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  1. 1. 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
  2. 2. Diagnosis and Management of Schizophrenia <ul><li>Process for diagnosing schizophrenia </li></ul><ul><li>Epidemiology </li></ul><ul><li>Genetics and environment </li></ul><ul><li>How to access severity </li></ul><ul><li>Capacity to Work </li></ul><ul><li>Current and future treatment </li></ul>
  3. 3. DSM-IV criteria for schizophrenia <ul><li>Characteristic Symptoms </li></ul><ul><li>Social/occupational dysfunction </li></ul><ul><li>Duration of 6 months </li></ul><ul><li>Schizoaffective and mood disorder exclusion </li></ul><ul><li>Substance/general medical exclusion </li></ul><ul><li>Relationship to pervasive developmental disorder </li></ul>
  4. 4. Diagnostic Process for Schizophrenia <ul><li>Physical and lab exams rule out psychotic disorder due to a medical condition and substance-induced psychosis </li></ul><ul><li>Imaging (CT, MRI, PET) are seldom helpful in diagnosis </li></ul><ul><li>The diagnosis is commonly made from history and the mental status exam </li></ul><ul><li>There are currently no reliable biomarkers for diagnosis or severity </li></ul>
  5. 5. Characteristic Psychotic Symptoms in Schizophrenia <ul><li>Audible thoughts </li></ul><ul><li>Voices arguing or commenting </li></ul><ul><li>Thought withdrawal or insertions by outside forces </li></ul><ul><li>Thought broadcasting </li></ul><ul><li>Impulses, volitional acts, or feelings imposed by outside forces </li></ul><ul><li>Delusional perceptions </li></ul>
  6. 6. Symptom dimensions in schizophrenia <ul><li>Psychotic </li></ul><ul><ul><li>Hallucinations </li></ul></ul><ul><ul><li>Suspiciousness </li></ul></ul><ul><ul><li>Delusions </li></ul></ul><ul><li>Negative </li></ul><ul><ul><li>Impoverished speech </li></ul></ul><ul><ul><li>Lack of motivation </li></ul></ul><ul><ul><li>Asociality </li></ul></ul><ul><ul><li>Decreased Affect </li></ul></ul><ul><li>Neurocognitive – Impairments </li></ul><ul><ul><li>Memory </li></ul></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Motor skills </li></ul></ul><ul><ul><li>Social cognition </li></ul></ul><ul><ul><li>Executive skills </li></ul></ul><ul><ul><li>Disorganized speech </li></ul></ul>
  7. 7. Epidemiology of Schizophrenia <ul><li>Lifetime prevalence of about 1% </li></ul><ul><li>No differences related to culture or race </li></ul><ul><li>Onset in men is usually earlier (15-24) than in women (25-34) </li></ul>
  8. 8. Top 10 Causes of DALYS in Adults (15-44 years) DALY=Sum of years of life lost due to premature mortality and years lost due to disability WHO. The World Health Report 2001. Available at http://www.who.int/whr/2001/en/index.html 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 anemia 2.6 Self-inflicted Injuries 3.0 Bipolar disorder 2.5 Schizophrenia 2.6 Schizophrenia 2.5 Abortion 2.5 Bipolar disorder 2.5 Bipolar disorder 2.4 Self-inflicted injuries 2.4 Violence 2.3 Iron deficiency anemia 2.1 Maternal sepsis 2.1
  9. 9. Course of Schizophrenia Age (Years) Good Function Psycho- pathology Poor 15 20 30 40 50 60 70 Sheitman BB, Lieberman JA. The natural history and pathophysiology of treatment-resistant schizophrenia. J Psychiatr Res. 1998(May-Aug);32(3-4):143-150 Premorbid Progression Stable Relapsing
  10. 10. Severity in Schizophrenia <ul><li>People with schizophrenia have different levels of disability varying from no disability to complete dependence on institutional care </li></ul><ul><li>The amount and type of disability is related to the symptoms of the individual’s illness and how responsive these symptoms are to treatment </li></ul>
  11. 11. Severity in Schizophrenia <ul><li>The severity of psychotic symptoms are related to </li></ul><ul><ul><li>How distracting </li></ul></ul><ul><ul><li>Do they influence behavior – eg, command hallucinations </li></ul></ul><ul><ul><li>Do they cause suffering </li></ul></ul><ul><ul><li>Do they impair social functioning – eg, suspiciousness </li></ul></ul>
  12. 12. Severity <ul><li>The severity of negative symptoms are related to </li></ul><ul><ul><li>Social isolation </li></ul></ul><ul><ul><li>Apathy </li></ul></ul><ul><ul><li>Lack of expressiveness </li></ul></ul><ul><li>The severity of cognitive impairments are related to </li></ul><ul><ul><li>Poor concentration </li></ul></ul><ul><ul><li>Poor memory </li></ul></ul><ul><ul><li>Inability to make simple decisions </li></ul></ul><ul><ul><li>Inability to interpret social signals </li></ul></ul><ul><ul><li>Slower pace </li></ul></ul>
  13. 13. Pharmacological Treatment of Acute Schizophrenia <ul><li>Antipsychotic medications are effective for decreasing the severity of psychotic symptoms </li></ul><ul><li>Nearly all patients on antipsychotic medications will experience some burden from side effects </li></ul><ul><li>Antipsychotics are relatively ineffective for negative symptoms and cognitive impairment </li></ul>
  14. 14. Long-term treatment of schizophrenia <ul><li>Antipsychotic medications are effective for preventing relapse in stabilized patients </li></ul><ul><li>Effective nonpharmacological treatments include patient and family education, skills training, supported employment, cognitive behavior therapies, and psychotherapies </li></ul><ul><li>For most individuals, antipsychotic medications control the symptoms while non-pharmacological treatments address the impairments in social, vocational, and educational functioning </li></ul>
  15. 15. Clinical Challenges <ul><li>Substance use disorders are common in people with schizophrenia </li></ul><ul><li>Insight can be impaired leading people with schizophrenia to refuse treatment </li></ul><ul><li>Adherence to treatments can be irregular </li></ul>