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Schizophrenia Overview
(part I)
Ewa Pilaczyńska-Jodkiewicz
What is schizophrenia?

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A chronic severe brain disorder; often
they hear voices, believe media are
broadcasting their thoughts to the
world or may believe someone is trying
to harm them.
In men it usually develops in teen years
and early 20s; in women it usually
develops in 20s and 30s.
Schizophrenia is the most
severe and debilitating mental
illness in psychiatry and is a
brain disorder
Definition


The schizophrenic disorders are characterized in general by
fundamental and characteristic distortions of thinking and
perception, and affects that are inappropriate or blunted.
Clear consciousness and intellectual capacity are usually
maintained although certain cognitive deficits may evolve in
the course of time.
The most important psychopathological phenomena include

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thought echo
thought insertion or withdrawal
thought broadcasting
delusional perception and delusions of control
influence or passivity
hallucinatory voices commenting or discussing the patient in the
third person
thought disorders and negative symptoms.
Diagnosis


Currently there is no physical or lab test
that can absolutely diagnose
schizophrenia.
A psychiatrist usually comes to the
diagnosis based on clinical symptoms.
Misdiagnosis


This is a common problem since
schizophrenia shares a significant
number of symptoms with other
disorders.
Per the Nat’l Depression & Bipolar
Support Alliance there is an average of
10 years from onset to correct diagnosis
& tx.
Schizophrenia


Schizophrenia occurs with regular frequency
nearly everywhere in the world in 1 % of
population and begins mainly in young age
(mostly around 16 to 25 years).
Schizophrenia is defined by


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a group of characteristic positive and negative
symptoms
deterioration in social, occupational, or
interpersonal relationships
continuous signs of the disturbance for at least 6
months
Schizophrenia


It has more impact on urban people
than rural people
It is a disease of the brain
Epidemiology


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M=F (equally man and women)
Females age of onset is generally later
– better outcome
Downward drift social-economically
Die younger – 10% suicide
History



Emil Kraepelin: This illness develops relatively early in
life, and its course is likely deteriorating and chronic;
deterioration reminded dementia („Dementia praecox“),
but was not followed by any organic changes of the brain,
detectable at that time.
Eugen Bleuler: He renamed Kraepelin’s dementia
praecox as schizophrenia (1911); he recognized the
cognitive impairment in this illness, which he named as a
„splitting“ of mind.
Kurt Schneider: He emphasized the role of psychotic
symptoms, as hallucinations, delusions and gave them the
privilege of „the first rank symptoms” even in the concept
of the diagnosis of schizophrenia.
Schizophrenia:
Historical Perspectives 1


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1893 Kraepelin distinguished “dementia
praecox” from manic-depressive psychosis
Emphasized course and prognosis
 Early onset
 Deteriorating course
 Dementia as the end state
An “organic” brain disorder
Schizophrenia:
Historical Perspectives 2


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1911 Bleuler coins “schizophrenia” in reference to
the splitting of mental functions
Emphasized psychological mechanisms
Four fundamental features (“the 4 A’s”)
 Loosening of Associations
 Autistic behavior and thought
 Disturbance in Affect
 Ambivalence
Psychosis = Accessory Symptoms
4 A (Bleuler)

Bleuler maintained, that for the diagnosis of schizophrenia
are most important the following four fundamental
symptoms:
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affective blunting
disturbance of association (fragmented thinking)
autism
ambivalence (fragmented emotional response)
These groups of symptoms, are called „four A’ s” and
Bleuler thought, that they are „primary” for this diagnosis.
The other known symptoms, hallucinations, delusions,
which are appearing in schizophrenia very often also, he
used to call as a “secondary symptoms”, because they
could be seen in any other psychotic disease, which are
caused by quite different factors — from intoxication to
infection or other disease entities.
Schizophrenia is not caused
by:
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Inadequate parenting
Overzealous mothers
Poor family relations
It is not split personality
Schizophrenia is a
heterogeneous illness

