SCHIZOPHRENIA & OTHER PSYCHOTIC
DISORDERS
Schizophrenia
1
DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA
1) delusions
2) hallucinations
3) disorganized speech
4) grossly disorganized or catatonic behaviour
5) negative symptoms (affective flattening
flattening, alogia)
DURATION
PREVAL.
delusions, hallucinations, disorganized
speech, flat or inappropriate affect, and
catatonia
6 months or
more
1.0%
Brief psychotic
disorder
delusions, hallucinations, disorganized
speech, flat or inappropriate affect, and
catatonia
Less than 1
month
Unknown
Schizophreniform
disorder
delusions, hallucinations, disorganized
speech, flat or inappropriate affect, and
catatonia
1 to 5 months
0.2%
Schizoaffective
disorder
both schizophrenia and a mood disorder
6 months or
more
Unknown
Delusional disorder
not bizarre delusions
1 month or
more
0.1%
Substance-induced
psychosis
Hallucinations or delusions caused
directly by a substance
No minimum Unknown
length
Shared psychotic
disorder
A.K.A folie à deux delusions that are held
by another individual
No minimum Unknown
length
Psychotic disorder
due to medical con.
Hallucinations or delusions caused by a
medical illness or brain damage
No minimum Unknown
length
Schizophrenia
2
• C. Duration: continuous signs of the disturbance must
persist for at least 6 months. This six month period
mustt include
i l d att least
l t one month
th off symptoms
t
that
th t meett
criterion A. This period must also include prodromal or
residual periods. During these prodromal or residual
periods, only negative symptoms or less severe
symptoms in Criterion A may be present.
• NOTE: Only one Criterion A symptom is required if
delusions are bizarre or if hallucinations consist of a
voice keeping a running commentary of the person’s
behaviour or thoughts, or 2 or more voices are
conversing with each other.
Schizophrenia
KEY FEATURES
Schizophrenia
• B. Social/occupational dysfunction: for a significant
portion of the time from the onset of the disturbance, the
patient is functioning well below their usual level in one
or more of the following areas: work, interpersonal
relations, and/or self care.
• A. Characteristic symptoms: two ore more of the
following, each present for a significant period of time
during a 1-month period
–
–
–
–
–
DISORDER
3
Schizophrenia
4
1
SCHIZOPHRENIA & OTHER PSYCHOTIC DISORDERS
• SCIZOPHRENIA: DSM-IV includes five subtypes
of schizophrenia, as shown below:
– CATATONIC: at least two of the following
psychomotor disturbances…immobility, excessive
motor activity, extreme negativism, posturing,
repetition of speech, sounds
– PARANOID:
O
ppreoccupation
p
with one or more delusions
or frequent auditory hallucinations, absence of
prominent schizophrenic symptoms such as
disorganized speech or behaviour, catatonic behaviour,
or flat or inappropriate affect
– UNDIFFERENTIATED: meets criteria for
schizophrenia but does not meet criteria for catatonic,
paranoid, or disorganized subtype
Schizophrenia
5
Schizophrenia
6
VARYING DEGREES OF PARANOID THINKING
– DISORGANIZED: presence of disorganized speech,
disorganized behaviour, flat or inappropriate affect,
does not meet criteria for catatonic type
• MILD
– AVERAGE PERSON: occasional suspicious thoughts
• MODERATE
– PARANOID PERSONALITY: a suspicious cognitive style
– PARANOID PERONALITY DISORDER: a suspicious cognitive
style so strong that is impairs effective behaviour. There are no
delusions. Reality testing is intact.
– DELUSIONAL (PARANOID)
(
) DISORDER: a stable
bl andd chronic
h i
delusional system. Reality testing good in all other areas.
– RESIDUAL: no longer active symptoms of
schizophrenia, and does not meet criteria for any
subtype continuing evidence of disturbance
subtype,
indicated by negative symptoms or two or more
symptoms of schizophrenia in mild forms
• SEVERE
– PARANOID SCHIZOPHRENIA: multiple delusions that are likely
to be fragmented, accompanied by marked loosening of associations,
obvious hallucinations, and other evidence of disorganization.
