Schizophrenia PART1

7/30/2019 Schizophrenia PART1

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Schizophrenia- Part 1 -

Tomasz Paweczyk MD, PhD

Department of Affective and Psychotic Disorders

Medical University of Lodz

Head: Prof. Jolanta Rabe- Jablonska MD, PhD


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Agenda for Todays Meeting

Lecture approx. 60 min

Break 15 min.

Cases presentation and discussion 30 min.

Break 15 min.

Inerview with Mr. Philipe 45 min.


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Plan of the lecture Definition of SCZ

Clinical features

History and classification

Clinical presentation and symptomatology

Course and outcome of schizophrenia

Symptom domains

Natural History

Epidemiology and risk factors

Differential diagnosis

Cases


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What is schizophrenia?

Schizophrenia is to psychiatry what cancer is to

medicine: a sentence as well as diagnosis.

- W. Hall, G. Andrews & G. Goldstein (1985)

... perhaps the most devastating disorder of

mankind.

- E.R. Kandel (1991)


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What is schizophrenia?

the disconnection or splitting of the

psychic functions Eugen Bleuler

1912, "a splitting of the mind,"

from German: Schizophrenie,

coined in 1910 by Swiss

psychiatrist Eugen Bleuler

(1857-1939), from Gk. skhizein

"to split + phren(gen.phrenos) "diaphragm, heart,

mind," of unknown origin. Slang

shortening schizo first attested

1920s as an adj., 1945 as a

noun.

Ethymology Dictionary


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Schizophrenia - definition

Schizophrenia is the most chronic and disabling

of the severe mental disorders, associated

with abnormalities ofbrain structure and

function, disorganized speech and behavior,

delusions, and hallucinations. It is sometimes

called a psychotic disorder or a psychosis

(Gale Encyclopedia of Mental Disorders)


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Psychosis - definition

Psychosis - Mental disorder in which the

thoughts, affective response, ability to

recognize reality, and ability to communicate

and relate to others are sufficiently impaired

to interfere grossly with the capacity to deal

with reality; the classical characteristics of

psychosis are impaired reality testing,hallucinations, delusions, and illusions

(Kaplan & Sadocks Comprehensive Textbook of Psychiatry)


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Historical treatment methods


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A mentally ill patient in a straitjacket and strapped into a

chair. Such chairs of restraint were meant to quieten

maniacs by depriving them of the capacity to agitate

themselves by violent motion; photograph after a wood-

engraving, 1908.


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1952 Chlorpromazine

the 1st antipsychotic drug

Introduced to the market


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Schizophrenia historical

milestones 1893 Emil Kraepelin dementia praecox

1908 Eugen Bleuler schizophrenia, the four As

1950s Kurt Schneider first rank psychotic

symptoms

1960s Arvid Carlsson dopamine hipothesis

1960s Jean Delay, Pierre Deniker chlorpromazine

the first neuroleptic drug 1980 Timothy Crow type I and II of schizophrenia


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Psychiatric disorders (1896):

1. Dementia precox (preterm dementia)

- catatonia, hebefrenia

2. Manic-depressive psychosis


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Emil Kraeplin (1856-1926): dementia

praecox develops relatively early in life

and its course is likely deteriorating and

chronic, deterioration reminded dementia

but was not followed by any organic

changes of the brain, detectable at that

time

Eugen Bleuler (1857-1939): schizophrenia meanssplitting of mindits functions: thinking, emotions,memory, perception, behavior are being separatedand start to act indepently. The 4 primary

symptoms of schizophrenia - reflect the splitting(4 As): affect, association, autism, ambivalence.The other symptoms: hallucinations, delusions,illusions are the secondary symptoms notspecific for schizophrenia, could be seen in otherpsychoses of toxic, infection orgin.


