Schizophrenia and Related Psychotic Disorders

1. Schizophrenia and Related Psychotic Disorders Diana O. Perkins, MD, MPH Associate Professor of Psychiatry Director, Schizophrenia Treatment and Evaluation Program

2. Schizophrenia and Related Psychotic Disorders • Clinical characteristics • Epidemiology • Etiology

3. Psychotic Disorders Clinical Characteristics

4. Schizophrenia is Heterogeneous... • A syndrome defined by a constellation of clinical symptoms • With multiple causes, that are similarly expressed

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6. Schizophrenia: Clinical Features • Positive Symptoms a distortion or excess of normal function • Negative Symptoms a decrease or loss in normal function • Disorganization of thoughts and behavior • Cognitive Impairments • Mood Symptoms

7. Features of Schizophrenia Positive symptoms Negative symptoms Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits Mood symptoms Disorganization

8. Positive Symptoms (Psychosis) • Disturbance of Perception (Hallucinations) • Disturbance of Thought Content (Delusions)

9. Positive Symptoms Disturbance of Perception • may effect any sensory modality

10. Positive Symptoms: Hallucinations Auditory Hallucinations • involve voices or sounds • single or multiple • familiar or unfamiliar • may make insulting remarks or be pleasant • may comment on behavior • may command person to perform acts

11. Positive Symptoms: Hallucinations Other Sensory Modalities • Tactile: may involve electrical, tingling, or burning sensations • Visual • Gustatory • Olfactory

12. Positive Symptoms: Delusions Delusions • fixed false beliefs • examples: • persecutory delusions • delusions of reference • delusions of being controlled • thought broadcasting/insertion/withdrawal • grandiose • religious • nihilistic • somatic

13. Features of Schizophrenia Positive symptoms- Hallucinations - Delusions Negative symptoms Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits Mood symptoms Disorganization

14. Negative Symptoms Negative symptoms include: • decreased expression of feelings • diminished emotional range • poverty of speech • decreased interests • diminished sense of purpose • diminished social drive

15. Differential Diagnosis of Negative Symptoms Negative Symptoms primary to schizophrenia: The “Deficit Syndrome”: primary and enduring negative symptoms in individuals with schizophrenia • The Deficit Syndrome occurs in about 20% of treated patients

16. Differential Diagnosis of Negative Symptoms Negative Symptoms may be secondary to: • antipsychotic EPS side effects • decreased emotional expression and apathy may be due to Parkinsonian side effects • lack of initiation of activity may be due to bradykinesia • psychosis • depression or anxiety • demoralization

17. Features of Schizophrenia Negative symptoms-emotional range -  expression of emotion -  motivation/drive -  interests -  social drive - poverty of speech Positive symptoms- Delusions- Hallucinations- Disorganization Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits Mood symptoms Disorganization

18. Positive Symptoms: Disorganization • Disorganization of Speech • tangential or circumstantial speech • looseness of associations • Disorganization of Behavior • odd mannerisms • catatonic stupor

19. Video Tape • Positive symptoms: • Hallucinations • Delusions • Disorganization • Speech • Behavior • Negative symptoms:

20. Features of Schizophrenia Negative symptoms-emotional range -  expression of emotion -  motivation/drive -  interests -  social drive - poverty of speech Positive symptoms- Delusions- Hallucinations- Disorganization Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits Mood symptoms Disorganization - speech - behavior

21. Cognitive Domains: Severe Impairment in Schizophrenia Moderate Impairment • Delayed recall • Distractibility • Immediate memory span • Visuomotor skills • Working memory Severe Impairments • Serial learning • Executive functioning • Vigilance • Motor speed • Verbal Fluency

22. Working Memory • Aspects of Working Memory • Temporary storage and manipulation of information • “workspace” for holding items of information in mind as recalled, manipulated, and associated with other ideas and information • Tests • patients with schizophrenia tend to perform 1-2 standard deviations below the mean • Tests: visual, spatial, auditory working memory

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27. Executive Function • Aspects of Executive Function • Focus attention • Distinguish the important aspect of a task or a situation from unimportant • Prioritize • Perform mental or physical activities proper sequence • Modulate behavior based on social cues • Tests: • Patients perform 2-3 standard deviations below mean • Examples: Trail Making Tests, Wisconsin Card Sort, Tower of London

28. The Wisconsin Card Sorting Test

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31. The Wisconsin Card Sorting Test

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33. The Wisconsin Card Sorting Test

34. The Wisconsin Card Sorting Test

35. The Wisconsin Card Sorting Test

36. The Wisconsin Card Sorting Test

37. The Wisconsin Card Sorting Test

38. The Wisconsin Card Sorting Test

39. Vigilance • Ability to monitor target stimuli over an extended duration of time • inability to attend to relevant stimuli and ignore irrelevant stimuli • inability to concentrate • increased susceptibility to distractions • inability to sustain effort and attention • Tests of Vigilance: • patients perform 2-3 standard deviations below the mean • example: CPT

40. Cognitive Functions: Mild or No Impairment in Schizophrenia No Impairment • Word recognition • Long-term factual memory Mild Impairment • Perceptual Skills • Delayed recognition memory • Confrontation naming

41. Features of Schizophrenia Negative symptoms-Decreased experience and expression of emotions - Decreased motivation/drive - Decreased initiative - Social withdrawal Positive symptoms- Delusions- Hallucinations- Disorganization Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits-Attention- Memory - Verbal fluency - Motor function- Executive function Disorganization - speech - behavior Mood symptoms

42. Mood Symptoms • Dsyphoric • anger, hostility, fear, irritability, depression, anxiety • high risk of suicide • Euphoric • sense of power, control, exhilaration

43. Mood Symptoms • Primary to schizophrenia • “Reactive” • psychosis is frightening • reality of illness is demoralizing • Co-morbid disorder • major depressive episode

44. Features of Schizophrenia Negative symptomsAnhedonia Affective flatteningAvolitionSocial withdrawal Alogia Positive symptomsDelusionsHallucinationsDisorganized speech Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficitsAttentionMemory Verbal fluencyExecutive function (eg, abstraction) Mood symptomsDepression/AnxietyAggression/Hostility Suicidality Disorganization - speech - behavior

45. Diagnosis of Schizophrenia Symptoms Severity/Impairment/Distress Duration

46. Differential Diagnosis of Schizophrenia • Significant psychotic symptoms for at least one week • Continuous signs of the disturbance for at least six months • Markedly impaired ability to function • Without known etiology

47. Differential Diagnosis of Schizophrenia Differential Diagnosis: related disorders • Schizophreniform Disorder • Brief Psychotic Disorder • Delusional Disorder • Schizoaffective Disorder • Schizoid Personality • Schizotypal Personality Disorder • Paranoid Personality Disorder

48. Differential Diagnosis of Schizophrenia Differential Diagnosis:Mood Disorders with Psychotic Features • Major Depression • Bipolar Disorder

49. Differential Diagnosis of Schizophrenia Organic Mental Disorders • substance induced (e.g. PCP, amphetamine, cocaine, hallucinogens, cannabis, alcohol, a variety of prescribed medications • most diseases affecting the central nervous system

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