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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