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Schizophrenia

Group 2A (2014)

Brain of a Schizophrenic patient:

PET scan shows disruption in brain activity, changes in brain structures (eg. Ventricles) & decrease function in the frontal cortex.

Schizophrenia

Define as major mental disorder characterized by disturbance of :

Thinking

Emotion

Behaviour

Often accompanied by deterioration in personality and functioning

have disorganized and abnormal thinking, behaviour and language and become emotionally unresponsive or withdrawn.

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Epidemiology

Worldwide (WHO)

affecting about 7/1000 of the adult population

affects about 24 million people wordwide

mostly in the age group 15-35 years.

the incidence is low (3-10,000) but the prevalence is high due to chronicity.

World health organization

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Malaysia

National Mental Health Registry report that 7351 cases had been registered from 2003 to 2005.

the median incidence rate was 15.2 per 100,000 (range of 7.7 to 43.0 per 100,000

The incidence was noted higher in males, urban and migrant population.

In a systematic review (SR) of the incidence of schizophrenia the median incidence rate was 15.2 per 100,000 (range of 7.7 to 43.0 per 100,000

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Findings of Malaysia National Mental Health Registry Report

a. Gender and age

More than 60% schizophrenia cases in Malaysia were males.

peak age of patients presentation was at the age of 30 in which males developed earlier illness compared to female.

b. Ethnic group

c. Marital status and occupation

Equally prevalent between both gender but differs in the onset and course of illness.men peak 10-25yr while women 25-35yr.There were 54% Malays, 28% Chinese, 9% Indians and 9% others. Most (80%) were single, divorced, widowed or separated and 70% were unemployed.

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d. Body weight

e. Duration of Untreated Psychosis (DUP)

f. Family history

A total of 21.6% had family history of mental illness, 20% had some

form of co-morbidity,

g. co-morbid conditions (substance abuse)

h. Medical co-occuring conditions

Diabetes mellitus and hypertension being the most common ones

Sixty percent had normal Body Mass Index (BMI30).

Duration of Untreated Psychosis was described as the time period

from onset of the first psychiatric symptom to initiation of antipsychotic

treatment.

From the cases registered, mean DUP was 28.7 months with a

median of 12 months (range 0 to 564 months). Males had a shorter DUP of

23 to 26 months while female had DUP of 30 to 33 months. substance abuse being the commonest (80%) of which cannabis was the most common substance abused followed by amphetamine.

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Predisposing Factors

Genetic

Those with family history of schizophrenia

Parents 6%

Siblings 9%

Children 13%

Dizygotic twin 17%

Children with two affected parents 46%

Monozygotic twin 48%

Parent: Offspring of older fathers, Unmarried mother

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Social

Cannabis abusers

Individual living in higher level of urbanisation (1.40-fold increased risk)

Environment

Those with history of childhood central nervous system infection.

history of obstetric complications

Viral

CNS infections during childhood may have a modest role as a risk

factor due to its relative rareness. Preeclampsia, Extreme prematurity,Hypoxia or ischemia during birth

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Dopamine Hypothesis

DOPAMINE HYPOTHESIS

The Dopamine hypothesis states that the brain of schizophrenic patients produces more dopamine than normal brains.

Evidence comes from

studies with drugs

post mortems

pet scans

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Normal Level of Dopamine In The Human Brain

Elevated Level of Dopamine In The Brain of a Schizophrenic Patient

(specifically the D2 receptor)

Neurons that use the transmitter dopamine fire too often and transmit too many messages or too often.

Certain D2 receptors are known to play a key role in guiding attention.

Lowering DA activity helps remove the symptoms of schizophrenia

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ROLE OF DRUGS

Amphetamines (agonists) lead to increase in DA levels

Large quantities lead to delusions and hallucinations

If drugs are given to schizophrenic patients their symptoms get worse

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Parkinsons disease

Parkinsons sufferers have low levels of dopamine

L-dopa raises DA activity

People with Parkinson's develop schizophrenic symptoms if they take too much L-dopa

Chlorphromazine (given to schizophrenics) reduces the symptoms by blocking D2 receptors

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Falkai et al 1988

Autopsies have found that people with schizophrenia have a larger than usual number of dopamine receptors.

Increase of DA in brain structures and receptor density (left amygdala and caudate nucleus putamen)

Concluded that DA production is abnormal for schizophrenia

POST MORTEM

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SIGNS AND SYMPTOMS

In general, the symptoms of schizophrenia can be divided into three catogories:

Positive

Negative

cognitive symptoms.

However, patients may develop their own unique combination of symptoms.

POSITIVE SYMPTOMS

Delusions

Hallucinations

Disorganised speech/thinking (thought disorder or loosening of

associations)

Grossly disorganised behaviour

Catatonic behaviours

Other symptoms:

Affect inappropriate to the situation or stimuli

Unusual motor behaviour (e.g. pacing and rocking)

Depersonalisation

Derealisation

Somatic preoccupations

These tend to respond more robustly to the current antipsychotic medications

NEGATIVE SYMPTOMS

The symptoms that appear to reflect a diminution or loss of normal

emotional and psychological function which includes:

i. Flat affect

the reduction in the range and intensity of emotional expression:

facial expression, voice tone, eye contact, and body language

ii. Alogia or poverty of speech

the lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts, and often manifested as short, empty replies to questions

iii. Avolition

psychological state characterized by general lack of drive, or motivation to pursue meaningful goals.

e.g. no longer interested in going out and meeting with friends, no longer interested in activities that the person used to show enthusiasm for, no longer interested in much of anything, sitting in the house for many hours a day doing nothing

iv. Anhedonia

inability to experience pleasure from activities usually found enjoyable

v. Attention (poor)

Negative symptoms are less obvious and often persist even after the

resolution of positive symptoms.

