Schizophrenia

Schizophrenia

❏ One of the most common of the serious ❏ Group of disorders with heterogeneous
mental disorder etiologies

❏ Clinical presentations, treatment response, and courses of

illness vary expression of these manifestations varies
❏ Bef. 25 years old across patients and over time, but the effect of the illness is
always severe and is usually long lasting

❏ Dx is based entirely on the psychiatric history and MSE

❏ Syndrome or Schizophrenia Spectrum ❏ No laboratory test
Etiology
 Genetic Factors

● The likelihood of a person having schizophrenia is correlated with the closeness of the
relationship to an affected relative

● Monozygotic twins who have identical genetic endowment

-> approximately 50 percent concordance rate for schizophrenia

● 4-5x concordance rate in dizygotic twins or the rate of occurrence found in other first-
degree relatives

● Dropped in 3rd and 4th degree relative

● Age of the father and mother

 Biochemical Factors
Dopamine Hypothesis Serotonin
● Too much dopaminergic activity ● Excess can cause positive or negative symptoms of
○ First is the efficacy and the potency of many schizophrenia
antipsychotic drugs ● Clozapine and 2nd Gen anti-psychotic drugs
○ Second are the drugs that increase dopaminergic activity ○ Decrease positive symptoms
(cocaine and amphetamine) are psychotomimetic
● Mesocortical and Mesolimbic
○ Dopaminergic neurons in these tracts project from their
cell bodies in the midbrain to dopaminoceptive neurons
in the limbic system and the cerebral cortex.
● Drug Free Schizophrenia
○ Increase D2 Receptors
○ Increase dopamine in amygdala
○ Decrease dopamine transporter
○ Increase numbers of dopamine type 4 receptors in the
enthorinal cortex
 Biochemical Factors
Norepinephrine GABA

● Prominent feature ● Loss of GABAergic neurons in the

○ Anhedonia
● Neural Degeneration within the
norepinephrine reward neural system
could account to anhedonia seen in
schizophrenia
hippocampus
● GABA has a regulatory effect on
dopamine activity, and the loss of
inhibitory GABAergic neurons could lead
to the hyperactivity of dopaminergic
neurons

ACTH and Nicotine
● Decreased muscarinic and
nicotinic receptors in the
caudate-putamen,
hippocampus, and selected
regions of the prefrontal
cortex
● Receptors play a role in the
regulation of neurotransmitter
systems involved in
cognition, which is impaired
in schizophrenia.
Biochemical Factors
Glutamate Neuropeptides
● Phencyclidine ● substance P and neurotensin
○ glutamate antagonist ● Localized and influence the
○ produces an acute action of catecholamine and
syndrome similar to indolamine
schizophrenia
● Hyperactivity, hypoactivity, and
glutamate-induced neurotoxicity
Neuropathology
 Neuropathology

PRE-FRONTAL
AREA

Frontal
Occipital

Temporal
Neuropathology
Subtypes
 Paranoid
● preoccupation with one or more delusions or
frequent auditory hallucinations.
● Show less regression than other types
● Typically tense, suspicious, guarded, reserved, and
sometimes hostile or aggressive, but they can
occasionally conduct themselves adequately in
social situations
● Intelligence remain intact
Disorganized
● Bef 25 years old
● characterized by a marked regression to
primitive, disinhibited, and unorganized
behavior and by the absence of symptoms that
meet the criteria for the catatonic type
● usually active but in an aimless, non-constructive
manner
● They often burst into laughter without any
apparent reason.
● Incongruous grinning and grimacing are
common in these patients, whose behavior is best
described as silly or fatuous.
DSM-5 Diagnostic Criteria for Schizophrenia

● The presence of hallucinations or delusions is not

necessary for a diagnosis of schizophrenia
● the patient’s disorder is diagnosed as schizophrenia
when the patient exhibits two of the symptoms
listed in symptoms 1 through 5 of Criterion A

