable than a cure mainstay of treatment is antipsychotic medication two classes of antipsychotics are generally thought equally effective for the treatment of the positive symptoms. Some researchers have suggested that the atypicals offer additional benefit for the negative symptoms and cognitive deficits associated with schizophrenia this type of drug primarily works by suppressing dopamine activity reducing positive symptoms of psychosis. Also shorten the duration of phycosis and prevents recurrences. Risperidone is a common atypical antipsychotic medication. Although expensive, the newer atypical antipsychotic drugs are usually preferred for initial treatment over the older typical antipsychotic, although they are more likely to induce weight gain and obesity-related diseases

 atypical antipsychotics have fewer extrapyramidal side effects than typical antipsychotics treatment-resistant schizophrenia is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics. Treat with clozapine (SE- agranulocytosis and myocarditis). If compliance becomes a problem depot preparations of antipsychotics may be given every two weeks to achieve control. Psychotherapy vocational and social rehabilitation are also important. In more serious caseswhere there is risk to self and othersinvoluntary hospitalization may be necessary Cognitive behavioral therapy -improves self esteem Family therapy or education

Outcome
Best when early and persistent treatment with antipsychotic medication are given soon after the onset of Schizophrenia. Other factors that are associated with a better prognosis include good premorbid adjustment, acute onset, later age at onset, good insight, being female, precipitating events, associated mood disturbance, brief duration of psychotic symptoms, good interepisode functioning, minimal residual symptoms, absence of structural brain abnormalities, normal neurological functioning, a family history of Mood Disorder, and no family history of Schizophrenia After each psychotic relapse there is increased intellectual impairment Unfortunately, even on antipsychotic medication, most individuals with Schizophrenia can't return to gainful employment due to the intellectual impairments caused by this illness (e.g., poor concentration, poor memory, impaired problem-solving, inability to "multi-task", and apathy). Life-long treatment with antipsychotic medication is essential for recovery from Schizophrenia. Individuals also require long-term emotional and financial support from their families