Schizophrenia
Understanding the Disease
What is Schizophrenia
Schizophrenia is a chronic and disabling brain
disorder that has been recognized throughout
recorded history.
It affects about 1% of the population of the United
States.
Symptoms usually emerge for men in 10-25. In
females 25-35.
Many people with this disorder have difficulty
holding a job or caring for themselves. This
creates a great burden for their families and for
society.
Epidemiology




First degree relatives have 10 time greater
risk of developing the disorder.
Up to 50% have substance abuse and
90% have smoking.
More prevalent in low socio Economices.
High frequent hospitalization.
Suicide in Schizophrenia

People with schizophrenia attempt suicide
much more often than people in the
general population. About 10% (especially
young adult males) succeed. It is hard to
predict which patients with the disorder
are prone to suicide. Listen when they talk
about harming themselves.
Presentation


Those with the disorder may hear voices
that others don’t hear. They may believe
that others are reading their minds,
controlling their thoughts, or plotting to
harm them.
They may not make sense when they talk
or they may seem perfectly fine until they
start talking about what they are really
thinking.
What are the symptoms?


The symptoms of schizophrenia fall into
three broad categories.
Positive Symptoms are unusual thoughts
or perceptions, including hallucinations,
delusions, thought disorder and disorder
of movement. Auditory hallucinations are
the most common.
Summary of Positive Symptoms






Delusions
Hallucinations
Disorganized thinking
Disorganized behavior
Catatonic behavior
Inappropriate responses
Symptoms Continued






Negative Symptoms refers to reductions in
normal emotional and behavioral states such as:
Flat affect with immobile facial expression,
monotonous voice.
Lack of pleasure in everyday life.
Diminished ability to initiate and sustain planned
activity.
Speaking infrequently even when forced to
interact
People with the disorder often neglect basic
hygiene and need help with ADL.
Summary of Negative Symptoms








Lack of emotion
Low energy
Lack of interest in life
Affective flattening
Alogia
Inappropriate social skills
Inability to make friends
Social isolation
Symptoms Continued




Cognitive Symptoms are subtle and often
detected only when neuropsychological test are
performed.
Poor executive functioning. (the ability to absorb
and interpret information and make decisions
based on that information).
Inability to sustain attention.
Problems with working memory (the ability to
keep recently learned information in mind and
use it right away).
Cognitive Symptoms

Difficulties in concentration and memory:







Disorganized thinking
Slow thinking
Difficulty understanding
Poor concentration
Poor memory
Difficulty expressing thoughts
Difficulty integrating thoughts, feelings,
behaviors
Types of Schizophrenia






Paranoid
Hebephrenic
Catatonic
Residual
Schizoaffective
Undifferentiated
Paranoid Schizophrenia


Persons are very suspicious of others and
often have grand schemes of persecution
at the root of their behavior.
During this phase they may have
hallucinations and frequent delusions.
Hebephrenic Schizophrenia



AKA disorganized schizophrenia; characterized
by emotionless, incongruous, or silly behavior,
intellectual deterioration, frequently beginning
insidiously during adolescence.
May be verbally incoherent and may have
moods and emotions that are not appropriate to
the situation.
Hallucinations not usually present.
Catatonic Schizophrenia


Person is extremely withdrawn, negative
and isolated.
May have marked psychomotor
disturbances.
Residual Schizophrenia


Lacks motivation and interest in day-today living.
Person is not usually having delusions,
hallucinations or disorganized speech.
Undifferentiated Schizophrenia


Conditions meeting the general diagnostic
criteria for schizophrenia but not
conforming to any of the previous types.
Exhibits more than one of the previous
types without a clear dominance of one.
Causes




The disorder is believed to result from a
combination of environmental and genetic
factors. It is well known that the disease
runs in families, and is seen in 10% of
people with a first degree relative.
Identical twins have 50% chance of
developing the disorder.
Child of one parent schizophrenia 12 and
two parent 40%.
Age of the father at conception time.
Cause


Although there is a genetic risk for
schizophrenia, it is not likely that genes alone
are sufficient to cause the disorder. Interactions
between genes and the environment are
thought to be necessary for the disorder to
develop.
Many risk factors have been identified such as
exposure to viruses or malnutrition in the womb,
problems during birth, and psychosocial factors
such as stressful environmental conditions.
Brain Function:
Neurotransmission Dysfunction







