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

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schizophrenia and related psychotic disorders

Schizophrenia and Related Psychotic Disorders

Diana O. Perkins, MD, MPH

Associate Professor of Psychiatry

Director, Schizophrenia Treatment and Evaluation Program

schizophrenia and related psychotic disorders2
Schizophrenia and Related Psychotic Disorders
  • Clinical characteristics
  • Epidemiology
  • Etiology
psychotic disorders

Psychotic Disorders

Clinical Characteristics

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

Positive symptoms

Negative symptoms

Functional ImpairmentsWorkInterpersonal relationshipsSelf-care

Cognitive deficits

Mood symptoms

Disorganization

positive symptoms psychosis
Positive Symptoms (Psychosis)
  • Disturbance of Perception (Hallucinations)
  • Disturbance of Thought Content (Delusions)
positive symptoms
Positive Symptoms

Disturbance of Perception

  • may effect any sensory modality
slide10

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
slide11

Positive Symptoms: Hallucinations

Other Sensory Modalities

  • Tactile: may involve electrical, tingling, or burning sensations
  • Visual
  • Gustatory
  • Olfactory
slide12

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
features of schizophrenia13
Features of Schizophrenia

Positive symptoms- Hallucinations

- Delusions

Negative symptoms

Functional ImpairmentsWorkInterpersonal relationshipsSelf-care

Cognitive deficits

Mood symptoms

Disorganization

negative symptoms
Negative Symptoms

Negative symptoms include:

  • decreased expression of feelings
  • diminished emotional range
  • poverty of speech
  • decreased interests
  • diminished sense of purpose
  • diminished social drive
differential diagnosis of negative symptoms
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
differential diagnosis of negative symptoms16
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
features of schizophrenia17
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

slide18

Positive Symptoms: Disorganization

  • Disorganization of Speech
    • tangential or circumstantial speech
    • looseness of associations
  • Disorganization of Behavior
    • odd mannerisms
    • catatonic stupor
video tape
Video Tape
  • Positive symptoms:
    • Hallucinations
    • Delusions
  • Disorganization
    • Speech
    • Behavior
  • Negative symptoms:
features of schizophrenia20
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

slide21

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
slide22

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
slide25
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slide26
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slide27

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
slide39

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
slide40

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
features of schizophrenia41
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

slide42

Mood Symptoms

  • Dsyphoric
    • anger, hostility, fear, irritability, depression, anxiety
    • high risk of suicide
  • Euphoric
    • sense of power, control, exhilaration
slide43

Mood Symptoms

  • Primary to schizophrenia
  • “Reactive”
    • psychosis is frightening
    • reality of illness is demoralizing
  • Co-morbid disorder
    • major depressive episode
features of schizophrenia44
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

diagnosis of schizophrenia
Diagnosis of Schizophrenia

Symptoms

Severity/Impairment/Distress

Duration

differential diagnosis of schizophrenia
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
differential diagnosis of schizophrenia47
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
differential diagnosis of schizophrenia48
Differential Diagnosis of Schizophrenia

Differential Diagnosis:Mood Disorders with

Psychotic Features

  • Major Depression
  • Bipolar Disorder
differential diagnosis of schizophrenia49
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
slide51

OVERVIEW

Demographics:

Michael is a 23 year old single male. He lives with his father. He completed some college and currently works at the shipping dock of a department store.

Occupational History:

Michael has worked for nearly a year at the shipping dock. He has had several other jobs that he quit when he felt “frustrated”. He has also been unemployed for several long periods. He calls in sick to work several times a month and is currently on probation at work.

Status of Current Treatment:

He is currently an outpatient in the psychiatric clinic. He was hospitalized for 4 days approximately two months ago.

Chief Complaint and Description of Problem:

Michael reports that he has trouble fitting in and believes that all his co-workers are “weird”. He reports feeling “a little confused” at work, but admits he usually goes to work “high” on marijuana or crack.

Vignette 1: Michael

slide52

History:

Michael had been in his usual state of good health until approximately three years ago. At the time he was smoking crack cocaine and marijuana several times a week and reports several episodes where he thought that the police were following him and bugging his phone. All of the episode occurred after a heavy episode of drug use, and resolved after one or two days. He eventually went to the psychiatric clinic for help with the episodes of paranoia, but denied any substance use to the clinic staff. He was prescribed haloperidol, which he took for two days, and then stopped because the medication made him feel “weird”.

Prior to three years ago, the patient had no history of mental illness. However, over the past 3 years he has frequently used crack and marijuana and during periods of heavy use he has consistently felt “more paranoid” and “cut-off from everyone”.

There are no other major life changes and there have been no deaths of close friends or relatives. However, his relationship with this father is quite strained. His mother died over 10 years ago.

About 2 months ago Michael was admitted to the hospital after becoming very aggressive towards his father. He accused his father of sabotaging his car, trying to kill him, and said he would “get dad before dad got me”. In the emergency room Michael was agitated, and was fearful that sirens were the police coming to arrest him. He also reported hearing “voices” telling him “bad stuff” while in the emergency room. Urine toxicology screen was positive for marijuana, PCP, and cocaine. His agitation and paranoid ideation, as well as the “voices” resolved by the third hospital day, without any medication treatment.

Vignette 1: Michael

slide53

Treatment History:

Michael has had one prior substance abuse inpatient stay lasting 6 days, where, off substances and without medication, his psychotic symptoms resolved.

Other Current Problems:

He reports that he always feels “weird and anxious”. He smokes marijuana or crack 1-3 times a day and drinks “several beers” daily.

Current Social Function:

Michael has no close friends although he will socialize with co-workers occasionally while at work. He is estranged from his father who feels that he does not try hard enough to get better. Outside of work, he watches TV and listens to music.

