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SCHIZOPHRENIA
PHENOMENOLOGY AND CLINICAL
FEATURES
BY MARLIES JANSEN
CONSULTANT ADULT PSYCHIATRIST
SCHIZOPHRENIA
• EARLY GREEKS DESCRIBED DELUSIONS OF GRANDEUR, PARANOIA,
DECLINE IN COGNITIVE FUNTIONING AND PERSONALITY
• SINCE 18TH CENTURY SCHIZOPHRENIA AS CONDITION RECOGNISED
• 19TH CENTURY VARIOUS PSYCHOTIC DISORDERS DESCRIBED AS ‘INSANITY’
OR ‘MADNESS’ - ‘REGRETTABLE AFFLICITONS’ RATHER THAN
‘REPREHENSIBLE BEHAVIOUR’.
• MAJOR BREAKTHROUGH WITH THE IDENTIFICATION AND TREATMENT OF
‘GENERAL PARESIS OF THE INSANE’ OR SYPHILITIC INSANITY –THEN
COMMON, WITH A LOT OF SYMPTOM OVERLAP WITH SCHIZOPHRENIA
• LATE 19TH CENTURY EMIL KRAEPELIN FURTHER SEPARATED OUT MANICDEPRESSIVE PSYCHOSIS AND DEMENTIA PRAECOX (HEBEPHRENIA,
PARANOIA AND CATATONIA)
EUGEN BLEULER (1911)
DEMENTIA NOT COMMON: DEMENTIA PRAECOX > ‘SCHIZOPHRENIA’
CENTRAL : DISASSOCIATION
• BETWEEN THOUGHTS
• BETWEEN THOUGHT, EMOTION AND BEHAVIOUR
eg
-LAUGHING WHEN SOMEONE CLOSE HAS DIED
-MAGICAL THINKING
-THOUGHT DISORDER
-SUDDEN ANGRY BEHAVIOUR WITHOUT FEELING ANGRY
DEPENDING ON THE PERSON’S ADAPTIVE CAPACITY AND ENVIRONMENT:
PRIMARY (DISASSOCIATION) SYMPTOMS LEAD TO SECONDARY SYMPTOMS,
HALLUCINATIONS, DELUSIONS, SOCIAL WITHDRAWAL, DIMINISHED DRIVE.
SCHIZOPHRENIA AS A CONCEPT
SINGLE DISEASE MODEL
WITH VARIOUS MANIFESTATIONS (AS IN IDDM,
SYPHILITIC INSANITY)
CHANGED WITH BLEULER TO:
SCHIZOPHRENIA A CLINICAL SYNDROME
WITH VARIOUS MANIFESTATIONS, NOT ONE
SINGLE DISEASE
SCHIZOPHRENIA -CLINICAL SYNDROME
SUFFICIENT COMMUNALITY OF SYMPTOMS TO DIFFERENTE
FROM AFFECTIVE DISORDERS, DRUG-INDUCED ETC
BUT:
•
•
•
•
•
LACK OF EVIDENCE THAT IT IS A SINGLE DISORDER,
MULTIFACTORIAL ORIGIN, INCLUDING MULTIPLE GENES
CLINICAL HETEROGENEITY
RANGE OF CLINICAL COURSES
DIFFERENT TREATMENT RESPONSES
GENETICS
• FAMILY STUDIES VALIDATED KRAEPELIN’S SEPARATION
MANIC-DEPRESSIVE PSYCHOSIS VS DEMENTIA PRAECOX
• CONCORDANCE RATES IN MONOZYGOTE TWINS CONFIRM
SEPARATION SCHIZOPHRENIA- MAJOR AFFECTIVE DISORDERS
• SOME SUBTYPES OF SCHIZOPHRENIA BREED TRUE, eg DEFICIT
SCHIZOPHRENIA (1O NEGATIVE SYMPTOMS) – INCREASED RISK
SZ WITH LESS RISK OF OTHER MENTAL ILLNESS IN FAMILY.
• CERTAIN CHROMOSOMAL AREAS > A GENERAL LIABILITY TO
MAJOR MENTAL ILLNESSES OF VARIOUS DIAGNOSES
NOSOLOGY
OUR CURRENT CLASSIFICATION OF PSYCHOTIC
DISEASES (ICD10, DSM-IV) IS LIKELY TO BE
CHALLENGED,
FUTURE NOSOLOGY GUIDED BY DEVELOPMENTS
IN GENETICS, MOLECULAR BIOLOGY, NEUROIMAGING GUIDING OUR UNDERSTANDING OF
AETIOLOGY AND PATHOPHYSIOLOGY.