● Criterion B requires that impaired functioning,

although not deteriorations, be present during the
active phase of the illness
● Symptoms must persist for at least 6 months, and a
diagnosis of schizoaffective disorder or mood
disorder must be absent
 Catatonic Undifferentiated Residual

● marked disturbance in ● Patients who clearly have ● Continuing evidence of the

motor function schizophrenia cannot be schizophrenic disturbance in
easily fit into one type or the absence of a complete
● stupor, negativism, another set of active symptoms or of
rigidity, excitement, or sufficient symptoms to meet
posturing the diagnosis of another type
of schizophrenia.
● Mutism is particularly
common
 Paraphrenia
● Paranoid schizophrenia
● Progressively deteriorating course
● Presence of well systematized
delusional system
Pseudoneurotic
● Anxiety, phobia, obsessions and
compulsions
● Free floating anxiety that rarely
subsides
● Seldom becomes overtly and
severely psychotic
Simple Deteriorative Disorder
(Simple Schizophrenia)
● Gradual, insidious loss of drive and
ambition
● PRIMARY SYMPTOM
○ Withdrawal from social and
work related situations

● BPD
 Other Subtypes

● Bouffee Delirante (Acute Delusional Psychosis)

● Latent
● Oneiroid
● Post Psychotic Depressive Disorder
● Early
● Adult Onset

Psychological Testing
● perform poorly on a wide range of
neuropsychological tests.
● Vigilance, memory, and concept
formation are most affected and
consistent with pathological
involvement in the frontotemporal
cortex
● Healstead-Reitan And Luria Nebraska
Battery- abnormal findings
● Motor ability is also impaired
Testing
Intelligence Testing Projective and Personality Test
● Rorschach Test and Thematic
● In comparison with general Apperception test = Bizarre ideation
population, schizophrenic
patients tend to score lower on ● MMPI- Abnormal results
intelligence test.
● Low intelligence os often present
at the onset and may continue to
deteriorate
 General Description Mood, Feelings and Affect Perceptual Disturbances
● Appearance can range from that ● Two common affective symptoms ● Hallucinations
of a completely disheveled, ○ Reduced emotional responsiveness-> ● Cenesthetic Hallucinations
screaming, agitated person to an Anhedonia ● Illusions
obsessively groomed, completely ○ Overly active and inappropriate
silent, and immobile person emotions such as extremes of rage,
happiness and anxiety
● behavior may become agitated or
violent, apparently in an
unprovoked manner, but usually
in response to hallucinations.
● PRECOX FEELING
 Clinical Features
1. No clinical sign or symptom is pathognomonic for schizophrenia; every sign or
symptom seen in schizophrenia occurs in other psychiatric and neurological disorders

2. Patient’s symptoms change with time

3. Clinicians must take into account the patient’s educational level, intellectual ability, and cultural
and subcultural membership
Mental Status Examination
 Thought

Thought Content
● reflect the patient’s ideas, beliefs, and interpretations of stimuli
● Patients may believe that an outside entity controls their thoughts or behavior or, conversely, that
they control outside events in an extraordinary fashion
● Loss of ego boundaries- lack of a clear sense of where the patient’s own body, mind, and influence
end and where those of other animate and inanimate objects begin
○ Ideas of reference- patients may think that other persons, the television, or the newspapers are
referring to them
○ Cosmetic Identity- patient has disintegrated and fused with the entire universe
 Thought