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Defined by a constellation of symptoms,
including psychosis
Multifactorial etiology, variable course
Social/occupational dysfunction a
required diagnostic criterion
Good treatment must address
symptoms and social/occupational
dysfunction
Etiology of schizophrenia
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Genetic
Structural brain changes
Functional brain changes
Dopamine hypothesis
What exactly might be the cause of Schizophrenia? Is there a concrete
explanation? The biological, cognitive, and behaviorist approaches all
have their different theories to resolve a cure for this disorder. Research
is revealing that schizophrenia is indeed a environmental impact during
the the development of the brain during pregnancy and childhood.
Another prediction is that is a result of the interaction of certain
variations of genes. These would be the damaged portions of genes.
The biological approach closely looks at the interaction between
the environment and genetics. Some might say that the biological
perspective is too radical, and reductionist, but it seems that
genetics due play a major role in the involvement of this disorder.
Research nowadays proposes the idea that schizophrenia is caused
by a genetic vulnerability which is coupled with the environmental
and psychological stressors. This is also known as the diathesisstress model. The idea basically says that whether the person
develops the disorder or not, for the most part it is determined by
the vulnerability.
In overall, as said before…the biological approach closely looks at
the genetic factors, and how they apply to the disorder. In this case,
if there is a genetic vulnerability, it is more likely for the person to
develop Schizophrenia.
Etiology of Schizophrenia

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The etiology and pathogenesis of
schizophrenia is not known
It is accepted, that schizophrenia is „the
group of schizophrenias“ which origin is
multifactorial:

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internal factors – genetic, inborn,
biochemical
external factors – trauma, infection of CNS,
stress
Structural Brain Abnormalities in
Schizophrenia

~40% increase in 3rd and lateral
ventricular volumes
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Associated with more
neuropsychological impairments and
negative symptoms
More prominent in males
3-4% decrease in whole brain
volume
Structural changes in brain

Increased loss of gray matter in
adolescence
Structural changes in brain

Hippocampus, amygdala,
parahippocamp.

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Smaller in affected twin
Disordered hippocampal pyramidal cells
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Correlation between cell disorder and severity
May be due to maternal influenza in 2nd
trimester
Also in entorhinal, cingulate,
parahippocampal cortex
Structural changes in brain

Larger ventricles

Subgroup: inverse correlation between
ventricle size and response to drugs
Structural Brain Abnormalities in
Schizophrenia

Hippocampus and Association
Cortices
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Decreased gray matter volume
No cell loss
Reductions in pre- and post-synaptic
markers
Structural Brain Abnormalities in
Schizophrenia
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Mediodorsal thalamic nucleus
 Decreased volume
 ~30% Decrease in neuronal
number
Structural Brain Abnormalities in
Schizophrenia

Convergent lines of evidence
indicate that schizophrenia is
associated with
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A reduction in synaptic connections in
the hippocampus and cerebral cortex.
Fewer neurons in the mediodorsal
thalamus.
Which neurotransmitter systems
are involved in these
Schizophrenia as a Genetic
Disorder

The morbid risk of schizophrenia
increases in relation to the
percentage of genes shared with
an affected individual.
Genetics of Schizophrenia
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Many psychiatric disorders are multifactorial
(caused by the interaction of external and
genetic factors) and from the genetic point of
view very often polygenically determined.
Relative risk for schizophrenia is around:

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1% for normal population
5.6% for parents
10.1% for siblings
12.8% for children
It seems that Identical Twins hold the highest risk percentage to
obtain this disorder…might this have a biological connection?
Schizophrenia and Genetic
Risk
relationship
% shared genes relative risk
Gen population NA
1%
3rd degree
12.5%
2%
2nd degree
25%
2-6%
1st degree
50%
6-17%
Both parents
100%
46%
Identical twin
100%
48%
The familial nature of schizophrenia is NOT
due simply to a shared environment
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The risk of schizophrenia is ~17% for fraternal twins and
~48% for identical twins.
The risk for adopted-away biological children of individuals
with schizophrenia…
 is elevated as expected for first-degree relatives.
 higher than rates of schizophrenia present in their adoptive
families.
 higher than rates of schizophrenia in the adopted-away
offspring of unaffected parents.
Dopamine hypothesis
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Amphetamine (very high doses)  paranoia,
delusions, auditory hallucination
Amphetamines worsen schizophrenia
symptoms
Effects blocked by dopamine antagonist
chlorpromazine (Thorazine)
Typical antipsychotics block D2 receptors and
alleviate positive symptoms.
Brain Dopamine Pathways
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Nigrostriatal
degenerates in Parkinson’s disease
Mesolimbic
positive symptoms of schizophrenia
Mesocortical
negative symptoms of schizophrenia
Tuberoinfundibular
Mesolimbic DA Hypothesis