COGNITIVE SYMPTOMS

Cognitive symptoms refer to the difficulties with concentration and memory

i.e.:

Disorganised thinking

Slow thinking

Difficulty understanding

Poor concentration

Poor memory

Difficulty expressing thoughts

Difficulty integrating thoughts, feelings and behaviour

These symptoms may poor work and school performance

Three Phase:

Symptoms of schizophrenia usually present in three phases:

Prodromal

Decline in functioning that precedes the first psychotic episode

The patient may become socially withdrawn and irritable

He or she may have physical complaints and/or newfound interest in religion or the occult

Psychotic

Perceptual disturbances, delusions, and disordered thought process/content

Residual

occurs between episodes of psychosis

It is marked by flat affect, social withdrawal, and odd thinking or behaviour (negative symptoms)

Patient can continue to have hallucinations even with treatment

Scheinders symptoms of first rank

Auditory hallucinations taking the form of the following:

Voices repeating the subjects thoughts out loud or anticipating their thoughts

Two or more hallucinatory voices discussing the subject or arguing about then in the third person

Voices commenting on the subjects thoughts or behaviour, often in the form of a running commentary

The sensation of alien thoughts being put into the subjects mind by some external agency (thought insertion) or of their own thoughts being taken away (thought withdrawal)

The sensation that the subjects thinking is no longer confined to their own mind, but is instead shared by, or accessible to, others (thought broadcasting)

The sensation of feelings, impulses, or acts being experienced or carried out under external control, so that the subject feels as if they were being hypnotised or had become a robot (delusion of control)

The experience of being a passive and reluctant recipient of bodily sensations imposed by some external agency (somatic delusion)

Delusional perception a delusion arising fully fledged on the basis of a genuine perception which others would regard as commonplace an unrelated

Diagnosis of Schizophrenia

DSM-V Criteria

Two or more of the following must be present for at least 1 month:

Delusions

Hallucinations

Disorganized speech (e.g Frequent derailment or incoherence)

Grossly disorganized or catatonic behaviour

Negative symptoms (e.g Diminished emotional expression or avolition)

- One of the two symptomsmustbedelusions,hallucinations, ordisorganized speech.

Level of functioning is markedly below the level achieved prior to the onset.

Duration of illness for at least 6 months which is well distinguished from schizophreniform disorder.

Symptoms not due to medical, neurological or substance-induced disorder

Makes the distinction between schizophrenia and an autism spectrum disorder or a communication disorder.

Schizoaffective disorder

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Schizophrenia Subtypes

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Paranoid type

Highest functioning type, older age of onset. Must meet the following criteria:

Preoccupation with one or more delusions (persecutory/grandeur) or frequent auditory hallucinations (single theme, persecutory)

No predominance of disorganized speech, disorganized or catatonic behavior, or inappropriate affect

They are typically guarded, tense, reserve and sometimes hostile. Intelligence remain intact

Disorganized type (Hebephrenia)

Poor functioning type, early onset. Must meet the following criteria:

Disorganized speech (loosening of association )

Disorganized behavior

Flat or inappropriate affect

Catatonic Type

Rare. Must meet at least two of the following criteria:

Motor immobility

Excessive purposeless motor activity

Extreme negativism or mutism

Peculiar voluntary movements or posturing (may hold awkward position for a long time)

Undifferentiated Type

Characteristic of more than one subtype or none of the subtypes

Prominent delusion

Hallucination

Incoherence

Grossly disturbed behavior

Residual Type

Prominent negative symptoms (such as flattened affect or social withdrawal)

Minimal evidence of positive symptoms (such as hallucinations or delusions)

Brief Psychotic, Schizophreniform, Schizoaffective Disorder

Schizophreniform disorder - symptoms have lasted between 1 and 6 months, whereas in schizophrenia the symptoms must be present for more than 6 months.

Brief Psychotic Disorder - Patient with psychotic symptoms as defined for schizophrenia; however, the symptoms last from 1 day to 1 month. Symptoms must not be due to general medical condition or drugs. This is a rare diagnosis, much less common than schizophrenia.

Schizoaffective disorder - Meet criteria for either major depressive episode, manic episode, or mixed episode (during which criteria for schizophrenia are also met)

Have had delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms (this condition is necessary to differentiate schizoaffective disorder from mood disorder with psychotic features)

Have mood symptoms present for substantial portion of psychotic illness

Schizophreniform disorder

Episode lasts for 1-6m or 50% patients having poor outcomes, repeated hospitalization, exacerbations of symptoms, episodes of major mood disorders and suicide attempts.

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Predictors for poor outcome

Features of the illnessInsidious onsetLong 1st episodePrevious psychiatric historyNegative symptomsYounger age at onsetFeatures of the patientMaleSingle, separated, widowed or divorcedPoor psychosexual adjustmentPoor employmentSocial isolationPoor compliance