Form of Thought
● objectively observable in patients’ spoken
and written language
● looseness of associations, derailment,
incoherence, tangentiality, circumstantiality,
neologisms echolalia, verbigeration, word
salad, and mutism
 Thought
Thought Process
● ideas and languages are formulated
● what and how the patient speaks, writes, or draws
● flight of ideas, thought blocking, impaired attention, poverty of thought
content, poor abstraction abilities, perseveration, idiosyncratic associations ,
overinclusion, and circumstantiality
○ Thought Control
■ Outside forces are controlling what he/she is thinking
○ Thought Broadcasting
■ Patient thinks others can read their minds and thoughts
 Violence
● Common among untreated patients
● Delusions of a persecutory nature,
previous episodes of violence, and
neurological deficits are risk factors
for violent or impulsive behavior.
● Management includes appropriate
antipsychotic medication.
● Emergency treatment consists of
restraints and seclusion
○ Lorazepam
Suicide Perceptual Disturbances
● No more likely to commit homicide
● single leading cause of premature death among ● If they commit homicide it may be for
people with schizophrenia unpredictable or bizarre reasons based
● occur “out of the blue,” without prior warnings on hallucinations or delusions
or expressions of verbal intent
● Most important factor is the presence of a major
depressive episode
● Clozapine and antidepressant medication
 Sensorium and Cognition

Orientation Memory
● usually oriented to person, time, and ● Intact
place. ● Minor cognitive deficiencies
● May give incorrect or bizarre answers
● The lack of such orientation should
prompt clinicians to investigate the
possibility of a medical or
neurological brain disorder
 Sensorium and Cognition
Cognitive Impairment
● better predictor of level of function than is the severity of psychotic symptoms
● subtle cognitive dysfunction in the domains of attention, executive function, working
memory, and episodic memory

Judgement and Insight

● Poor insight into the nature and the severity if their d/o
● Lack of insight = Poor compliance in treatment

Reliability
● No less reliable than any other psychiatric patient
 Somatic Comorbidity
Neurologic Findings
● Localizing and non-localizing neurological signs ( hard and soft signs)
● Nonlocalizing
○ Dysdiadochokinesia, astereognosis, primitive reflexes and diminished dexterity
● (+) Neurological Signs= increase severity, affective blunting and poor prognosis

Eye Examination
● Elevated blink rate
● Reflection of hyperdopaminergic activity

Speech
● Forme fruste if aphasia
● inability of schizophrenia patients to perceive the prosody of speech or to inflect their own speech
can be seen as a neurological symptom of a disorder in the nondominant parietal lobe
 Other Comorbidity

❏ Obesity
❏ CVD
❏ HIV
❏ COPD
❏ RA
 Prognosis

● 10-20% - Good outcome

● >50 % - Poor outcome
 Differential Diagnosis

Disorder

● Secondary Psychiatric Disorder

● Schizophreniform disorder
● Brief psychotic disorder
● Schizoaffective disorder
● Delusional disorder
● MDD
● Personality Disorder
Treatment
 Hospitalization Pharmacotherapy

● diagnostic purpose ● Chlorpromazine

● Antipsychotics can be categorized into two main
● stabilization of medications groups:

● For patients’ safety ,inability to take care of a. First-generation antipsychotics dopamine receptor
basic needs such as food, clothing, and shelter antagonist
b. Second generation antipsychotics or serotonin
● Short stays of 4 to 6 weeks are just as dopamine antagonists (SDAs)
effective as long-term hospitalizations, and
hospital settings with active behavioral
approaches produce better results than do
custodial institutions.
 Phases of Treatment
Treatment of Acute Psychosis
● Focus on alleviating the most severe psychotic symptoms
● Last for 4-8 weeks
● Antipsychotics and benzodiazepines
○ result in relatively rapid calming of patients
● With highly agitated patients-> IM administration
● advantage of an antipsychotic is that a single intramuscular injection of haloperidol (Haldol),
fluphenazine (Prolixin, Permitil), olanzapine (Zyprexa), or ziprasidone (Geodon) will often result
in calming effect without excessive sedation
● Low-potency antipsychotics are often associated with sedation and postural hypotension,
particularly when they are administered Intramuscularly
● Benzodiazepines are also effective for agitation during acute psychosis
 Phases of Treatment

