Schizophrenia

Department of psychology The first affiliated hospital of ZZU Huirong guo

Preface
♦ schizophrenia is much the most difficult

to define and describe
 over the past 100 years, many widely divergent

concepts of schizophrenia have been held in different countries by different psychiatrists
 Radical differences of opinion persist to the

present day

Preface
♦ a simple comparison between two basic
concepts-acute schizophrenia and chronic schizophrenia
 in acute schizophrenia the predominant clinical

features are delusions, hallucinations and interference with thinking. Features of this kind are often called ’positive’ symptoms  the main features of chronic schizophrenia are apathy, lack of drive, slowness, and social withdrawal. These features are often called ‘negative’ symptoms

Epidemiology
♦ The lifetime prevalence of schizophrenia is

usually estimated to be between 0.5% and 1% ♦ Incidence rates are considerably lower than prevalence rates and are estimated to be approximately 1 per 10,000 per year

Etiology
♦ Genetics ♦ Neurological abnormalities ♦ Biochemistry and

psychopharmacological factors ♦ Psychosocial factors

Genetics -Family studies
♦ The first systematic family study of dementia

praecox was carried out in Kraepelin’s department by Ernst Rudin, who showed that the rate of dementia praecox was higher among the siblings of probands than in the general population (Rudin 1916)

Genetics -Family studies
♦ Kallmann (1938) found increased rates not

only among the probands’siblings but also among their children. There was quite a lot studies afterwards. Although the morbidity risks vary somewhat from one another but that the general pattern is consistent

Genetics -Twin studies
♦ These studies compare the concordance rates

for schizophrenia in monozygotic (MZ) and dizygotic (DZ) ♦ Luxenberger (1928), who found concordance in 11 of this 19 MZ pairs and none of his 13 DZ pairs carried out the first substantial twin study in Munich ♦ Representative figures for concordance are about 50 per cent for MZ pairs and about 17 per cent for DZ pairs

Genetics -Adoption studies
♦ Heston (1966) studied 47 adults who had been
born by schizophrenic mothers and separated from them within three days of birth

 Amongst the offspring of schizophrenic mothers,
five were diagnosed as schizophrenic as against none of the controls  There was also an excess of antisocial personality and neurotic disorders among the children of schizophrenic mothers

Genetics -Adoption studies
♦ Denmark, which has national registers of

psychiatric cases and adoptions, confirmed those of Heston described above (1971) ♦ Wender et al found no increase in schizophrenia amongst adoptees that had normal biological parents and a schizophrenic adoptive parent

Genetics -Mode of inheritance
♦ As the rations of the frequencies of

schizophrenia in different relatives do not fit any simple Mendelian pattern ♦ The polygenic theory proposes a cumulative effect of several genes

Neurological abnormalities
♦It is possible that some of these signs
resulted from coincidental neurological disease

 In the past, investigators searched for gross pathological changes in the brains of schizophrenics, but found none  Recent research is concerned with four issues: nonlocalizing (soft) neurological signs; possible abnormalities of the corps callosum; evidence of ventricular enlargement and changes in the EEG

Biochemistry and psychopharmacological factors
♦ Most attention has been paid to those
concerned with dopaminergic transmission
 Carlsson and Lindqvist (1963) show that such

drugs increase dopamine turnover. This effect was interpreted as a feedback response of the presynaptic neuron to blockade of postsynaptic dopamine receptors  much additional evidence that antipsychotic drugs block postsynaptic dopamine receptors

Biochemistry and psychopharmacological factors
♦ This effect is produced in vitro by the different

antipsychotic drugs correlates closely with their clinical potency ♦ The antipsychotic drugs do not have effects specific to schizophrenia; they are equally effective in mania ♦ Also, it is important to recall the analogy of Parkinsonism

Biochemistry and psychopharmacological factors
♦ In this condition, anticholinergic drugs have
therapeutic effects even though the biochemical lesion is not an excess of acetylcholine but a deficiency in dopaminergic neurons due to selective degeneration

Because of these difficulties of interpretation, more direct evidence has been sought by biochemical studies of post-mortem brains from schizophrenic patients . (Owen et al (1978) )  Further studies of unmedicated patients are needed before definite conclusions can be reached.

