Schizophrenia
Padmavati Lanka
1496
Schizophrenia: A Brief History
Emil Kraepalin:
Coined the term
‘Dementia Precox’
(precox meaning early
onset).
Used the term ‘paranoia’ to
identify a separate group
‘characterized by persistent
persecutory delusions’.
Schizophrenia: A Brief
History
Eugene Bleuler:
 Introduced ‘schizophrenia’ in
1908 .
 ‘Schizo’ (schism) is Greek for
“splitting” - of the mind
 Represents the breaks
between thought and reality or
the separation of function
between personality, thinking,
memory, and perception
Defining Schizophrenia
Schizophrenia is a mental disorder, or a group of
disorders characterized by positive and negative
symptoms along with cognitive and mood
disturbances.
Positive:
Symptoms apparent in schizophrenics but not in ‘normal’
population (hallucinations).
Negative:
Traits/characteristics found in normal persons but lacking
in schizophrenics (i.e. blunted affect, loss of desire, etc.).
Schizophrenia Symptoms:
Positive symptoms
• Psychotic symptoms, such as hallucinations,
which are usually auditory; delusions; and
disorganized speech and behavior
Negative symptoms
• A decrease in emotional range, poverty of
speech, and loss of interests and drive; the
person with schizophrenia has tremendous
inertia
Schizophrenia Symptoms:
Cognitive symptoms
 Neurocognitive deficits (deficits in working memory
and attention and in executive functions, such as the
ability to organize and abstract); patients also find it
difficult to understand nuances and subtleties of
interpersonal cues and relationships
Mood symptoms
 Patients often seem cheerful or sad in a way that is
difficult to understand; they often are depressed
Definitions of Symptoms
Delusion: false belief not shared by culture
(Zombies are real and are out to get me).
Illusion: misperception of real stimuli
(That tree or person is a zombie).
Hallucination: sensory impression or
activation without actual stimuli
(I hear the zombies).
75% of hallucinations in schizophrenia
are auditory.
Diagnosing Schizophrenia:
DSM-V Criteria:
Requires 2 of the following from Criterion A:
1. Delusions.
2. Hallucinations.
3. Disorganized speech.
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (flattened affect,
alogia, avolution, anhedonia).
•
•
At least two of the five symptoms must be present for at
least one month.
One of the two symptoms must be delusions,
halucinations, or disorganized speech.
DSM-V Criteria Cont.:
Criterion B: Social/occupational dysfunction.
Impaired functioning is present throughout
the active phase of the illness.
Criterion C: Duration must be of six months.
Criterion D: No diagnosis of schizoaffective
disorder or mood disorder.
Criterion E: Not due to drugs or medical
condition.
Schizophrenia Subtypes – DSM-IV-R
eliminated due to poor validity, reliability, etc.
Paranoid: Preoccupation with one or more delusions or many auditory
hallucinations
Disorganized: Prominent disorganized speech and behavior, as well as flat or
inappropriate affect.
Catatonic: primarily has at least two of the following symptoms: difficulty
moving, resistance to moving, excessive movement, abnormal movements,
and/or repeating what others say or do
Undifferentiated: characterized by episodes of two or more of the following
symptoms: delusions, hallucinations, disorganized speech or behavior,
catatonic behavior or negative symptoms, but the individual does not qualify
for a diagnosis of paranoid, disorganized, or catatonic type of schizophrenia.
Residual: While the full-blown characteristic positive symptoms of
schizophrenia are absent, the sufferer has a less severe form of the disorder
or has only negative symptoms
Schizophrenia: Etiology
The causes of schizophrenia are not
known.
Key Risk Factors: Genetic and Perinatal.
 Other Risk factors
 undefined socio-environmental factors may
increase the risk of schizophrenia in
international migrants or urban populations of
ethnic minorities.
 Increased paternal age is associated with
greater risk of schizophrenia
Genetic Factors
 The risk of schizophrenia in first-degree relatives of
persons with schizophrenia is 10%.
 If both parents have schizophrenia, the risk of
schizophrenia in their child is 40%.