Reality markedly distorted.
Schizophrenia
7
Schizophrenia
8
2
FOUR TYPES OF DELUSIONS
• DELUSIONS
– persistent false beliefs, not in keeping with individual cultural
background (e.g. suicide in war in middle east), it is accepted as
truth by individual
•
Persecution – the RCMP is out to get me
•
Reference – people on the bus talk about me,
neighbours are making fun of me
•
Being controlled – the devil is controlling my
thoughts and behaviours
•
Grandeur – I am Jesus, on a special mission from the
Lord.
• HALLUCINATION
– a mental phenomenon that is independent of external organs. a
person believes he sees or hears things that have no basis in
objective
bj ti stimuli
ti li
• ILLUSIONS
– an erroneous perception of a real sensory impression
Schizophrenia
9
FOUR DIMENSIONS OF SCHIZOPHRENIA
Schizophrenia
DIFFERENCES BETWEEN POSITIVE-SYMPTOM (TYPE 1) AND
NEGATIVE-SYMPTOM (TYPE 2) SCHIZOPHRENIA
• EMOTIONAL
Positive (Type 1)
Schizophrenia
Negative (Type 2)
Schizophrenia
SYMPTOMS
delusions
hallucinations
incoherence
bizarre behaviour
poverty of speech
flat affect
social withdrawal
apathy
PREMORBID
ADJUSTMENT
good
poor
PROGNOSIS
good
poor
SEX
DISTRIBUTION
more likely to be
women
more likely to be
men
– flat affect, disorganized, inappropriate, child-like
• COGNITIVE
– delusions, hallucinations, poor concentration
• BEHAVIOURAL
– disorganized, inappropriate, catatonic
• PHYSIOLOGICAL
– Sleep, sex, autonomic differences (GSR)
Schizophrenia
11
10
Schizophrenia
12
3
100
MEN
WOMEN
50
0
-2
26 5
-3
36 5
-4
46 5
-5
56 5
-6
66 5
-7
5
75
+
16
13
Schizophrenia
14
WHY?
1) HIGHER STRESS - psychologically, increased biological
Economic Status and Schizophrenia
and genetic risk, fewer coping skills taught, less access to
health care
1.9
2) DOWNWARD DRIFT
1.3
0.9
3) VIRUS and PREGNANCY PROBLEMS 08
0.8
schizophrenics
hi h i births
bi th higher
hi h in
i late
l t winter
i t & early
l spring
i andd
this is reversed in southern climates. Small increase 5-50%
above expectancy, poorer health care
0.4
Lower
2) WOMEN HAVE MORE MOOD
SYMPTOMS AND YOUNG MALES
MORE
O
AGG
AGGRESSIVE
SS
testosterone) - reduction in symptoms when
pregnant
Schizophrenia
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
accepted, more support systems, married
4) BIOLOGICAL FACTORS (estrogen,
Age at onset
% o f R is k
Numbee r of indiv iduals
EXPLANATION FOR GENDER
DIFFERENCES
1) SOCIAL ROLES - problems or differences
150
Lowermiddle
Middle
Schizophrenia
Uppermiddle
Upper
15
Schizophrenia
16
4
BEHAVIOUR
CONTINUUM OF REPRODUCTIVE CASUALTY
• BIOLOGY & ENVIRONMENT
• GENETIC:
– Predictable ..... mendel
– Mutations ...... down's syndrome
– Combinations .... impulsivity, startle, shyness,
temperament
• OTHER BIOLOGICAL FACTORS
– Prenatal .... nutrition, rubella, toxic
– Perinatal .... anoxia, labour
– Diseases …. syphilis
Schizophrenia
17
Minor Physical Anomalies
Schizophrenia
• 1) 5-10 MILL. CONCEPTIONS
– 2-3 MILL SPONTANEOUS ABORTIONS …
CHROMOSOME DEFECTS ETC.
