Schizophrenia

FAHAD ALOSAIMI
MBBS, SSC-PSYCH
PSYCHOSOMATIC MEDICINE CONSULTANT
ASSISTANT PROFESSOR
KING KHALID UNIVERSITY HOSPITAL
KING SAUD UNIVERSITY, RIYADH
 Schizophrenia (Background)

 Schizophrenia is a severe, persistent & debilitating brain

disease.
 It is not a single disease but a group of disorders with
heterogeneous etiologies.
 Symptoms include disturbances in thoughts
(delusions),perceptions(hallucinations), mood (or
affects),behaviurs and relationships with others.
 People with schizophrenia have lower rates of employment,
marriage, and independent living than other people.

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Impression?!
Can schizophrenic patient win Nobel prize?

"It is conceivable that the susceptibility of humans to depression or to

bipolar disorder may correlate positively specifically with the
composition of poetry," Nash said. He noted that the American poet
Robert Lowell was hospitalized at McLean Hospital near Boston at the
same time that Nash was admitted for schizophrenia.
 Schizophrenia (Epidemiology)

 Found in all societies and countries with equal

prevalence & incidence worldwide.
 A life prevalence of 0.6 – 1.9 %
 Annual incidence of 0.5 – 5.0 per 10,000
 Peak age of onset are: 10-25 years for ♂
25-35 years for ♀.
 10% of schizophrenia patients committed suicide.
 They die 15 years younger than normal population
partly because of multiple medical co-morbidities.
 Outlines

Etiology
Clinical features & diagnosis.
Differential diagnoses
Course & Prognosis
Treatment (Pharmacological)
Treatment (Psychological )
 Case of Mr.J
 Mr.J is a 25-year-old male with the diagnosis of schizophrenia.
He was a healthy child, but his parents report that he was a
bedwetter and seemed slower to develop than his brothers and
sisters.
 A maternal uncle has also been diagnosed with schizophrenia.
 Mr.J had 2 brief hospitalizations in his late teens that were
precipitated by anger at his boss, depression, and voices in his
head. He has believed that CIA is following him & control his
thoughts as well.
 He found the hospital stays unhelpful. He was treated with
haloperidol which gave him dystonic symptoms; he was then
treated with olanzapine and gained 10 Kg and
developed diabetes mellitus.
 Cont. Case of Mr.J

 John smokes marijuana and tobacco frequently to calm

himself; he also occasionally use amphetamine.
 John's parents support him financially.
 His brothers & sisters are angry and frightened of him and
have nothing to do with him. They are particularly upset by
his lack of interest in the outside world.
 John lives in a boarding home and works in a sheltered
workshop with difficulty.
 John sees a psychiatrist for 15 minutes every 2 months but
sometimes misses his appointment. He has a social worker
whom he sees often.
 Cont. Case of Mr.J

The psychiatrist would like to switch him to long-

acting injectable antipsychotic treatment, but John
is afraid of injections and isn't sure that he needs
medication.
He usually misses his appointments with his
primary care physician.
Etiology (Exact etiology is unknown)

1- Stress-Diathesis Model:
 Integrates biological, psychosocial and
environmental factors in the etiology of
schizophrenia.
 Symptoms of schizophrenia develop when a person
has a specific vulnerability that is acted on by a
stressful influence.
2- Neurobiology

a- Dopamine Hypothesis;
Too much dopaminergic activity ( whether it is ↑ release of
dopamine, ↑ dopamine receptors, hypersensitivity of
dopamine receptors to dopamine, or combinations is not
known ).
b- Other Neurotransmitters;
Serotonin, Norepinephrine, GABA, Glutamate &
Neuropeptides
c- Neuropathology;

Neuropathological and neurochemical

abnormalities have been reported in
the brain particularly in the limbic
system, frontal cortex, basal ganglia
and cerebellum. Either in structures or
connections.
d- Psychoneuroimmunology;
↓ T-cell interlukeukin-2 & lymphocytes, abnormal cellular and
humoral reactivity to neurons and presence of antibrain
antibodies.
These changes are due to neurotoxic virus ? or endogenous
autoimmune disorder ?
e- Psychoneuroendocrinology;
Abnormal dexamethasone-suppression test
↓ LH/FSH
A blunted release of prolactin and growth hormone on
stimulation.
3- Genetic Factors

- A wide range of genetic studies strongly suggest a

genetic component to the inheritance of
schizophrenia that outweights the environmental
influence.
- These include: family studies, twin studies and
chromosomal studies.
Schizophrenia: genes plus stressors
Schizophrenia is mostly caused by
various possible combinations of
many different genes (which are
involved in neurodevelopment,
neuronal connectivity and
synaptogenesis) plus stressors from
the environment conspiring to cause
.abnormal neurodevelopment
There is also abnormal
neurotransmission at glutamate
synapses, possibly involving
. hypofunctional NMDA receptors

Stephen M The Genetics Of Schizophrenia

Converge,Upon,The NMDA Glutamate Receptor, CNS Spectr.
2007
4- Psychosocial Factors;

 In family dynamics studies:

**no well-controlled evidence indicates specific family pattern plays a
causative role in the development of schizophrenia.