 Concordance for schizophrenia is about 10% for dizygotic
twins and 40-50% for monozygotic twins
 Loci of particular interest include the following:
 Catechol-O-methyltransferase (COMT) gene
 RELN gene
 Nitric oxide synthase 1 adaptor protein (NOS1AP) gene
 Metabotropic glutamate receptor 3 (GRM3) gene
Perinatal Factors
 Women who are malnourished or who have
certain viral illnesses during their pregnancy may
be at greater risk of giving birth to children who
later develop schizophrenia.
 Obstetric complications may be associated with a
higher incidence of schizophrenia.
 Children born in the winter months may be at
greater risk for developing schizophrenia
Schizophrenia: Epidemiology
United States and international statistics
Lifetime prevalence: approximately 1% worldwide.
Incidence of 4.0 - 7.2 per 1000 population
Prevalence estimates from countries considered
least developed were significantly lower than those
from countries classed as emerging or developed.
Immigrants to developed countries show increased
rates of schizophrenia, with the risk extending to the
second generation.
Schizophrenia: Epidemiology
Age and Sex related demographics
The onset of schizophrenia usually occurs between
the late teens and the mid 30s. The prevalence of
schizophrenia is about the same in men and
women.
Age of Onset:
 Males: early to middle 20s
 Females: late 20s - 30s.
 The onset of schizophrenia is later in women than in men,
and the clinical manifestations are less severe. This may be
because of the anti-dopaminergic influence of estrogen.
Pathophysiology of Schizophrenia:
Anatomic Abnormalities
• Neuroimaging studies show differences between
the brains of those with schizophrenia and those
without this disorder
• Abnormalities identified included loss of wholebrain volume in both gray and white matter and
increases in lateral ventricular volume
Pathophysiology of Schizophrenia:
Neurotransmitter System Abnormalities
 Dopamine (DA) Involvement:
 Over-activity of DA systems correlate with positive
symptoms. Drugs that increase DA activity (AMPH) can
cause schizo-like symptoms, and anti-psychotic drugs are
D2R antagonists.
 Serotonin (5-HT):
 Excess 5-HT levels correlated with positive and negative
symptoms.
 GABA:
 May also be involved, interacts with both 5-HT and DA
systems.
 Glutamate:
 Phencyclidine (GLU antagonist) can induce a
schizophrenia-like condition.
Pathophysiology of Schizophrenia:
Course: Schizophrenia has 3 phases
Prodromal:
 Signs and symptoms occur prior to first psychotic episode
(avoidance of social activities, physical complaints, new
interest in religion, occult, or philosophy)
Active/Psychotic phase:
 Person loses touch with reality; disorders of thought (form,
content and process) occur during acute episode
Residual phase:
 Is time between psychotic episodes. Patient is in touch
with reality but does not behave normally. Typically
characterized by negative symptoms
Prognosis
 Full recovery is unusual.
 Better Prognosis:
 Older age of onset, is married, has social relationships, is
female, has a good employment history, has mood
symptoms, has few negative symptoms, and has few
relapses
 5 to 10 yrs. after initial hospitalization, only 10-20% of
patients are considered to have had ‘good outcomes’.
 Poor Prognosis:
 Early onset of illness, family history of schizophrenia,
structural brain abnormalities, and prominent cognitive
symptoms
 60% or more of patients remain significantly impaired for the
remainder of their lives.
Prognosis
Only 20-30% of schizophrenics are considered to
lead ‘normal’ lives.
Vocational difficulties  Poverty  Poor
Prognosis
 Limited access to medical care, which may lead to poor
control of the disease; homelessness; and incarceration,
typically for minor offenses.
People with schizophrenia have a 5% lifetime risk
of suicide.
 More than 50% attempt suicide, 10% of them succeed.
Differential Diagnosis:
Medical and Neurological:
Substance Induced:
•
•
Cocaine or AMPH-induced psychosis,
PCP and other drug use, alcohol or barbiturate
withdrawal.
Medical Condition:
• Many conditions that  brain damage can result
in schizophrenia-like symptoms
• HIV, encephalitis, Huntington’s, Wilson’s disease,
Wernicke-Korsakoff.