Dopamine Pathway.
Serotonin pathway.
Norepinephrine pathway.
GABAergic system.
Neuropeptide (substance P, neurotensine).
Glutamate( Glutamate antagonist-PCP and
psychosis ).
Acetylcholine and Nicotine(cognition
regulation)
Brain Function:
Neuropathology







Cortex & Cerebral ventricles.
Reduced symmetry.
Limbic system:( amigdala, hypocumpus,…)
decreased size.
Prefrontal cortex.
Thalamic nuclei.
Basal ganglia and cerebellum(movement
disorders and psychosis).
Neural circuits.
Brain function:





Brain metabolism.
Applied electrophysiology.
Complex partial seizure and psychosis.
Evoked potential and delayed transmission
velocity.
Eye movement Dysfunction.
Psychoneuroimmunology



Decreased T-cell interlukin-2 production.
Abnormal cellular reactivity to neurons.
Presence of antibrain antibody.
=Neurotoxic viral infectin? Or endogenous
autoimmune disorders.
DSM-IV diagnostic criteria

A screening test


http://www.schizophrenia.com/sztest/survey2.php
At least two characteristic symptoms for one
month(or shorter on treatment):


+Delusions *
+Hallucinations *
* Only one symptom required if it is bizarre delusions or
continually commenting or conversing auditory hallucinations



+Disorganized speech
+Grossly disorganized or catatonic behavior
Negative symptoms
More diagnostic criteria



Significantly long-lasting marked
impairment of social or occupational
functioning or self-care.
Lasts for six continuous months, including
at least one month of active phase
symptoms
No major depressive, manic, or mixed
mood episodes
The syndrome duration

Total duration must be at least 6
months
Prodrome Active Phase
Prodrome
Prodrome
Residual Phase
Active Phase Residual Phase
Active Phase
Residual Phase
The active phase must last at least 1 month
0ther psychotic disorders





Schizoaffective disorder.
Brief psychotic disorder.
Shizophreniforme disorder.
Delusional disorders.
Substance induced psychotic disorders.
Schizophrenia vs
Schizoaffective Disorder



Schizoaffective disorder is characterized by both
the psychotic thought problems of schizophrenia
and the mood problems of depression or bipolar
disorder.
Two conditions must be meet to qualify as
schizoaffective disorder:
1. Psychotic symptoms sufficient for the
diagnosis of schizophrenia are present –
specifically active hallucinations or delusions
present for at least two weeks in a row.
Schizoaffective Disorder


2. One or more major depressive episodes,
manic episodes, or mixed mood episode occur
concurrent with the psychotic episode.
Doctors differ on whether it is better to diagnose
schizoaffective disorder, or to diagnose a bipolar
or major depression and schizophrenia
separately. It is not sure at this time if
schizoaffective disorder describes a single
disease entity or not.
Mechanism of Action
of Antipsychotics



While the precise mechanism of action that accounts for
the effects of antipsychotic medications is still unknown,
the dopamine hypothesis is the predominate theory used
to explain the action of these drugs.
Schizophrenia is caused by an excess in dopamine
activity in the brain, which is inhibited by blockade of the
receptors
There are two core components to the dopamine theory:
(1) psychosis is induced by increased levels of dopamine
activity and (2) most antipsychotic drugs block
postsynaptic dopamine receptors
Antipsychotics


Antipsychotic medications have been available
since the mid 1950’s. These drugs have greatly
improved the lives of patients with schizophrenia
since their first development, but these
medications do not cure the disease.
The older antipsychotic medications effectively
alleviate the positive symptoms of schizophrenia.
These which are considered conventional or
typical medications produced side effects which
made compliance difficult.
Antipsychotics


Most of these older "conventional"
antipsychotics differed in the side effects they
produced. Side effects such as orthostatic
hypotension, sedation, anticholinergic effect and
extrapyramidal effects.
These conventional antipsychotics include
chlorpromazine (Thorazine), fluphenazine
(Prolixin), haloperidol (Haldol), thiothixene
(Navane), trifluoperazine (Stelazine),
perphenazine (Trilafon), and thioridazine
(Mellaril).
Extrapyramidal Effects