SCHIZOPHRENIA
PSYCHOTIC SYMPTOMS
BUT ALSO:
• DISTURBANCES OF THOUGHT
• DISTURBANCES OF EMOTION
• DISTURBANCES OF BEHAVIOUR
IT IS A:
• A NEURO-DEVELOPMENTAL DISORDER IN WHICH
PSYCHOSIS IS FOUND
• AFFECTING MANY BRAIN FUNCTIONS
• MANIFESTATIONS IN BODY IE, OUTSIDE THE BRAIN
FIRST RANK SYMPTOMS- KURT SCHNEIDER
• AUDIBLE THOUGHTS – HALLUCINATIONS IDENTIFIED AS OWN
THOUGHTS
• VOICES ARGUING – 3ED PERSON HALLUCINATIONS
• RUNNING COMMENTARY – AUDITORY HALLUCINATIONS
• SOMATIC PASSIVITY EXPERIENCES – STRANGE INFLUENCES
AFFECT BODY, EG DEVICES, RAYS
• THOUGHT WITHDRAWAL AND INSERTION
• THOUGHT BROADCAST – THOUGHTS NOT PRIVATE
• DELUSIONAL PERCEPTION - ACTUAL PERCEPTION BUT
ABNORMAL SELF REFERENCED MEANING, DISTURBANCE OF
THOUGHT
• DELUSIONS OF CONTROL OF FEELINGS, DRIVES AND
VOLITION
FEQUENCY OF SYMPTOMS
WESTERN EUROPE (n=1,000, PSE, WHO)
•
•
•
•
•
•
•
•
•
LACK OF INSIGHT
SUSPICIOUSNESS
DELUSIONS OF PERSECUTION
IDEAS OF REFERENCE
DELUSIONS OF REFERENCE
FLAT AFFECT
AUDITORY HALLUCINATIONS
SECOND PERSON HALLUCINATIONS
THOUGHT ALIENATION
88
59
63
60
60
68
40
39
50
%
DSM-IV AND ICD-10
• NO VALIDATED MARKERS FOR THE DIAGNOSIS
• DIAGNOSIS BY EXCLUSION AS WELL AS SYMPTOMS PATTERNS
• CLASSIFICATIONS LARGELY CONCORDANT AND ‘FIELD TESTED’
• MAJOR DIFFERENCES:
• DURATION OF SYMPTOMS: DSM 6/12, ICD 1/12
• DETERIORATION IN SOCIAL AND OCCUPATIONAL
FUNCTIONING DSM +, ICD –
• SIMPLE SCHIZOPHRENIA(NO PSYCHOSIS) ICD ONLY
DSM-IV
SYMPTOMS FOR 1 MONTH (OR LESS IF SUCCESSFULLY TREATED)
CRITERION A
 ONLY 1 SYMPTOMS NEEDED IF:
• RUNNING COMMENTARY
• 2 OR MORE VOICES CONVERSING
• BIZARRE DELUSION
 OTHERWISE 2 SYMPTOMS OUT OF HALLUCINATIONS, DELUSIONS,
DISORGANISED SPEECH, GROSSLY DISORGANISED OR CATATONIC
BEHAVIOUR
OR
 ONE OF THESE PSYCHOTIC SYMPTOMS PLUS A NEGATIVE SYMPTOM
(BLUNTED AFFECT,ALOGIA, AVOLITION)
NO DISTINCTION BETWEEN 1O OR 2O NEGATIVE SYMPTOMS
DSM-IV
CRITERION B
CRITERION C
CRITERION D
CRITERION E
CRITERION F
OCCUPATIONAL AND SOCIAL
DYSFUNCTION
DURATION: AT LEAST 6/12
INCL, AT LEAST 1/12 OF CRITERION A
SYMPTOMS
INCL PRODROMAL, RESIDUAL
EXCLUDE SCHIZO-AFFECTIVE /
MOOD DISORDER
NOT SU OR MEDICAL CONDITION
IF AUTISM: 1/12 PROMINENT
PSYCHOSIS
ICD-10
SEE SEPARATE PAGE
DIAGNOSIS
DIAGNOSTIC INSTRUMENT: PSE (PRESENT SATTE EXAMINATION
SEVERITY:
BPRS, PANSS, SANS
(BRIEF PSYCH RATING SCALE, POS AND NEG SYNDROME SCAL, SCALE FOR ASSESSMENT OF NEG SYMPTOMS)
PHASES OF ILLNESS -PRECLINICAL
CHILDHOOD- ADOLESCENCE
• POOR SOCIAL RELATIONSHIPS
• MILD MOTOR ABNORMALITIES (MILD, ABNORMAL
INVOLUNTARY MOVEMENTS, POOR COORDINION)
• COGNITIVE PROBLEMS (POOR MEMORY, PROCESSING SPEED,
ATTENTION)
SOME PTS HAVE MANY, OTHER NO SUCH SYMPTOMS
PHASES OF ILLNESS - PRODROMAL
• PERIOD OF DETERIORATION PRIOR TO FRANK
PSYCHOSIS (WEEKS, YEARS)
• DETERIORATION OF FUNCTIONING SOCIALLY,
SCHOOL
• INCREASING ISOLATION AND DISTRESS, OFTEN
ANXIETY AND DEPRESSION
PHASES OF ILLNESS - PSYCHOSIS
•
AGE OF ONSET ADOLESENCE/EARLY ADULT, SLIGHTLY LATER FOR WOMEN (SECOND
PEAK AROUND AGE 60)
•
ONSET INSIDEOUS OR ACUTE
•
GREAT VARIATION IN SYMPTOMS:
– PSYCHOTIC SYMTOMS ( HALLUCINATIONS, DELUSIONS, DISORGANISATION, THOUGHT
DISORDER)
– NEGATIVE SYMPTOMS
– CO-MORBID -NEURODEVELOPMENTAL
-OCD, ANXIETY, DEPRESSION, POLYDIPSIA
•
•
•
RESPONSE TO TREATMENT
COURSE OF ILLNESS (SOME NEVER IMPROVE MUCH, A MINORITY ONGOING
SEVERE).