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E. Bleuler Head of Burghlzli Clinic, Zurich

Bleulerian criteria the 4 As:Affect flat, inappropriate, blunt (unchanginig facial,vocal, gestural expression)

Associations loose, fragmented thinking, disorganized

speech (difficulty or lack of logic verbal contact with a

patient)Autism being in a world ofones own (little intrest ofwhat is going around him, not recognizing real situations,

living after the wall made of glass)

Ambivalence the capicity to believe, to speak, tobehaviour, to react emotionally in contradictory ways(laugh when told about death of his mother)


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background - cont. The first rank Schneiderian symptoms:

I hear voices arguing to each other. Someone is

commenting on what I am doing. Someone is putting

thoughts into my head. My thoughts are beingtransmitted to other people so that they know what

I am thinking. I am being made to want things I

would not want myself. Some mystical force made

me do or say things that I do not intend, as though Iwas a robot or automation


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background - cont. T. Crow proposed a classification of types I and II based

on the presence and absence ofpositive (productive)symptoms and negative (deficit) symptoms

The positive symptoms: delusions and hallucinations,

formal thought disorder

The negative symptoms: affective flattening, poverty ofspeech (alogia) or speech content, lack of motivation(avolition), anhedonia, social withdrawal

Type I patients have normal CT scans of brain, goodresponse to treatment (mostly)

Type II patients have brain abnormalities on CT scans,

poor response to treatment


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background cont. A. Carlsson, J. Deley, P. Deniker Dopamine

Hypothesis, neurpleptic activity of chlorpromazine

Dopamine is a neurotransmitter that acts in the

nigrostriatal, the mesolimbic, mesocortical system.Increase of dopamine neurotransmition via D2 rec. inmesolimbic system is said to be the cause ofproductive symptoms, the decrease of dopamineneurotransmition in mesocortical system is likely to bethe cause of negative symptoms of schizophrenia

Chlorpromazine (Fenactil) blocks rec. D2 thus reducesdopaminergic activity and positve symptomsrespectively


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Diagnosis: DSM-IV TR Criteria


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Auditory hallucinations,delusions of persecuctionor grandeur

Schizophrenia subtypes DSM -IV

Schizophrenia paranoid typeMOST FREQUENT SUBTYPE of SCZ

40% of patients


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Karl Ludwig Kahlbaum

Described the clinical picture of

Catatonia (1874)

7% of patients


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Ewald Hecker, 1843

1909

Schizophrenia

Disorganized Type

Co-worker

and a friend of

K. L. Kahlbaum

Described hebefrenia 1871(hence the Greek hebe for youth

plus phrenia for mind)

11% of patients


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14 % of patients

18% of patients


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Schizophrenia subtypesDSMIV vs ICD-10

DSM IV classifies the 5 subtypes based mainly

on clinical picture. The subtypes are notclosely correlated with different prognoses.

ICD 10 classifies 9 subtypes (additionally

postschizophrenic depression, simple

schizophrenia, other schizophrenia,

schizophrenia unspecified)


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The Criteria of Diagnosis: ICD-10

For the diagnosis of schizophrenia is necessary

presence of one very clear symptom - from point A to D

or the presence of the symptoms from at least two groups - from point E to

H

for one month or more:

A) the hearing of own thoughts, the feelings of thought withdrawal, thoughtinsertion, or thought broadcasting

B) the delusions of control, outside manipulation and influence, or the feelingsof passivity, which are connected with the movements of the body orextremities, specific thoughts, acting or feelings, delusional perception

C) hallucinated voices, which are commenting permanently the behavior of thepatient or they talk about him between themselves, or the other types ofhallucinatory voices, coming from different parts of body

D) permanent delusions of different kind, which are inappropriate andunacceptable in given culture


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The Criteria of Diagnosis

E) the lasting hallucination of every form

F) blocks or intrusion of thoughts into the flow of thinking and resultingincoherence and irrelevance of speach, or neologisms

G) catatonic behavior

H) the negative symptoms, for instance the expressed apathy, poor speech,blunting and inappropriatness of emotional reactionsExpressed and conspicuous qualitative changes in patients behavior, theloss of interests, hobbies, aimlesness, inactivity, the loss of relations toothers and social withdrawal

Symptoms are not an effect of organic brain disease, intoxication,substance dependency or withdrawal

Diagnosis ofacute schizophorm disorder (F23.2) if the conditions for diagnosis ofschizophrenia are fulfilled, but lasting less than one month

Diagnosis ofschizoaffective disorder (F25) - if the schizophrenic and affectivesymptoms are developing together at the same time


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A delusion is a fixed, false

personal belief held with

absolute conviction despite

all evidence to the contrary.

