Schizophrenia Schizophrenia

Understanding the DiseaseUnderstanding the Disease

What is SchizophreniaWhat is Schizophrenia

Schizophrenia is a chronic and disabling Schizophrenia is a chronic and disabling brain disorder that has been recognized brain disorder that has been recognized throughout recorded history.throughout recorded history.

It affects about 1% of the population of the It affects about 1% of the population of the United States.United States.

Symptoms usually emerge for men in 10-25. Symptoms usually emerge for men in 10-25. In females 25-35. In females 25-35.

Many people with this disorder have Many people with this disorder have difficulty holding a job or caring for difficulty holding a job or caring for themselves. This creates a great burden themselves. This creates a great burden for their families and for society.for their families and for society.

EpidemiologyEpidemiology

First degree relatives have 10 time First degree relatives have 10 time greater risk of developing the greater risk of developing the disorder.disorder.

Up to 50% have substance abuse Up to 50% have substance abuse and 90% have smoking.and 90% have smoking.

More prevalent in low socio More prevalent in low socio Economices.Economices.

High frequent hospitalization.High frequent hospitalization.

Suicide in SchizophreniaSuicide in Schizophrenia

People with schizophrenia attempt People with schizophrenia attempt suicide much more often than people suicide much more often than people in the general population. About 10% in the general population. About 10% (especially young adult males) (especially young adult males) succeed. It is hard to predict which succeed. It is hard to predict which patients with the disorder are prone patients with the disorder are prone to suicide. Listen when they talk to suicide. Listen when they talk about harming themselves.about harming themselves.

PresentationPresentation

Those with the disorder may hear Those with the disorder may hear voices that others don’t hear. They voices that others don’t hear. They may believe that others are reading may believe that others are reading their minds, controlling their their minds, controlling their thoughts, or plotting to harm them. thoughts, or plotting to harm them.

They may not make sense when they They may not make sense when they talk or they may seem perfectly fine talk or they may seem perfectly fine until they start talking about what until they start talking about what they are really thinking.they are really thinking.

What are the symptoms?What are the symptoms?

The symptoms of schizophrenia fall The symptoms of schizophrenia fall into three broad categories.into three broad categories.

Positive Symptoms are unusual Positive Symptoms are unusual thoughts or perceptions, including thoughts or perceptions, including hallucinations, delusions, thought hallucinations, delusions, thought disorder and disorder of movement. disorder and disorder of movement. Auditory hallucinations are the most Auditory hallucinations are the most common.common.

Summary of Summary of PositivePositive Symptoms Symptoms

DelusionsDelusions HallucinationsHallucinations Disorganized thinkingDisorganized thinking Disorganized behaviorDisorganized behavior Catatonic behaviorCatatonic behavior Inappropriate responsesInappropriate responses

Symptoms ContinuedSymptoms Continued Negative Symptoms refers to reductions in Negative Symptoms refers to reductions in

normal emotional and behavioral states normal emotional and behavioral states such as: such as:

Flat affect with immobile facial expression, Flat affect with immobile facial expression, monotonous voice.monotonous voice.

Lack of pleasure in everyday life.Lack of pleasure in everyday life. Diminished ability to initiate and sustain Diminished ability to initiate and sustain

planned activity.planned activity. Speaking infrequently even when forced to Speaking infrequently even when forced to

interactinteract People with the disorder often neglect People with the disorder often neglect

basic hygiene and need help with ADL. basic hygiene and need help with ADL.

Summary of Summary of NegativeNegative Symptoms Symptoms

Lack of emotionLack of emotion Low energyLow energy Lack of interest in lifeLack of interest in life Affective flatteningAffective flattening AlogiaAlogia Inappropriate social skillsInappropriate social skills Inability to make friendsInability to make friends Social isolationSocial isolation

Symptoms ContinuedSymptoms Continued

Cognitive Symptoms are subtle and often Cognitive Symptoms are subtle and often detected only when neuropsychological detected only when neuropsychological test are performed.test are performed.

