Schizophrenia Part – II :Clinical Manifestations and Phenomenology, Differential Diagnosis, Course, Prognosis Management & Rehabilitation 13th November’2009 ::Moderator ::Dr. Kamala DekaAssociate Professor :: Speaker ::Dr. Santanu GhoshPostgraduate Student Department of Psychiatry, Assam Medical College
Layout of presentation: Introduction Clinical Manifestation Phenomenology Differential Diagnosis Course Prognosis Management Rehabilitation Conclusion Take home message Bibliography
Introduction Schizophrenia is a stress-related, neurobiological disorder characterized by disturbances in the form and content of an individual's thought and perceptual processes, affect and social and instrumental role behavior. The pervasive impact of schizophrenia across perceptual, cognitive, emotional and behavioral domains, as well as the heterogeneity within those domains require a multimodal and comprehensive approach to treatment and rehabilitation which involves the individual and his or her environment. A multidimensional and interactive model that includes stress, vulnerability, and protective factors best guides the types of interventions for treating and rehabilitating persons with schizophrenia.
Clinical Features of Schizophrenia Negative symptomsAutism Affective flatteningAvolitionSocial withdrawan Alogia Functional ImpairmentsWork/school performanceInterpersonal relationships &Self-care deterioration Positive symptomsDelusionsHallucinations Mood symptomsDepression/AnxietyAggression/Hostility Suicidality Disorganization Inappropriate affect Disorganized behavior Thought disorder Cognitive deficitsAttentionMemory Verbal fluencyExecutive function
Prodromal Symptoms Severe anxiety Severe distractibility Person feels “strange” Symbolization, mysterious thinking Profound withdrawal, isolation, Rejection, paranoid thinking Preoccupation with religion Altered sexuality, preoccupation with homosexual themes Speech and language disturbance
Phenomenology can be defined as the study of events or phenomena, either psychological or physical, by means of empathy & immaculate clinical observation, but without embellishing those events or phenomena with explanation of cause or function.
In psychiatry, phenomenology is the way of understanding & describing the psychological phenomena, involved in various psychopathological states.
Phenomenology of Schizophrenia:(Historical Overview)
Emil Kraepelintranslated Morel’s “demenceprecoce” into “dementia praecox”, to emphasize the distinct cognitive decline (dementia) & early onset (praecox) of the disorder.
EugenBleulercoined the term “schizophrenia”to mean “splitting” of the psychic functions. Bleuler made a distinction between the fundamental & accessory symptoms of schizophrenia.
The fundamentalsymptoms of Bleuler, which were also designated as the four “A”sare- Disturbance of Association (e.g, looseness), Affective disturbance(eg, flattening), Autism (i.e. withdrawn from reality into an inner fantasy world) & Ambivalence.
Phenomenology of Schizophrenia:(Historical Overview)
Bleulerviewed some of the most frequent & striking symptoms were accessory (or secondary). These include- hallucinations, delusions, catatonia & abnormal behavior.
Adolf Meyersaw schizophrenia & other mental disorders as reactions to life stress & he called these “schizophreniform reaction”.
Harry Stack Sullivanemphasized social isolation as a cause & a symptom of schizophrenia.
Phenomenology of Schizophrenia:(Historical Overview)
Ernst Kretschmercompiled data to support the idea that schizophrenia occurs more in persons with asthenicbody built.
Gabriel Langfeldtproposed a distinction between “true schizophrenia” having insidious onset, derealization, depersonalization, autism, emotional blunting and poor outcome; from “schizophreniform states”
Phenomenology of Schizophrenia:(Historical Overview)
Karl Kleist, looked for association between brain pathology & different subtypes of psychotic illness.
Leonhard, distinguished schizophrenia from “cycloid psychosis”. He divided schizophrenia into 2 groups-
Systematic schizophrenia, which included catatonias, hebephrenias & paraphrenias.
Non- systematic schizophrenia, which included affect- laden paraphrenia, schizophasia & periodic catatonia.
Phenomenology of Schizophrenia:(Historical Overview)
T. J. Crowproposed a classification of schizophrenic patients into type- I & type- II, on the basis of the presence or absence of positive (or productive) & negative (or deficit) symptoms.
Carpentercoined the term ‘ deficit schizophrenia’ for specifically to those negative symptoms that are present as enduring traits. Deficit symptoms may be present during & in between episodes of exacerbation of positive symptoms regardless of patient’s medication status.