The belief is outside thepersons normal culture or

subculture and dominates

their viewpoint and behavior.

Delusions may be classified in terms of their

content, for example delusions of...

Persecution - An outside person or force is in some way

interfering with the sufferers life orwishes them harm, e.g.

The people upstairs are watching me by using satellites

and have poisoned my food.

Reference - The behavior of others, objects, or broadcasts

on the television and radio have a special meaning or refer

directly to the person, e.g. A parcel came from Sun

Alliance and the radio said that the son of man is here, ona Sunday, so I am the son of God.

Control - The sensation of being the passive recipient of

some controlling or interfering agent that is alien and

external. This agent can control thoughts, feeling and

actions (passivity experiences), e.g. I feel as if my face is

being pulled upwards and something is making melaugh when Im sad.

Doubles - A person known to the patient, most frequently

their spouse, has been replaced by

another (also known as Capgras syndrome or, confusingly,

illusion of doubles)

Diagnosis -

DELUSIONS


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Prodrome Active Phase Residual Phase

Prodrome Active Phase Residual Phase

Pro-

dromeActive Phase Residual Phase

Total duration at least 6 months

The active phase at least 1 month

Schizophrenia natural history



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Epidemiological findings

morbid risk - 1% of population

lifetime morbidity 0,6-8,3/1000 (avr. 1-

5/1000)

prevalance 0,09-0,7/1000/year (avr.

0,2/1000)

begins mainly in young age (1625), earlier in

men (avr.21) than in women (avr.27)

standard mortality ratio avr. 2.0

suicide risk 10%


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Schizophrenia - age of onset

youth schizophrenia

below 15 years - 4%

below 10 years - 0,1-1%

between 15 - 45 years - 80% late-onset schizophrenia

above 45 years - 15%

schizophrenia


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Epidemiologicalfindings

- role of criteria


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Epidemiological findings cont.

Place of Birth


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Epidemiological findingscont.

Gender


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Epidemiological findings cont.

Month of Birth Effect


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Schizophrenia-Differential Diagnosis

Summary

drug or substance abuse induced psychotic symptoms(phencyclidine, cocaine, amphetamine, alkohol,corticosteroids, levodopa, anticholinergic agents)laboratory tests, psychoses usually develop within 2 weeksafter the last use and disappear within 1 month

psychoses due to general medical condition (infections,tumors of CNS, endocrine disorders, temporal lobe epilepsy,dementia) diagnosis of the basic disease, CT, MRI

psychotic decompensation in the course of BorderlinePersonality Disorder

psychotic depression, psychotic mania

schizoaffective disorder

delirium


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Lets Have a Break!

15 min.


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Cases - presentation


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Cases discussion

Medical/Psychatric History?

Presenting signs and symptoms?

Diagnosis?

What subtype of illness?

Differential diagnosis?

Management?

C t d #1


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Case study #1History

Eddy is 24 years old. He worked as a mechanic until recently, giving up his job out of the blue, saying it was a waste

of time. He did rea-sonably well at school, was sociable and positive in his outlook, last year proposing marriage to his

girlfriend. He smoked cannabis occa-sionally at weekends, but used no other drugs and didn't drink alcohol. His parentsare divorced and he lives with his mother. Her boyfriend, with whom she has a long-term and stable relationship, has

recently moved in.

Over the last 6 months Eddy's mother has noticed that he has become increasingly introverted. He stopped going

out and no longer returns his friends' calls. He has lost his appetite over the past month and has obviously lost weight.

His fiance has left him, saying she was fed up with him being depressed and moody all the time.