Extrapyramidal Side Effects are a group of
symptoms that can occur in persons taking
antipsychotic medications. They are more
commonly caused by the typical antipsychotics
but can and do occur with all of them.
Extrapyramidal side effects include:
tremor, akathisia, slurred speech,
dystonia, bradykinesia, and muscular
rigidity
Extrapyramidal Effects


Akathisia is a movement disorder characterized
by inner restlessness and the inability to sit or
stand still. Akathisia may appear as a side effect
of long-term use of antipsychotic medications,
Lithium, and some other psychiatric drugs.
Persons with akathisia typically have restless
movements of the arms and legs such as
tapping, marching in place, rocking, crossing
and uncrossing the legs. They may feel anxious
at the thought of sitting down.
Extrapyramidal Effects


Dystonia is a neurological movement disorder
characterized by involuntary muscle
contractions, which force certain parts of the
body into abnormal, sometimes painful,
movements or postures.
Acute dystonic reactions are characteristically
sustained contraction of the muscles of neck
(torticollis), eyes (oculogyric crisis), tongue, jaw
and other muscle groups typically occurring
within 10-14 days after initiation of the
neuroleptic.
Extrapyramidal Effects



Bradykinesia means "slow movement."
Bradykinesia essentially refers to a component
of parkinsonism. The full spectrum of
parkinsonism is derived from the features of
Parkinson's disease, which include bradykinesia,
tremor, and rigidity.
Rigidity is defined as hypertonia in which the
following are true:
The resistance to externally imposed joint
movement is present at very low speeds of
movement, does not depend on imposed speed,
and does not exhibit a speed or angle threshold;
Antipsychotics


In the 1990’s, new drugs, called atypical
antipychotics, were developed.
These medications appear to be equally effective
for helping reduce the positive symptoms like
hallucinations and delusions - but may be better
than the older medications at relieving the
negative symptoms of the illness, such as
withdrawal, thinking problems, and lack of
energy.
Antipsychotics


The atypical antipsychotics include aripiprazole
(Abilify), risperidone (Risperdal), clozapine
(Clozaril), olanzapine (Zyprexa), quetiapine
(Seroquel), and ziprasidone (Geodon).
Current treatment guidelines recommend using
one of the atypical antipsychotics other than
clozapine as a first line treatment option for
newly diagnosed patients.
Antipsychotics



Clozapine (Clozaril) was the first atypical introduced. It
treats psychotic symptoms effectively even in people
who do not respond to other medications.
It can produce a serious problem called agranulocytosis.
This is a loss of the white blood cells that fight infection
in the body. Patients who take clozapine must have their
white blood cell count monitored weekly and then
monthly for the extent of use.
Even with this complication, it is still the drug of choice
with those whose symptoms do not respond to the other
antipsychotic medications, old or new.
Antipsychotics


Side Effects – When patients first start to
take the atypical antipsychotics, they may
become drowsy or experience dizziness
when they change positions (orthostatic
hypotension).
They may have blurred vision, or develop
a rapid heartbeat, menstrual problems, a
sensitivity to the sun, or skin rashes.
Antipsychotics
Side Effects


Many of these symptoms will go away after the
first few days but could last for up to one to two
weeks. Advise your patients that if the
symptoms do not go away after two to three
weeks to notify the practitioner who prescribed
the medication.
Also advise them that they should not be driving
until they adjust to their new medication.
Antipsychotics
Side Effects




The atypical antipsychotics produce much less
extrapyramidal symptoms but they can cause
weight gain and metabolic changes associated
with an increase risk of diabetes and
cardiovascular disease.
When starting these medications a baseline
check is made for risk factors for diabetes.
Baseline laboratory test: Fasting glucose, HDL,
Triglycerides, Blood Pressure.
BMI if older than 27 year old.
Monitoring



On monthly visits monitor for things such as
over eating, weight gain, polyuria (increase
urination), polydipsia (increased thirst).
When each of you see your clients, if they have
recently been put on an antipsychotic, discuss
the above symptoms with them.
Have them notify the practitioner if they are
having problems with any of these symptoms.
Summary




Relapses occur most often when people with
schizophrenia stop taking their antipsychotic
medication.
They may feel better, or their side effects or so
bad they stop the medication.
At times they don’t feel taking their medication
regularly is important.
It is our responsibility to education our patient to
be compliant and monitor them to keep them
healthy.