PRODROME PRIOR TO ANOTHER EPISODE (INCREASING DEPRESISON, ANXIETY,
IRRITABILITY, NEGATIVE SYMPTOMS AND/OR MILD PSYCHOSIS) LASTING DAYS WEEKS
PHASES OF ILLNESS – POST-PSYCHOSIS
• RECOVERY FROM PSYCHOSIS VERY VARIABLE
• FUNCTIONAL
• RESIDUAL SYMPTOMS
• NONE
• SUBTLE, PSYCHOTIC LIKE SYMPTOMS (eg ILLUSIONS, FLEETING IDEAS OF
REFERENCE)
• MILD PSYCHOTIC
• NUMBER OF RELAPSES VERY VARIABLE (DIFFERENT ICD-10 CODES)
• TYPICAL COURSE:
FIRST 5-10 YEARS AFTER FIRST FRANK PSYCHOSIS SYMPTOMS MOST
SEVERE
BEFORE GRADUAL OVERALL LEVEL OF FUNCTIONING IMPROVES,
EXCEPT ANY COGNITIVE PROBLEMS AND PRIMARY NEGATIVE
SYMPTOMS
SUB-TYPES
(PTS OFTEN CHANGE SUBTYPE OVER TIME)
PARANOID – MORE STABLE. ONE OR MORE DELUSIONS,
FREQUENT HALLUCINATIONS (OFTEN RELATED TO THE
DELUSIONS)
DISORGANISED (HEBPHRENIC) – THOUGHT DISORDER,
IN DSM ALSO DISORGANISED BEHAVIOUS, FLAT OR
INAPPORPRIATE AFFECT.
FRAGMENTED HALLUCINATIONS AND DELUSIONS ONLY
POOR PREMORBID FUNCTION, INSIDEOUS ONSET,
CONTINUOUS COURSE, POOR PROGNOSIS
SUB-TYPES CON’T
CATATONIC
LESS COMMON DEVELOPED WORLD -DUE TO TREATMENT?
CATATONIA ALSO IN AFFECTIVE DISORDERS.
PROMINENT MOTOR AND BEHAVIOURAL SYMPTOMS WITH AT
LEAST 2 OUT OF 5 SYMPTOMS:
• IMMOBILITY (STUPOR OR CATALEPSY (RIGID MAINTAINED
BODY POSITION)
• EXCESSIVE PURPOSELESS ACTIVITY
• NEGATIVISM
• PERCLIAR MOVEMENTS (MANNERISMS, POSTURING,
GRIMASSING, STEREOTYPES)
• ECHOLALIA OR ECHOPRAXIA
SUB-TYPES CON’T
UNDIFFERENTIATED
MEET CRITERIA OF SCHIZOPHRENIA BUT NOT NEATLY FITTING IN
A CATEGORY -DIAGNOSIS BY EXCLUSION
RESIDUAL
PAST ONE OR MORE PSYCHOTIC EPSIODE MEETING CRITERIA OF
SCHIZOPHRENIA. NO LONGER PSYCHOTIC BUT NEGATIVE
SYMPTOMS OR RESIDUAL SYMPTOMS.
CHRONIC OR TRANSIENT PRIOR TO RECOVERY
SUB-TYPES - NEITHER ICD OR DSM
SIMPLE SCHIZOPHRENIA NO PROMINENT PSYCHOSIS, MOSTLY
NEGATIVE SYMPTOMS, RESIDUAL SCHIZOPHRENIA -TYPE
SYMPTOMS, INSIDIOUS ONSET, ODD BEHAVIOUR, DECREASE
SOCIAL FUNCTION
DEFICIT SCHIZOPHRENIA PROMINENT AND ENDURING,
IDIOPATHIC OR PRIMARY NEGATIVE SYMPTOMS.
DIFFERENT FROM OTHER Sz PTS IN RISK FACTORS, COURSE,
FAMILY Hx, FUNCTIONAL AND STRUCTURAL IMAGING,
NEUROCOGNITION, RESPONSE TO TREATMENT.
MORE MEN, INSIDUOUS,POOR PREMORBID FUNCTIONING, POOR QOL