schizophrenia l kraepelin-dementia precox l bleuler-schism between thought, emotion and behavior in...

SchizophreniaSchizophrenia Kraepelin-dementia precox Bleuler-schism between thought, emotion

and behavior in affected patients 4 A’s

– ambivalence– associations– affect– autism

Schizophrenia and DSMSchizophrenia 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.Positive & Negative Sx.

Delusions Hallucinations Disorganized thinking Misperceptions

Blunted affect Poor initiation &

planning with tasks Poverty of speech Anhedonia

DelusionsDelusions

Grandeur Guilt Jealousy Passivity Persecution Poverty Reference

Other Symptoms of Other Symptoms of SchizophreniaSchizophrenia

Cognitive Dysfunction Dysphoria Absence of Insight Sleep disturbance Suicide Illusions Echopraxia

Why accurate Dx is important?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

EpidemiologyEpidemiology

Gender-15-25 vs. 25-35 Comorbid with substance abuse Deinstitutionalization (>2/3) Dx has increased with the onset of

neuroliptics

EtiologyEtiology

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

GeneticsGeneticsGeneral 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 Factors related to good prognosis in Schizophreniaprognosis 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 Factors related to poor prognosis in Schizophreniaprognosis 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Young and insidious onset No precipitating factors Poor premorbid social, sexual, and work histories Withdrawn, autistic behavior; assaultive history Single, divorced or widowed Neurological signs and symptoms/prenatal trauma Family history of schizophrenia No remission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 IssuesMedication 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 Common antipsychotic medication side effectsmedication side effects

Dry mouth Constipation Blurred vision Drowsiness

Less common antipsychotic Less common antipsychotic medication side effectsmedication side effects

Decreased sexual desire Menstrual changes Stiff muscles on one side of the neck or jaw

Serious antipsychotic Serious antipsychotic medication side effectsmedication side effects

Restlessness Muscle stiffness Slurred speech Extremity tremors Agranulocytosis

Ethnicity and Antipsychotic Ethnicity and Antipsychotic medication efficacy medication efficacy

(Frackiewicz, et al., 1997)(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 StrengthsWork 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 LimitationsWork 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 Common types of work accommodationsaccommodations

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)

ComorbidityComorbidity 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 variantsCultural 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 SchizophreniaCatatonic 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 SchizophreniaDisorganized 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 Undifferentiated SchizophreniaSchizophrenia

Meets basic criteria for Schizophrenia but not Paranoid, Disorganized or Catatonic types

Diagnosis of exclusion..what is left

Residual TypeResidual 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 SchizophreniaParanoid 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 DisorderSchizophreniform 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 Factors related to good prognosis of prognosis of

Schizophreniform DisorderSchizophreniform Disorder Actual psychotic features begin within 4

weeks of the 1st noticeable change in the patient’s functioning or behavior

Pt. confused or perplexed when psychotic Good premorbid social or job functioning Affect is neither blunt nor flattened