Lecture 11 - Schizophrenia Spectrum Disorders Flashcards
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion A
Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
- Delusions.
- Hallucinations.
- Disorganized speech (e.g., frequent derailment or incoherence).
- Grossly disorganized or catatonic behavior.
- Negative symptoms (i.e., diminished emotional expression or avolition).
Typical symptoms (and their characteristic features)
Positive symptoms.
- Hallucinations
- Delusions
- Formal thought disorder
- Behavioural/Motor disturbances
- Lack of insight
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion C
Continuous signs of disturbance are present for at least 6 months
- May include a gradual deterioration in functioning
- Must include at least one-month of psychotic symptoms
_____________________________
Continuous signs of the disturbance persist for at least 6 months.
This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion D
Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion B
Clinically significant impact to social/occupational functioning
(functioning is below that prior to onset of the disorder)
Diagnostic criteria of schizophrenia (as per DSM-5)
Criterion E & F
D-F. Not better accounted for by other diagnosis: schizoaffective, substance, autism
_____________________________
E: The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
F: If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).
Diagnostic criteria of schizophrenia (as per DSM-5)
Specify If:
The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.
First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
Unspecified
Specify if: With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119–120, for definition).
Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizophrenia to indicate the presence of the comorbid catatonia.
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of schizophrenia can be made without using this severity specifier.
What is psychosis?
Refers to loss of contact with external reality characterised by
• Impaired perceptions
• Thought processes
What are the different types of Psychotic disorders in the DSM-5?
(9)
(SSBSSSPC)
- Schizophrenia
- Schizotypal (Personality) Disorder
- Brief Psychotic Disorder (sudden, <1mth, return to functioning)
- Schizophreniform Disorder (>1mth<6mths & individual has recovered; bipolar/depressive disorder ruled out; provisional diagnosis)
- Schizoaffective Disorder (mood disorder criteria present)
- Substance-/Medication-induced Psychotic Disorder
- Psychosis due to a medical condition
- Catatonia & other unspecified (exclude neuro developmental or medical condition)
Typical symptoms (and their characteristic features)
Negative symptoms.
Affective Flattening, inc
- social withdrawal
- anhedonia (inability to feel pleasure in normally pleasurable activities)
- emotional blunting
- confusion
Avolition, inc.
- amotivation
- apathy
- self-neglect
Alogia
- poverty of speech
- poverty of content
Presence of negative symptoms suggest poorer response to treatment
What does a positive symptom refer to?
The presence of problematic (behaviours) - weird word choice because I would argue it was also cognition…
What does a negative symptom refer to?
Absence of healthy (behaviours)
What are the epidemiological characteristics of schizophrenia?
Prevalance:
- Lifetime prevalence of schizophrenia: 1-2%
- Male to Female ratio: 3:2
Age of onset
- Typical onset in late adolescence & early adulthood (tends to be later for women)
- Onset typically preceded by a gradual deterioration in functioning followed by appearance of more acute symptoms
- Onset coincides with an often stressful time of life, further complicated by impact of schizophrenia
- Early onset associated with poorer outcomes
Early treatment associated with better outcomes (yet delay in treatment common)
What do Family Therapy interventions provide?
- Education about schizophrenia and its treatment
- Realistic goal setting skills
- Communications training (empathic not critical)
- Problem Solving skills
- Promote social support
Take home messages…
- Schizophrenia is a severe neurodevelopmental disorder with prominent genetic and environmental/psychosocial aetiology
- The prognosis for people living with schizophrenia varies depending on the amount of support & the type of treatment received.
- People can function well - esp. if family is supportive and if patients adhere to medication/treatment
- It is important to promote acceptance, support and recovery for people living with schizophrenia and related psychotic disorders.
Which chapter of the DSM-5 is schizophrenia in?
Schizophrenia Spectrum and Other Psychotic Disorders
Why are Family therapy interventions good?
Family interventions shown to reduce relapse and enhance family support
Why were family therapy interventions developed?
