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Chapter THIRTEEN
Schizophrenia & Related Disorders
Schizophrenia & Related Disorders
• Symptoms
• Differential Diagnosis
• Epidemiology
• Etiology & Course
• Treatments
Schizophrenia & Related Disorders
• Symptoms
• Differential Diagnosis
• Epidemiology
• Etiology & Course
• Treatments
Schizophrenia Symptom Categories
POSITIVE
NEGATIVE
DISORGANIZED
delusions
anhedonia
disorganized
speech
hallucinations
blunted/
flat affect
disorganized
behavior
alogia
catatonic
posturing
avolition
Positive (Psychotic) Symptoms
Functions that are present that shouldn’t be
 HALLUCINATIONS
 heightened sensory (perceptual)
experiences that are not due to external stimuli
 experienced by 5 senses; most common, auditory
 DELUSIONS (when is a belief delusional?)
 rigidly held beliefs that are inaccurate or
inconsistent with how people experience reality
 5 types: persecutory, referential, grandiose,
somatic, religious
 can be “bizarre” or “non-bizarre”
Negative Symptoms
Aspects of normal behavior and social relationships
that should be present, but are absent
 ANHEDONIA
 lack of pleasure or interest
 ALOGIA
 lack of spontaneous speech
 AVOLITION
 lack of will power
 BLUNTED/FLAT AFFECT
 lack of expressiveness (e.g., facial)
Disorganized Symptoms
Do not fit characteristics of positive or negative symptoms
and reflect bizarre behaviors & thought disturbances
 DISORGANIZED SPEECH
Clips: 1
2
3
 tangential speech, very difficult to follow
 conveys little meaning due to poor context
maintenance (word salad)
 GROSSLY DISORGANIZED/BIZARRE BEHAVIORS
 ranges from child-like silliness to
unpredictable agitation
 CATATONIC MOTOR BEHAVIORS
Criteria for Schizophrenia
AT LEAST 1 MONTH
Prodromal
Active
Residual
Duration of Entire Disorder
AT LEAST 6 MONTHS
A. In the ACTIVE phase, must have IMPAIRMENT in
functioning + TWO or more of the following:
 delusions
 disorganized speech
 grossly disorganized
or catatonic behavior
 hallucinations
 negative symptoms
B. During the PRODROMAL and RESIDUAL phases, may
have only negative symptoms, or other symptoms
in less severity (e.g., odd beliefs instead of
delusions)
Schizophrenia Subtypes
• PARANOID
 One or more delusions OR frequent hallucinations; no
prominent disorganized behaviors/speech, catatonic behavior
or flat/inappropriate affect
• DISORGANIZED
 Disorganized speech & behavior, and flat/inappropriate affect
• CATATONIC
• UNDIFFERENTIATED
 Met Criterion A, but does not fit the other subtypes
• RESIDUAL
 Attenuated symptoms in Criterion A OR presence of Negative
Symptoms
Schizophrenia & Related Disorders
• Symptoms
• Differential Diagnosis
• Epidemiology
• Etiology & Course
• Treatments
Excluding Related Disorders
Before a diagnosis of schizophrenia can be
given, disorders with similar symptoms must be
ruled out as a possibility
1.
Mood Disorders with Psychotic Symptoms
1.
Schizoaffective Disorder
1.
Schizophreniform Disorder
1.
Brief Psychotic Disorder
1.
Delusional Disorder
Schizophrenia vs.
Mood Disorders with psychotic symptoms
• SCHIZOPHRENIA with mood symptoms
IF depression and mania symptoms are
present, their duration must be brief in
relation to the duration of active and
residual schizophrenia symptoms.
• MOOD DISORDERS with psychotic symptoms
the psychotic symptoms only occur during
a manic or depressive episode.
SCHIZOPHRENIA with mood symptoms
Aug
Sept
Oct
Nov
Mood Sx
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Jan
Feb
Mar
Psychotic Sx
Dec
MOOD DISORDER with psychotic symptoms
Schizophrenia vs.
Schizoaffective Disorder
• SCHIZOPHRENIA with mood symptoms
– length of time that mood symptoms are present is
brief in comparison to the duration of psychotic
disturbance
• SCHIZOAFFECTIVE DISORDER
– mood symptoms must be present for a substantial
portion of the psychotic disturbance
– delusions and hallucinations must be present for
at least 2 weeks without prominent mood
symptoms.