Poor executive functioning. (the ability to Poor executive functioning. (the ability to absorb and interpret information and absorb and interpret information and make decisions based on that make decisions based on that information).information).

Inability to sustain attention.Inability to sustain attention. Problems with working memory (the ability Problems with working memory (the ability

to keep recently learned information in to keep recently learned information in mind and use it right away). mind and use it right away).

Cognitive SymptomsCognitive Symptoms

Difficulties in concentration and Difficulties in concentration and memory:memory: Disorganized thinkingDisorganized thinking Slow thinkingSlow thinking Difficulty understandingDifficulty understanding Poor concentrationPoor concentration Poor memoryPoor memory Difficulty expressing thoughtsDifficulty expressing thoughts Difficulty integrating thoughts, feelings, Difficulty integrating thoughts, feelings,

behaviorsbehaviors

Types of SchizophreniaTypes of Schizophrenia

ParanoidParanoid HebephrenicHebephrenic CatatonicCatatonic ResidualResidual SchizoaffectiveSchizoaffective UndifferentiatedUndifferentiated

ParanoidParanoid Schizophrenia Schizophrenia

Persons are very suspicious of others Persons are very suspicious of others and often have grand schemes of and often have grand schemes of persecution at the root of their persecution at the root of their behavior.behavior.

During this phase they may have During this phase they may have hallucinations and frequent hallucinations and frequent delusions.delusions.

HebephrenicHebephrenic Schizophrenia Schizophrenia

AKA disorganized schizophrenia; AKA disorganized schizophrenia; characterized by emotionless, characterized by emotionless, incongruous, or silly behavior, intellectual incongruous, or silly behavior, intellectual deterioration, frequently beginning deterioration, frequently beginning insidiously during adolescence. insidiously during adolescence.

May be verbally incoherent and may have May be verbally incoherent and may have moods and emotions that are not moods and emotions that are not appropriate to the situation.appropriate to the situation.

Hallucinations not usually present.Hallucinations not usually present.

CatatonicCatatonic Schizophrenia Schizophrenia

Person is extremely withdrawn, Person is extremely withdrawn, negative and isolated. negative and isolated.

May have marked psychomotor May have marked psychomotor disturbances.disturbances.

ResidualResidual Schizophrenia Schizophrenia

Lacks motivation and interest in day-Lacks motivation and interest in day-to-day living.to-day living.

Person is not usually having Person is not usually having delusions, hallucinations or delusions, hallucinations or disorganized speech.disorganized speech.

UndifferentiatedUndifferentiated Schizophrenia Schizophrenia

Conditions meeting the general Conditions meeting the general diagnostic criteria for schizophrenia diagnostic criteria for schizophrenia but not conforming to any of the but not conforming to any of the previous types.previous types.

Exhibits more than one of the Exhibits more than one of the previous types without a clear previous types without a clear dominance of one.dominance of one.

CausesCauses

The disorder is believed to result from a The disorder is believed to result from a combination of environmental and genetic combination of environmental and genetic factors. It is well known that the disease factors. It is well known that the disease runs in families, and is seen in 10% of runs in families, and is seen in 10% of people with a first degree relative. people with a first degree relative.

Identical twins have 50% chance of Identical twins have 50% chance of developing the disorder.developing the disorder.

Child of one parent schizophrenia 12 and Child of one parent schizophrenia 12 and two parent 40%.two parent 40%.

Age of the father at conception time.Age of the father at conception time.

CauseCause

Although there is a genetic risk for Although there is a genetic risk for schizophrenia, it is not likely that genes schizophrenia, it is not likely that genes alone are sufficient to cause the disorder. alone are sufficient to cause the disorder. Interactions between genes and the Interactions between genes and the environment are thought to be necessary environment are thought to be necessary for the disorder to develop. for the disorder to develop.