• 2) 3-5 MILL REACH 20 WEEKS
– 1.5% DIE BEFORE DELIVERY
– 1.5% DIE IN POSTNATAL MONTH
– 1.5% SEVERE CONGENITAL PROBLEM
– 10% LEARNING PROBLEMS
• CONTINUUM REFERS TO MINOR OR LESS VISIBLE
PROBLEM AREAS
•
CONTINUUM OF ENVIRONMENTAL
CASUALTY
Schizophrenia
18
Minor Physical Anomalies
19
Schizophrenia
20
5
Minor Physical Anomalies
Genetics of Scizophrenia
60
46
% o f R is k
50
48
40
30
20
2
4
U n c le /A u n t
N e p h e w /N e ic e
5
6
H a lf-S ib
2
G r a n d c h ild
1
F ir s t C o u s in
1
Spo use
10
9
13
17
0
(B) Monochorionic Twins –
shared circulation (approx 2/3
of MZ)
Infection implicated
Schizophrenia
23
I d e n tic a l
T w in s
C h ild o f T w o
S c h iz o
F r a te r n a l
T w in s
C h ild o f o n e
S c h iz o
(A) Dichorionic Twins –
separate circulation (all
DZ and 1/3 of MZ)
21
S ib
G enera l
P o p u la tio n
Schizophrenia
Schizophrenia
22
Subjects Separated from Their Mothers in Early
Infancy (Spectrum of Disorders)
ASSESSMENT
Number of subjects
Mean age at follow-up
Overall ratings of disability
(low score indicates more
pathology)
Number diagnosed
schizophrenic
Number diagnosed mentally
retarded
Number diagnosed
psychopathic
Number diagnosed neurotic
OFFSPRING OF
CONTROL
SCHIZOPHRENIC OFFSPRING,
MOTHERS
MOTHERS NOT
SCHIZOPHRENIC
47
50
35.8
36.3
65.2
80.1
5
0
4
0
9
2
13
7
spectrum of disability
Schizophrenia
24
6
Improved,
relatively
independent
25%
RELAPSE ISSUES
• Families high in expressed emotion (EE) are
defined by:
Completely
recovered
25%
Deceased (mostly
suicide)
15%
– emotional over involvement with a patient; and
– a tendency to become hostile and make negative
patient
comments to the p
Hospitalized,
unimproved
25%
10%
Improved, but
extensive support
required
Schizophrenia
25
Total Group
N = 128
1. On medication
12%
• High expressed emotion:
– predicts schizophrenic relapse; and
– is probably both a cause and consequence of patients’
p
symptoms.
y p
schizophrenic
High EE
51%
2. Not on medication
15%
<35 hours
28%
3. On medication
15%
4. Not on medication
42%
Schizophrenia
26
RELAPSE ISSUES
Relapse Rates (Vaughn & Leff, 1976)
Low EE
13%
Schizophrenia
>35 hours
69%
5. On medication
53%
6. Not on medication
92%
27
Schizophrenia
28
7
• SUMMARY OF GENETIC KNOWLEDGE
For Relapse Only
– 1) Life time risk of schizo by 55 1%
– 2) Risk of schiz. increases with biology
– 3) Risk of schiz. Proportional to severity of proband and # of
relatives affected
– 4) Gender is not NB except for age of onset (males earlier)
– 5) MZ concordance 3 times DZ and 50% higher than norm
– 6) 50% MZ discordant
– 7) Rate of concordance in twins the same if reared together or
apart (stress unpredictable)
•Prenatal trauma
•Viral infection
•Birth complications
Schizophrenia
29
Schizophrenia
30
• SUMMARY OF GENETIC KNOWLEDGE
– 8) Children of schiz. adopted at birth develop schiz. at same
rate as those raised by their own schiz. parents
– 9) Adoptive relatives do not have a higher rate of schiz.
(therefore not transmittable organic or psychological)
– 11) Children of normal parents fostered in home where one
parent becomes
b
schiz.
hi Do
D not hhave iincreasedd rate off schiz.
hi (no
(
psychological transmission
– 12) Probands with schiz. like illness after head injury do not
transmit schiz.
– 13) Appears that no environmental cause will invariably or
moderate probability lead to sciz. In those with no schiz.
Relatives
Schizophrenia
31
8