Treatment During Stabilization and Maintenance Phase

● illness is in a relative stage of remission
● prevent psychotic relapse and to assist patients in improving their level of functioning
● patients are usually in a relative state of remission with only minimal psychotic symptoms.
● Stable patients who are maintained on an antipsychotic have a much lower relapse rate than
patients who have their medications discontinued
● patients who have had only one episode have a four in five chance of relapsing at least once over
the following 5 years
● It is generally recommended that multiepisode patients receive maintenance treatment for at least
5 years, and many experts recommend pharmacotherapy on an indefinite basis.
Noncompliance
● An estimated 40 to 50 percent of patients become noncompliant
within 1 or 2 years.
● Compliance increases when long-acting medication is used
instead of oral medication
 Strategies for Poor
Responses

● Approximately 60 %will improve to the extent that they will achieve a complete remission or
experience only mild symptom
● 40 % of patients will improve but still demonstrate variable levels of positive symptoms that are
resistant to the medications.
● Some resistant patients are so severely ill that they require chronic institutionalization
● A 4- to 6-week trial on an adequate dose of an antipsychotic represents a reasonable trial for most
patients
● Patients who demonstrate even a mild amount of improvement during this period may continue to
improve at a steady rate for 3 to 6 months
 Managing Side Effects

● Extrapyramidal Side Effects

○ reducing the dose of the antipsychotic
○ adding an anti-Parkinson medication
■ changing the patient to an SDA that is less likely to cause extrapyramidal
side effects.
■ Anticholinergic
○ B blockers for akathisia
○ If conventional antipsychotics are being prescribed, clinicians may consider
prescribing prophylactic anti-Parkinson medications for patients who are likely
to experience disturbing extrapyramidal side effects.
 Managing Side Effects
Tardive Dyskinesia

● About 20 to 30 percent of patients on long-term treatment with a conventional DRA will exhibit symptoms of tardive
dyskinesia
● The risk in elderly patients is much higher
● it can affect walking, breathing, eating, and talking when it occurs
● onset within 4 weeks of discontinuing an oral antipsychotic or 8 weeks after the withdrawal of a depot antipsychotic
● for preventing and managing tardive dyskinesia
○ using the lowest effective dose of antipsychotic;
○ prescribing cautiously with children, elderly patients, and patients with mood disorders;
○ examining patients on a regular basis for evidence of tardive dyskinesia;
○ considering alternatives to the antipsychotic being used and considering dosage reduction when tardive dyskinesia is
diagnosed; and
○ considering a number of options if the tardive dyskinesia worsens, including discontinuing the antipsychotic or
switching to a different drug
Thank you!
Schizophreniform
Disorder
 General Description
● Gabriel Langfeldt
● Sudden onset and benign
course
● Same symptom with
schizophrenia
● Symptoms last for at least 1
month but less than 6 months
● return to their baseline level of
functioning after the disorder
has resolved
Epidemiology Etiology
● most common in adolescents and young ● Unknown
adults and is less than half as common as
schizophrenia ● some patients have a disorder
similar to schizophrenia, others
● Men> Women have a disorder similar to a
mood disorder.
● Patients with schizophreniform disorders
are more likely to have mood disorders
than are the relatives of patients with
schizophrenia
 Brain Imaging Diagnosis
● activation deficit in the inferior prefrontal region of the ● acute psychotic disorder that has a rapid onset and lacks a long prodromal
brain while the patient is performing a region-specific phase
psychological task ( Wisconsin Card Sorting Test)
● a progressive decline in social and occupational functioning
● deficit to be limited to the left hemisphere and found
impaired striatal activity suppression limited to the left ● initial symptom profile is the same as that of schizophrenia in that two or
hemisphere during the activation procedure more psychotic symptoms
1. Hallucinations
● enlarged cerebral ventricles 2. Delusions
3. disorganized speech
4. Behavior
5. negative symptoms

● patients with schizophreniform disorder return to their baseline state within

6 months.