Many risk factors have been identified such Many risk factors have been identified such as exposure to viruses or malnutrition in the as exposure to viruses or malnutrition in the womb, problems during birth, and womb, problems during birth, and psychosocial factors such as stressful psychosocial factors such as stressful environmental conditions.environmental conditions.

Brain Function:Brain Function:Neurotransmission Dysfunction Neurotransmission Dysfunction

Dopamine Pathway.Dopamine Pathway. Serotonin pathway.Serotonin pathway. Norepinephrine pathway.Norepinephrine pathway. GABAergic system. GABAergic system. Neuropeptide (substance P, neurotensine).Neuropeptide (substance P, neurotensine). Glutamate( Glutamate antagonist-PCP and Glutamate( Glutamate antagonist-PCP and

psychosis ).psychosis ). Acetylcholine and Nicotine(cognition Acetylcholine and Nicotine(cognition

regulation) regulation)

Brain Function:Brain Function:NeuropathologyNeuropathology

Cortex & Cerebral ventricles.Cortex & Cerebral ventricles. Reduced symmetry.Reduced symmetry. Limbic system:( amigdala, hypocumpus,Limbic system:( amigdala, hypocumpus,

…) decreased size.…) decreased size. Prefrontal cortex.Prefrontal cortex. Thalamic nuclei.Thalamic nuclei. Basal ganglia and cerebellum(movement Basal ganglia and cerebellum(movement

disorders and psychosis). disorders and psychosis). Neural circuits. Neural circuits.

Brain function:Brain function:

Brain metabolism.Brain metabolism. Applied electrophysiology.Applied electrophysiology. Complex partial seizure and Complex partial seizure and

psychosis.psychosis. Evoked potential and delayed Evoked potential and delayed

transmission velocity. transmission velocity. Eye movement Dysfunction. Eye movement Dysfunction.

PsychoneuroimmunologyPsychoneuroimmunology

Decreased T-cell interlukin-2 Decreased T-cell interlukin-2 production.production.

Abnormal cellular reactivity to Abnormal cellular reactivity to neurons.neurons.

Presence of antibrain antibody.Presence of antibrain antibody.

=Neurotoxic viral infectin? Or =Neurotoxic viral infectin? Or endogenous autoimmune disorders. endogenous autoimmune disorders.

DSM-IV diagnostic criteriaDSM-IV diagnostic criteria

A screening test http://www.schizophrenia.com/sztest/http://www.schizophrenia.com/sztest/

survey2.phpsurvey2.php At least two characteristic symptoms for At least two characteristic symptoms for

one month(or shorter on treatment):one month(or shorter on treatment): +Delusions *+Delusions * +Hallucinations *+Hallucinations *

* Only one symptom required if it is bizarre delusions * Only one symptom required if it is bizarre delusions or continually commenting or conversing auditory or continually commenting or conversing auditory hallucinationshallucinations

+Disorganized speech+Disorganized speech +Grossly disorganized or catatonic behavior+Grossly disorganized or catatonic behavior Negative symptomsNegative symptoms

More diagnostic criteriaMore diagnostic criteria

Significantly long-lasting marked Significantly long-lasting marked impairment of social or occupational impairment of social or occupational functioning or self-care.functioning or self-care.

Lasts for six continuous months, Lasts for six continuous months, including at least one month of including at least one month of active phase symptomsactive phase symptoms

No major depressive, manic, or No major depressive, manic, or mixed mood episodesmixed mood episodes

The syndrome durationThe syndrome duration

Total duration must be at least 6 monthsTotal duration must be at least 6 months

ProdromeProdromeActive PhaseActive Phase Residual PhaseResidual Phase

ProdromeProdrome Active PhaseActive PhaseResidual PhaseResidual Phase

Pro-dromePro-

drome Active PhaseActive Phase Residual PhaseResidual Phase

The active phase must last at least 1 month

0ther psychotic disorders0ther psychotic disorders

Schizoaffective disorder.Schizoaffective disorder. Brief psychotic disorder.Brief psychotic disorder. Shizophreniforme disorder.Shizophreniforme disorder. Delusional disorders.Delusional disorders. Substance induced psychotic Substance induced psychotic

disorders.disorders.