Presently, schizophrenia is diagnosed by using classification systems of DSM- IV & ICD- 10. These have the advantage of international comparability, but many have criticized them for trading of validity for the sack of reliability & were conceived as “gatekeepers”- i.e. the minimum numbers of checklist symptoms needed to make a diagnosis.
Thought disorders found in schizophrenia 1. Disorders of the Form of Thinking: (Formal Thought Disorders)
Predominantly a disturbance ofconceptual or abstract thinking & association between consecutive thoughts.
Camerongrouped thought disorganization symptoms into 4 groups-
Delusions of Grandeur (sometimes in paranoid schizophrenia)
Misidentifications Capgras syndrome (Capgras and Reboul-Lachaux, 1923) An uncommon syndrome in which the patient believes that a person to whom they are close, usually a family member, has been replaced by exact double. Associated with paranoid, suspicious beliefs Intermetamorphosis(Courbon and Tusques, 1932) Characterized by Delusion that people have swapped identities while maintaining the same appearance . Involves a false recognition of both appearance and identity
Misidentification contd… Fregoli delusion or Fregoli syndrome The is a rare disorder in which a person holds a delusional belief that different people are in fact a single person who changes appearance or is in disguise. The syndrome may be related to a brain lesion, and is often of a paranoid nature with the delusional person believing themselves persecuted by the person they believe is in disguise. The condition is named after the Italian actor Leopoldo Fregoli who was renowned for his ability to make quick changes of appearance during his stage act.
Spatial Form (Dysmegalopsia- micropsiaormacropsia)
These are rarely found in schizophrenia & are suggested to be involved in formation of neurotic symptoms like hypochonricalor dysmorphophobic symptoms seen in few schizophrenics.
Disorders of Experience of Time (sense of slowing or fastening of physical or personal events) are also considered as sensory distortions, are seen in some schizophrenics.
Disorders of perception contd… II. Sensory Deceptions:
Illusions: Rare in schizophrenia. Can occur in all sensory modalities, mostly visual.
Type of illusion present in schizophrenia
Pareidolia- (vivid illusions without the patient making any effort)- due to excessive fantasy thinking & vivid visual imagery. Seen in schizophrenics with excessive autistic thinking.
Disorders of perception contd… III. Hallucinations: (“perception occurring without the presence of a corresponding object in sensory field”)
Jaspers distinguished between true hallucinations & pseudo- hallucinations, by the person’s experience of the hallucinatory object being located in the objective or subjective space respectively.
The term “pseudo- hallucination” was given by Hagen . Earlier it was also known as “pale hallucination” & “apperceptive hallucination”.
Hillers argued schizophrenic hallucinations to be mental images based on patient’s thought or affect, rather than true perceptions. E.g. a schizophrenic with persecutory delusions can report that his food tasted of arsenic, which in fact is tasteless & which he never tasted.
Disorders of perception contd… Hallucinationscan be the resultof intense emotions, suggestion, disorders of sense organ, sensory deprivation, CNS disorders & several other causes. Schizophrenic hallucinations are- Auditory: It can be elementary (noises), or partly organized (music), or completely organized (hallucinatory voices). Classical schizophrenic hallucinations are persistent, prominent & organized. Hallucinatory voices are characteristic of schizophrenia.
Occasionally, hallucinatory voices may speak incomprehensible nonsenseor may useneologism.
Disorders of perception contd…
Unlike normal people, many schizophrenic are quite undisturbed by their inability to describe the direction & the sex of the speaker of those voices. These have variable effects on the patient’s behavior (some quite unconcerned & others totally disturbed).
Tactile, Gustatory, Olfactory & Somatic hallucinations- Not common in schizophrenia (related to patient’s delusional theme).
Cenesthetic Hallucinations- can occur in schizophrenia (e.g. Burning in Brain, Pushing sensation in Blood Vessels, or Cutting sensation in Bone Marrow etc )
Disorders of Mood & Affect:
Inadequacy & incongruity of emotional reactions are hallmarks of schizophrenia.
The emotional status of schizophrenic patient’s vary between 2 extremes groups-
One group shows reduced emotional responsiveness (Shallow, Blunt & Flat ), which when severe lead to “Anhedonia” or “Apathy”. These inadequacies or blunting of affect was termed as “Parathymia” by Bleuler.
