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By Dr. Muhd. Najib Mohd. Alwi Dept. of Psychiatry Universiti Sains Malaysia Schizophrenia • Definition: a major psychotic disorder with onset in early adulthood, characterised by bizarre delusions, auditory hallucinations, strange behaviour and a progressive decline in personal, domestic, social and occupational competence, all occurring in clear consciousness. To diagnose, (ICD-10 & DSMIV) require one or more discrete symptoms to be present for more than one month or longer 2 History of Schizophrenia – Benedict Morel (1856): • “demense precoce” – Emil Kraepelin (1893): • “dementia praecox” – cognitive disorder (dementia) – early onset (praecox) • included hebephrenia, catatonia, paranoia, simple schizophrenia – Bleuler (1911) • coined “schizophrenia” = “splitting of the mind” • Primary / Fundamental symptoms (4A’s) – Ambivalence – Affective abnormalities (blunting, inappropriate) – Autism – Loosening of Association • Secondary / Accessory symptoms – hallucinations, delusions 3 History of Schizophrenia • Kurt Schnieder (1959) – First Rank Symptoms : • thought passivity – insertion – broadcast – withdrawal • ‘made’ phenomena – actions – impulses – feelings • auditory hallucinations – thought echo – running commentary – voices arguing • somatic passivity (delusion of bodily influence) • delusional perception – Second Rank Symptoms: • all other hallucinations • secondary delusions • catatonic behaviour 4 Schneider’s First Rank Symptoms • Characteristic, not pathognomonic • 1/5 patients with Schizophrenia have never had any FRS • 1/10 non-Schizophrenic patients have experienced some FRS 5 Timothy Crow (1980) • Type I Schizophrenia – – – – acute onset positive symptoms normal ventricles good response to medication – a/w increased dopaminergic activity – better prognosis • Type II Schizophrenia – – – – insidious onset negative symptoms enlarged ventricles poor response to medication – deteriorating course – poorer prognosis 6 Nancy Andreasen (1982) • Positive Symptoms – – – – delusions hallucinations bizarre behaviour due to presence of abnormal brain mechanisms – responds to typical (D2 receptor antagonists) anti-psychotics • Negative Symptoms – – – – – avolition anhedonia affective blunting loosening of association due to loss of brain mechanisms – may respond to atypical antipsychotic drugs (e.g. Clozapine) 7 Epidemiology How common is it? Schizophrenia • Incidence and Prevalence – occurs in all cultures – prevalence is geographically stable – Incidence: • 2 to 4 per 10 000 per year! – Lifetime risk: • 1% • Age and sex – equal for both sexes – peak incidence: • men: 15-25 • women: 25-35 • In Malaysia – 100 000 - 500 000 Schizophrenia sufferers at any one time (could be underestimation!) 9 Aetiological Theories Think Bio Psycho Social Biological Theories • Genetics – at least 30% of patients will have an affected relative (Gottesman 1991) – Lifetime Risk • • • • • 13% DZ, 48% MZ 10% siblings 5% for parents 13% if one parent 46% if both parents – 70% of heretability is genetic • only 10% of adoptedaway children (of affected parents) • only 1% of adoptedinto (affected parent) – polygenic / multifactorial threshold genetic menchanism – Current view: • gene/environment interaction model 11 Biological Theories • Dopamine Hypothesis – Opposing facts: • amphetamine do not produce negative symptoms • anti-psychotics are also effective in other psychotic conditions • blockade of D2 within hours but efficacy within days or weeks – Schizophrenia is caused by excess dopamine activity within the mesolimbicmesocortical systems – Supporting facts: • amphetamine releases dopamine and causes positive symptoms • More recent theories: • all effective antipsychotics are D2 receptor – Serotonin overactivity antagonists • atypical affinity to 5HT2A/2C • anti-psychotic efficacy – Insufficient Excitatory Amino correlates with D2 Acid Hypothesis (glutamate) 12 occupancy Biological Theories – Neurodevelopmental theory • abnormalities seen in the brain of Schizophrenic patients from neuroimaging and neuropathological studies: – limbic system: size of amygdala, hippocampus, parahippocampus – basal ganglia: D2 receptors in caudate nucleus • Imaging and pathological findings revealed lesions representing developmental anomalies rather than disease dating probably from mid-gestation. • Some supporting findings in epidemiological studies: – season of birth (winter) – prenatal influenza – obstetric complications 13 Psychological Theories • Attempts to explain the origin of Schizophrenic symptoms – over-inclusive thinking (Cameron) • loss of conceptual boundaries – concrete thinking (Goldstein) • impairment of abstract thinking – filter theories (Frith) • inadequate filtering of background environmental stimuli – cognitive defect theory • impaired ability to perceive, assess and judge cognitive input 14 Social Theories • Family processes: – Double Bind Communication (Bateson, 1956) • parent giving conflicting messages, can not escape or respond to both => irrational / ambiguous behaviour => Schizophrenia – Skew and Schism (Lidz, 1957) • caused by shifts in the traditional power roles in a family – skew: mother dominant, father submissive – schism: parents hostile towards each other => split