Schizophrenia vs Schizophrenia vs Schizoaffective DisorderSchizoaffective Disorder

Schizoaffective disorder is characterized Schizoaffective disorder is characterized by both the psychotic thought problems of by both the psychotic thought problems of schizophrenia and the mood problems of schizophrenia and the mood problems of depression or bipolar disorder. depression or bipolar disorder.

Two conditions must be meet to qualify as Two conditions must be meet to qualify as schizoaffective disorder:schizoaffective disorder:

1. Psychotic symptoms sufficient for the 1. Psychotic symptoms sufficient for the diagnosis of schizophrenia are present – diagnosis of schizophrenia are present – specifically active hallucinations or specifically active hallucinations or delusions present for at least two weeks in delusions present for at least two weeks in a row. a row.

Schizoaffective DisorderSchizoaffective Disorder

2. One or more major depressive episodes, 2. One or more major depressive episodes, manic episodes, or mixed mood episode manic episodes, or mixed mood episode occur concurrent with the psychotic occur concurrent with the psychotic episode.episode.

Doctors differ on whether it is better to Doctors differ on whether it is better to diagnose schizoaffective disorder, or to diagnose schizoaffective disorder, or to diagnose a bipolar or major depression diagnose a bipolar or major depression and schizophrenia separately. It is not sure and schizophrenia separately. It is not sure at this time if schizoaffective disorder at this time if schizoaffective disorder describes a single disease entity or not.describes a single disease entity or not.

Mechanism of ActionMechanism of Actionof Antipsychoticsof Antipsychotics

While the precise mechanism of action that While the precise mechanism of action that accounts for the effects of antipsychotic accounts for the effects of antipsychotic medications is still unknown, the dopamine medications is still unknown, the dopamine hypothesis is the predominate theory used to hypothesis is the predominate theory used to explain the action of these drugs. explain the action of these drugs.

Schizophrenia is caused by an excess in Schizophrenia is caused by an excess in dopamine activity in the brain, which is inhibited dopamine activity in the brain, which is inhibited by blockade of the receptors by blockade of the receptors

There are two core components to the dopamine There are two core components to the dopamine theory: (1) psychosis is induced by increased theory: (1) psychosis is induced by increased levels of dopamine activity and (2) most levels of dopamine activity and (2) most antipsychotic drugs block postsynaptic dopamine antipsychotic drugs block postsynaptic dopamine receptors receptors

Antipsychotics Antipsychotics

Antipsychotic medications have been available Antipsychotic medications have been available since the mid 1950’s. These drugs have since the mid 1950’s. These drugs have greatly improved the lives of patients with greatly improved the lives of patients with schizophrenia since their first development, schizophrenia since their first development, but these medications do not cure the disease. but these medications do not cure the disease.

The older antipsychotic medications The older antipsychotic medications effectively alleviate the positive symptoms of effectively alleviate the positive symptoms of schizophrenia. These which are considered schizophrenia. These which are considered conventional or typical medications produced conventional or typical medications produced side effects which made compliance difficult.side effects which made compliance difficult.

AntipsychoticsAntipsychotics

Most of these older "conventional" Most of these older "conventional" antipsychotics differed in the side effects antipsychotics differed in the side effects they produced. Side effects such as they produced. Side effects such as orthostatic hypotension, sedation, orthostatic hypotension, sedation, anticholinergic effect and extrapyramidal anticholinergic effect and extrapyramidal effects.effects.

These conventional antipsychotics include These conventional antipsychotics include chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). .

Extrapyramidal EffectsExtrapyramidal Effects

Extrapyramidal Side EffectsExtrapyramidal Side Effects are a are a group of symptoms that can occur in group of symptoms that can occur in persons taking antipsychotic medications. persons taking antipsychotic medications. They are more commonly caused by the They are more commonly caused by the typical antipsychotics but can and do typical antipsychotics but can and do occur with all of them.occur with all of them.