Eddy has told his mother that he is concerned for her safety, but he would not explain further. When questioned

about his concerns he became upset and angry. At other times he has shut himself in his room. She has heard him

talking angrily, sometimes shouting; he denies this.His uncommunicativeness, anger and suspiciousness have gradu-ally increased, and things came to a head one

evening when he became agitated and smashed the mirror in the sitting room, cutting his hand. He was so agitated and

distressed that his mother's partner felt it nec-essary to restrain him physically; Eddy got a black eye in the process.

His paternal uncle has a history of schizophrenia, and his father has been described as isolated and "a loner".

The following day, Eddy's mother attended her primary care centre and expressed her concerns. She has been

unable to persuade him to come and see the doctor, who agreed to visit. When he did, he could not gain access to

Eddy, who locked himself in his room, and would only answer "I'm alright, go away" to all questions.The physician arranged an emergency multidisciplinary assessment with the local psychiatrist. At this visit Eddy

reluctantly emerged from his room, and seemed frightened and agitated. He was initially unwill-ing to discuss the

events of the previous evening, but eventually admitted that he felt he had to smash the mirror because it was the door

to another frightening world from which he felt electric currents entering his spine and thereby controlling his stomach

and bowels. He is convinced that he and his mother are in terrible danger, and is unsure whether his mother's

boyfriend is part of a conspiracy against them emanating from this place. He has heard voices describing his bodily

functions, though did not wish to elaborate. At times these voices have spoken directly to him, threatening him with

damnation, and he admits it is this that has frightened him and caused him to shout when isolated in his room.

C t d #2


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Matt Briggs is 37 years old and has just registered with the health centre. The previous notes are not available, but

a recent hospital letter was faxed in advance. Matt was diagnosed at the age of 26 as suffer-ing from paranoid

schizophrenia. He had a history of substance abuse, including cannabis, LSD, ecstasy, cocaine and amphetamines. Hisillness had a gradual onset over a period of 2 years, including growing suspiciousness, withdrawal from his family and

social networks, and loss of his job, culminating in an acute psychotic breakdown. At the time of his breakdown he

suffered from an elaborate delusional system, including the belief that he was a "Messiah". He was admitted to a

mental hospital in London under section 2 of the Mental Health Act. This was changed to a section 3, and he spent a

total of 8 months in hospital, the last two as a voluntary patient. According to the letter, his symptoms have always

been difficult to control, and he has already had treatment with trifluoperazine, chlorpromazine, thioridazine, pimozide

and a year on depot flupenthixol, during which he relapsed. All have been at therapeutic doses.

He presents with a request for your advice on his medication. He has, until recently, had some contact with thecommunity mental health team in his area, and has had a reasonable relationship with a com-munity psychiatric nurse.

However, he has never been enthusiastic about his antipsychotic medication and has stopped taking it on at least three

occasions in the past 10 years. Each time he has ended up in psychi-atric hospital. He is now on oral haloperidol (10 mg,

three times a day) and an anticholinergic drug.

He wants to stop taking his medication again and wonders what you think about this.

He has the mask-like face and slow movements of drug-induced Parkinsonism. He is restless and shows evidence

of akathisia. There is some evidence of facial involuntary movement.When you question him more closely about his reasons for wanting to stop taking medication he begins to become

excited. He points out, quite reasonably, that the physical side-effects of the medication are difficult for him to tolerate.

He argues that the medication is acting as a barrier between him and his mission to the people. He believes that he has

been sent on this mission by a higher power. When you ask him what the mission consists of, he replies that he must

spread the truth, and speak to people about their lives and what they really need. He feels he cannot do this as long as

he is taking antipsychotics, as they are blocking his thoughts and preventing the message getting through to him. He is

not experiencing auditory hallucinations, and seems to want to engage in a discussion with you.

Case study #3


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Mrs Philodopolous is 68 years old and lives with her husband, who is 10 years her senior. She has had a number

of psychotic breakdowns in her life. These began when she was in her mid-30s, after she had been married for 10 years.