Vignette 1: Michael

slide54

For the past several months, Michael has said he feels anxious and depressed most of the time, because he feels he has no life and no future. He says he never feels interested in anything, and he wishes that he were “more motivated”. His appetite is fine and he has had no change in weight. He reports that his sleep is “pretty good” and he is sleeping 6-8 hours a night. He denies motor changes (either periods of agitation or motor slowing), and his movements and rate of speech are normal during the SCID interview. He states his energy is “fine”. He feels hopeless about the future, specifically that he will never get a “good job” or have a “decent place to live” but denies feeling worthless or guilt. He blames his father for his current living and work situation. He states that his concentration is “fine”, and there is no evidence of impaired concentration during the interview. He denies recurrent thoughts of death or suicidal ideation. He denies any other periods of depression or loss of interest/motivation in the past five years. Michael denies any periods of time when he has felt euphoric or irritable.

  He denies thoughts that others take special notice of him. He acknowledges “feeling paranoid” at times when he smokes crack and marijuana. At these times he believes that the police are bugging his phone, and following him and trying to “get him”. He denies any other unusual beliefs. After smoking crack and marijuana he admits that he also occasionally hears muffled voices coming up from the floor, but the voices are indistinct. He admits to hearing the sirens in the emergency room, but he says “I think I was really hearing that”. He denies any other perceptual abnormalities. He states that the paranoid ideas or the “voices” have always resolved when he has stopped the drugs for a week or more, as is true during this hospitalization. On examination, he is reasonably well dressed and well groomed. His motor behavior is normal and well organized. He exhibits a full range and normal display of affect. His speech is normal in rate and rhythm, and his thought form is generally well-organized. He exhibits poor eye contact .

watches TV and listens to music.

Vignette 1: Michael

schizophrenia epidemiology
Schizophrenia: Epidemiology

Common disease:

  • One in every 100 people develops schizophrenia
  • Each year, 100,000 people are newly diagnosed with schizophrenia in the U.S.
  • On any given day, 600,000 people are in active treatment for schizophrenia in the U.S.
etiology risk factors for schizophrenia
Etiology Risk Factors for Schizophrenia
  • Genetic Vulnerability Factors
  • Environmental Risk Factors
    • Obstetrical Trauma
    • In-utero events
      • Infectious Pathogens
      • Nutritional Factors
    • Substance Abuse
    • Stressful life events
      • College
      • Boot Camp
slide58

Schizophrenia

Schizophreniais a genetic

neurodevelopmentaldisorder

Schizophreniaoccurs inall racesall culturesall social classesand both sexes

Schizophreniacan be treatedbut not cured…yet!

What does your baby’s future hold?

Courtesy of Canadian Schizophrenia Society

schizophrenia course
Schizophrenia: Course

Age of onset

  • may begin at any age
  • typically begins in late adolescents and early adulthood
  • late onset form
  • males often have earlier age on onset than females
slide62

Schizophrenia

Course

  • varies from recovery to severe disability
  • in treatment settings commonly see more severe, chronic course
natural history of schizophrenia
Natural History Of Schizophrenia

Stages Of Illness

Premorbid

Prodromal

Onset/Deterioration

Residual/Stable

Healthy

WorseningSeverity OfSigns AndSymptoms

Gestation/Birth

10

20

30

40

50

Years

natural history of schizophrenia64
Natural History of Schizophrenia

Stages of Illness

residual/stable

prodromal

premorbid

onset/deterioration

Healthy

Worsening Severity of Signs and Symptoms

10

40

50

30

Gestation/Birth

20

schizophrenia
Schizophrenia

Course: Variable

  • Complete recovery (~ 5-10%)
  • Complete, or almost complete remission of symptoms, but with periodic exacerbations of illness symptoms
  • Chronic symptoms, serious impact in function
schizophrenia66
Schizophrenia

Factors affecting prognosis:

  • age of onset
  • sex
  • premorbid function
  • abrupt versus insidious onset
  • family history of mood disorder
  • precipitating events
  • duration of untreated illness
  • substance abuse
prospective study of first episode schizophrenia
Prospective Study of First Episode Schizophrenia

Time to Remission

100

80

60

Percent of Patients Remitting

40

Remission Rate 87%

Median Time to Remission 11 wks

20

0

1

4

7

10

13

16

19

22

25

28

31

34

37

40

43

46

49

52

Weeks of Treatment

Robinson et al. 1999

first episode predictors of treatment response
First-Episode: Predictors ofTreatment Response
  • Duration of untreated illness :

MeanMedian

Active psychosis: 52 wks 11 wks

Prodrome: 151 wks

  • The longer the duration of pre-treatment symptoms, the poorer the clinical outcome (r=.4, p=.0001)
  • The longer the duration of pretreatment symptoms, the longer the time to respond to antipsychotic medication treatment (p=.03)

Loebel et al. Am J Psychiatry 1992;149:1183-1188

cumulative relapse rates by episode of illness
Cumulative relapse rates by episode of illness

* Refers to year(s) after recovery from the previous episode

Robinson et al 1999

slide70

Mean Time to Response

Successive Episodes

Episode (N=40)

1

2

Episode (N=12)

1

2

3

0

20

40

60

80

100

120

Days to Therapeutic Response

Lieberman JA. J Clin Psychiatry. 1996;57(suppl):68-71

slide72

Alternative Pathways to the Development of Residual Positive Symptoms in Schizophrenia:

  • A Treatment Resistant Clinical Sub-type: Patients who have persistent positive symptoms despite treatment with antipsychotics early in the course of illness.
  • Neuroprogressive Pathology:Symptoms that are initially treatment responsive and become unresponsive after subsequent episodes of illness.