Psych - Schizophrenia

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4 As of schizophrenia (negative symptoms)

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Autism, ambivalence, affect, anergia.

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5 Symptom clusters in schizophrenia

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Positive

Negative

Disorganization

Cognitive

Mood

Severity of sx in these clusters are pretty independent.

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Catatonia

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Seen in psychotic disorders

Abnormal motor movement (either too much or too little).

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Speech in patients with psychotic disorders

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Slowed, pressured, mechanical, inappropriately loud.

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Mood in patients with psychotic disorders

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Depressed, manic, anhedonic/apathetic (can't exp pleasure in pleasurable things), no mood really.

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Affect in patients with psychotic disorders

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Failing to correspond to thoughts or situation

Flat

Psychomotor retardation or agitation.

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Thought process in patients with psychotic disorders

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Delusions (false personal beliefs)

Ideas of reference (stimuli are referring to me...such as TV or radio)

Eccentric thinking (magical thinking)

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Erotomanic delusion

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A celebrity is my lover

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Somatic delusions

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Feet are mechanical and a device is implanted in me.

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Bizarre delusions

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Electric circuit in brain controlled by president to manipulate political events.

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Hallucinations

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Auditory, visual, olfactory, tactile, gustatory.

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Illusion

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Has some ground to it. For instance, a curtain is a ghost.

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Distortion example

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Floor is wavy.

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Why DSM criteria for schizophrenia?

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Allows for precide consistent syndromal diagnosis.

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DSM-IV criteria for schizophrenia

Category A (characteristic symptoms)

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Need two or more for a significant portion of a month.
Only need one if delusions are bizarre, hallucinations consist of running commentary or hallucinations consist of 2+ voices conversing with each other...

Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms

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DSM-IV criteria for schizophrenia

Categories B - F

(need all of these I think)

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B. Social/occupational dysfunction - work, school, interpersonal, self-care functioning is markedly worse.

C. 6 months of continuous symptoms (duration)

D. Schizoaffective and mood disorder
Exclusion: brief or no mood episodes

E Substance/general medical exclusion

F Relationship to pervasive development disorder -- must have hallucinations or delusions.

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DSM-IV criteria for schizoaffective disorder

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A. Major depressive, manic or mixed episodes concurrent with criterion A for schizophrenia.

B. Delusions/hallucination for 2+ weeks in the absence of mood symptoms

Mood symptoms present for substantial portion of total duration

Substance/general medical exclusion

Subtypes - Bipolar type and depressive type

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DSM-IV criteria for delusional disorder

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Non-bizarre delusions at least for a month

Criterion A for SCZ never met

Functioning, behavior not markedly impaired

Mood episodes brief relative to delusional periods

Substance/general medical exclusion

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DSM-IV criteria for schizophreniform disorder

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Criteria A, D, E for SCZ are met

An episode lasts 1-6 months (including prodromal, active and residual phases)

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Brief psychotic disorder

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One or more of:
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior

Duration is 1 day to 1 month with full return to premorbid function

Not better accounted for by other disorders

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Subtypes of brief psychotic disorder (3)

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With marked stressor

Without marked stressor

With postpartum onset.

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Shared psychotic disorder
DSM criteria

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A delusion develops in context of close relationship with another who has an already-established delusion.

Delusion is similar to other person's

Not better accounted for by other psychotic, mood, substance or general medical disorders.

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Psychotic disorder NOS (not otherwise specified)

DSM

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Psychotic symptomatology and:

Inadequate information

Contradictory information

Doesn't meet criteria for any specific psychotic disorder

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Mood disorders (2)

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Major depression with psychotic features

Bipolar disorder with psychotic features

Note: Psychosis does not persist independent of mood episodes.

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Cluster A personality disorders

DSM

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Paranoid: Distrust and suspiciousness

Schizoid: Detachment from social relationships and restricted emotional expression

Schizotypal: Social/interpersonal deficits, and cognitive/perceptual distortions, and eccentric behavior.

(increased in families with schizophrenia)

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Anxiety disorders

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PTSD
Flashbacks, re-experiencing
20% frequency of psychotic symptoms

OCD
Severe obsessions can be difficult to distinguish from delusions
Ritualistic, obsessive behaviors common in schizophrenia.

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Substance induced psychotic disorders

DSM

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Prominent hallucinations or delusions in excess of usualy intoxication, withdrawal.

Developed within a month of substance intox or withdrawal, or medication use (i.e. steroid)

Not better accounted for by other psych disorder

Not exclusively during delirium
(e.g. alcoholic hallucinosis)

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Psychotic disorder due to general medical condition

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Prominent hallucinations or delusions

Direct physiologic consequence of general medical condition

Not better accounted for by another psychotic disorder

Not exclusively during delirium
(e.g. psychosis due to hormone secreting tumor)

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Delirium

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Disturbance of consciousness and perceptual disturbances
(classically non-auditory hallucinations such as delerium tremens)

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Dementia

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High frequency of agitation and psychotic symptoms.

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Subtypes of SCZ

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Paranoid - preoccupation with delusions or frequent auditory hallucinations, without prominent disorganization or catatonia

Disorganized - disorganized speech, behavior and flat or inappropriate affect.

Catatonic - Motor immobility, stupor, or excessive motor anxiety, extreme negativism, posturing or stereotyped movements, echolalia (immediate repitition of a phrase).
These are diminishing in frequency

Undifferentiated - Not meeting above criteria

Residual - Attenuated (less extreme) delusions, hallucinations, disorganization or catatonia.