In response to higher relapse rates for patients from families high in Expressed Emotion (EE)
TREATMENT:
Psychological Interventions
Systematic reviews & Meta-analyses
§ Lutgens et al (2017): Psychological and psychosocial
interventions for negative symptoms (72 studies)
• CBT, skills-based training, exercise, music treatment found
beneficial
§ Jauhar et al (2014):
• Evidence for only small effects on overall symptoms
TREATMENT:
Psychological Interventions
§ Need to be tailored to the stage of illness
§ Designed to target specific deficits or objectives:
• social skills training for interpersonal deficits
• medication compliance
• managing delusions/hallucinations
• stress management
• Important to work from the patient perspective
1.
Schizophrenia
‘Split mind’ (Bleue: 1911)
1. Fragmentation of thoughts
2. Splittingofthoughtsfromemotions 3. Withdrawalfromreality
NOT split personality
(classified as Dissociative Identity Disorder)
What are hallucinations?
- perception-like experiences that occur in absence of any external stimulus: vivid, clear, and not under voluntary control
- occurs in clear sensorium: hypnagogic (while falling asleep) and hypnopompic (while waking up) are not included
What are the different types of hallucinations? (5)
- Auditory
- Visual (not illusion/misperception)
- Olfactory (smells)
- Gustatory (taste)
- Tactile (insects crawling)
What percentage of schizophrenic patients report experiencing hallucinations?
75%
What are auditory hallucinations?
Hearing voices (distinct from own thoughts).
• Voices inside head or coming from external sources
• Own thoughts spoken aloud (describing feeling/thinking/fears) • Can be comforting
• Derogatory or insulting voices
• Third person commentary
• Commands to perform unacceptable behaviors
How many report auditory hallucinations?
60%-70% report auditory hallucinations
What are delusions?
- False firm beliefs despite what others believe and despite evidence to contrary
- Beliefs are not culturally accepted
Typically categorised based on content and bizarreness.
What are the different kinds of delusions? (5)
- Paranoid or Persecutory Delusions
False belief that one is being harmed/persecuted by a person/group - Referential Delusions
Neutral event interpreted to have personal meaning - Grandiose Delusions
False belief that one has special powers, abilities, fame - Nihilistic Delusions
Belief of non-existence of self, part of the body,
others or the world - Erotomanic Delusions
False belief that another person (a stranger, high status or famous) is in love with him/her
What is formal thought disorder?
§ Disorganised thinking
=> disturbances in flow and/or form of SPEECH
(as opposed to content as in delusions)
What are the positive symptoms of formal thought disorder? (6)
POSITIVE manifestations
(addition of disturbed thought processes/speech)
- Circumlocution or circumstantiality (very indirect, long-winded descriptions)
- Derailment (comments slipping from one to next, only partially-related topic)
- Tangentiality (irrelevant responses to questions)
- Echolalia (involuntary parrot like repetition; acute phase)
- Word salad (incomprehensible stream of words)
- Clang associations (phrases linked through sound rather than meaning;
e. g., “Pass me the spoon, moon, I’m cocoon.”)
What are the negative symptoms of formal thought disorder?
NEGATIVE manifestations
(deficits in though processes/speech)
• Reduced stream of thoughts & poverty of speech
- What is Catatonic behaviour?
a marked decrease in reactivity to the environment
- from childlike stillness to unpredicatble agitation
- medication reduced prevalence but ~ 32% still affected (Ungvari et al., 2005)
- What are the symptoms of
Symptoms: E.g.
- Stupor (no psychomotor activity; not actively relating to environment)
- Catalepsy (a rigid posture/positions of limbs despite gravity)
- Waxy flexibility (remaining in a posture even when limbs moved into place by another person)
- Grimacing
- Negativism (opposition or no response to instruction/stimuli) § Mutism (no, or very little response)
- Echopraxia (imitating another’s movement)
Describe the epidemiological characteristics of schizophrenia?
