Chapter THIRTEEN

Chapter THIRTEENChapter THIRTEEN

Schizophrenia & Related Disorders

• Symptoms• Differential Diagnosis• Epidemiology• Etiology & Course• Treatments


• Symptoms• Differential DiagnosisDifferential Diagnosis• EpidemiologyEpidemiology• Etiology & CourseEtiology & Course• TreatmentsTreatments


Schizophrenia Symptom Categories

POSITIVE NEGATIVE DISORGANIZED

delusions anhedonia disorganized speech

hallucinations blunted/flat affect

disorganized behavior

alogia catatonic posturing

avolition

Positive (Psychotic) SymptomsFunctions that are present that shouldn’t be

HALLUCINATIONS heightened sensory (perceptual)

experiences that are not due to external stimuli experienced by 5 senses; most common, auditory

DELUSIONS (when is a belief delusional?) rigidly held beliefs that are inaccurate or

inconsistent with how people experience reality 5 types: persecutory, referential, grandiose,

somatic, religious can be “bizarre” or “non-bizarre”

Negative SymptomsAspects of normal behavior and social relationships that should be present, but are absent ANHEDONIA

lack of pleasure or interest ALOGIA

lack of spontaneous speech AVOLITION

lack of will power BLUNTED/FLAT AFFECT

lack of expressiveness (e.g., facial)

Disorganized SymptomsDo not fit characteristics of positive or negative symptoms and reflect bizarre behaviors & thought disturbances DISORGANIZED SPEECH Clips:

tangential speech, very difficult to follow conveys little meaning due to poor context

maintenance (word salad)

GROSSLY DISORGANIZED/BIZARRE BEHAVIORS ranges from child-like silliness to

unpredictable agitation

CATATONIC MOTOR BEHAVIORS

1 2 3

Criteria for Schizophrenia

A. In the ACTIVE phase, must have IMPAIRMENT in functioning + TWO or more of the following:

delusions hallucinations disorganized speech negative

symptoms grossly disorganized or catatonic behavior

B. During the PRODROMAL and RESIDUAL phases, may have only negative symptoms, or other symptoms in less severity (e.g., odd beliefs instead of delusions)

Prodromal Active Residual

AT LEAST 1 MONTH

Duration of Entire Disorder AT LEAST 6

MONTHS

• PARANOID One or more delusions OR frequent hallucinations; no

prominent disorganized behaviors/speech, catatonic behavior or flat/inappropriate affect

• DISORGANIZED Disorganized speech & behavior, and flat/inappropriate

affect

• CATATONIC• UNDIFFERENTIATED

Met Criterion A, but does not fit the other subtypes

• RESIDUAL Attenuated symptoms in Criterion A OR presence of

Negative Symptoms

Schizophrenia Subtypes

• SymptomsSymptoms• Differential Diagnosis• EpidemiologyEpidemiology• Etiology & CourseEtiology & Course• TreatmentsTreatments


Excluding Related DisordersBefore a diagnosis of schizophrenia can be given, disorders with similar symptoms must be ruled out as a possibility

1. Mood Disorders with Psychotic Symptoms 1. Schizoaffective Disorder1. Schizophreniform Disorder1. Brief Psychotic Disorder1. Delusional Disorder

Schizophrenia vs.Mood Disorders with psychotic

symptoms• SCHIZOPHRENIA with mood symptoms

IF depression and mania symptoms are present, their duration must be brief in relation to the duration of active and residual schizophrenia symptoms.

• MOOD DISORDERS with psychotic symptoms

the psychotic symptoms only occur during a manic or depressive episode.

SCHIZOPHRENIA with mood symptoms

Aug Sept Oct Nov Dec Jan Feb Mar


Mood Sx Psychotic Sx

MOOD DISORDER with psychotic symptoms

Schizophrenia vs. Schizoaffective Disorder

• SCHIZOPHRENIA with mood symptoms– length of time that mood symptoms are

present is brief in comparison to the duration of psychotic disturbance

• SCHIZOAFFECTIVE DISORDER– mood symptoms must be present for a

substantial portion of the psychotic disturbance– delusions and hallucinations must be present

for at least 2 weeks without prominent mood symptoms.

SCHIZOAFFECTIVE DISORDER


Mood Sx Psychotic Sx


SCHIZOPHRENIA with mood symptoms

Brief Psychotic Disorder vs. Schizophreniform Disorder vs.

Schizophrenia

Brief Psychotic Disorder

Schizophreniform Disorder

Schizophrenia

1 Day(1 day to < 1

mo.)

1 Month(1 mo. to < 6 mos.)

6 Months(> 6 months)

Delusional Disorder vs. Schizophrenia

DELUSIONAL DISORDER• Non-bizarre delusions are the prominent

psychotic symptom.

• Other schizophrenic symptoms, such as hallucinations, disorganized and negative symptoms are largely absent.

So, What is the Difference… between Mood disorders w/Psychosis,

Schizophrenia & Schizoaffective Disorder?THE DURATION OF MOOD SYMPTOMS and PSYCHOTIC SYMPTOMS

… between Schizophrenia, Schizophreniform Disorder & Brief Psychotic Disorder?THE DURATION OF ENTIRE DISTURBANCE

… between Schizophrenia & Delusional Disorder?TYPE OF DELUSION & PRESENCE/ABSENCE OF OTHER SYMPTOMS

• SymptomsSymptoms• Differential DiagnosisDifferential Diagnosis• Epidemiology• Etiology & CourseEtiology & Course• TreatmentsTreatments


Prevalence of Schizophrenia across Western and Non-Western Countries

Lifetime prevalence rate in general population is around 1%

0.0% 1.0% 2.0% 3.0% 4.0% 5.0%

Lifetime risk(in percents)