Extrapyramidal side effects include: Extrapyramidal side effects include: tremor, akathisia, slurred speech, tremor, akathisia, slurred speech,

dystonia, bradykinesia, and muscular dystonia, bradykinesia, and muscular rigidity rigidity

Extrapyramidal EffectsExtrapyramidal Effects

AkathisiaAkathisia is a movement disorder is a movement disorder characterized by inner restlessness and the characterized by inner restlessness and the inability to sit or stand still. Akathisia may inability to sit or stand still. Akathisia may appear as a side effect of long-term use of appear as a side effect of long-term use of antipsychotic medications, Lithium, and some antipsychotic medications, Lithium, and some other psychiatric drugs. other psychiatric drugs.

Persons with akathisia typically have restless Persons with akathisia typically have restless movements of the arms and legs such as movements of the arms and legs such as tapping, marching in place, rocking, crossing tapping, marching in place, rocking, crossing and uncrossing the legs. They may feel and uncrossing the legs. They may feel anxious at the thought of sitting down.anxious at the thought of sitting down.

Extrapyramidal EffectsExtrapyramidal Effects

DystoniaDystonia is a neurological movement is a neurological movement disorder characterized by involuntary disorder characterized by involuntary muscle contractions, which force certain muscle contractions, which force certain parts of the body into abnormal, sometimes parts of the body into abnormal, sometimes painful, movements or postures. painful, movements or postures.

Acute dystonic reactions are Acute dystonic reactions are characteristically sustained contraction of characteristically sustained contraction of the muscles of neck (torticollis), eyes the muscles of neck (torticollis), eyes (oculogyric crisis), tongue, jaw and other (oculogyric crisis), tongue, jaw and other muscle groups typically occurring within muscle groups typically occurring within 10-14 days after initiation of the 10-14 days after initiation of the neuroleptic. neuroleptic.

Extrapyramidal EffectsExtrapyramidal Effects Bradykinesia means "slow movement." Bradykinesia means "slow movement."

Bradykinesia essentially refers to a Bradykinesia essentially refers to a component of parkinsonism. The full component of parkinsonism. The full spectrum of parkinsonism is derived from spectrum of parkinsonism is derived from the features of Parkinson's disease, which the features of Parkinson's disease, which include bradykinesia, tremor, and rigidity.include bradykinesia, tremor, and rigidity.

Rigidity is defined as hypertonia in which Rigidity is defined as hypertonia in which the following are true:the following are true:

The resistance to externally imposed joint The resistance to externally imposed joint movement is present at very low speeds of movement is present at very low speeds of movement, does not depend on imposed movement, does not depend on imposed speed, and does not exhibit a speed or speed, and does not exhibit a speed or angle threshold; angle threshold;

AntipsychoticsAntipsychotics

In the 1990’s, new drugs, called atypical In the 1990’s, new drugs, called atypical antipychotics, were developed. antipychotics, were developed.

These medications appear to be equally These medications appear to be equally effective for helping reduce the positive effective for helping reduce the positive symptoms like hallucinations and symptoms like hallucinations and delusions - but may be better than the delusions - but may be better than the older medications at relieving the negative older medications at relieving the negative symptoms of the illness, such as symptoms of the illness, such as withdrawal, thinking problems, and lack of withdrawal, thinking problems, and lack of energy. energy.

AntipsychoticsAntipsychotics

The atypical antipsychotics include The atypical antipsychotics include aripiprazole (Abilify), risperidone aripiprazole (Abilify), risperidone (Risperdal), clozapine (Clozaril), (Risperdal), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). (Seroquel), and ziprasidone (Geodon).

Current treatment guidelines recommend Current treatment guidelines recommend using one of the atypical antipsychotics using one of the atypical antipsychotics other than clozapine as a first line other than clozapine as a first line treatment option for newly diagnosed treatment option for newly diagnosed patients. patients.