SCHIZOPHRENIA with mood symptoms
Aug
Sept
Oct
Nov
Mood Sx
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Jan
Feb
Mar
Psychotic Sx
Dec
SCHIZOAFFECTIVE DISORDER
Brief Psychotic Disorder vs. Schizophreniform
Disorder vs. Schizophrenia
Brief Psychotic Schizophreniform
Schizophrenia
Disorder
Disorder
1 Day
1 Month
6 Months
(1 day to < 1 mo.)
(1 mo. to < 6 mos.)
(> 6 months)
Delusional Disorder vs. Schizophrenia
DELUSIONAL DISORDER
• Non-bizarre delusions are the prominent
psychotic symptom.
• Other schizophrenic symptoms, such as
hallucinations, disorganized and negative
symptoms are largely absent.
So, What is the Difference
… between Mood disorders w/Psychosis, Schizophrenia
& Schizoaffective Disorder?
THE DURATION OF MOOD SYMPTOMS and PSYCHOTIC
SYMPTOMS
… between Schizophrenia, Schizophreniform Disorder &
Brief Psychotic Disorder?
THE DURATION OF ENTIRE DISTURBANCE
… between Schizophrenia & Delusional Disorder?
TYPE OF DELUSION & PRESENCE/ABSENCE OF OTHER
SYMPTOMS
Schizophrenia & Related Disorders
• Symptoms
• Differential Diagnosis
• Epidemiology
• Etiology & Course
• Treatments
Prevalence of Schizophrenia across
Western and Non-Western Countries
Lifetime prevalence rate in general population is around 1%
England
Japan
Russia
Lifetime risk
(in percents)
United States
Ireland
Urban India
Rural India
Denmark
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
Schizophrenia & Related Disorders
• Symptoms
• Differential Diagnosis
• Epidemiology
• Etiology & Course
• Treatments
Etiology of Schizophrenia
• Before birth:
 Genes
 Maternal exposure to virus
 Complications/illness during pregnancy
• During birth:
 Complications during delivery
• At various times during development:
 Brain abnormalities
• During childhood & adolescence:
 Socioeconomic status (SES)
 Family factors
Genes
• Adoption and twin studies indicate a genetic
influence
• Pair-wise concordance rates show:
 MZ concordance = 48 percent
 DZ concordance = 17 percent
• Twin concordance rate also
implicate other factors beyond
genetics
Socioeconomic Status (SES)
• Highest prevalence of Schizophrenia
found in those with lower SES…Why?
 Hypothesis 1: “Social Causation”
negative factors related to low SES lead to
development of illness
 Hypothesis 2: “Social Selection”
cognitive/social impairments associated
with the illness lead individuals to drift to a
lower SES
Family Factor: Expressed Emotions (EE)
• EE = family members’ negative, critical & hostile
attitudes & behavior towards patient AND/OR
emotional over-involvement & intrusiveness of family
 Families can be classified as high or low on EE
• Patients who return to live with families are more
likely to relapse if at least one relative was high in EE
 Relapse is defined as return of positive symptoms,
increase in medication dosage, OR re-hospitalization
• It is also possible that families exhibit high EE following
a relapse
Relapse Rate for EE
and Level of Contact
70
60
50
58
42
High contact
(>35 hr/wk)
40
26
30
18
20
Low contact
(<35 hr/wk)
10
0
High EE
Low EE
High EE families close contact
Low EE families close contact
risk of relapse
risk of relapse
Gender Differences in Schizophrenia
• Age of onset (younger for men)
• Premorbid social functioning (better for
women)
• Typical symptoms (men have more negative
symptoms)
• Course of illness & Response to tx (men more
chronic and poorer response to treatment)
Multiple Pathways to Schizophrenia
Schizophrenia
Hints of psychosis
combined
liability
adolescence
young adult
Time
middle age
Schizophrenia & Related Disorders
• Symptoms
• Differential Diagnosis
• Epidemiology
• Etiology & Course
• Treatments
Treatment: Older Antipsychotic
Medications
• Target dopamine receptors
• Work well for positive symptoms
(somewhat effective for 75% of patients)
• Induce side effects resembling Parkinson’s Disease:
Extrapyramidal Symptoms
Tremors, agitation, involuntary posturing, motor rigidity
and inertia
Tardive Dyskinesia
Involuntary movements of mouth and face (lip
puckering, chewing) and spasmodic body movements
Treatment: Newer Antipsychotics
• Better at treating negative symptoms
• Also have side effects (Clozapine has 1%
chance of lethal blood condition)
• Affect other neurotransmitters like
serotonin and norepinephrine
• Relapse rates are high if medication stops,
some relapse even if medication is
continued
Treatment: Psychosocial
• Psychosocial treatments focus on long-term
strategies to improve aspects of patient’s life
other than the reduction of psychotic symptoms
such as improving social competence, housing
stability, employment, etc.