Differential Diagnosis:
Other Psychiatric Illnesses:
• Schizophreniform disorder
• Brief psychotic disorder
• Atypical psychosis
• Schizoaffective disorder
• Post-psychotic depression
• Delusional Disorder
• Shared psychotic disorder
Treatment
 Treatment programs for people with Schizophrenia should
be individualized and comprehensive, taking into account
the
 Medical
 Psychological and
 Psychosocial needs of the patient
 Attention must also be paid to continuity of care as
outside of primary symptoms, obesity, diabetes,
cardiovascular disease, and lung diseases are prevalent in
schizophrenic patients.
 Any care given should be as non-restrictive as possible
and every attempt should be made to reintegrate the
patient into the community
Treatment:
Pharmacotherapy (antipsychotic drugs) are
good, but not sufficient.
Psychosocial Therapies can help to
increase the degree of recovery.
• Cognitive Remediation**
• Vocational Rehabilitation
• Assertive community treatment
• Family Intervention
Single approaches do not generally work
Well and a combination approach must be applied.
Treatment: Typical Antipsychotics
• ‘Typical’ or conventional Antipsychotics have
been in use since mid 1950’s.
• DA drugs have been effective for treating positive
symptoms but not so good for the negative ones.
•
•
•
•
Chlorpromazine (Thorazine)
Haloperidol (Haldol)
Perphenazine (Etrafon, Trilafon)
Fluphenazine (Prolixin)
Treatment: Atypical Antipsychotics
Generally preferred for initial treatment over typicals, but
more expensive and may cause varied side effects. (more
weight gain).
•
•
•
Clozapine (Clozaril)
Risperidone (Risperdal)
Olanzapine (Zyprexia)
Clozapine is the most effective medication but is not
recommended as first-line therapy because it has a high burden
of adverse effects (agranulocytosis and myocarditis), requires
regular blood work, and has not outperformed other medications
in first-episode patients
References
 Braff, David L, and Mark A. Geyer. "Acute and chronic LSD effects on rat startle: Data supporting an
LSD–rat model of schizophrenia.." Biological Psychiatry 15(6) (2012): n. pag. PsycINFO. Web. March.
2015.
 Buckley, P., Miller, B., Lehrer, D., & Castle, D. (2008, November 14). Abstract. National Center for
Biotechnology Information. Retrieved March 7, 2015 from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659306/#__ffn_sectitle
 Dryden-Edwards, R. (2014, April 11). Schizophrenia Symptoms, Causes, Treatment - What is
schizophrenia? - MedicineNet. Retrieved March 7, 2015, from
http://www.medicinenet.com/schizophrenia/page2.htm#what_is_schizophrenia
 Frankenburg, F. (2014, December 22). Schizophrenia . Retrieved March 7, 2015, from
http://emedicine.medscape.com/article/288259-overview
 Maria, Y. (2013, August 28). DSM-5: Schizophrenia. - Maria Yang, MD. Retrieved March 7, 2015, from
http://www.mariayang.org/2013/08/28/dsm-5-schizophrenia/
 Schizophrenia: An Information Guide. (n.d.). Retrieved March 7, 2015, from
http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/schizo
phrenia/schizophrenia_information_guide/Pages/schizophrenia_whatis.aspx
 Stotz, I. G. (2000). Epistemological aspects of Eugen Bleuler's conception of schizophrenia in 1911.
Medicine, Health Care and Philosophy, 3(2), 153-159.
 The Dopamine Connection Between Schizophrenia and Creativity | Psych Central. (n.d.). Psych
Central.com. March 8, 2015 from http://psychcentral.com/lib/the-dopamine-connection-betweenschizophrenia-and-creativity/0003505
 What Causes Schizophrenia? | Psych Central. (n.d.). Psych Central.com. Retrieved March 7, 2015, from
http://psychcentral.com/lib/what-causes-schizophrenia
 Williams, I. C. (Lecturer) (2015, February 9). SCHIZOPHRENIA AND OTHER PSYCHOTIC
DISORDERS. Behavioral Science . Lecture conducted from Windsor University School of Medicine, St.
Kitts .