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Hyperactivity of mesolimbic DA
mediates positive symptoms of
psychosis
Accounts for these psychotic
symptoms whether in SZ or other
disorders
Mesocortical DA Hypothesis

Deficit of mesocortical DA mediates
negative and cognitive symptoms of
psychosis
- more controversial
- degenerative in some SZ patients
- may be primary deficit
- may be secondary drug effect
Etiology of Schizophrenia Dopamine Hypothesis

The most influential and plausible are the hypotheses,
based on the supposed disorder of neurotransmission in the
brain, derived mainly from
1.
2.
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the effects of antipsychotic drugs that have in common the ability to
inhibit the dopaminergic system by blocking action of dopamine in
the brain
dopamine-releasing drugs (amphetamine, mescaline, diethyl amide
of lysergic acid - LSD) that can induce state closely resembling
paranoid schizophrenia
Classical dopamine hypothesis of schizophrenia: Psychotic
symptoms are related to dopaminergic hyperactivity in the
brain. Hyperactivity of dopaminergic systems during
schizophrenia is result of increased sensitivity and density
of dopamine D2 receptors in the different parts of the brain.
Dopamine blockade effects
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Limbic and frontal cortical regions:
antipsychotic effect
Basal ganglia: Extrapyramidal side
effects (EPS)
Hypothalamic-pituitary axis:
hyperprolactinemia
Deficits in Prefrontal Cortical
Dopamine Neurotransmission in
Schizophrenia
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Normal function of the DLPFC depends upon
appropriate stimulation of dopamine D1 receptors
Individuals with schizophrenia may have
 Decreased dopamine axons in the DLPFC
 Increased levels of D1 receptors in the DLPFC
 Improvement in DLPFC function with dopamine
agonists
Dopamine Neurotransmission in
Schizophrenia
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The cognitive symptoms of
schizophrenia may be associated with
a functional deficit of dopamine at D1
receptors in the prefrontal cortex.
The psychotic features of
schizophrenia may be associated with
a functional excess of dopamine at D2
receptors in the striatum
(caudate/putamen).
But, Schizophrenia Also Appears to
be Associated with an Excess of
Dopamine Neurotransmission
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Amphetamines can induce
psychotic symptoms.
All antipsychotic drugs share
antagonism of the dopamine D2
receptor.
Subjects with schizophrenia show
excess release of dopamine in the
striatum.
Catechol-O-methyltransferase
(COMT)
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Enzyme involved in the metabolic degradation of
dopamine.
COMT appears to be the major contributor to the
termination of dopamine action in the prefrontal
cortex due to low levels of the dopamine
transporter.
Single guanine to adenine transition (common)
changes val to met at codon 108.
Val-COMT has 4-fold greater activity than metCOMT, leading to decreased prefrontal dopamine
levels.
Schizophrenic individuals with val/val COMT show
greater impairments on working memory
Etiology of Schizophrenia Contemporary Models
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Dopamine hypothesis revisited: various
neurotransmitter systems probably takes place in the
etiology of schizophrenia (norepinephric,
serotonergic, glutamatergic, some peptidergic
systems); based on effects of atypical antipsychotics
especially.
Contemporary models of schizophrenia conceptualize
it as a neurocognitive disorder, with the various signs
and symptoms reflecting the downstream effects of a
more fundamental cognitive deficit:
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the symptoms of schizophrenia arise from “cognitive
dysmetria” (Nancy C. Andreasen)
concept of schizophrenia as a neurodevelopmental disorder
(Daniel R. Weinberger)
Schizophrenia as an Environmental
Disorder
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A variety of “environmental” events appear to
increase the risk for schizophrenia:
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Pregnancy and labor/delivery complications
Late winter/early spring births
Urban place of birth and rearing
Advanced paternal age
However, the predictive value of all of these risk
factors is low.
Etiology of Schizophrenia Neurodevelopmental Model
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Neurodevelopmental model supposes in schizophrenia
the presence of “silent lesion” in the brain, mostly in the
parts, important for the development of integration
(frontal, parietal and temporal), which is caused by
different factors (genetic, inborn, infection, trauma...)
during very early development of the brain in prenatal or
early postnatal period of life.
It does not interfere too much with the basic brain
functioning in early years, but expresses itself in the
time, when the subject is stressed by demands of
growing needs for integration, during formative years in
adolescence and young adulthood.
Schizophrenia as a
Neurodevelopmental Disorder

