Schizophrenia

Kraepelin-dementia precox
Bleuler-schism between thought, emotion
and behavior in affected patients
4 As
ambivalence
associations
affect
autism
Schizophrenia and DSM
Disturbance of 6 months or more that
includes one month of 2 or more* of the
following active-phase symptoms
Delusions
Hallucinations (3/4 @ some point)
Disorganized Speech
Grossly disorganized or catatonic behavior
Negative symptoms
Positive & Negative Sx.
Delusions
Hallucinations
Disorganized thinking
Misperceptions
Blunted affect
Poor initiation &
planning with tasks
Poverty of speech
Anhedonia
Delusions
Grandeur
Guilt
Jealousy
Passivity
Persecution
Poverty
Reference
Other Symptoms of
Schizophrenia
Cognitive Dysfunction
Dysphoria
Absence of Insight
Sleep disturbance
Suicide
Illusions
Echopraxia
Why accurate Dx is important?
Frequency-1%
Chronicity
Schizophrenic patients die younger
Males 5.1 greater mortality
Suicide rate 10-13% higher overall
2x MVAs; More disease & homelessness
Severity
Management*
80% vs. 30% relapse rate @ 1 year
Epidemiology
Gender-15-25 vs. 25-35
Comorbid with substance abuse
Deinstitutionalization (>2/3)
Dx has increased with the onset of
neuroliptics
Etiology
Many different problems that converge on
the same syndrome, not just a single disease
>50% of Sx appear to be associated with
brain abnormalities (especially + Sx).
Stress Diathesis Model
Dopamine Hypothesis
Genetics
General Population 1.0%
Nontwin sib of Schz. pt. 8.0%
Child with 1 Schz. parent 12.0%
Dyzygotic twin of Schz.
parent
12.0%
Child of 2 Schz. parents 40.0%
Monozygotic twin
of a Schz. parent
47.0%



Factors related to good
prognosis in Schizophrenia
Late onset
Obvious precipitating factors
Acute onset
Good premorbid social, sexual, and work history
Married
Family/Personal history of mood disorders
Good support systems
Positive symptoms
Factors related to poor
prognosis in Schizophrenia
Young and insidious onset
No precipitating factors
Poor premorbid social, sexual, and work histories
Withdrawn, autistic behavior; assaultive history
Single, divorced or widowed
Neurological signs and symptoms/prenatal trauma
Family history of schizophrenia
No remission in 3 years; many relapses
Medication Issues
Chlorpromazine (Thorazine); Fluphenazine
(Prolixin); Haloperidol (Haldol); Thiothixene
(Navane); Thioridazine (Mellaril) & Perphenazine
(Trilafon)
Benzodiazepines
Valium (diazepam)
Librium (chordiazepoxide)
Tardive dyskenesia
Newer drugs (Risperdal, Clozaril & Zyprexa)
Tablet or liquid form with depot formulations
Common antipsychotic
medication side effects
Dry mouth
Constipation
Blurred vision
Drowsiness
Less common antipsychotic
medication side effects
Decreased sexual desire
Menstrual changes
Stiff muscles on one side of the neck or jaw
Serious antipsychotic
medication side effects
Restlessness
Muscle stiffness
Slurred speech
Extremity tremors
Agranulocytosis
Ethnicity and Antipsychotic
medication efficacy
(Frackiewicz, et al., 1997)
Asians responded to lowest dosages
Limited AfA results, with differences apparently due to
prescribing practices
Authors highlight the problem of this line of cross-cultural
research where Western ethnic groups are seen as
homogenous
AfA are diagnosed significantly more with Scz than EA
and less with depression
Satcher (2001) AfAs and Latinos
AfA more likely to receive medication and less likely to be
referred for therapy (Richardson, 2001)
Work Behavior Strengths
Minimal physical limitations
Generally have at least average IQ
Medications provide good control over
symptoms for most
If onset in late 20s, the consumer may have
a work history of > HS education
Work Behavior Limitations
Difficulty multitasking
Difficulty interacting with co-workers
Difficulty accepting criticism or supervision
May have difficulty with customer service
or customer contact
Cyclic symptoms lead to inconsistent perf.
Needs work space with limited stimulation
Common types of work
accommodations
Flexible schedule to allow time off during
times when symptoms exacerbate or need
treatment
Loss stress, low stimulation work
environment
Training and education staff
Modifying simple job tasks
Developing on site services (e.g. EAP)
Comorbidity
91% with accompanying substance abuse or
mental health disorders (Judd, 1989)
Strongest relationship with mood disorders
81.4% with comorbid mood disorder
59% with comorbid unipolar depression
22% with comorbid bipolar depression
38% with comorbid mood disorder made at least one
suicide attempt
28.9%% suicide attempts in pts. with comorbid bipolar
disorder
Cultural variants
Women are less vulnerable to cognitive
deficits than men (particularly verbal
processing) Goldstein, et al., 1998
Sx. Expression on the BSI were
significantly higher in HA compared to EA
Coelho, et al., 1998
Cognitive differences must be covaried by
premorbid language functioning
Catatonic Schizophrenia
Meets basic criteria for Schizophrenia
At least 2 catatonic symptoms predominate:
Stupor or motor immobility (catalepsy or waxy
flexibility)
Hyperactivity w/o apparent purpose or not
influenced by external stimulation
Mutism or marked negativism
Peculiar posturing, stereotypes, or mannerisms
Echolalia or echopraxia
Disorganized Schizophrenia
Meets all of the basic criteria for
Schizophrenia plus
Disorganized behavior
Disorganized speech
Affect is flat or inappropriate
Not meet criteria for Catatonic Schz.
Undifferentiated
Schizophrenia
Meets basic criteria for Schizophrenia but
not Paranoid, Disorganized or Catatonic
types
Diagnosis of exclusion..what is left
Residual Type
At one time met criteria for Schizophrenia,
Catatonic, Disorganized, or Undifferentiated Type
No longer has pronounced catatonic behavior,
delusions, hallucinations, or disorganized speech
or behavior
Still ill as indicated by either
Negative symptoms
Attenuated form of at least 2 symptoms of Schz
Paranoid Schizophrenia
Meets basic criteria for Schizophrenia
Preoccupied with delusions or frequent
auditory hallucinations
None of these symptoms is prominent:
Disorganized speech
Disorganized behavior
Inappropriate of flat affect
Catatonic behavior
Schizophreniform Disorder
A criteria symptoms for at least a month
Delusions (only 1 required, if bizarre)
Hallucination(s)*
Incoherent, derailed, or disorganized speech
Severely disorganized or catatonic behavior
Negative symptom
From prodromal to active and residual, symptoms
last at least one month but no longer than six
months
Factors related to good
prognosis of
Schizophreniform Disorder
Actual psychotic features begin within 4
weeks of the 1st noticeable change in the
patients functioning or behavior
Pt. confused or perplexed when psychotic
Good premorbid social or job functioning
Affect is neither blunt nor flattened