BEHAVIORAL SCIENCE

IzBen C. Williams, MD, MPHInstructor

Lecture 10

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

SchizophreniaDEFINITION

Schizophrenia is a mental disorder, or a group of disorders, which may be chronic and debilitating, and is characterized by:positive symptoms, and negative symptoms

SchizophreniaDEFINITION

Positive symptoms are those that are additions to expected behaviorDelusionsHallucinationsAgitation(Talkativeness)

SchizophreniaDEFINITION

Negative symptoms: are characterized by things missing from expected behavior and include lack of motivation, social withdrawal, flattened affect, anhedonia cognitive disturbances, Impoverished thought (form, process, content) Impoverished content of speech

Schizophrenia

This classification of symptoms can be useful in predicting the effects of antipsychotic drugsPositive symptoms: respond well to most

traditional and atypical antipsychotic agentsNegative symptoms:

Respond better to atypical than to traditional antipsychotics

SchizophreniaDIAGNOSISA. Two of the following for most of a month:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

Only one of these is required if delusions are bizarre or if hallucinations are running and prominent

SchizophreniaDIAGNOSISA. Two of the following for most of a month:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

Only one of these is required if delusions are bizarre or if hallucinations are running and prominent

SchizophreniaDIAGNOSIS (cont’d)

B. Marked social or occupational dysfunctionC. Duration of at least six months of persistent

symptoms (negative or positive)D. Symptoms of schizoaffective and mood disorder

are ruled outE. Substance abuse or medical conditions are ruled

out as etiology

SchizophreniaSUBTYPES (first meet the diagnostic criteria, then….)

Paranoid: preoccupation with one or more delusions or frequent auditory hallucinations

Disorganized: all these are present – disorganized speech and behavior, flat or inappropriate affect

Catatonic: at least two of: motoric inability, extreme negativism or mutism, excessive activity, peculiarities of voluntary movement, echolalia or echopraxia

Undifferentiated: cant differentiate subtypesResidual: symptoms present in attenuated form

SchizophreniaEPIDEMIOLOGY:

Incidence: .03% to .12% a year for individuals older than 15 years.Greatest rate in industrial nations and among the

culturally disrupted Rate: ?occurs equally in men and women?Peak age of onset:

15-25 for men25-35 for women

SchizophreniaEPIDEMIOLOGY:

Prevalence: as with incidence, it is lower in developing countries, as is prognostic expectationsPoint prevalence: estimated to range from less

than.01% to 3.0%Lifetime prevalence: in the US < 1.0%

SchizophreniaEPIDEMIOLOGY:

ONSET tends to be earlier in men than women. It usually occurs in late adolescence or early adulthood, although cases continue to appear with decreasing frequency throughout adult life :

Patients with early onset tend to have more disorganized features, and worse prognosis for recovery and preservation of function

Patients with late onset tend to have more paranoid features and better prognosis and preservation of function

SchizophreniaEPIDEMIOLOGY:

COURSE: Schizophrenia has three phases:Prodromal: signs and symptoms occur prior to first

psychotic episode (avoidance of social activities, physical complaints, new interest in religion, occult, or philosophy)

Psychotic phase: person loses touch with reality; disorders of thought (form, content and process) occur during acute episode

Residual phase: (time between psychotic episodes) patient in touch with reality but does not behave normally. Typically characterized by negative symptoms

SchizophreniaEPIDEMIOLOGY:

PROGNOSIS: The course and prognosis vary widely depending on a variety of social, economic, and treatment factors as well as the diagnostic criteria used to define the populationSocial recovery is more common than complete

remission of symptoms. Over a period of 15 years or longer more than ⅔ of patients experience complete (or “social”) recovery with adequate treatment

Recovery rates are better for those with late onset and those from developing countries,

SchizophreniaEPIDEMIOLOGY:

PROGNOSIS: After repeated psychotic episodes, the illness usually stabilizes in midlife

Suicide is common in patients with schizophrenia. More than 50% attempt suicide. 10% succeed.

The prognosis is better, and suicidality lower, if patient is older at onset, is married, has social relationships, is female, has a good employment history, has mood symptoms, has few negative symptoms, and has few relapses

SchizophreniaETIOLOGIC THEORIES: Despite intensive

research, a single causative factor has not been discovered for schizophrenia. Many theories: Genetic theoriesBiochemical theoriesNeurophysiologic theoriesNeurologic & Neuropathologic theoriesPsychological theoriesFamily Interaction theories

SchizophreniaETIOLOGIC THEORIES: Neural pathology

Anatomy: Abnormalities of the frontal lobesLateral and third ventricle enlargementDecreased volume of limbic structures

Neurotransmitter abnormalitiesDopamine hypothesisSerotonin hyperactivityGlutamate implicated

SchizophreniaETIOLOGIC THEORIES:

Some other etiologic considerations Season of birthEnvironmental factors

Downward drift hypothesis (lower socioeconomic groups, eg homeless

Social factors:

The Genetics relationship correlated with incidence of Schizophrenia

Approximate occurence

The general population 1%

Sibling schizophrenic 10%

Persons with one parent schizophrenia, 12%

Dizygotic twin of a person with schizophrenia 15%

Person who has two parents with schizophrenia 40%

Monozygotic twin of a person with schizophrenia 50%

SchizophreniaDIFFERENTIAL DIAGNOSIS:

Medical illnessesMedicationsOther psychiatric illnesses (mood, cognitive,

substance-relatedPersonality disorders (schizotypal, paranoid,

borderline

Other Psychotic Disorders

Schizophreniform disorderBrief psychotic disorderAtypical psychosisSchizoaffective disorderPostpsychotic depressionDelusional DisorderShared psychotic disorder

TreatmentTreatment programs for people with

Schizophrenia should be individualized and comprehensive, taking into account theBiologicPsychological and Social needs of the patient

Attention must also be paid to continuity of care. The care setting should be as non-restrictive as possible and every attempt should be made to reintegrate the patient into the community

Hospitalization

TreatmentHospitalization (indications, goals, side

effects, the changing role, )Melieu treatment (structure, flexibility,

ward community, …….)Group therapyIndividual psychotherapyCase management

TreatmentPsychosocial rehabilitationConsumer movementIllness managementCognitive remidiationPharmacologic treatment and ECT