AntipsychoticsAntipsychotics Clozapine (Clozaril) was the first atypical Clozapine (Clozaril) was the first atypical

introduced. It treats psychotic symptoms introduced. It treats psychotic symptoms effectively even in people who do not respond to effectively even in people who do not respond to other medications.other medications.

It can produce a serious problem called It can produce a serious problem called agranulocytosis. This is a loss of the white blood agranulocytosis. This is a loss of the white blood cells that fight infection in the body. Patients who cells that fight infection in the body. Patients who take clozapine must have their white blood cell take clozapine must have their white blood cell count monitored weekly and then monthly for the count monitored weekly and then monthly for the extent of use. extent of use.

Even with this complication, it is still the drug of Even with this complication, it is still the drug of choice with those whose symptoms do not respond choice with those whose symptoms do not respond to the other antipsychotic medications, old or new. to the other antipsychotic medications, old or new.

AntipsychoticsAntipsychotics

Side Effects – When patients first start Side Effects – When patients first start to take the atypical antipsychotics, to take the atypical antipsychotics, they may become drowsy or they may become drowsy or experience dizziness when they change experience dizziness when they change positions (orthostatic hypotension).positions (orthostatic hypotension).

They may have blurred vision, or They may have blurred vision, or develop a rapid heartbeat, menstrual develop a rapid heartbeat, menstrual problems, a sensitivity to the sun, or problems, a sensitivity to the sun, or skin rashes. skin rashes.

AntipsychoticsAntipsychoticsSide EffectsSide Effects

Many of these symptoms will go away Many of these symptoms will go away after the first few days but could last for after the first few days but could last for up to one to two weeks. Advise your up to one to two weeks. Advise your patients that if the symptoms do not go patients that if the symptoms do not go away after two to three weeks to notify away after two to three weeks to notify the practitioner who prescribed the the practitioner who prescribed the medication.medication.

Also advise them that they should not be Also advise them that they should not be driving until they adjust to their new driving until they adjust to their new medication.medication.

AntipsychoticsAntipsychoticsSide EffectsSide Effects

The atypical antipsychotics produce much The atypical antipsychotics produce much less extrapyramidal symptoms but they less extrapyramidal symptoms but they can cause weight gain and metabolic can cause weight gain and metabolic changes associated with an increase risk changes associated with an increase risk of diabetes and cardiovascular disease.of diabetes and cardiovascular disease.

When starting these medications a When starting these medications a baseline check is made for risk factors for baseline check is made for risk factors for diabetes. diabetes.

Baseline laboratory test: Fasting glucose, Baseline laboratory test: Fasting glucose, HDL, Triglycerides, Blood Pressure.HDL, Triglycerides, Blood Pressure.

BMI if older than 27 year old.BMI if older than 27 year old.

MonitoringMonitoring

On monthly visits monitor for things such as On monthly visits monitor for things such as over eating, weight gain, polyuria (increase over eating, weight gain, polyuria (increase urination), polydipsia (increased thirst).urination), polydipsia (increased thirst).

When each of you see your clients, if they When each of you see your clients, if they have recently been put on an antipsychotic, have recently been put on an antipsychotic, discuss the above symptoms with them.discuss the above symptoms with them.

Have them notify the practitioner if they are Have them notify the practitioner if they are having problems with any of these having problems with any of these symptoms. symptoms.

SummarySummary

Relapses occur most often when people Relapses occur most often when people with schizophrenia stop taking their with schizophrenia stop taking their antipsychotic medication. antipsychotic medication.

They may feel better, or their side effects They may feel better, or their side effects or so bad they stop the medication. or so bad they stop the medication.

At times they don’t feel taking their At times they don’t feel taking their medication regularly is important. medication regularly is important.

It is our responsibility to education our It is our responsibility to education our patient to be compliant and monitor them patient to be compliant and monitor them to keep them healthy.to keep them healthy.