2. CASE :1
• A previously healthy 20-year-old student had been behaving
in an odd way. At times he appeared angry and told his friends
that he was being persecuted; at other times he was seen to
be laughing to himself for no apparent reason. For several
months he had seemed increasingly preoccupied with his own
thoughts. His academic work had deteriorated. When
interviewed, he was restless, suspicious, and exhibited odd
mannerisms. He described hearing voices commenting on his
actions and abusing him. He believed that the police had
conspired with his university teachers to harm his brain and
interfere with his thoughts. He also suspected that they could
read his thoughts
3. CAES ; 2
• A middle-aged man lives with his family. He spends
most of his time alone. He is usually dishevelled and
unshaven, and cares for himself only when
encouraged to do so by others. His social behaviour
seems odd and stilted. His speech is slow, and its
content is vague and incoherent. He shows few signs
of emotion. For several years this clinical picture has
changed little except for brief periods of acute
symptoms, which are usually related to upsets in the
ordered life of the family.
4. Schizophrenia
• has puzzled physicians, philosophers, and
general public for centuries.
• A clinical syndrome with a profound
influence on public health, schizophrenia has
been called “arguably the worst disease
affecting mankind, even AIDS not excepted”
(Nature 1988).
5. What Is Schizophrenia?
• Schizophrenia is a chronic, severe, debilitating
mental illness characterized by disordered
thoughts that impairs judgment, behavior,
cognition, emotions & ability to interpret
reality leads to abnormal behaviors, and anti-
social behaviors.
• It is a psychotic disorder, meaning the person
with schizophrenia does not identify with
reality at times.
6. schizophrenia
• Schizophrenia is well established as a brain disorder,
with structural and functional abnormalities visible in
neuroimaging studies and a genetic component as
seen in twin studies.
• The disorder is usually chronic, with a course
encompassing a prodromal phase, an active phase,
and a residual phase
7. Who Is Affected?
• Schizophrenia affects about 1 % of the world's
population
• Schizophrenia is most commonly diagnosed between
the ages of 16 to 30
• Schizophrenia can be hereditary (runs in families)
• Schizophrenia and its treatment has an enormous
effect on the economy.
8. Epidemiology of Schizophrenia
• Average age of onset:
–Males: 15 : 25
–Females: 20 : 30
–Range: Early childhood to 50’s/60’s
• Male slightly > female
9. Schizophrenia in Children?
• Schizophrenia in young children is rare.
• The National Institute of Mental Health
(NIMH) estimates only 1 in 40,000 children
experience the onset of schizophrenia
symptoms before the age of 13.
11. Positive ( Psychotic) Symptoms
• The "positive," or overtly psychotic, symptoms
are symptoms not seen in healthy people,
include:
• Delusions
• Hallucinations
• Disorganized speech or behavior
• Catatonia or other movement disorders
12. Clinical features:Delusions
(false fixed beliefs)
• Paranoid/persecutory
• Ideas of reference
• External locus of control
• Thought broadcasting
• Thought insertion,
withdrawal
• Jealousy
• Guilt
• Grandiosity
• Religious delusions
• Somatic delusions
13. Clinical features:
Formal Thought Disorders
• Neologisms
• Tangentiality
• Derailment
• Loosening of associations (word salad)
• Private word usage
• Perseveration
16. Negative (Deficit) Symptoms
• "Negative" symptoms disrupt normal emotions
and behaviors and include:
• Social withdrawal
• "Flat affect," dull or monotonous speech, and lack
of facial expression
• Difficulty expressing emotions
• Lack of self-care
• Inability to feel pleasure (anhedonia)
17. Cognitive Symptoms
• Cognitive symptoms may be most difficult to
detect and these include:
• Inability to process information and make
decisions
• Problems with memory or learning new tasks
18. Clinical features:
Mood and Affect
• Inappropriate affect
• Blunting of affect/mood
• Flat affect
• Isolation or dissociation of affect
• Incongruent affect
19. A. Two (or more) of the following, each present for a
significant portion of time during a 1-month period (or
less if successfully treated). At least one of these must
be 1, 2, or 3.