Psychosocial factors
♦ Personality
 Abnormal personality is common among people who

later become schizophrenic
 Schizoid personality (But such ideas must be treated

with caution since it is difficult to distinguish between premorbid personality and the prodromal phase of a slowly developing illness )

♦ Social factors  Low socioeconomic status, unsatisfactory living conditions, migration, social isolation etc

Clinical features
♦The acute syndrome (‘positive’ symptoms )
 appearance and behavior: awkward  though disorder (speech ; disorders of the stream

of though; Loosening of association )  Abnormalities of mood :anxiety, depression, irritability, or euphoria ; blunting of affect ;incongruity of affect  Auditory hallucinations ; Visual hallucinations ; Tactile, olfactory, gustatory, and somatic hallucinations

Clinical features
 Delusions :Persecutory delusions ; delusions of

reference and of control, and delusions about the possession of thought  Orientation (normal); Concentration(impaired); memory(nrmal)  Insight: impaired

It should be kept in mind that schizophrenic patients do not necessarily experience all these symptoms, and the clinical picture is variable

Clinical features
♦ The chronic syndrome (‘negative’ symptoms )
 underactivity :diminished volition  lack of drive:motor disturbance (catatonic, stupor ,

waxy flexibility , stereotypy )  social withdrawal :Social behavior may deteriorate (collect and hoard objects ; break social conventions by talking intimately to strangers, or shouting obscenities in public )  and emotional apathy :blunted , incongruous

Clinical features
 Speech is often abnormal, showing evidence of

thought disorder of the kinds found in acute syndrome  Hallucinations are common, again in any of the forms occurring in the acute syndrome described above  Delusions are often systematized. In chronic schizophrenia, delusions may be held with little emotional response

Clinical features
 Orientation is normal  Attention and concentration are often poor  Memory is not generally impaired though some

patients have difficulty in giving their age correctly  Insight is impaired : the patient does not recognize that his symptoms are due to illness

Also, the symptoms and signs are combined in many ways so that the clinical picture is variable

Subgroups of schizophrenia
♦ Hebephrenic( 青春型 ) ♦ Catatonic (紧张型) ♦ Paranoid (偏执型) ♦ And simple schizophrenia (单纯型)

Subgroups of schizophrenia
♦ Patients with hebephrenic schizophrenia

often appear silly and childish in their behavior. Affective symptoms and thought disorder are prominent. Delusions are common, and not highly organized. Hallucinations also are common, and not elaborate

Subgroups of schizophrenia
♦ In catatonic schizophrenia is characterized

by motor symptoms and by changes in activity varying between excitement and stupor. Hallucinations, delusions and affective symptoms occur but are usually less obvious

Subgroups of schizophrenia
♦ In paranoid schizophrenia the clinical

picture is dominated by well-organized paranoid delusions. Thought processes and mood are relatively spared, and the patient may appear normal until his abnormal beliefs are uncovered

Subgroups of schizophrenia
♦ Simple schizophrenia is characterized by

the insidious development of odd behavior, social withdrawal, and declining performance at work

Subgroups of schizophrenia
♦ As to undifferentiated schizophrenia, the

psychotic conditions exhibiting more than one group of symptoms without a clear predominance of a particular set of diagnostic characteristics

Diagnosis
♦ Here the diagnosis criteria for schizophrenia of

ICD-10 were outlined
♦ G1. Either at least one of the syndromes, symptoms

and signs listed under (1) below or at least two of the symptoms and signs listed under (2) should be present for most of the time during an episode of psychotic illness lasting for at least 1 month (or at some time during most of the days)

Diagnosis
♦ (1)At least one of the following must be present
 Thought echo, thought insertion or withdrawal, or thought

broadcasting; delusions of control, influence or passivity, clearly referred to body or limb movements or specific thoughts, actions or sensations; delusional perception; hallucinatory voices giving a running commentary on the patients’ behavior, or discussing the patient between themselves, or other types of hallucinatory voices coming from some part of the body; persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather, or being in communication with aliens from another world)