● In some instances, the illness is episodic, with more than one episode
occurring after long periods of full remission.
DSM-5 Diagnostic Criteria for Schizophreniform Disorder
 Course and Prognosis Treatment

● progression to schizophrenia range between ● Hospitalization

60 and 80 percent ○ Assessment
● Some will have a second or third episode ○ Treatment
during which they will deteriorate into a more ○ Supervision of a patient’s behavior
chronic condition of schizophrenia ● Antipsychotic Drug
● A few, however, may have only this single ○ 3-6 months
episode and then continue on with their lives ● Psychotherapy
Delusional Disorder
 General Description
● False fixed beliefs not in keeping with
culture
● Exhibits non-bizarre delusions of at least 1
month’s duration that cannot be attributed
to other psychiatric disorders
Epidemiology
● Prevalence 0.2-0.3 percent
● Annual incidence 1-3 cases/
100,000 persons
● Mean Age of Onset 40 years
● Female -> Delusions of
erotomania
● Male->Paranoid delusions
● Married and employed
Etiology
● Unknown
● increased prevalence of
delusional disorder and related
personality traits in the relatives
of delusional disorder probands
 Biological Factors

● Limbic System and Basal Ganglia

● Patients whose delusions are caused by neurological

diseases and who show no intellectual impairment tend to
have complex delusions similar to those in patients with
delusional disorder

● Patients with neurological disorder with intellectual

impairments often have simple delusions unlike those in
patients with delusional disorder

● can arise as a normal response to abnormal experiences in

the environment, the peripheral nervous system, or the
central nervous system
 Psychodynamic Factor
Freud’s Contribution
● Part of healing process rather than a symptom
● Projection as the main defense mechanism in Paranoia
● Role of Projection in formation of delusional thought
Paranoid Pseudocommunity
● Norman Cameron
● 7 situations
○ increased expectation of receiving sadistic treatment
○ situations that increase distrust and suspicion,
○ social isolation,
○ situations that increase envy and jealousy
○ situations that lower self-esteem
○ situations that cause persons to see their own defects
in others
○ situations that increase the potential for rumination
over probable meanings and motivations
● Pseudocommunity—a perceived community of plotters
 Defense Mechanism

Reaction formation
● against aggression, dependence needs, and feelings of affection and transform the need for dependence into staunch
independence
Denial
● avoid awareness of painful reality

Projection
● they project their resentment and anger onto others
● protect themselves from recognizing unacceptable impulses in themselves
 Diagnosis and
Clinical Features
Mental Status
 General Description Mood, Feelings and Perceptual Disturbances Thought
Affect

● Well groomed and well dressed, without
evidence of gross disintegration of
personality or of daily activities, yet
they may seem eccentric, odd,
suspicious, or hostile
● Quite normal except for a markedly
abnormal delusional system - MOST
REMARKABLE FEATURE
● Patients’ moods are ● No prominent or sustained ● Disorder of thought
consistent with the hallucinations content
content of their
delusions. ● Few have auditory rather ● Systematized and are
than visual characterized as possible
● A patient with
grandiose delusions ● the veracity of a patient’s
is euphoric; one with beliefs should be checked
persecutory delusions before deeming their
is suspicious. content to be delusional
 Sensorium and Cognition Impulse Control Judgement and Insight Reliability

● No abnormality in orientation ● Clinicians must ● No insight into their ● usually reliable in their
● Memory and other cognitive evaluate patients condition information, except
process are ntact with delusional when it impinges on
disorder for ● Judgment can best be their delusional
ideation or plans assessed by evaluating system.
to act on their the patient’s past,
delusional present, and planned
material by behavior
suicide, homicide,
or other violence
 Type

● Persecutory Type
● Jealous Type
● Erotomatic
● Somatic
● Grandiose
● Mixed
● Unspecified
● Shared Psychotic
 Course and Prognosis Treatment

