04 Schizophrenia - Overview

Question 1

Importance of Schizophrenia treatment

Answer 1

• serious debilitating mental disorder (“psychosis” that manifests in early adulthood
• prevalence (1%), core symptoms and course quite uniform across cultures (highly genetic?)
• life expectancy 12-15 y under average
• high suicide rates
• high comorbidity
• high costs

Question 2

schizophrenia - neurological findings

Answer 2

• evidence of early neurodegeneration
• evidence for dysconnectivity between brain regions
• dopaminergic projections from striatum to prefrontal cortex underlying positive symptoms

Question 3

DSM-5 criteria for Schizophrenia

Answer 3

at least 2 symptoms (at least 1 of first 3) for at least 1 month (attenuated symptoms at least 6 months)
- delusions
- hallucinations
- disorganized speech (e.g. frequent derailment or incoherence)
- disorganized behavior (e.g. catatonia)
- negative symptoms (flat effect = no or inappropriate emotions, alogia = poverty of speech, avolition/amotivation = little interest or drive)

Question 4

Schizophrenia - positive, cognitive and negative symptoms

Answer 4

• positive: something new that should not be there, delusions, hallucinations
• cognitive: ineffective coding, retrieval and processing, disorganized speech/behavior, executive function decline, improvised speech and language, motor dysfunction
• negative symptoms: something’s missing which should be there

Question 5

natural course of schizophrenia

Answer 5

• premorbid phase: cognitive, motor, or social deficits
• prodromal phase: brief/attenuated positive symptoms and/or functional decline
• psychotic phase: florid positive symptoms
• stable phase: negative symptoms, cognitive/social deficits, functional decline

Question 6

heterogeneity of schizophrenia

Answer 6

• variety of disorders in psychotic spectrum
• symptomatic (and genetic) overlap to affective psychoses (e.g. bipolar disorder, MDD) and neurocognitive or affective disorders (Autism)

Question 7

Schizophrenia - epidemiology

Answer 7

• prevalence: 0,5% (1 mio. in Germany)
• incidence: 1 / 10.000 / year
• sex differnces: onset in women 5 years later (bimodal distribution), less severe symptoms, shorter duration, less negative symptoms

Question 8

Schizophrenia - main risk factor

Answer 8

genetics
- complex genetic disorder with high heritability (80%)
- neurotransmitter systems: dopamine-agonists induce positive symptoms, glutamate-antagonists may induce all core symptoms, dysfunction of GABAergic (inhibitory) neurotransmission, all antipsychotics block D2-receptors
- histological, structural and functional brain abnormalities (hippocampus, PFC, medial temporal cortex, white matter connectivity)

Question 9

Schizophrenia - other risk factors

Answer 9

perinatal and early childhood risk factors
- obstetric complications, low birthweight, in-utero-infection
- increasing age of father
- maternal infections during pregnancy (e.g., influenza)
environmental factors
- infections
- high expressed emotion families
- growing up in large cities (OR = 2)
- immigration status (OR = 2-5)

Question 10

Schizophrenia treatment - antipsychotics

Answer 10

first generation
- efficacy against positive symptoms
- side effects: extrapyramidal symptoms including parkinsonism, dystonia, akathisia, tardive dyskinesia
second generation
- agranulocytosis/neutropenia (clozapine)
- weight gain, diabetes, hyperlipidemia
- lower risk for EPS

Question 11

Schizophrenia - most effective antipsychotic

Answer 11

Clozapine
- only antipsychotic treatment effective in treatment resistant patients
- efficacious in treatment of negative symptoms
- without active monitoring, causes agranulocytosis
- worst antipsychotic for treatment emergent weight gain

Question 12

Schizophrenia - psychosocial interventions

Answer 12

• CBT, social skills training, family therapy, vocational rehabilitation and supported employment
• may be only effective treatment for negative symptoms
• overall increase in quality of life