Schizophrenia

Question 1

What schizophrenia is not

Answer 1

• Everyday language: Schizophrenia is often used to describe a state of contradictory or incompatible elements –> split personality
• Media: Often used to describe any person with psychotic symptoms who is out of touch with reality –> sometimes thought that anyone with a chronic mental illness has schizophrenia.
• Neither description is accurate.

Question 2

Schizophrenia and psychosis

Answer 2

Psychosis –> a loss of contact with reality that usually includes:
• Delusions = firm, false fixed beliefs about what is taking place or who one is
• Hallucinations = seeing or hearing things that aren’t there

• People diagnosed with schizophrenia spectrum illnesses may not have active psychotic symptoms
• Psychotic symptoms are associated with illnesses/conditions other than schizophrenia

Question 3

History of schizophrenia

- 4 A’s

Answer 3

The modern concept of schizophrenia has developed over the past 100 years = psychiatric illness with a specific group of symptoms

Emil Kraepelin (1855-1926) –> first described the symptoms of schizophrenia
• Considered symptoms single illness = “dementia praecox”
• Distinguished schizophrenia from bipolar disorder

Eugen bleuler (1857-1939) –> focused more on the nature of symptoms than on the course of the disorder
• Saw as the essential feature of schiz (split) in the mind (phren) –> mind drawn in many directions
• Identified the 4 A’s
o Autism –> social withdrawal
o Ambivalence –> lack of motivation
o Affect –> inappropriate or flat (expressed mood)
o Association –> loose associations, disorganization, disconnectedness

Question 4

DSM diagnostic criteria for schizophrenia

Answer 4

A. Characteristic symptoms (2 or more) for significant portion of the time during 1-month period (less if successfully treated)

• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative or deficit symptoms
• –> alogia (not talking)
• –> affective flattening
• –> avolition (lack of motivation)

B. Social or occupational dysfunction –> one of more major areas of functioning are markedly below the level achieved prior to onset

Additional criteria
- Duration –> continuous signs of disturbance for at least 6 month
• One month must have criterion A symptom
- Rule out schizoaffective disorder and mood disorders
- Rule out substance abuse and medical conditions as a cause
- If history of an autism spectrum disorder, there must be prominent hallucinations or delusions

Specifiers –> used after one year duration of disorder

• first episode –> currently in acute episode, partial remission, or full remission
• multiple episodes –> currently in acute episode, partial remission, full remission
• continuous –> some people have ongoing symptoms that stay relatively constant at all time
• with catatonia –> a state where people typically don’t speak and may be completely immobile
• also with specifiers for current severity (each symptom rated on a scale of 0-4)

Question 5

• Delusional disorder

- Brief psychotic disorder

Answer 5

Delusional disorder –> one or more delusions of one month duration or longer, not meeting criteria for schizophrenia
- Subtypes –> erotomanic, grandiose, jealous, persecutory, and somatic

Brief psychotic disorder –> psychotic symptoms of at least 1 day but less than 1 month (may be in response to a stressor)

Question 6

Schizophreniform disorder

Answer 6

Criteria A schizophrenia symptoms (>1 month, schizophrenia before we’re sure that its schizophrenia; don’t want to diagnose someone until we’re sure of the diagnosis

Good prognostic features 
•	Rapid onset of symptoms
•	Confusion
•	Good premorbid functioning
•	Absence of blunted or flat affect

Question 7

• Schizoaffective disorder
• Substance/medication induced psychotic disorder
• Psychotic disorder due to another medical problem

Answer 7

Schizoaffective disorder –> “between” schizophrenia and mood disorders (particularly bipolar)

• Delusions or hallucinations (>2 weeks) in absence of mood symptoms –> rules out a primary mood disorder
• Symptoms meeting criteria for mood disorder present for majority of the total duration of entire disorder

Substance/medication induced psychotic disorder –> e.g. cannabis induced psychotic disorder, onset during intoxication with severe cannabis use disorder

Psychotic disorder due to another medical problem –> e.g. thyroid

Question 8

Positive symptoms in schizophrenia spectrum disorders

Answer 8

Positive symptoms = symptoms that are present and that the patient can tell you about (as opposed to deficits)
1. Delusions –> false, fixed ideas
• Persecutory, reference, control, grandiose, somatic, guilt, thought broadcasting
• Bizarre –> implausible, not from ordinary life experience
2. Disorganization
• Disorganized speech (tangentiality, incoherence, looseness of association, word salad)
• Inappropriate affect (laughing oddly at sad situations)
• Grossly disorganized or catatonic behavior
3. Hallucinations –> false perceptions; can be auditory, visual, gustatory, tactile or olfactory