psyche in child => Schizophrenia 15 Social Theories • Family processes: – Life Events • relapse preceded by an excess of life events (compared to Relapse Rates Over 9 Months normal controls, but not Low EE High EE High EE compared to other psy. <35h/wk >35h/wk patients) Anti12% 15% 53% – High Expressed Emotion (EE): psychotic No Anti15% 42% 92% • relapse risk increasing: psychotic – hostility – emotional over-involvement – critical comments • relapse risk reducing: – positive remarks – warmth 16 Social Theories • Socio-economic status – higher in lower SES, urban areas (industrialized countries) • social drift hypothesis: – effected individuals move to lower SES due to social and occupational incompetence (parents normally higher SES) • social causation hypothesis: – stresses related to SE deprivation causes Schizophrenia • immigrants: – Afro-Carribean in UK have higher rates of Schizophrenia – ? Stresses of leaving own country, adapting to new environment 17 • Prodromal • Acute • Chronic Premorbid and Prodromal Phases • Premorbid personality: – subtle motor, linguistic and social deficits in preschizophrenic children – increased developmental deviance with age and more marked cognitive impairment in early adolescence • Prodromal phase: – decline in the level of functioning: insiduous and gradual – changes in behaviour: odd ideas, eccenteric interests, changes in affect, unusual speech and bizarre perceptual experiences 19 Acute Phase • Common features: – prominent positive symptoms: persecutory ideas, auditory hallucinations – gradual social withdrawal / impaired work performance 10 most common sx in acute phase SYMPTOM FREQUENCY (%) Lack of insight 97 Auditory 74 Hallucinations Ideas of reference 70 Suspiciousness 66 Flatness of affect 66 Voices talking to 65 patient Delusional mood 64 Persecutory 64 delusion Thought 52 alienation 20 Thought echo 50 Chronic Phase • Complete recovery possible after one ot two acute episodes, but many patients have a protracted illness with residual symptoms persisting between acute relapses • Characterized by: – thought disorder – negative symptoms • lack of drive • underactivity • social withdrawal • emotional apathy • THREE clinical syndromes noted in chronic schizophrenia: – psychomotor poverty (negative symptoms) • poverty of speech, decreased spontaneous movement, catatonia, blunting of affect – disorganisation • inappropriate affect, incoherent speech, poverty of content of speech – reality distortion • delusions, hallucinations 21 Diagnosis, Course, Treatment Important facts to remember…. Diagnosis • DSM-IV Criteria: • >= major symptoms during 1 month period delusions hallucinations disorganized speech grossly disorganized or catatonic behaviour negative symptoms • social/occupational dysfunction • continuous signs of disturbance for at least 6 months 23 Diagnosis • DSM-IV Criteria: • subtypes: Paranoid type: delusions, auditory hallucinations Disorganized type: disorganized speech and behaviour, flat/inappropriate affect Catatonic type: waxy flexibility, stupor, extreme negativism, posturing, stereotyped movements, motor excitement Undifferentiated type Residual type: negative symptoms in absence of prominent delusions, hallucinations, disorganized speech or behaviour or catatonic behaviour 24 Catatonic Symptoms • Stupor: akinetic mutism - immobile, mute, unresponsive but fully conscious • Excitement: uncontrolled motor activity, agitation, uninfluenced by external stimuli • Waxy flexibility: allowing to be placed in awkward postures without evidence of distress (a.k.a. catalepsy) • Negativism: opposing every movement instructed to do • Pillow sign: sleeping with head raised as if there is a pillow underneath the head • Stereotypy: repetitive fixed pattern of purposeless movements • Mannerism: habitual seemingly goal directed movements 25 Course • In most cases there are FOUR patterns: – single episode only, no residual impairment (22%) – several episodes, no or minimal impairment (35%) – impairment after 1st episode, subsequent exacerbation, no return to normality (8%) – increasing impairment with each episode, no return to normality (35%) 26 Outcome • Better in developing country (social rather than clinical recovery) – ? better social support • Life span of schizophrenics is shortened by 10 years – suicide • 50% attempted • 10% commit suicide (commonly early stage): depressive symptoms, educated, good premorbid adjustment – common causes of death include accidents and cardiovascular disease (? complication of medication) 27 Prognosis • Predictors of good outcome: – sociodemographic: • married, female – premorbid adjustment: • no previous psy. history • good social relationships • good work/educational record – clinical: • acute onset • precipitated by stressful event • older age of onset • short episode • florid psychotic symptoms • good initial response to medication • good compliance to medication 28 Management • Principles: – Biological • antipsychotics: typical / atypical • Electroconvulsive therapy (ECT) – Psychological • psychotherapy: supportive, cognitive therapy, token economy – Social • family intervention, social skills training, rehabilitation programmes 29 And little by little I can look upon madness as a disease like any other Vincent van Gogh