Diagnosis and Management of

Schizophrenia
Stephen R. Marder, M.D.
Professor and Director, Section on Psychosis
Semel Institute for Neuroscience at UCLA
VA Desert Pacific Mental Illness Research, Education,
and Clinical Center
 Diagnosis and Management of
Schizophrenia
• Process for diagnosing schizophrenia
• Epidemiology
• Genetics and environment
• How to access severity
• Capacity to Work
• Current and future treatment
 DSM-IV criteria for schizophrenia
A. Characteristic Symptoms
B. Social/occupational dysfunction
C. Duration of 6 months
D. Schizoaffective and mood disorder exclusion
E. Substance/general medical exclusion
F. Relationship to pervasive developmental
disorder
 Diagnostic Process for Schizophrenia
• Physical and lab exams rule out psychotic
disorder due to a medical condition and
substance-induced psychosis
• Imaging (CT, MRI, PET) are seldom helpful in
diagnosis
• The diagnosis is commonly made from history
and the mental status exam
• There are currently no reliable biomarkers for
diagnosis or severity
 Characteristic Psychotic Symptoms in
Schizophrenia
• Audible thoughts
• Voices arguing or commenting
• Thought withdrawal or insertions by outside
forces
• Thought broadcasting
• Impulses, volitional acts, or feelings imposed
by outside forces
• Delusional perceptions
Symptom dimensions in schizophrenia
• Psychotic • Neurocognitive –
– Hallucinations Impairments
– Suspiciousness – Memory
– Delusions – Attention
• Negative – Motor skills
– Impoverished speech – Social cognition
– Lack of motivation – Executive skills
– Asociality – Disorganized speech
– Decreased Affect
 Epidemiology of Schizophrenia
• Lifetime prevalence of about 1%
• No differences related to culture or race
• Onset in men is usually earlier (15-24) than in
women (25-34)
 Top 10 Causes of DALYS in Adults (15-44 years)
% % %
Both Sexes Total Male Total Female Total
HIV/AIDS 13.0 HIV/AIDS 12.1 HIV AIDS 13.9
Depressive disorders 8.6 Road traffic accidents 7.7 Depressive disorders 10.6
Road traffic accidents 4.9 Depressive disorders 6.7 Tuberculosis 3.2
Tuberculosis 3.9 Alcohol Use Disorders 5.1 Iron deficiency anemia 3.2
Alcohol Use Disorders 3.0 Tuberculosis 4.5 Schizophrenia 2.8
Self-inflicted Injuries 2.7 Violence 3.7 Obstructed labor 2.7
Iron-deficiency 2.6 Self-inflicted Injuries 3.0 Bipolar disorder 2.5
anemia
Schizophrenia 2.6 Schizophrenia 2.5 Abortion 2.5
Bipolar disorder 2.5 Bipolar disorder 2.4 Self-inflicted injuries 2.4
DALY=Sum
Violence of years of life lost due2.3
to premature
Ironmortality and years
deficiency lost due to2.1
anemia disability Maternal sepsis 2.1
WHO. The World Health Report 2001. Available at http://www.who.int/whr/2001/en/index.html
 Course of Schizophrenia
Good

Function
Psycho-
pathology

Premorbid Progression Stable

Relapsing
Poor
15 20 30 40 50 60 70
Age (Years)
heitman BB, Lieberman JA. The natural history and pathophysiology of treatment-resistant schizophrenia.
Psychiatr Res. 1998(May-Aug);32(3-4):143-150
 Severity in Schizophrenia
• People with schizophrenia have different
levels of disability varying from no disability
to complete dependence on institutional care
• The amount and type of disability is related to
the symptoms of the individual’s illness and
how responsive these symptoms are to
treatment
 Severity in Schizophrenia
• The severity of psychotic symptoms are
related to
– How distracting
– Do they influence behavior – eg, command
hallucinations
– Do they cause suffering
– Do they impair social functioning – eg,
suspiciousness
 Severity
• The severity of negative symptoms are related to
– Social isolation
– Apathy
– Lack of expressiveness
• The severity of cognitive impairments are related
to
– Poor concentration
– Poor memory
– Inability to make simple decisions
– Inability to interpret social signals
– Slower pace
 Pharmacological Treatment of Acute
Schizophrenia
• Antipsychotic medications are effective for
decreasing the severity of psychotic symptoms
• Nearly all patients on antipsychotic
medications will experience some burden
from side effects
• Antipsychotics are relatively ineffective for
negative symptoms and cognitive impairment
Long-term treatment of schizophrenia
• Antipsychotic medications are effective for
preventing relapse in stabilized patients
• Effective nonpharmacological treatments include
patient and family education, skills training,
supported employment, cognitive behavior
therapies, and psychotherapies
• For most individuals, antipsychotic medications
control the symptoms while non-pharmacological
treatments address the impairments in social,
vocational, and educational functioning
 Clinical Challenges
• Substance use disorders are common in
people with schizophrenia
• Insight can be impaired leading people with
schizophrenia to refuse treatment
• Adherence to treatments can be irregular