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Schizophrenia and other
psychotic disorders
Symptoms, models, course,
epidemiology
Lucie Bankovská Motlová
Psychotic Disorder
– Psychotic: loss of contact with reality,
inability to distinguish reality from fantasy,
impaired reality testing, with the creation of
a new reality
– Characteristics:
» disorganized and delusional thinking
» disturbed perceptions
» inappropriate emotions and actions
substance-induced
psychotic disorder
schizoaffective PSYCHOSES
disorder
brief psychotic
disorder
schizophrenia
schizophreniform
disorder
Psychotic Disorders:
Classification
Diagnostic and Statistical
Manual of Mental Disorders
DSM-IV
• Schizophrenia
• Schizophreniform disorder
• Schizoaffective disorder
• Delusional disorder
• Brief psychotic disorder
• Shared psychotic disorder
• Psychotic disorder due to a
general medical condition
• Substance-induced
psychotic disorder
International Classification of
Diseases and Related Health
Problems
ICD-10
• Schizophrenia
• Schizotypal disorder
• Persistent delusional
disorders
• Acute and transient
psychotic disorders
• Induced delusional disorder
• Schizoaffective disorders
Schizophrenia
John Nash
Symptoms
• Positive
• Negative
• Cognitive
Positive Symptoms
Auditory, Visual,
Tactile,Olfactory
Symptom
Hallucinations
Disorganized Speech
Bizarre/catatonic
behavior
Delusions
Persecutory, Paranoid,
Grandiose, Religious,
Jealous, Somatic
Function Distorted
Perception
Thought/Language
Behavioral monitoring
Inferential thinking
April 1991
Bryan Charnley
1949-1991
May 1991
Stefan M., Travis M. and Murray R., An Atlas of Schizophrenia, 2002
June 1991
Stefan M., Travis M. and Murray R., An Atlas of Schizophrenia, 2002
DOPAMIN
Neurochemical sensitization in
mesolimbic dopaminergic system
(studies in schizophrenia)
• Endogenous dopaminergic sensitization: PET
• Amphetamines intake = ↑↑↑ endogenous dopamin in
schizophrenia patients in the acute phase, in comparison
with healthy persons
• Relapse of schizophrenia = recurrence of hyperdopaminergic
state in subcortical structures
• IMPLICATIONS FOR TREATMENT
Chronic blockade of D2 receptors:
blocking of sensitization processes
Laurelle 1999
Negative Symptoms
Symptom
Alogia
Affective blunting
Avolition
Anhedonia
Function Diminished
Fluency of speech/thought
Emotional expression
Volition and drive
Hedonic capacity
Impair ability to function in daily life
Holding a job
Attending school
Forming friendships
Having intimate family relationships
Cognitive Symptoms
Symptom
• forgetfullness
• distractibility
• reasoning/problem
solving
Function Diminished
• working memory
• Attention span
• "set-shifting", i.e. the
ability to display
flexibility in the face of
changing schedules of
reinforcement
Learning difficulties
Inability to read
Problems with planning
Historical Concepts
• Emil Kraepelin
• Eugen Bleuler
• Kurt Schneider
Video: 1942
Emil Kraepelin (1856-1926)
Dementia Praecox
“Dementia praecox consists of a series
of states, the common characteristic
of which is a peculiar destruction of
internal connections of the psychic
personality....the majority of the
clinical pictures are the expression of
a single morbid process, though
outwardly they often diverge very far
from one another.”
Eugen Bleuler (1857-1939):
Group of Schizophrenias
“Of the thousands of
associative threads that
guide our thinking, this
disease seems to interrupt,
quite haphazardly,
sometimes single threads,
sometimes a whole group,
and sometimes whole
segments of them.”
Bleuler’s Fundamental
Symptoms: 4 „A“
•
•
•
•
Associations
Affective Blunting
Autism
Ambivalence
Kurt Schneider (1887-1967)
First-Rank Symptoms
First-Rank Symptoms of Kurt Schneider
•
•
•
•
•
•
•
•
•
•
Audible thoughts
Voices arguing or discussing
Voices commenting on patient´s actions
Somatic passivity
Thought withdrawal
Thought broadcasting
Made feelings
Made impulses or drives
Made volitional acts
Delusional perception
Syndromes, models,
classification systems
John Hughlins Jackson
Timothy Crow
ICD -10, DSM IV
John Hughlins Jackson (1835-1911)
Positive and negative symptoms
Positive
•Delusions, hallucinations
•Pathological disinhibition
of cortical functions
•Absent in normal
„psyche“
Negative
•Flat affect, apathy, lack of
motivation
•Generalized loss of
functions
•Normal „psyche“ lost
them
Timothy Crow
Schizophrenia type I and II
I
•Positive symptoms
•Normal size of brain
ventricules
•Better prognosis
•Better treatment response
II
•Negative symptoms
•Brain ventricules enlargement
•Worse prognosis
•Worse treatment response
Classification
ICD-10 Europe; DSM-IV-USA
• General criteria
1st rank symptoms
according to Schneider
• Long-term course types
• Clinical subtypes
Traditional clinical Subtypes
•
•
•
•
Paranoid
Disorganized (Hebephrenic)
Catatonic
Simplex
• Undifferentiated
• Residual
Out of the Shadow
What symptoms of schizophrenia
have you identified?
Course and prognosis
of schizophrenia
Long-term course: Attack, Relapse, Remission
M
20
30
E
D
I
K
40
A
C
50
roky
E
60
70
The natural history of schizophrenia: a 5-year follow-up.
Early
Warning
Signs
Early
Warning
Signs
Early Warning Symptoms of Relapse
Patient
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Troubles with sleep.
Decreased appetite.
Difficulty concentrating on reading or
watching television.
Fear, anxiety or annoying feelings
from other people.
Restlessness, irritability or quick
temperedness.
Feeling that something unusual and
incomprehensible is about to happen
around me.
Loss of energy or interests.
Decreased capacity to cope with
everyday problems.
Experience of hearing people's
voices speaking when nobody
seems to be around.
Have you noticed any of your
individual warning signs since last
evaluation?
Family member
1.
Troubles with sleep.
2.
Marked behavioral changes.
3.
Social withdrawal.
4.
Decline in daily activities.
5.
Decline in personal hygiene.
6.
Loss of initiative, motivation.
7.
Preoccupation with peculiar ideas and
thoughts.
8.
Marked poverty of speech or content of
speech.
9.
Irritability, quick temperedness or
aggression.
10.
Have you noticed any of warning signs
individual for your relative since last
evaluation?
Relapse rates
(%)
80
70
60
50
40
30
20
30-50%
40-60%
80%
80%
10
1 year
2 years
5 years
15 years
(Shepherd et al ,
1989, Hogarty et al
1993, Möller et al.,
1995, Wieden a
Olfson 1995, Mason
et al, WHO studie,
1996, Doering et
al.,1998, Wiersma et
al. 1998, Robinson et
al. 1999, Ohmori et
al . 1999, Rabinowitz
et al. 2001, Gaebel
2002, Schooler et al.,
2003)
Epidemiology
Onset and Prevalence of Schizophrenia worldwide
About 0.2% to 1.5% (or about 1% population)
Often develops in early adulthood
Can emerge at any time
Schizophrenia Is Generally Chronic
Most suffer with moderate-to-severe lifetime
impairment
Life expectancy is less than average
Schizophrenia Affects Males and Females About
Equally
Females tend to have a better long-term prognosis
Onset differs between males and females
Schizophrenia has a Strong Genetic Component