Others are overtly active & show inappropriate emotional expression. Reactivity is present & range may be labile, called “Affective Incontinence” or “Compulsive Affect” & seen in hebephrenic schizophrenia (e.g. silly euphoria, querulous ill- humor, careless indifference & autistic depression).
Disorders of Mood & Affect contd…
Schizophrenics include Perplexity, Overwhelming Ambivalence, a sense of isolation & depression.
These abnormal emotional expressions in schizophrenics does not allow empathy or rapport to establish. In addition, dissociation of affect, affectionless personality & effects of anxiety may also lead to diagnostic dilemma.
Disorders of Motor Behavior:
General appearance of a schizophrenic can range from a completely disheveled, screaming & agitated patient to an obsessively groomed or completely silent & immobile patient
The motors disorders of schizophrenia are viewed by some as organic neurological signs. Karl Ludwig Kahlbaumfollowed this view while describing the features of catatonia.
Several others considered them to be the result of patient’s conscious or unconscious attitudes (e.g. stereotypy is explained as having some symbolic meaning).
Disorders of Motor Behavior contd… Some common motor abnormalities in schizophrenia are-
Usually schizophrenics are conscious & well oriented. Meyer- Grossdescribed “Oneiroid Schizophrenia”,characterized by clouding of consciousness, disorientation, perceptual disturbances & a dream- like state.
Several localizing (hard) or non- localizing (soft) neurological signs (e.g. dysdiadochokinesia, astereognosis, primitive reflexes, diminished dexterity, abnormalities of motor tones & movements).
Suicide in schizophrenia People with schizophrenia attempt suicide much more often than people in the general population. About 10% (especially young adult males) succeed. I t is hard to predict which people with schizophrenia are prone to suicide so if someone talks about or tries to commit suicide, professional help should be sought right away Source: NIMH site
Mood Disorders (especially with psychotic symptoms).
Affective symptoms of schizophrenic episode, post- psychotic depression & Side- effects of anti- psychotics add to diagnostic dilemma.
Personality Disorders (Schizotypal, Schizoid PD).
Course of Schizophrenia
Course of Schizophrenia Prodromal phase Active phase Residual phase
Psychosis Level of symptoms REMISSION Pre-psychotic VULNERABILITY Prodromal phase Premorbid phase 1ST admission Neurodevelopmental anomalies adolescence 4-5 years Time
Course of Schizophrenia: The ¼, ¼, ½ Rule Enormous individual variability About 1/4 of those who experience an episode of schizophrenia recover completely; another 1/4 experience recurrent episodes, but often with only minimal impairment of functioning The other one-half, schizophrenia becomes a chronic mental illness, and the ability to function normally in society may be severely impaired.
Course & outcome: Luc Ciompi1980 report shows: Complete remission-27% Remission with minor residual deficit- 22% Intermediate outcome- 24% Unstable or uncertain outcome- 9% ICMR report shows:
Course of Schizophrenia Stages of Illness residual/stable prodromal premorbid onset/deterioration Higher Function More symptoms 10 20 40 50 30 Gestation/Birth
Indian Study on course & outcome The International Pilot Study of Schizophrenia (IPSS; WHO, 1979)and the Determinants of Outcomeof Severe Mental Disorders (DOSMED) study (Sartorius et al,1986) have provided convincing evidence for a better outcomein India thanin the West. This finding of a good outcome of treatment alsoemerged in the Chandigarh studies (Kulhara & Wig, 1978;Kulhara, 1994). Kulharaet al (1989) showed that regardlessof diagnostic definition, the outcome in Indian patients wasfavourable. One spin-off of the IPSS in India was the multi-siteStudy of Factors Affecting the Course and Outcome of Schizophrenia(SOFACOS).This was a 5-year follow-up of 386 patients in three centers,aimed at identifying social and clinical factors affectingcourse and outcome. The 2-year follow-up revealed that amongthe 423 patients followed up, 64% were in remission, and only11% continued to be ill (Vergheseet al, 1989). Data fromthe Madras centre also revealed a better outcome for womenat the end of 5 years of follow-up (Thara & Rajkumar, 1992).