During childhood and adolescence,
individuals who subsequently manifest
schizophrenia may exhibit…
 Motor abnormalities
 Social abnormalities
 Impairments in IQ and school
performance
Schizophrenia as a
Neurodevelopmental Disorder
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Early model: Brain lesion from early in life
remains clinically silent until normal
developmental processes during
adolescence bring the structures affected
by the lesion “on line.”
Late model: Brain dysfunction arises as a
result of altered brain development (e.g.,
synaptic pruning) during adolescence.
“The Behaviourist Approach interprets abnormal behavior as simply
maladaptive learning.”
From this, the behaviourist approach would then say that
Schizophrenia is not regarded at all differently to other forms of
abnormal behaviour.
In other words, the behaviourist approach would actually see the
term Schizophrenia as having no etiological value.
Although the behaviourist approach does not believe that there
seems to be an etiology for this disorder, it does have a number of
different treatments for it, such as token economy.
Schizophrenia affects multiple complex
brain systems as evidenced by the range
of clinical features
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Positive symptoms: Delusions, hallucinations,
thought disorder
Negative symptoms: Decreased motivation,
diminished emotional expression
Cognitive deficits: Impairments in attention,
executive function, certain types of memory
Sensory abnormalities: “Gating” disturbances
Sensorimotor abnormalities: Eye tracking
disturbances
Motor abnormalities: Posturing, impaired
coordination
Features of Schizophrenia
Negative symptoms
Positive
symptoms
Functional Impairments
Work
Interpersonal relationships
Self-care
Cognitive deficits
Mood symptoms
Disorganizatio
n
Positive Symptoms (Psychosis)


Disturbance of Perception (Hallucinations)
Disturbance of Thought Content
(Delusions)
Features of Schizophrenia
Positive symptoms
Delusions
Hallucinations
Functional Impairments
Work/school
Interpersonal relationships
Self-care
Cognitive deficits
Attention
Memory
Verbal fluency
Executive function
(eg, abstraction)
Disorganization
Speech
Behavior
Negative symptoms
Anhedonia
Affective flattening
Avolition
Social withdrawal
Alogia
Mood symptoms
Depression/Anxiety
Aggression/Hostility
Suicidality
Positive Symptoms
Disturbance of Perception
 may effect any sensory
modality
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
Positive Symptoms: Hallucinations
Other Sensory Modalities
• Tactile: may involve electrical, tingling,
or burning sensations
• Visual
• Gustatory
• Olfactory
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 Schizophrenia
Positive symptoms
- Hallucinations
- Delusions
Negative symptoms
Functional Impairments
Work
Interpersonal relationships
Self-care
Cognitive deficits
Mood symptoms
Disorganization
Negative Symptoms
Negative symptoms include:
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decreased expression of feelings
diminished emotional range
poverty of speech
decreased interests
diminished sense of purpose
diminished social drive
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
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