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Subtypes of SCZ

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(old)

Catatonic - Motor immobility, stupor, or excessive motor anxiety, extreme negativism, posturing or stereotyped movements, echolalia (immediate repitition of a phrase).
These are diminishing in frequency

Undifferentiated - Not meeting above criteria

Residual - Attenuated (less extreme) delusions, hallucinations, disorganization or catatonia.

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SCZ increased risk with env insults?

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Yes - esp in first trimester.

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SCZ onset

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Typically teens to 20s.

Women typically have later onset. They also have better premorbid function, better response to meds. And estrogen has neuroprotective effects and inhibits D2 receptors.

Best to treat at first episode.

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3 phases in the course of SCZ

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Prodromal - Social, cognitive deficits may precede active phase by many years

Active phase - full syndrome, typically 3-4 decades (teens or 20s-50s)

Residual phase - 1/3 remission, 1/3 attenuation of symptoms in older years. Dopamine levels drop after age 50.

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Complications

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Shorter life expectancy (suicide, victimization, chronic med conditions, medication effects)
Concurrent substance use (destabilized the scz too!)
Homelessness, unemployment, undereducation, impaired relationships, family discord.

Suicide (usually in first decade of illness), violence (more likely with command hallucinations or persecutory delusions)

Clozapine

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Clozapine

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Reduces risk of suicide and violence.

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Reward Deficiency Syndrome

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Dysfuction of dopamine receptors leading to inability of brain to endogenously stimulate reward pathways

SCZ and bipolar pts have huge likelihood to abuse drugs.

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Complic of substance use in scz pts

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Earlier onset, higher relapse, tx non-compliance, poor medication response, increased risk of violence, HIV, hepatitis. Greater brain volume loss over 5 years.

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SCZ and nicotine

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90% smoke. But it reduces cognitive deficits (but also lung CA).

Freq caffeine overuse as well.

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Neuroanatomic findings

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5% cerebral atrophy

Enlarged ventricles

Reduced vol of various structures (caudate, hippocampus)

Poor organization of cortical layers

Histo evidence of disordered neuronal migration connect and atrophy

PET, fMRI, show deficits in PFC and hippocampus during specific tasks.

Decrease in dendritic spines

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Genreal Pathophys of schizophrenia

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Functional brain abnormalities (diffuse cerebral dysfunction, particularly prefrontal and medial temporal)

Neurochemical brain abnormalities (DA hyperactivity in mesolimbic and hypo in mesocortical; glutamate, serotonin, GABA, NE, ACh)

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Mesolimbic pathway

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Midbrain ventral tegmental area to ventral striatum (nucleus accumbens), olfactory tubercle, and parts of limbic system.

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Mesocortical pathway

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From midbrain VTA to frontal cortex. Implicated in aspects of learning and memory.

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Nigrastriatal pathway

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Involved in control of movement

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Tuberoinfundibular pathway

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From hypothalamus to anterior pituitary gland and controls prolactin secretion.

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Positive sx of scz arise from...

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overactivity of mesolimbic pathway

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Negative and cognitive sx of scz arise from...

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reduction of dopamine activity in the mesocortical pathways.

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Goal of tx in scz

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Reduce mesolimbic activity, increase mesocortical activity, preserve the pathways regulatin motor movement and prolactin secretion.

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Genetics in scz

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50% in identical twins.

Genes impacting prefrontal cortex circuits and interplay of DA, glutamate and GABA

example - COMT - a val allele has increased activity, is associated with SCZ, and metabolizes more DA in prefrontal cortex.

Val/val also more likely to smoke pot.

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3 models for etiology of scz

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Neurodevelopmental
Neurodegenerative
Stress-diathesis

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Neurodevelopmental model

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early brain abnormality, development of hypofrontality, subsequent mesolimbic hyperactivity.

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Neurodegenerative model

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NMDA glutamate receptor antagonists somehow form

bc the drug NMDA antags replicate the positive, negative and cognitive sx of schizophrenia.

Also glutamate dysreg can lead to apoptosis and there may be excitotoxic damage during psychosis.

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Stress-diathesis model

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Neurobiologic vulnerability and various stressors can trigger onset of scz

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Tx of scz

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Hospitalization

Antipsychotics

Comm mental health centers

case management

Psychosocial rehab

Peer support

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Antipsychotic meds (3)

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D2 or 5HT2 antagonists.

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Effects of antipsychotics

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Reduce psychotic sx, agitation disorganization

Prev relapse (really well!)

Some reduce neg sx and cognitive impairments (partic 2nd and 3rd gen agents)

10-20% remission rates.

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Evidence-based practice project to help tx SCZ

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illness management/recovery skills

SUPPORTED EMPLOYMENT

family psychoeducation

assertive community tx

integrated dual disorders tx

standardized pharmacological tx

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Dual disorders treatment

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Sequential tx

Parallel tx

Integrated tx (both disorders are primary, behavioral basis. single locus of tx responsibility. eliminates suppresion of substance abuse treatment response)

Integrated dual disorder treatment has been found to be very effective. (more remission)

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Novel antipsychotics and rehabilitation

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Found to have interactions and they benefit each other (with APs, less negative sx, more cognition, and thus more able to be rehabilitated).