Prognosticfactors: Good Prognostic Factors Poor Prognostic Factors Acute or abrupt onset 1. Insidious onset Onset > 35 years of age 2. Onset < 20 years of age Presence of stressor 3. Absence of stressor Catatonic subtype 4. Disorganized, simple, undiff Good premorbid adjustment 5. Poor premorbid adjustment Short duration(<6 months) 6. Chronic course(>2 years) Presence of depression 7. Absence of depression Predominant positive symptoms 8. Predominant negative symp Family h/o mood disorder 9. Family h/o schizophrenia Female sex 10. Male sex Good social support 11. Poor social support Normal cranial CT scan 12. Ventricular enlargement on CT
Challenges in the Treatment of Schizophrenia Stigma Impaired “insight”– no agreement on problem Treatment “compliance” Substance abuse very common Violence risk Suicide risk Medical problems common, often unrecognized
Important Consideration in Treatment Comprehensive & continuous treatment for prolonged periods for most. Integrated, bio- psychosocial approach to care. Active collaboration with the family while planning & delivering treatment. Treatment sensitive to the patient’s needs & empirically titrated to the patient’s response & progress.
Minimum duration of 4-6 weeks for all drugs, except Clozapine (3-6 months)
Doses need to be individualized. Recommended dose is mostly in the range of 300- 1000 mg of Chlorpromazine equivalents per day.
Tapering of dose @ 20% of the initial dose in every 6 months, until a minimum effective dose is reached.
Duration of treatment: It should be individualized. The suggested guidelines are: 1st episode patients : 1-2 years of maintenance Patients with several episode or exacerbation : ≥5 years of maintenance Patient with h/o aggression, suicide attempts : Indefinite period even life long
Algorithm for the Treatment of Schizophrenia Trial of single SGA (Resperidone, Olanzepine, Aripiprazole, Qutiapine, Ziprasidone) ne Stage 1 Partial or No response Trial of a single SGA or FGA (not SGA tried in Stage 1) Stage 2 Partial or No response CLOZAPINE Stage 3 Partial or No response CLOZAPINE + (FGA, SGA or ECT Stage 4 Nonresponse Trial of a single agent FGA or SGA (not tried in Stages 1 or 2 ) Stage 5 Nonresponse Combination Therapy e.g. SGA + FGA, combination of SGAs, + ECT, + other agent (e.g. mood stabilizer) Stage 6 Source: IPS clinical Guidelines
Typical Antipsychotic limitation: Extrapyramidal side effects (EPS) Parkinsonism Akathesia Dystonia Tardive Dyskinesia (TD)-- the worst form of EPS-- involuntary movements
Typical Antipsychotic limitation: Other common side effects Anticholinergic side effects: dry mouth, constipation, blurry vision, tachycardia Orthostatic hypotension (adrenergic) Sedation (antihistamine effect) Weight gain “Neurolepticdysphoria”
Parkinsonian side effects Rigidity, tremor, bradykinesia, mask like facies Management: Lower antipsychotic dose if feasible Change to different drug (i.e., to an atypical antipsychotic) Anticholinergic medicines: Benztropine Trihexylphenidile Promethazine Procylidine
Akathesia Restlessness, pacing, fidgeting; subjective jitteriness; associated with suicide Resembles psychotic agitation, agitated depression Management: lower antipsychotic dose if feasible Change to different drug (i.e., to an atypical antipsychotic) Adjunctive medicines: Propranolol (or another beta-blocker) Benztropine Benzodiazepines
Acute dystonia Muscle spasm: oculogyric crisis, torticollis, opisthotonus, tongue protrusion Dramatic and painful Treat with intramuscular (or IV) promethazine or benztropine
Tardive Dyskinesia (TD) Involuntary movements, often choreoathetoid Often begins with tongue or digits, progresses to face, limbs, trunk Etiologic mechanism unclear Incidence about 3% per year with typical antipsychotics Higher incidence in elderly
Tardive Dyskinesia (TD) Major risk factors: high doses, long duration, increased age, women, history of Parkinsonian side effects, mood disorder Prevention: minimum effective dose, atypical meds, monitor with AIMS test Treatment: lower dose, switch to atypical, Vitamin E (?), tetrabenazine
Acute exacerbations not controlled with drugs
Severe side effects with drugs in presence of untreated or resistant schizophrenia
Risk of suicide,homicide or danger of physical assault.
Non Pharmacological Management
Psychoeducation It empowers the patient so they can take control of their own illness. Start basic and acquire consent to discuss with patient’s family. Be quite confident with your diagnosis because it’s pretty unfair to label a patient schizophrenic if they’re not. They have to wear the stigma for the rest of their lives!