She has been admitted to mental hospital on a number of occasions, sometimes as a voluntary patient, sometimesunder compulsion. She has been treated with a number of antipsy-chotics in her life, including chlorpromazine,

haloperidol, thioridazine and finally settling on depot medication, flupenthixol decanoate (80 mg, administered every 2

weeks), at her primary care centre. None of these treatments have ever entirely abolished her psychotic symptoms,

although they have been effective to different degrees in reducing her agitation and distress.

Mrs Philodopolous initially presented with thought insertion and broadcast, intensely distressed that sexual

thoughts put into her mind by a neighbour were available to anyone in her house, who would look down on her and

think she was dirty because of their content. She felt she was responsible for the thoughts and tried to resist them. She

kept her house spotlessly clean so as to suggest to her neighbours and friends her pure heart and good housekeeping,and was very anxious at the thought of dirt that would confirm these people's negative views of her. By her second

admission and consistently since, she had a delusional system which includes the belief that she has been visited by an

unknown man during the night who sexually assaults her while she and her husband sleep; she thinks she may be

pregnant. Mr and Mrs Philodopolous have never had children.

Until 5 years ago she had been attending a psychiatric outpatient clinic regularly, every 6 months. She had been

under the care of the same consultant psychiatrist for over 20 years. After his retirement she had stopped attending

outpatients. She had become increasingly with-drawn and suspicious, and had refused to leave her house over the last4 months. During this period she had stopped attending her GP's surgery for her depot medication, so this had been

administered by a commu-nity psychiatric nurse who visited the home.

Her husband, who suffers from chronic obstructive pulmonary disease, has become increasingly unwell during

this period and is less able to care for her. He seems less tolerant of her, and appears exhausted. In response to this she

has withdrawn from the sitting room to her bedroom, and her delusion of pregnancy has become stronger, and

increasingly preoccupies her thoughts. She has shouted in the night that she is in labour on more than one occasion. An

increase in the dose of the depixol has not produced any improvement in her mental state. Unfortunately, she has

developed Parkinsonian-type adverse effects on the higher dose.

Case #1


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Case #1

A young, unmarried woman, age 20, was admitted to a psychiatric hospital because she had

become violent toward her parents, had been observed gazing into space with a rapt

expression, and had been talking to invisible persons. She had been seen to strike odd

postures. Her speech had become incoherent.She had been a good student in high school, then went to business school and, a year

before admission to the hospital started to work in an office as a stenographer. She had

always been shy, and although she was quite attractive, she had not been dating much.

Another girl, who worked in the same office, told the patient about boys and petting and

began to exert a great deal of influence over her. The second girl would communicate with

her from across the room. Even when they went home at night, the patient would get voice

messages telling her to do certain things. Then pictures began to appear on the wall, most ofthem ugly and sneering. Those pictures had namesone was named shyness, another

distress, another envy. Her office friend sent her messages to knock on the wall, to hit the

pictures.

The patient was agitated, noisy, and uncooperative in the hospital for several weeks after she

arrived, and required sedation. She was given a course of insulin coma therapy, with no

significant or sustained improvement. Later she received several courses of

electroconvulsive treatment, which also failed to influence the schizophrenic process to any

significant degree. Ten years later, when antipsychotic drugs became available, she received

pharmacotherapy.

Despite all those therapeutic efforts, her condition throughout her many years of stay in a

mental hospital has remained one of chronic catatonic stupor. She is mute and practically

devoid of any spontaneity, but she responds to simple requests. She stays in the same

position for hours or sits curled-up in a chair. Her facial expression is fixed and stony.

Case #2


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Case #2

An unmarried man, aged 27, had been working as a teacher and was admitted to a

psychiatric hospital because he had become increasingly agitated and irrational after several

nights of wakefulness. He was extremely talkative and ran about aimlessly. His behavior

became very strange; for instance, he tried to clean everything in the house, moved hiswristwatch up to his shoulder, stripped his clothes off, chewed large wads of paper in the

belief that it was good for him, talked about killing himself, and then said that he might

already be dead.