Question 9

Negative symptoms in schizophrenia spectrum disorders

Answer 9

Negative symptoms –> deficit symptoms; may be either primary or secondary (e.g. related to anti-psychotic side effects, environmental deprivation, or positive symptoms)

1. Blunted affect –> decreased expressiveness, constrained, dampened emotional tone
2. Alogia –> poverty of speech
3. Avolition –> lack of will and motivation to do things

Question 10

Relational and cognitive problems in schizophrenia spectrum disorders

Answer 10

Relational problems –> social interactions, intimacy

Cognitive dysfunction –> broadly generalized across domains of cognitive performance

• Attention/vigilance
• Processing speed
• Reasoning and problem solving
• Verbal learning and memory
• Visual learning and memory
• Working memory
• Social cognition

Cognitive impairment in schizophrenia

• Core feature of the illness –> onset in childhood, early adolescence; often observed in family members
• Not a linear relationship to hallucinations and delusions
• Have a more reliable relationship to functional status than symptomatology and provide a target for interventions –> psychopharmacological and psychosocial

Question 11

Deficit syndrome of schizophrenia

Answer 11

Not a DSM V diagnosis, but often referred to –> at least two of the following 6 negative symptoms must be present:

• restricted affect
• diminished emotional range
• poverty of speech
• curbing of interests
• diminished sense of purpose
• diminished social drive

People with the deficit syndrome differ from others with schizophrenia –> don’t do as well

Question 12

Key points to remember about schizophrenia

Answer 12

o An important feature of schizophrenia is its heterogeneity of presentation
o What we now call schizophrenia likely represents two or more different diseases
o Symptoms can wax and wane
o Interpretation of symptoms may depend on cultural context

Question 13

Diagnosis

Answer 13

There is no single pathognomonic sign or symptom of schizophrenia

Evaluation includes the following:

• History (patient, family, friends, teachers, other professionals)
• Physical Exam (rule out other causes of symptoms)
• Mental Status Exam
• Medical Records
• Laboratory Tests (urine toxicology exam)

Question 14

Possible etiologies

Answer 14

o Neurodevelopmental model –> A subtle defect in cerebral development disrupts late-maturing, highly evolved neocortical functions, manifests in adult life.
o Neurodegenerative model –> Evidenced by decrease in grey matter volume (especially older patients) and larger ventricles in people with schizophrenia. Not diagnostic
o Stress-Diathesis model –> Person with specific vulnerability (diathesis) experiences a “stressful” event which can lead to development of schizophrenia
- Stress = environmental insult
- Diathesis = genetic vulnerability

o Genetics –> significant genetic component

• • Linkage studies have identified several potential gene locations
• • It is likely that schizophrenia is multifactorial with several genes and environmental factors playing a role.

Question 15

Pathophysiology - neurotransmitters

Answer 15

Dopamine hypothesis –> there is a hyperactivity of dopaminergic systems in schizophrenia
• All anti-psychotics bind to dopamine receptors
• Clinical potency of typical anti-psychotic drugs correlated with binding affinity to D2 receptors
• Increased dopamine exacerbates some psychotic symptoms

Problems with dopamine hypothesis
• Effectiveness of DA antagonists not limited to people with schizophrenia
• Immediate blockade –> 6 weeks for effects
• Antipsychotics improve positive, not negative symptoms

Modified dopamine hypothesis
• Positive symptoms may be mediated by dopamine excess in limbic regions
• Negative symptoms may be mediated by hypodopaminergia in prefrontal areas
• Side effects are caused by antidopaminergic effects of medications in the basal ganglia

Question 16

Prevalence, development and course of schizophrenia

Answer 16

o Schizophrenia usually develops between the ages of 16 and 25 although women tend to develop the illness somewhat later than men  Estrogen may be protective for woman.
o The first signs of the illness are often social withdrawal and decline in functioning
o Some people who develop schizophrenia have social problems growing up, others do not
o Families undergo severe stress, especially at the beginning of the illness  Schizophrenia is a family crisis
o Schizophrenia is typically a lifelong illness with an episodic course which fluctuates over time; level of disability stabilizes after 5-10 years
o Symptoms tend to gradually improve over the patient’s lifetime
o People with schizophrenia have 5-6% chance of suicide (DSM 5; 10% according to prior studies, as much as 20x higher than general population
o Suicide only partially accounts for the reduced life expectancy.
o Increased rates of co-occurring medical disorders and substance use contribute  behavioral and health factors including obesity, reduced exercise, and overall poor health habits are problematic.