Family Psychoeducation contd… Provides information about schizophrenia: course, symptoms, treatments, coping strategies Supportive One aim is to decrease expressed emotion (hostility, criticism, etc.) Not blaming
Relapse signature and relapse prevention plans It is a set of individualised symptoms occurring in a specific order over a particular time that the patient can learn to identify and manage themselves. It helps to identify the earliest signs of impending psychotic relapse (Subtle changes in thought, affect and behaviour precede development of frank psychosis) It offers timely and effective intervention to arrest their progression towards frank psychosis.
Focused on the “here and now” of the patient's life Aims to help the patient define reality more clearly and solve practical problems. Involves providing reassurance, offering explanations and clarification, and giving guidance and suggestions.
Supportive therapy contd… Regular and supportive interaction with a psychotherapist may help sustain a patient with schizophrenia and may reduce the patient's feelings of aloneness and despair. A positive relationship with the prescribing psychiatrist may also enhance the patient's adherence to prescribed medication. It may reduce suicidal ideas and behaviours.
Cognitive behavioural strategies Emotional distress is assumed to be associated with faulty thinking, which, if modified, can alter emotional responses. Generally starts with several sessions assessing the patient's specific symptoms and the distress associated with the symptoms. Coping strategies that the patient has used may also be reviewed. The therapy aims to address issues systematically over a fixed number of sessions.
Steps of CBT Concerned Topic Determine the focus of the subsequent sessions Specific therapeutic strategies Application Homework exercises, Activity schedule maintenance advised The therapist focuses on any coexisting anxiety and depression Therapist turns to specific positive psychotic symptoms that the patient experiences Negative symptoms is addressed, but only after work has been completed on positive symptoms.
Families and expressed emotion (EE) High levels of criticism, hostility, or over involvement, have more frequent relapses. The three attitudes pertaining to expressed emotion are known as hostile, critical, and emotional over-involvement. The relatives influence the outcome of the disorder through negative comments and nonverbal actions. The stress from the family for the patient to recover and end certain behaviours causes the person a relapse in their illness.
Common factors associated with psychotic relapse
Antipsychotics not completely effective
“Noncompliance”—inconsistent antipsychotic medication use
Steps Participants are told what skill they will learn and why they should learn it. Introduction to Skill Video Tape Demonstration videotaped demonstration of the skill that is stopped periodically . Each participant roleplays the skill that was demonstrated. Role Play Participants apply the problem solving method to resolve difficulties that may occur when they try to get the resources – time, money, etc. Resource Problem Solving Participants apply the problem solving method to resolve difficulties that may occur when they implement the skill and the outcomes are not as expected. Outcome Problem Solving Participants generalize what they have learned by practicing the skill outside of the learning environment. In Vivo Assignment Participants generalize what they have learned by either practicing or completing a related task on their own. Home Work Assignment
Take Home Message Schizophrenia usually starts in late adolescence or early adulthood The most common symptoms are lack of insight, auditory hallucinations, and delusions Clinicians should suspect the disorder in a young adult presenting with unusual symptoms and altered behavior Treatments can alleviate symptoms, reduce distress, and improve functioning Delayed treatment worsens the prognosis
Conclusion To describe the differential diagnosis of psychosis – schizophrenia, Schizotypal, Schizoid PD and depression Explore some of the phenomenology – has diagnostic utility and misidentifications are particularly interesting Understand the main etiological factors – good evidence for biological supporting Examine the evidence for most effective management – good evidence for drug treatment but other approaches are very important 5. Treatment of schizophrenia should be done as a team work with Psychiatrist, family & social support.
Bibliography: CTP – Kaplan & Sadock, 8thed, P 1329-1558 Synopsis of Psychiatry, Kaplan & Sadock, 10thed, P 467-97 Symptoms in the mind, Andrew Sims,3rded, Saunders Fish’s clinical psychopathology, 3rd ed. IPS clinical practice guideline on schizophrenia Textbook of post graduate Psychiatry, Vyas & Ahuja 2nded, P 151-86 A short Textbook of Psychiatry, Niraj Ahuja, 6thed, P 57-73 Web: - http://www. schizophreniabuletine.com - http://www.medscape.com/psychiatryhome - http://www.schizophrenia.com/ - http://www.rcpsych.ac.uk/info/schiz.htm - http://www.schizophrenia-world.org.uk/ - http:// www.googleimage.com