1) Delusions
2) Hallucinations
3) Disorganized speech (freq. derailment or
incoherence)
4) Grossly disorganized or catatonic behavior
5) Negative symptoms (i.e., diminished emotional
expression or avolition
Diagnosis of Schizophrenia:DSM-5
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
American Psychiatric Publishing, Washington DC, 2013
20. B. Social/occupational dysfunction
C. Duration: Continuous signs for at least 6 months
(psychosis + prodrome + residual sx)
D. Schizoaffective and psychotic mood disorder have
been excluded
E. Not attributable to substance or general medical
condition
F. Not a manifestation of a pervasive developmental
disorder
Diagnosis of Schizophrenia: DSM-5
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
American Psychiatric Publishing, Washington DC, 2013
21. Prodrome
• Highly variable in quality and duration
• May last from weeks to years
• May include cognitive, negative, attenuated
positive, and various other symptoms
22. Types of Schizophrenia
• There are five types of schizophrenia (discussed in
the following slides). They are categorized by the
types of symptoms the person exhibits when they
are assessed:
• Paranoid schizophrenia
• Disorganized schizophrenia
• Catatonic schizophrenia
• Undifferentiated schizophrenia
• Residual schizophrenia
23. Paranoid Schizophrenia
• Paranoid-type schizophrenia is distinguished by
paranoid behavior, including delusions and auditory
hallucinations. Paranoid behavior is exhibited by
feelings of persecution, of being watched, or
sometimes this behavior is associated with a famous
or noteworthy person a celebrity or politician, or an
entity such as a corporation. People with paranoid-
type schizophrenia may display anger, anxiety, and
hostility. The person usually has relatively normal
intellectual functioning and expression of affect.
24. Disorganized Schizophrenia
• A person with disorganized-type schizophrenia
will exhibit behaviors that are disorganized or
speech that may be bizarre or difficult to
understand. They may display inappropriate
emotions or reactions that do not relate to the
situation at-hand. Daily activities such as
hygiene, eating, and working may be
disrupted or neglected by their disorganized
thought patterns.
25. Catatonic Schizophrenia
• Disturbances of movement mark catatonic-type
schizophrenia. People with this type may vary
between extremes: they may remain immobile or
may move all over the place. They may say nothing
for hours, or they may repeat everything you say or
do. These behaviors put these people with catatonic-
type schizophrenia at high risk because they are
often unable to take care of themselves .
26. Undifferentiated Schizophrenia
• Undifferentiated-type schizophrenia is a
classification used when a person exhibits
behaviors which fit into two or more of the
other types of schizophrenia, including
symptoms such as delusions, hallucinations,
disorganized speech or behavior, catatonic
behavior.
27. Residual Schizophrenia
• When a person has a past history of at least
one episode of schizophrenia, but the
currently has no symptoms (delusions,
hallucinations, disorganized speech or
behavior) they are considered to have
residual-type schizophrenia. The person may
be in complete remission, or may at some
point resume symptoms.
29. Other psychotic disorders
• Brief Psychotic
• Schizophreniform
• Schizoaffective
• Delusional
• Substance-induced
Psychosis
• Psychosis d/t gen’l
medical disorder
• Other
– Persistent AH
– Attenuated psychosis
– Overlapping mood/delusions
– Partner of delusional pt.
• Unspecified
30.
31. What Are Causes of Schizophrenia?
• Schizophrenia has multiple, intermingled
causes which may differ from person to
person, including:
• Genetics (runs in families)
• Environment
• Brain chemistry
• History of abuse or neglect
33. Is Schizophrenia Hereditary?
• Schizophrenia has a genetic component. While
schizophrenia occurs in only 1% of the general
population, it occurs in 10% of people with a
first-degree relative (parent, sibling) with the
disorder. The risk is highest if an identical twin
has schizophrenia. It is also more common in
people with a second-degree relative (aunts,
uncles, cousins, grandparents) with the
disorder.