Positive Symptoms: Disorganization
• Disorganization of Speech
– tangential or circumstantial speech
– looseness of associations
• Disorganization of Behavior
– odd mannerisms
– catatonic stupor
Features of Schizophrenia
Positive symptoms
- Delusions
- Hallucinations
- Disorganization
Functional Impairments
Work
Interpersonal relationships
Self-care
Cognitive deficits
Negative symptoms
-  emotional range
-  expression of
emotion
-  motivation/drive
-  interests
-  social drive
- poverty of speech
Mood symptoms
Disorganization
Cognitive Domains:
Severe Impairment in Schizophrenia
Severe Impairments
– Serial learning
– Executive
functioning
– Vigilance
– Motor speed
– Verbal Fluency
Moderate Impairment
– Delayed recall
– Distractibility
– Immediate memory
span
– Visuomotor skills
– Working memory
Cognitive Deficits in
Schizophrenia: Core Features of
the Illness

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Present in individuals at high risk
Premorbid and prodromal phase
marker
Persistent (progressive?) during
illness
Predictor of long-term outcome
Diagnosis of Schizophrenia
A. Characteristic symptoms
-Delusions
-Hallucinations
-Disorganized speech
-Grossly disorganized or catatonic behavior
-Negative symptoms
B. Social/occupational dysfunction
C. Overall duration > 6 months
D. Exclude mood disorders, drugs, pervasive
developmental disorders
Positive Symptoms
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Additions to normal function
Delusions
Hallucinations
Distorted language/communication
Disorganised speech / behaviour
Catatonic behaviour
Agitation
Negative Symptoms
Losses of normal function
-Affective flattening
-Alogia
-Avolition
-Anhedonia
-Attentional impairment

Blunted affect, emotional withdrawal, poor rapport,
passivity, apathetic, social withdrawal
Cognitive Symptoms

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
Thought disorder
Odd use of language
incoherence, loose associations, neologisms
Impaired attention / cognition
reduced verbal fluency
learning/memory
executive functions
Subtypes of schizophrenia
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Paranoid
Disorganized
Catatonic
Undifferentiated
Residual
Course of Illness

Course of schizophrenia:
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continuous without temporary improvement
episodic with progressive or stable deficit
episodic with complete or incomplete remission
Typical stages of schizophrenia:
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prodromal phase
active phase
residual phase
Clinical Picture

Diagnostic manuals:
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
lCD-10 („International Classification of Disease“, WHO)
DSM-IV („Diagnostic and Statistical Manual“, APA)
Clinical picture of schizophrenia is according to lCD-10,
defined from the point of view of the presence and
expression of primary and/or secondary symptoms (at
present covered by the terms negative and positive
symptoms):



the negative symptoms are represented by cognitive disorders,
having its origin probably in the disorders of associations of
thoughts, combined with emotional blunting and small or missing
production of hallucinations and delusions
the positive symptom are characterized by the presence of
hallucinations and delusions
the division is not quite strict and lesser or greater mixture of
symptoms from these two groups are possible
Positive and Negative Symptoms
Negative
Alogia
Affective flattening
Avolition-apathy
Anhedonia-asociality
Positive
Hallucinations
Delusions
Bizarre behaviour
Positive formal
thought disorder
Attentional impairment
Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In: Schizophrenia, Hirsch S.R.
and Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995
The Criteria of Diagnosis
For the diagnosis of schizophrenia is necessary

presence of one very clear symptom - from point a) to d)
 or the presence of the symptoms from at least two groups - from
point e) to h)
for one month or more:
a) the hearing of own thoughts, the feelings of thought withdrawal,
thought insertion, or thought broadcasting
b) the delusions of control, outside manipulation and influence, or the
feelings of passivity, which are connected with the movements of the
body or extremities, specific thoughts, acting or feelings, delusional
perception
c) hallucinated voices, which are commenting permanently the behavior
of the patient or they talk about him between themselves, or the
other types of hallucinatory voices, coming from different parts of
body
d) permanent delusions of different kind, which are inappropriate and
unacceptable in given culture
The Criteria of Diagnosis
e) the lasting hallucination of every form
f) blocks or intrusion of thoughts into the flow of thinking and
resulting incoherence and irrelevance of speach, or neologisms
g) catatonic behavior
h) „the negative symptoms”, for instance the expressed apathy, poor
speech, blunting and inappropriatness of emotional reactions
i) expressed and conspicuous qualitative changes in patient’s
behavior, the loss of interests, hobbies, aimlesness, inactivity, the
loss of relations to others and social withdrawal