Diagnosis
♦ (2)Or at least two of the following
 Persistent hallucinations in any modality, when occurring

very day for at least 1 month, when accompanied by delusions (which may be fleeting or half-formed) without clear affective content, or when accompanied by persistent overvalued ideas.  Neologism, breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech;  Catatonic behavior, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor;  ‘Negative’ symptoms such as marked apathy, paucity of speech and blunting or incongruity of emotional responses (it must be clear that these are not due to depression or to neuroleptic medication)

Diagnosis
♦ G2 Most commonly used exclusion clauses
 If the patient also meets the criteria for manic episode

or depressive episode,  The criteria listed under G (1) and G (2) above must have been met before the disturbance of mood developed.  The disorder is not attributable to organic brain disease or to alcohol- or drug- related intoxication dependence or withdrawal

Diagnosis
♦ Criteria for simple schizophrenia
 There is slow but progressive development, over a

period of at least 1 year, of all three of the following:  A significant and consistent change in the overall quality of some aspects of personal behavior, manifest as loss of drive and interests, aimlessness, idleness, a self absorbed attitude and social withdrawal;

Diagnosis
♦ Criteria for simple schizophrenia
 Gradual appearance and deepening of ‘negative’

symptoms such as marked apathy, paucity of speech, under-activity, blunting of affect, passivity and lack of initiative, and poor non-verbal communication (by facial expression, eye contact, voice modulation and posture)
 Marked decline in social, scholastic or occupational

performance

Diagnosis
 At no time are there any of the symptoms referred to in

criterion G1 nor are there hallucinations or wellformed delusions of any kind, i.e. the individual must never have met the criteria for any other types of schizophrenia, or for any other psychotic disorder.
 There is no evidence of dementia or any other organic

mental disorder

The diagnostic criteria of schizophrenia in CCMD-3
♦ Symptom criteria :Two of the following criteria are
   

met (1) Repeated auditory hallucinations that are usually not mood congruent; (2) Loosening of association, derailment, incoherence in thinking or poverty of thought; (3) Thought insertion or withdrawal, though block or forced thinking; (4) Delusion of control, influence or passivity, though broadcasting;

The diagnostic criteria of schizophrenia in CCMD-3
♦ Symptom criteria :
 (5)

   

Primary delusions including delusional perception, delusional mood or other bizarre delusion; (6) Incongruous emotion, symbolic thought or neologism; (7) Alexithymia or apathy; (8) Catatonic syndrome, unusual or silly behavior; (9) Avolition.

The diagnostic criteria of schizophrenia in CCMD-3
 Course criteria :(1) Clinical picture satisfying with both

symptom criteria and severity criteria persists for more than one month. But there are separate course criteria of simple type of schizophrenia; (2) If there are concurrent schizophrenic and affective symptoms satisfying the diagnostic criteria of both schizophrenia and mood disorders, with the duration of schizophrenia symptoms being 2 weeks longer than the affective component after the duration of both concurrent symptoms for at least 2 weeks, a single diagnosis of schizophrenia should be made

The diagnostic criteria of schizophrenia in CCMD-3
 Severity criteria :The patients ‘s insight into the

illness is partial or absent and accompanied by marked impairment in social functioning and communication skill  Exclusion: Organic mental disorders, psychoactive substance and non-addictive substance induced mental disorders

Diagnostic criteria of subgroups of schizophrenia
Paranoid schizophrenia
(1) Conditions meeting the general symptom criteria of schizophrenia; (2) Predominance of delusions usually accompanied by hallucinations, often auditory hallucination.

Diagnostic criteria of subgroups of schizophrenia
Hebephrenic schizophrenia
(1) Conditions meeting the general symptom criteria of schizophrenia; (2) It is often adolescent in onset; (3)Predominance of thought disorders, shallow affection and behavioral disturbance. For instance, loosening of affection, incongruity of affection, childish behavior

Diagnostic criteria of subgroups of schizophrenia
Catatonic schizophrenia (1) Conditions meeting the general symptom criteria of schizophrenia; (2) Predominance of catatonic symptoms (usually stupor)

Diagnostic criteria of subgroups of schizophrenia
Simple schizophrenia
(1) Predominance of poverty of thought, apathy and abulia, lack of positive psychotic symptoms; (2) Severe impairment in social functioning with gradual decline; (3) The onset is insidious and progression is gradual with duration of at least 2 years