Question 17

Factors predicting poor prognosis

Answer 17

• Early onset
• No precipitating factors, insidious onset
• Poor premorbid social, sexual and work history
• Withdrawn, autistic behavior
• Family history of schizophrenia
• Poor support systems
• Negative symptoms
• Neurological signs and symptoms

Question 18

Anti-psychotic medications

Answer 18

Schizophrenia PORT 2003: Recommendation #1 –> Use of antipsychotic medications (other than clozapine) as the first-line treatment to reduce positive psychotic symptoms for people with schizophrenia who are experiencing an acute exacerbation of their illness

Older (typical; 1st generation) antipsychotics = chlorpromazine, perphenazine, haloperidol –> work primarily through D2 blockade and have extrapyramidal side effects

Newer (atypical; 2nd generation) antipsychotics = olanzapine, risperidone, quetiapine –> work on the dopamine system but vary in affinity to DA receptors; have more metabolic side effects

CATIE study (Lieberman et al 2005) indicates 1st and 2nd generation antipsychotic equally effective but with different side effect profiles

Choice of antipsychotic medication should be made from approved antipsychotic medications on the basis of the following:
• Patient’s prior individual treatment response, side effect experience and preference
• Adherence history
• Relevant medical history
• Individual medication side effect profile
• Long-term treatment planning.

Question 19

Treatment recommendations

Answer 19

• A first psychotic episode should be treated with antipsychotic medication –> dosages should start at lower end of the recommended range
• Clozapine –>unique atypical which should be offered to people with schizophrenia with persistent and clinically significant positive symptoms in spite of adequate treatment with antipsychotic agents (i.e., non-responders).

Question 20

Psychosocial treatments

Answer 20

Psychosocial treatments include cognitive behavioral, social skills training, family and supportive employment interventions (all recommended by Schizophrenia PORT 2003)

Evidence-based psychosocial treatments are recommended along with pharmacotherapy.

Why use psychological therapies for people with schizophrenia?
• Support in dealing with a disabling illness
• Enhance coping strategies to promote well-being and recovery
o Promote well-being
o Improve quality of life
o Facilitate recovery
• Alter underlying pathophysiology and process of illness

Question 21

• Cognitive behaviorally oriented therapies
• Social skills training
• family psychosocial intervention

Answer 21

Cognitive behaviorally oriented therapies (CBT)

• Collaboration between therapist and patient
• Identify key symptoms
• Training in specific cognitive and behavioral strategies to cope with symptoms
• Focus on distress, anxiety and stigma
• Most helpful in reducing belief in delusions and stress related to delusions

Social skills training
- People with schizophrenia who have skill deficits such as problems with social skills or activities of daily living should be offered skills training.
- Social dysfunction results from lack of key social skills, failure to use social skills when needed, socially inappropriate behavior
- Steps in Social Skills Training
• Instructions on how to perform skill
• Modeling of skill by trainer
• Role play with trainer; feedback and reinforcement
• Practice and training in the individual’s day-to-day environment.

Family psychosocial intervential
- People with schizophrenia who have ongoing contact with their families should be offered a family psychosocial intervention 
- Key elements 
•	Duration of at least 9 months
•	Illness education
•	Crisis intervention
•	Emotional support
•	Training in how to cope with illness symptoms

Question 22

• Supported employment

- Assertive communitvy treatment

Answer 22

Supported employment

• Individualized job development with focus on patient preferences
• Rapid placement emphasizing competitive employment
• De-emphasis on prevocational training and assessment
• Ongoing job supports
• Integration of vocational and mental health services

Assertive community treatment  intensive outpatient psychiatric treatment for some people with schizophrenia

• Multi-disciplinary team (with a psychiatrist)
• Shared caseload among team members
• Direct service provision by team members
• High frequency of patient contact (>3 x/week)
• Low patient to staff ratios
• Outreach in the community
• Focus on high-risk patients

Question 23

Recovery

Answer 23

A familiar concept in addiction treatment but relatively new in mental health

Common clinical definitions often imply something akin to cure
• Symptom remission
• No need for maintenance treatment
• Return to premorbid level of functioning

What is recovery? Consumer perspective:
• Recovery is a process, rather than an end state or outcome.
• Recovery is strengths-based, rather than symptom-based, and involves:
o Hope
o Respect
o Empowerment
• Recovery is a model that involves the nature of treatment

Why is a recovery model important?
• Traditional models of care have often been paternalistic and not respectful of individual’s strengths, preferences, and goals
• Traditional care has not always considered the potential of the individual to grow and to function
• There is a consumer and family mandate for a partnership with providers
• Recovery is the overarching goal of the President’s New Freedom Commission on Mental Health