Diagnosis of acute schizophorm disorder (F23.2) – if the conditions
for diagnosis of schizophrenia are fulfilled, but lasting less than one
month
Diagnosis of schizoaffective disorder (F25) - if the schizophrenic and
affective symptoms are developing together at the same time
DSM-IV Schizophrenia

2 or more of the following for most of 1 month:

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


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


Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
Social/occupational dysfunction
Duration of at least 6 months
Not schizoaffective disorder or a mood disorder
with psychotic features
Not due to substance abuse or a general
medical disorder
F20-F29 Schizophrenia, Schizotypal
and Delusional Disorders
F20
F20.0
F20.1
F20.2
F20.3
F20.4
F20.5
F20.6
F20.8
F20.9
Schizophrenia
Paranoid schizophrenia
Hebephrenic schizophrenia
Catatonic schizophrenia
Undifferentiated schizophrenia
Post-schizophrenic depression
Residual schizophrenia
Simple schizophrenia
Other schizophrenia
Schizophrenia, unspecified
F20-F29 Schizophrenia, Schizotypal
and Delusional Disorders
F21
Schizotypal disorder
F22
F22.0
F22.8
F22.9
Persistent delusional disorders
Delusional disorder
Other persistent delusional disorders
Persistent delusional disorder, unspecified
F23
F23.1
Acute and transient psychotic disorders
Acute polymorphic psychotic disorder with symptoms
of schizophrenia
Acute schizophrenia-like psychotic disorder
Other acute predominantly delusional psychotic
disorders
Other acute and transient psychotic disorders
Acute and transient psychotic disorder, unspecified
F23.2
F23.3
F23.8
F23.9
F20-F29 Schizophrenia, Schizotypal
and Delusional Disorders
F24
Induced delusional disorder
F25
F25.0
F25.1
F25.2
F25.8
F25.9
Schizoaffective disorders
Schizoaffective disorder, manic type
Schizoaffective disorder, depressive type
Schizoaffective disorder, mixed type
Other schizoaffective disorders
Schizoaffective disorder, unspecified
F28
Other nonorganic psychotic disorders
F29
Unspecified nonorganic psychosis
Symptoms

Positive symptoms: common schizophrenia behaviors




Delusions: false beliefs kept despite contrary evidence. (believing
you are the Virgin Mary)
Hallucinations: false perceptions (usually hearing voices)
mental disturbance: illogical thought, incoherent speech, word
usage shifts.
Negative Symptoms: absence of expected behavior




Physical immobility
No emotional expression
Little speech
Withdrawal from social world
Schizophrenia: the affected
person may:





Talk to himself
Gesture to himself
Dress in layers in any weather
Fail to bathe and get a haircut
Gain an odd interest in ordinary things
(like religion)
Schizophrenia: the affected
person may:





May even believe he is God
See things
Feel people are out to get them
Believe in all sorts of conspiracies
Have ideas that no amount of evidence
to the contrary can dislodge
Schizophrenia: the affected
person may:






Be unable to work
Stop talking or greatly reduce
conversation
Appear lazy, unmotivated and
uninterested
May look like he has dementia
Lose the ability to get and keep friends
Be tense
Positive Symptoms

Delusions. Those where the patient
thinks he is being followed or watched
are common; also the belief that
people on TV, radio are directing special
messages to him/her.
Positive Symptoms


Hallucinations. Distortions or
exaggerations of perception in any of
the senses.
Often they hear voices within their own
thoughts followed by visual
hallucinations.
Positive Symptoms