40. Glutamate, GABA and the NMDA
receptor
• Psychotomimetic effect of PCP (NMDA
antagonist)
• Abnormalities in glutamate levels,
release, receptors in schizophrenia
41. Neuro-natomical abnormalities
• Enlargement of lateral ventricles
• Smaller than normal total brain volume
• Cortical atrophy
• Widening of third ventricle
• Smaller hippocampus
42. Physiologic studies:
PET and SPECT
• Generally normal global cerebral flow
• Hypofrontality
• Failure to activate dorsolateral prefrontal
cortex (problem-solving, adaptation, coping
with changes)
44. Prognosis of Schizophrenia?
• The prognosis for people with schizophrenia can vary
depending on the amount of support and treatment
the patients receives. Many people with
schizophrenia are able to function well and lead
normal lives. However, people with schizophrenia
have a higher death rate and higher incidence of
substance abuse. When medications are taken
regularly and the family is supportive, patients can
have better outcomes.
50. Atypical antipsychotics:
• Broader spectrum of receptor activity
(Serotonin, dopamine, GABA)
• May be better at alleviating negative
symptoms and cognitive dysfunction
- Clozapine ; associated with agranulocytosis,
seizures
52. Schizophrenia Treatment -
Psychosocial Interventions
• Family psycho-education: It is important to
include psychosocial interventions in the
treatment of schizophrenia. Including family
members to support patients decreases the
relapse rate of psychotic episodes and
improves the person's outcomes. Family
relationships are improved when everyone
knows how to support their loved one dealing
with schizophrenia.
53. Psychosocial Treatment
• Education, compliance
• Hospitalize for acute loss of functioning
• Outpatient treatment is rehabilitative
• Psychoanalysis, exploratory therapies have
limited value
• Families should be involved
57. - Leads to suicide in ~10% of cases,
especially in first decade of illness
- SUBESTANCE ABUSE
58. Brief Psychotic Disorder
A. Presence of ≥1 of: delusions; hallucinations;
disorganized speech; grossly
disorganized/catatonic behavior
B. Duration of sx: ≥ 1 day, < 1 month; full return to
premorbid function
C. Not d/t mood, other psychotic disorder or
substances or gen’l med. Condition
D. Specifiers: w/ vs w/o marked stressors;
postpartum
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
American Psychiatric Publishing, Washington DC, 2013
59. Schizophreniform Disorder
A. Criteria A, D, & E of schizophrenia are met
B. Episode (including prodromal, active, residual
phases) lasts ≥ 1 month but <6 months
C. “Provisional” if waiting for 6-month point
D. Specifiers: w/ vs w/o good prognostic features;
w/ catatonia
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
American Psychiatric Publishing, Washington DC, 2013
60. Schizoaffective Disorder
A. Period of illness w/ either mania or major
depression and criteria A of schizophrenia
B. During same episode as above, delusions or
hallucinations x ≥2 weeks w/o mood sx
C. Prominent mood episodes throughout total
duration of illness
D. Not d/t substances, gen’l med. Condition
E. Specifiers: Bipolar/Depressive type
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
American Psychiatric Publishing, Washington DC, 2013
61. Delusional Disorder
A. Delusion(s) of ≥ 1 month duration
B. Criteria A of schizophrenia never fully met
C. Behavior & function not markedly impaired except as
affected by delusions
D. Total duration of mania or depression brief relative to
duration of delusions
E. Not d/t substances or gen’l med. condition
F. Specifiers: Erotomanic, grandiose, jealous, persecutory,
somatic, mixed; bizarre
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
American Psychiatric Publishing, Washington DC, 2013
62. Other causes of psychosis
Psychiatric illness
• Major depression
• Mania
• OCD
• Dementias
• Personality disorders (esp
BPD)
• Dissociative disorders
• Substance use
Non-psychiatric illness
• Epilepsy (TLE)
• Mass intracranial lesions
• Metabolic disorders
• Encepahlopathies
• Infection
• Autoimmune
• Nutritional
• Drugs & toxic states
63. What do we do?
Early intervention is important
Psychodeducation
Pharmacogenomic testing
CBT-P
Assisted Outpatient Probate (?)
Medications