● delusional disorder is considered a fairly stable diagnosis ● Psychotherapy

● About 50 percent of patients have recovered at long-term follow-up ● Hospitalization
● 20 percent show decreased symptoms, and 30 percent exhibit no ● Pharmacotherapy
change
● The following factors correlate with a good prognosis:
1. high levels of occupational
2. Social
3. functional adjustment
4. Female sex
5. onset before age 30 years
6. sudden onset
7. short duration of illness
8. presence of precipitating factors
Brief Psychotic Disorder
 Definition
● Psychotic condition that involves the sudden
onset of psychotic symptoms, which lasts 1 day
or more but less than 1 month.
● Remission is full, and the individual returns to
the premorbid level of functioning.
Epidemiology
● Generally considered uncommon.
● occurs more often among younger patients (20s
and 30s) than among older patients
● Women
● low socioeconomic classes and in those who
have experienced disasters or major cultural
changes
● industrialized settings
● major psychosocial stressors
 Etiology Diagnosis
● Unknown ● Psychotic symptoms last at least 1
day but less than 1 month and are not
● Have vulnerability to development of associated with a mood disorder, a
psychotic symptoms substance-related disorder, or a
psychotic disorder caused by a
general medical condition
● 3 Subtypes
○ the presence of a stressor
○ the absence of a stressor,
○ postpartum onset.
Clinical Feature
● 1 major clinical symptom of
psychosis
○ Hallucination
○ Delusions
○ disorganized thought
● Characteristic symptoms in brief
psychotic disorder
○ emotional volatility
○ strange or bizarre behavior
○ screaming or muteness
Iimpaired memory of recent
events
● Precipitating Factors
○ Major Life Events that would
cause any person significant
emotional upset
 Course and Prognosis Treatment
● Hospitalization
● Good Prognosis ● Pharmacotherapy
○ Antipsychotic Drug
● 50 to 80 percent of all patients have no ○ Benzodiazepine (short term treatment)
further major psychiatric problems ○ Anxiolytic drug
● Psychotherapy
Schizoeffective
Disorder
Patients with schizophrenia who have mood symptoms

Patients with mood disorder who have symptoms of schizophrenia

Patients with both mood disorder and schizophrenia

6 Types
Patients with a third psychosis unrelated to schizophrenia and mood disorder

Patients whose disorder is on a continuum between schizophrenia and mood disorder

Patients with some combination of the above

 General Description Epidemiology Etiology

● Has both features of ● Prevalence <1% (0.5-0.8%) ● unknown

schizophrenia and mood ● Sex differences are parallel in sex ● may be a :
disorders differences seen in mood disorders ○ type schizophrenia
● Depressive type ○ a type of mood
○ Adults >Younger people disorder
● Bipolar type may be ○ Simultaneous
○ Younger people > Adults expression of each
heterogeneous group of
disorders encompassing
all of these possibilities
● disrupted in schizophrenia 1
(DISC1) gene, located on
chromosome 1q42,
DSM-5 Diagnostic Criteria for Schizo effective Disorder

● First, to meet the Criterion B

(psychotic symptoms in the absence
of a major mood episode [depressive
or manic])
● Second, to meet Criterion C, the
length of all mood episodes must be
combined and compared with the total
length of the illness. If the mood
component is present for the majority
(>50 percent) of the total illness, then
that criterion is met.
 Course and Prognosis Treatment
● Similar to an episodic mood disorder, a chronic ● Mood stabilizers
schizophrenic course, or some intermediate ● Selective Serotonin Inhibitors
outcome ● Tricyclic Drugs
● ECT
● Increasing presence of schizophrenic symptoms ● Psychosocial Treatment
predicted a worse prognosis

● After 1 year, patients with schizoaffective

disorder had different outcomes, depending on
whether their predominant symptoms were
effective (better prognosis) or schizophrenic
(worse prognosis)
END