EnglandJapanRussiaUnited StatesIrelandUrban IndiaRural IndiaDenmark

• SymptomsSymptoms• Differential DiagnosisDifferential Diagnosis• EpidemiologyEpidemiology• Etiology & Course• TreatmentsTreatments


Etiology of Schizophrenia• Before birth:

Genes Maternal exposure to virus Complications/illness during pregnancy

• During birth: Complications during delivery

• At various times during development: Brain abnormalities

• During childhood & adolescence: Socioeconomic status (SES) Family factors

Genes• Adoption and twin studies indicate a

genetic influence • Pair-wise concordance rates show:

MZ concordance = 48 percent DZ concordance = 17 percent

• Twin concordance rate also implicate other factors beyond

genetics

Socioeconomic Status (SES)• Highest prevalence of Schizophrenia

found in those with lower SES…Why? Hypothesis 1: “Social Causation”

negative factors related to low SES lead to development of illness

Hypothesis 2: “Social Selection” cognitive/social impairments associated with the illness lead individuals to drift to a lower SES

Family Factor: Expressed Emotions (EE)

• EE = family members’ negative, critical & hostile attitudes & behavior towards patient AND/OR emotional over-involvement & intrusiveness of family Families can be classified as high or low on EE

• Patients who return to live with families are more likely to relapse if at least one relative was high in EE Relapse is defined as return of positive symptoms,

increase in medication dosage, OR re-hospitalization

• It is also possible that families exhibit high EE following a relapse

Relapse Rate for EE and Level of Contact58

18

42

26

0

10

20

30

40

50

60

70

High EE Low EE

High contact(>35 hr/wk)

Low contact(<35 hr/wk)

High EE families close contact risk of relapse Low EE families close contact risk of relapse

Gender Differences in Schizophrenia

• Age of onset (younger for men)

• Premorbid social functioning (better for women)

• Typical symptoms (men have more negative symptoms)

• Course of illness & Response to tx (men more chronic and poorer response to treatment)

combinedliability

adolescence young adult middle age Time

Multiple Pathways to Schizophrenia

Schizophrenia

Hints of psychosis

• SymptomsSymptoms• Differential DiagnosisDifferential Diagnosis• EpidemiologyEpidemiology• Etiology & CourseEtiology & Course• Treatments


Treatment: Older Antipsychotic Medications

• Target dopamine receptors • Work well for positive symptoms

(somewhat effective for 75% of patients)• Induce side effects resembling Parkinson’s Disease:

Extrapyramidal SymptomsTremors, agitation, involuntary posturing, motor rigidity and inertiaTardive DyskinesiaInvoluntary movements of mouth and face (lip puckering, chewing) and spasmodic body movements

Treatment: Newer Antipsychotics• Better at treating negative symptoms• Also have side effects (Clozapine has 1%

chance of lethal blood condition)

• Affect other neurotransmitters like serotonin and norepinephrine

• Relapse rates are high if medication stops, some relapse even if medication is continued

Treatment: Psychosocial• Psychosocial treatments focus on long-

term strategies to improve aspects of patient’s life other than the reduction of psychotic symptoms such as improving social competence, housing stability, employment, etc.

• Types of psychosocial treatment include:1. Family therapy2. Social skills training3. Vocational rehabilitation4. Assertive community treatment (ACT)

Treatment: Family Therapy• Most effective if the family is

high in expressed emotion• Some psychosocial treatments

aim to improve family coping skills and reduce relapse.• Eliminating unrealistic

expectations for the patient • Improving communication and

problem-solving skills of family members

Assertive Community Treatment• A comprehensive team works together to

meet the needs of the client including: Psychiatrists Nurses Social workers Vocational counselors Recreational counselors

• Staff to client ratio is high, staff is available 24/7, and contact with clients is frequent

• Good outcomes

Cognitive Behavioral Therapy for Psychosis

• Goals 1. decrease conviction of delusional beliefs2. promote more effective coping strategies3. reduce distress

• Teaches skills to challenge & modify beliefs experimental reality testing

• Effectiveness superior to control condition in clinical studies significantly decreases positive symptoms continued improvement at 6-month follow-up



OPTIONAL SLIDES & I-CLICKER ACTIVITY

Vulnerability Marker• is a sign or an evidence that a person

is more vulnerable to developing a disorder than someone else.

• importance: can provide clues about who is at risk for developing a disorder

• specific measure or test useful in identifying people vulnerable to a disorder e.g., we can localize a marker to a

gene on a specific chromosome

Vulnerability Markers: Characteristics

• Must have sensitivity1. Should see marker as a stable trait in all

people with schizophrenia2. Should be more common among 1st

degree relatives than general population3. Should predict future episodes of

schizophrenia among those who have the marker, but have not experienced a psychotic episode

• Must have specificity distinguish those with schizophrenia from

other groups

Example: Eye-Tracking Dysfunction

• Difficulty with smooth-pursuit eye movements when tracking the motion of a pendulum or similar oscillating stimulus

• Individuals with schizophrenia typically exhibit rapid eye movements

Target Non-Sz subject Sz subject

• Is it a vulnerability marker for Schizophrenia?


Schizophrenia & Related DisordersI-CLICKER ACTIVITY

Differential Diagnoses

Did psychotic symptoms occur at times other than during mood episodes?

No Yes

Has duration of mood episodes been brief relative to duration of schizophrenia symptoms (including negative symptoms and odd beliefs)?

No Yes

YesNo

Has duration of schizophrenia symptoms been 6 months or longer?

Has the duration of schizophrenia symptoms been at least 1 month?

YesNo

1

2

3

4 5

Which disorder should go on box #1

A. SchizophreniaB. Schizoaffective DisorderC. Schizophreniform DisorderD. Mood Disorder with PsychosisE. Brief Psychotic Disorder









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