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Schizophrenia Overview • Often a severe and enduring psychiatric illness • Comprises a significant proportion of the consumers of mental health services • Require long-term treatment using a range of modalities and services • Associated with significant psychiatric and physical morbidity, as well as mortality Clinical Presentation • Presentation may vary from acute to insidious • A severe psychotic illness characterised by delusions, hallucinations (usually auditory), thought disorder and behavioural disturbance • Often deterioration in social, occupational and cognitive function • Clear consciousness – ie to be distinguished from delirium First Rank Symptoms • Thought insertion/broadcast/withdrawal • Made feelings/impulses/actions/somatic sensations (a type of delusion) • Third person auditory hallucinations (running commentary or arguments) • Delusional perception • Thought echo (echo de la pensee or gendankenlautwerden) – a type of hallucination First Rank Symptoms contd. • 58% of patients with a diagnosis of schizophrenia show at least one FRS • 20% never show FRS • 10% of patients who do not have schizophrenia show FRS Classification • Crow Type I and II – Type I – positive symptoms, good response to treatment – Type II – negative symptoms, poorer response to treatment Classification contd. • Andreasen – positive and negative symptoms • Positive symptoms – hallucinations, delusions, bizarre behaviour, formal thought disorder, inappropriate affect • Negative symptoms – affective flattening, poverty of speech/thought, avolition – apathy, anhedonia, social withdrawal, inattentiveness Epidemiology • • • • Lifetime risk – 1% Incidence – 20/100 000 per year Low rates in some areas eg Hutterites in US High rates in some parts of Sweden, Ireland Epidemiology contd • Equal prevalence in males and females • Males diagnosed earlier than women (males age 15-25 years, females age 25 – 35 years) Etiological Theories • Biological, psychological and social theories proposed • Biological – biochemical, genetic and neurodevelopmental Genetics • Greatest risk factor is having a relative with SCZ • 70% of the heritability of schizophrenia is genetic • MZ twin – 48% risk; DZ twin 17% • Child of one parent with SCZ – 13% • Child of two parents with SCZ – 46% Genetics • Adoption studies indicate that heritability rates are similar even if adopted away • Probably polygenic/multifactorial model • No clear gene responsible although interest in various genes Neurodevelopmental Theories • Hypothesis states that impaired fetal or neonatal brain development may sow the seeds of the onset of psychotic symptoms in later life • Patients with SCZ have lower than average IQ, often subtle psychomotor, behavioral, and social abnormalities Neurodevelopmental Theories • Patients with SCZ have more developmental structural brain abnormalities • Soft neurological signs • Increase in craniofacial and dermatoglyphic abnormalities • More obstetric complications recorded • Exposure to influenza virus? Clinical Presentation • May present with a florid, rapidly evolving psychosis, or a more insidious onset • May be preceded by a prodromal period • Some seem to have had difficulties from ealry childhood eg preferring solitary play, anxious and asocial, lack social confidence Acute Schizophrenia • May develop acutely or be preceded by days/weeks of delusional mood, bizarre behavior, social withdrawal, poor self-care • Anxiety, depression and euphoria may be seen • Increased risk of suicide and violence • May lack insight • Often need hospitalization Chronic Schizophrenia • Characterized by a volition, depression, social withdrawal, and poverty of thought/speech • May need encouragement in basic self-care • Occupational and social activity diminished • Insight often very poor • Some will require long-tern residential care Diagnosis and Investigation • Diagnosis – presence of typical symptoms • Exclusion of other disorder eg organic causes » » » » CVA Drug-induced eg cannabis, speed, steroids Alcoholic hallucinosis dementia Investigations • No diagnostic test • Screen for drugs of abuse (urine) • Bloods for biochemistry, blood glucose, TFTs, TPHA and VDRL • EEG • ECG • CT and MRI brain Treatment • May require admission if acutely disturbed or present a risk to self or others • Admission may be useful in assessment • Essential to assess suicide risk as there is a mortality of about 10% from suicide in SCZ • May require involuntary detention in some cases Treatment contd. • Antipsychotic drugs are mainstay of treatment • Generally a typicals are first-line treatment eg olanzapine, respiridone, amisulpiride • May require depot injection • Side effects of typicals can be stigmatising • Side effects of a typicals – screen for DM Treatment contd. • A typicals have fewer extra-pyramidal side effects and tend to be better for negative symptoms that typicals • Initial management may include use of sedative medication such as lorazepam • IM medication may be required in a very disturbed, involuntary patient Treatment contd. • Maintenance treatment – generally maintenance on one medication • Compliance may be a significant problem because of long-term nature of treatment and lack of insight Treatment contd. • Psychosocial treatment » Education of patient and carers » Reduction of high expressed emotion – shown to affect relapse rates » Cognitive behavioural therapy – controversial » Rehabilitation » Self –help – Schizophrenia Ireland Prognosis • 22% have one episode and no residual impairment • 35% have recurrent episodes and no residual impairment • 8% have recurrent epsiodes and develop significant non-progressive impairment • 35% have recurrent episodes and develop significant progressive impairment Prognosis contd. • The majority therefore do not recover fully • Suicide rate is up to 13% • Little evidence that anitpsychotic have altered the course of illness for most patients • However, evidence that prolonged psychosis which is untreated has a bad prognosis Prognosis contd. • Good outcome is associated with: – – – – – – – – – Female Older age of onset Married Higher SEG Living in a developing (as opposed to developed) country Good premorbid personality No previous psych history Good education and employment record Acute onset, affective symptoms, good compliance with meds Prognosis contd. • Some of the predictors of outcome are the consequence of a less severe illness • Predicting risk of suicide » Acute exacerbation of psychosis » Depressive symptoms » History of attempted suicide