Diagnostic criteria of subgroups of schizophrenia
Undifferentiated schizophrenia
(1) Conditions meeting the general symptom criteria of schizophrenia with marked positive psychotic symptoms; (2) The clinical feature does not satisfy the full criteria of any of the subtypes mentioned above; (3) This type is also called mixed type or unclassified type

Treatment
♦ Antipsychotic drugs
 Treatment of acute schizophrenia  Treatment after the acute phase

Interaction of maintenance treatment

and social treatment ECT

Antipsychotic drugs
♦ Treatment of acute schizophrenia
 The effectiveness of antipsychotic medication in

the treatment of acute schizophrenia has been established by several well-controlled, doubledblind studies( the NIMH collaborative project (Cole et
al. 1964) compared chlorpromazine, fluphenazine, and thioridazine with placebo. Three-quarters of the patients receiving antipsychotic treatment for six weeks improved, whatever the drug, whilst a half of those receiving placebo worsened )

Antipsychotic drugs
 Treatment of acute schizophrenia
 Drug treatment has most effect on the positive

symptoms of schizophrenia, such as hallucinations and delusions, and least effect on the negative symptoms
 The various antipsychotic drugs do not differ in

therapeutic effectiveness, although their sideeffects vary

Antipsychotic drugs
♦ Treatment after the acute phase  It has also become clear that some chronic schizophrenics do not respond even to long-term medication, and that others remain well without drugs  Since long-continued antipsychotic madication may lead to irreversible dyskinesias, it is important to known how long such treatment needs to be given  Hogarty and Ulrich (1977) reported that, over a threeyear period, maintenance anti-psychotic medication was 2.5 to 3 times better than the placebo in preventing relapses of schizophrenia, depot injections are more successful than continued oral medication

Antipsychotic drugs
♦ Treatment after the acute phase  Schooler et al. (1980) found that depot injections offered no such advantage  Davis et al (1980), in the long-term management of schizophrenia there is no difference in the usefulness of the various antipsychotic drugs available

Interaction of maintenance treatment and social treatment
♦ Since both medication and social casework

appear effective in the management of schizophrenia, it is reasonable to enquire whether the two kinds of treatment interact
 Hogarty et al. (1974) studied the use of ‘major role

therapy’ (i.e. social casework) with and without drugs. Given alone, social casework had only a small effect in reducing relapse rate; combined with medication, it had a larger effect

Interaction of maintenance treatment and social treatment
♦ In a study of the effect of adding day

hospital treatment to continued medication, Linn et al (1980) found that day care conferred extra benefit on patients when it was of low intensity and based on occupational therapy, but not when it included more active treatments such as group therapy

ECT
In the treatment of schizophrenia, the indications for ECT are catatonic stupor and severe depressive symptoms accompanying schizophrenia. The effects ECT are often rapid and striking in both these conditions

Some clinical cases
A 31-year-old male vocational nurse  A 59-year-old divorced power company engineer

Summary
 Schizophrenic disorders are a complex syndrome characterized by a disturbance in reality testing, marked impairment of social functional, and severe personality disorganization involving disturbances in though, affect, and behavior  There is no single cause, although in many cases there do appear to be medical and biological bases present within early childhood  Psychosocial factors play an important part in the development and in the treatment of the schizophrenic disorders

Summary
 Treatment should consist of various combined
bio-psychosocial methods and should include the formation of a therapeutic alliance with the schizophrenic person, as well as contact with friends and family, if needed and available  Although schizophrenia has remained the most serious psychiatric illness known for the past 200 years, a comprehensive approach to the care and treatment of schizophrenic disorders has improved the quality of life for patients and their families and also greatly improved the treated outcome as compared to the natural course

Summary
 We might have reached the point at which early
intervention to arrest the deterioration that comes from successive psychotic episodes has become a possibility and a goal  If efforts at prevention are to be successful for the next generation of young people with schizophrenia, we have to begin treatment as early as possible and keep the psychotic episodes as brief as possible New medications hold promise for better treatment with fewer side effects, particularly when coupled with effective psychosocial treatments and support.

Thank you See you next time

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