Disorganized thinking/speech.
loose associations; speech is tangential,
loosely associated or incoherent enough
to impair communication.
Positive Symptom



Grossly disorganized behavior.
Difficulty in goal directed behavior
(ADLs), unpredictable agitation or
silliness, social disinhibition, or bizarre
behavior.
There is a purposelessness to behavior.
Positive Symptom


Catatonic behavior.
Marked decrease in reaction to
immediate environment, sometimes just
unaware of surroundings, rigid or
bizarre postures, aimless motor activity.
Other Positive Symptoms





Inappropriate response to stimuli
Unusual motor behavior (pacing,
rocking)
Depersonalization
Derealization
Somatic preoccupations
Summary of Positive
Symptoms






Delusions
Hallucinations
Disorganized thinking
Disorganized behavior
Catatonic behavior
Inappropriate responses
Positive Symptoms


Positive symptoms are those that have
a positive reaction from some
treatment.
In other words, positive symptoms
respond to treatment.
Negative Symptoms


Those that appear to reflect a
diminution or loss of normal functions.
May be difficult to evaluate because
they are not as grossly abnormal as
positive symptoms.
Negative Symptoms


Affective flattening.
Reduction in the range and intensity of
emotional expression, including facial
expression, voice tone, eye contact and
body language.
Negative Symptom


Alogia (poverty of speech)
Lessening of speech fluency and
productivity, thought to reflect slowing
or blocked thoughts; often manifested
as short, empty replies to questions.
Negative Symptom


Avolition
The reduction, difficulty or inability to
initiate and persist in goal-directed
behavior. Often mistaken for apparent
disinterest.
Examples of Avolition




No longer interested in going out with
friends
No longer interested in activities that
the person used to show enthusiasm
No longer interested in anything
Sitting in the house for hours or days
doing nothing
Disorganized Symptoms


This one is somewhat new and may not
be considered valid.
It is thought disorder, confusion,
disorientation and memory problems.
Summary of Negative Symptoms








Lack of emotion
Low energy
Lack of interest in life
Affective flattening
Alogia
Inappropriate social skills
Inability to make friends
Social isolation
Cognitive Symptoms

Difficulties in concentration and
memory:







Disorganized thinking
Slow thinking
Difficulty understanding
Poor concentration
Poor memory
Difficulty expressing thoughts
Difficulty integrating thoughts, feelings,
behaviors
Negative Symptoms

Currently there is no treatment that has
a consistent impact on negative
symptoms.
What are the symptons
associated with the different
types of schizophrenia?
Paranoid Schizophrenia




Delusions, hallucinations, misinterpretation of facts
Violent, suicidal behavior - high risk
Ex: patient images that he is someone else or
someone is trying to harm him.
Imaginary voices
F20.0 Paranoid Schizophrenia


Paranoid schizophrenia is characterized
mainly by delusions of persecution, feelings
of passive or active control, feelings of
intrusion, and often by megalomanic
tendencies also. The delusions are not usually
systemized too much, without tight logical
connections and are often combined with
hallucinations of different senses, mostly with
hearing voices.
Disturbances of affect, volition and speech,
and catatonic symptoms, are either absent or
relatively inconspicuous.
Paranoid Schizophrenia


Persons are very suspicious of others
and often have grand schemes of
persecution at the root of their
behavior.
During this phase they may have
hallucinations and frequent delusions.
F20.1 Hebephrenic Schizophrenia



Hebephrenic schizophrenia is characterized by
disorganized thinking with blunted and inappropriate
emotions. It begins mostly in adolescent age, the behavior
is often bizarre. There could appear mannerisms,
grimacing, inappropriate laugh and joking,
pseudophilosophical brooding and sudden impulsive
reactions without external stimulation. There is a tendency
to social isolation.
Usually the prognosis is poor because of the rapid
development of "negative" symptoms, particularly
flattening of affect and loss of volition. Hebephrenia should
normally be diagnosed only in adolescents or young adults.
Denoted also as disorganized schizophrenia
Hebephrenic Schizophrenia