He heard voices ordering him about incessantly, and he frequently laughed without any

apparent cause. After chewing the paper he would spit in it and then drink his saliva. He

rolled into odd postures on the bed, with his tongue sticking out. He started to jump and

dance when taken to the bathroom by a nursing assistant for a shower and destroyed thebathroom furnishings. His gait was manneristic. His speech was utterly incomprehensible. He

refused to take any medication and had to be sedated by parenteral medication.

He remained noisy, excited, destructive, and irrational in his behavior for a month; then he

improved in response to high dosages of antipsychotic medication and a few

electroconvulsive treatments. Three months after admission he was discharged from the

hospital, symptom free, with good insight into the nature of his illness. For more than 10

years he has been employed as a teacher.

Case #3


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Case #3

A 56-year old woman, X-ray technician who had emigrated as an adult from Europe, and

married late in life, presented to the emergency room. Her complaints were that her

husband's business partner of many years intended to get her husband to resign from the

business and to destroy their home. Over a number of months she had become graduallyaware that a variety of apparently inconsequential incidents (such as unusual cars parked on

her isolated residential street, seeing individuals she knew at restaurants, and feeling as if

she were being followed each time she drove her car) pointed to a conspiracy to disrupt and

ultimately destroy their lives. Her delusion of persecution was remarkably systematized and

detailed; her mood in describing this was tense and irritable. There was no evidence of

hallucinations, confusion, thought disorder, or mood disorder. Cognition was intact. The

patient was quite intelligent and saw the clinical consultation as a means of assisting herhusband to deal with the distress of being targeted in such a manner. (The husband had

accompanied his wife on these consultations. He also had experienced some delusional

thinking in accord with hers.)

The patient showed no evidence that suggested suicidality or potential for violence toward

others. She initially refused all medication but gradually over several months of therapy and

parallel frequent legal consultations agreed reluctantly to take risperidone (Risperda) and

later, for postpsychotic depression, paroxetine (Paxil). She responded within weeks to 0.5 to

1 mg of risperidone administered daily or on alternate days; she refused to take the

medication continuously. Within a year, she began to focus on other issues and the emotional

intensity of the delusional concerns diminished although they could be aroused with modest

stimulation in conversation or from happenings in her home or neighborhood.

Case #4


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A 15-year-old girl attended a summer camp where she had difficulties in getting along with the

other children and developed animosity toward one of the counselors. On her return home,

she refused to listen to her parents, and she heard the voice of a man talking to her, although

she could not see him. She rapidly began to show bizarre behavior, characterized by

grimacing, violent outbursts, and inability to take care of herself.Her school record had always been good, and she was fluent in three languages. Her parents

described her as having been a quiet, rather shut-in child, with no abnormal traits in

childhood. Family relations were reported as having been satisfactory.

When the patient was admitted to a psychiatric hospital, her speech was incoherent. She

showed marked disturbances of formal thinking and blocking of thoughts. She was impulsive

and seemed to be hallucinating. She stated that she heard voices in her right ear and that a

popular singer was running after her with a knife. She also thought that her father was intenton killing her and that she was pregnant because she had hugged one of the residents.

Two months of neuroleptic treatment brought no apparent improvement. She was then given

a course of intensive electroconvulsive therapy and continuous sleep treatment. Over a period

of a year, she received close to 200 electroconvulsive treatments and 50 subcoma insulin

treatments, with little improvement. She was then transferred to another mental hospital,

where her behavior has remained very disturbed for almost 20 years.She is often incontinent and most of the time neglects her physical appearance. Occasionally

she spends hours dressing herself, looking in the mirror, and putting on excessive makeup. At

times, she has been discovered eating her feces. Occasionally, she adopts the role of a singer

or a dancer. She makes statements like "Will I live forever? Nurse, I didn't throw my love

away. It is in my stomach, and it hurts." In the dining room she attempts to grasp the genitals

of male patients. High doses of neuroleptics are continuously required to control her behavior.

The ultimate prognosis is very poor.

S f i


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Schizophrenia PART1

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