• Types of psychosocial treatment include:
1. Family therapy
2. Social skills training
3. Vocational rehabilitation
4. Assertive community treatment (ACT)
Treatment: Family Therapy
• Most effective if the family is high
in expressed emotion
• Some psychosocial treatments aim
to improve family coping skills and
reduce relapse.
• Eliminating unrealistic
expectations for the patient
• Improving communication and
problem-solving skills of family
members
Assertive Community Treatment
• A comprehensive team works together to meet
the needs of the client including:





Psychiatrists
Nurses
Social workers
Vocational counselors
Recreational counselors
• Staff to client ratio is high, staff is available
24/7, and contact with clients is frequent
• Good outcomes
Cognitive Behavioral Therapy for Psychosis
• Goals
decrease conviction of delusional beliefs
2. promote more effective coping strategies
3. reduce distress
1.
• Teaches skills to challenge & modify beliefs
 experimental reality testing
• Effectiveness
 superior to control condition in clinical studies
 significantly decreases positive symptoms
 continued improvement at 6-month follow-up
Chapter THIRTEEN
Schizophrenia & Related Disorders
OPTIONAL SLIDES & I-CLICKER ACTIVITY
Vulnerability Marker
• is a sign or an evidence that a person
is more vulnerable to developing a
disorder than someone else.
• importance: can provide clues
about who is at risk for
developing a disorder
• specific measure or test
useful in identifying people
vulnerable to a disorder
 e.g., we can localize a marker to a
gene on a specific chromosome
Vulnerability Markers: Characteristics
• Must have sensitivity
1. Should see marker as a stable trait in all
people with schizophrenia
2. Should be more common among 1st degree
relatives than general population
3. Should predict future episodes of
schizophrenia among those who have the
marker, but have not experienced a psychotic
episode
• Must have specificity
 distinguish those with schizophrenia from
other groups
Example: Eye-Tracking Dysfunction
• Difficulty with smooth-pursuit eye
movements when tracking the motion of
a pendulum or similar oscillating stimulus
• Individuals with schizophrenia typically
exhibit rapid eye movements
Target
Non-Sz subject
Sz subject
• Is it a vulnerability marker for Schizophrenia?
Chapter THIRTEEN
Schizophrenia & Related Disorders
I-CLICKER ACTIVITY
Differential Diagnoses
Did psychotic symptoms occur at
times other than during mood
episodes?
No
Yes
Has duration of mood episodes been brief relative
to duration of schizophrenia symptoms (including
negative symptoms and odd beliefs)?
1
No
2
Yes
Has duration of schizophrenia symptoms been 6
months or longer?
No
Yes
Has the duration of schizophrenia symptoms been at
least 1 month?
No
4
Yes
5
3
Which disorder should go on box #1
A.
B.
C.
D.
E.
Schizophrenia
Schizoaffective Disorder
Schizophreniform Disorder
Mood Disorder with Psychosis
Brief Psychotic Disorder
Which disorder should go on box #2
A.
B.
C.
D.
E.
Schizophrenia
Schizoaffective Disorder
Schizophreniform Disorder
Mood Disorder with Psychosis
Brief Psychotic Disorder
Which disorder should go on box #3
A.
B.
C.
D.
E.
Schizophrenia
Schizoaffective Disorder
Schizophreniform Disorder
Mood Disorder with Psychosis
Brief Psychotic Disorder
Which disorder should go on box #4
A.
B.
C.
D.
E.
Schizophrenia
Schizoaffective Disorder
Schizophreniform Disorder
Mood Disorder with Psychosis
Brief Psychotic Disorder
Which disorder should go on box #5
A.
B.
C.
D.
E.
Schizophrenia
Schizoaffective Disorder
Schizophreniform Disorder
Mood Disorder with Psychosis
Brief Psychotic Disorder