 High Expressed Emotion family : increase risk of relapse.

Weight of different RF: Family history comes first

PLOS Medicine
Diagnosis

# DSM-IV-TR Diagnostic Criteria for Schizophrenia:

A- ≥ two characteristic symptoms of :
1- Delusions
2- Hallucinations
3- Disorganized speech
4- Disorganized behavior
5- Negative symptoms
B- Social / Occupation dysfunction
C- Duration of at least 6 months
D- Schizoaffective & mood disorder exclusion
E- Substance / General medical condition exclusion
F- Relationship to pervasive developmental disorders
Subtypes of Schizophrenia

Paranoid type

Disorganized type

Catatonic type

Undifferentiated type

Residual type
Clinical Features

No clinical sign or symptom is pathognomonic for

schizophrenia
Patient's history & mental status examination are
essential for diagnosis.
 Premorbid history includes schizoid or
schizotypal personalities, few friends & exclusion
of social activities.
 Prodromal features include obsessive compulsive
behaviors
- Picture of schizophrenia includes positive and
negative symptoms.
- Positive symptoms like: delusions & hallucinations.
- Negative symptoms like: affective flattening or
blunting, poverty of speech, poor grooming, lack of
motivation, and social withdrawal.
Cognitive deficits in schizophrenia
 Mental status examination

- Appearance & behavior ( variable presentations)

- Mood, feelings & affect ( reduced emotional responsiveness,
inappropriate emotion)
- Perceptual disturbances ( hallucinations, illusions )
- Thought:
*Form ( looseness of association, ward salad, neologisms)
*stream ( thought blocking, poverty of thought content )
*content ( delusions)
*possessions of thoughts ( thought insertion, withdrawal &
broadcasting)
- Impulsiveness, violence, suicide & homicide
- poor cognitive functioning, poor abstraction.
- Poor insight and judgment
 Differential Diagnosis
Nonpsychiatric disorders: Psychiatric disorders:
Substance-induced Schizophreniform disorder
disorders Brief psychotic disorder
Epilepsy ( TLE) Delusional disorder
CNS diseases Affective disorders
Trauma Schizoaffective disorder
Others Personality disorders
( schizoid, schizotypal &
borderline personality)
Malingering & Factitious
disorders
 Course & prognosis

25% will be able to lead somewhat normal live.

25% will continue to have episodic exacerbation &
inter-episodic moderate residual impairment.
50 % will remain significantly impaired by their
illness for their entire live.

 Schizophrenia has better prognosis in developing

courtiers because of family relationships, informal
economies, segregation of the mentally ill and
community cohesion.
 Prognosis
Poor P.F Good P.F
1. Young age of onset 1. Late age of onset
2. Insidious onset 2. Acute onset
3. Lack of P.F. 3. Obvious
4. Multiple relapses precipitating factors
5. Low IQ
6. Poor premorbid 4. Presence of mood
personality component
7. Negative symptom 5. Good response to
8. Positive family Tx
history 6. Good supportive
system (developing
countries)
Treatment

What are the indications for hospitalization?

Diagnostic purpose
Patient & other's safety
Initiating or stabilizing medications
Establishing an effective association between patient
& community supportive systems.
Biological therapies

 Antipsychotic medications are the mainstay of the treatment

of schizophrenia.
 Generally, they are safe.
 Two major classes:
-Dopamine receptor antagonists ( haloperidol, chlorpromazine )
-Serotonin-dopamine receptor antagonists ( Risperidone,
clozapine, olanzapine ).
 Depot forms of antipsychotics eg. Risperidone Consta is
indicated for poorly compliant patients.
 - Electroconvulsive therapy (ECT) for catatonic or poorly
responding patients to medications.
 Other drugs:
-Anticonvulsants -Lithium
-Benzodiazepines
 Pharmacolog
ical
Treatment
Algorithm
Adapted
from the
Maudsley
prescribing
Guidelines
(Taylor et al,
2005)
Side effects of antipsychotics
Side effects of antipsychotics
Side effects of atypical antipsychotics
Metabolic effects of atypical antipsychotics
Psychosocial therapies

Social skills training

Family oriented therapies
Group therapy
Individual psychotherapy
Assertive community treatment
Vocational therapy
 Other Psychotic Disorders
 Psychotic Disorders due to a general medical condition (e.g
Complex partial seizure (e.g. temporal lobe epilepsy,CNS
infections,frontal lobe pathology..)
Substance-induced psychotic disorder (e.g. amphetamine,
cocaine …)
Schizoaffective disorde(Concurrent presence of mood
disturbance and schizophrenia features for ≥6m: (there must be
delusions or hallucinations, for at least two weeks in the absence
of prominent mood symptoms during some phase of the illness).


 Other Psychotic Disorders

 Schizophreniform disorder (1-6 m, a deterioration in social

or vocational functioning is not required)

 Brief psychotic disorder(<1m)

 Delusional disorder(>1m), only non-bizzare delusion.

 Outlines

Etiology
Clinical features & diagnosis.
Differential diagnoses
Course & Prognosis
Treatment (Pharmacological)
Treatment (Psychological )