Disorganized schizophrenia; characterized by
emotionless, incongruous, or silly behavior,
intellectual deterioration, frequently
beginning insidiously during adolescence.
May be verbally incoherent and may have
moods and emotions that are not appropriate
to the situation.
Hallucinations not usually present.
Catatonic Schizophrenia






Negative Symptoms
Abnormal posture/movements
Repeated motions
Motionlessness
Inactivity/Excitement periods
Impulsiveness
F20.2 Catatonic Schizophrenia


Catatonic schizophrenia is characterized mainly by
motoric activity, which might be strongly
increased (hypekinesis) or decreased (stupor), or
automatic obedience and negativism.
We recognize two forms:


productive form — which shows catatonic excitement,
extreme and often aggressive activity. Treatment by
neuroleptics or by electroconvulsive therapy.
stuporose form — characterized by general inhibition of
patient’s behavior or at least by retardation and
slowness, followed often by mutism, negativism,
fexibilitas cerea or by stupor. The consciousness is not
absent.
Catatonic Schizophrenia


Person is extremely withdrawn,
negative and isolated.
May have marked psychomotor
disturbances.
F20.5 Residual Schizophrenia

A chronic stage in the development of
schizophrenia with clear succession from the
initial stage with one or more episodes
characterized by general criteria of
schizophrenia to the late stage with longlasting negative symptoms and deterioration
(not necessarily irreversible).
Residual Schizophrenia


Lacks motivation and interest in day-today living.
Person is not usually having delusions,
hallucinations or disorganized speech.
F20.4 Postschizophrenic
Depression


A depressive episode, which may be
prolonged, arising in the aftermath of a
schizophrenic illness. Some schizophrenic
symptoms, either „positive“ or „negative“,
must still be present but they no longer
dominate the clinical picture.
These depressive states are associated with
an increased risk of suicide.
F20.6 Simple Schizophrenia


Simple schizophrenia is characterized by early
and slowly developing initial stage with
growing social isolation, withdrawal, small
activity, passivity, avolition and dependence
on the others.
The patients are indifferent, without any
initiative and volition. There is not expressed
the presence of hallucinations and delusions.
Schizoaffective Disorder

There will be symptoms of
schizophrenia as well as mood disorder
(depression, bipolar, mixed mania).
Undifferentiated Schizophrenia


Conditions meeting the general
diagnostic criteria for schizophrenia but
not conforming to any of the previous
types.
Exhibits more than one of the previous
types without a clear dominance of one.
Summary


Before a diagnosis the psychiatrist must
make a thorough evaluation including a
physical/medical exam, a mental status
exam, appropriate labs, and a full
history.
History includes changes in thinking,
behavior, movement, mood, etc. as
seen by the family.
Increased Mortality Rates for Medical
Disorders in schizophrenia
50% increased risk of death from
medical causes in schizophrenia, and
20% shorter lifespan
(Harris et al. Br J Psychiatry
1998;173:11)
123
Medical Comorbidity With Schizophrenia
Is Very Common
Physical Disease With Increased Frequency in Schizophrenia








Tuberculosis
HIV++
Hepatitis B/C
Osteoporosis/decreased bone
mineral density
Poor dental status
Impaired lung function
Sexual dysfunction
Extrapyramidal side effects of
antipsychotic drugs; motor signs
in antipsychotic-naive patients






Obstetric complications++
Hyperprolactinemia-related side
effects of antipsychotics (eg,
irregular menses, galactorrhea)
Cardiovascular problems++
Hyperpigmentation (side effect of
chlorpromazine)
Obesity++, diabetes,
hyperlipidemia, metabolic
syndrome
Thyroid dysfunction
(++) very good evidence for increased risk (eg, population-based studies).
124
Conclusions



Morbidity in terms of rates of a number
of physical illnesses is clearly increased
in schizophrenia.
The amount and quality of
epidemiolgical studies found in some
areas – especially some hot topics –
could be better (e.g. obesity where
more work is underway)
Surprising medical particularities such
125