(Prevalence and age of onset)
Prevalence
- Lifetime prevalence of schizophrenia: 1-2%
- Male to Female ratio: 3:2
Age of onset
- Typical onset in late adolescence & early adulthood (tends to be later for women)
- Onset typically preceded by a gradual deterioration in functioning followed by appearance of more acute symptoms
- Onset coincides with an often stressful time of life, further complicated by impact of schizophrenia
- Early onset associated with poorer outcomes
- Early treatment associated with better outcomes (yet delay in treatment common)
- Schizophrenia: Clinical course
§ Highly variable in presentation and course
- one or more episodes, with periods of normal (or near normal) functioning between episodes
§ Chronic condition without full recovery
- most remain chronically unwell with a deteriorating course
• 50% unable to work, <25% employed
• Social isolation, homelessness, low income & poor health
• Sufferers often frightened, perplexed & confused over emerging symptoms
- Clinical course of psychotic disorders
see slide 18
SCHIZOPHRENIA: Prognostic factors
Good premorbid functioning
- Acute onset
- Later age of onset (females)
- Precipitating event (e.g., drug induced psychosis)
- Low substance use
- Brief duration of active phase
- Absence of structural brain abnormalities
- No family history of schizophrenia
SCHIZOPHRENIA: Prognostic factors
Poor premorbid functioning
- Slow insidious onset
- Prominent negative symptoms
- Duration of untreated psychosis
- Slower or less complete recovery
- Lower socioeconomic class
- Migrant status
- Social support network
*SCHIZOPHRENIA: Aetiological Factors
NOT WELL UNDERSTOOD
• Heterogeneous range of disorders with a presumed common underlying biological vulnerability
Implicated factors:
- Genetic
- Biochemical
- Neuroanatomical
- Psychosocial
slide 20 has diagram
*Schizophrenia: Genetic Factors
Degree of risk related to degree of heretability
determine susceptibility => disorder triggered by other factors
• 7 % siblings
• 9 % for children of 1 affected parent
• 46 % for children with 2 affected parents
Twin studies concordance rates: • 12 % for DZ twins
• 44 % for MZ twins
Adoption studies:
• Higher rates among children whose biological parents have schizophrenia (19%), compared to children with no biological parents with schizophrenia (10%)
- Risk of schizophrenia as a function of genetic relatedness
(Gottesman, 1991)
- Biochemical Factors
Dopamine hypothesis: overproduction or oversensitivity of dopamine receptors
- Excess L-Dopa in Parkinson’s disorder precipitate psychotic episodes
- Amphetamine (dopamine agonist) psychosis: abnormally large responses to low amphetamine doses suggests over-sensitivity rather than excessive dopamine level
- Response to anti-dopaminergic medication (e.g. chlorpromazine) - effective in 60% with more impact on positive symptoms
- Lack of impact on negative symptoms hints at 2 separate syndromes
i. Caused by dopamine activity & associated with POSITIVE symptoms
ii. Caused by brain degeneration & associated with NEGATIVE symptoms.
- Schizophrenia: Neuroanatomical Factors
Most consistent neuroanatomical finding:
- Enlarged ventricles in schizophrenia (post-mortem; CT scans; MRI studies)
- Relative size more than twice that of normal controls
Most likely cause is loss of brain tissue; scans indicate chronic schizophrenia is associated with brain abnormalities
- Schizophrenia: Neuroanatomical Factors
Greater brain tissue loss in prefrontal cortex
- Linked to negative symptoms (damage to executive functioning system)
Recent findings of smaller left hippocampal volume in those:
• with schizophrenia
• at very high risk of developing schizophrenia
• without a family history
§ Structural brain abnormalities appear to predate onset of psychosis and worsens with progressive illness
§ Early neurodevelopmental damage (e.g., from viruses) may play a key aetiological role
- Aetiology: Seasonal variations & place of birth
• Greater likelihood of winter or spring birth
? Viral illnesses or Vitamin D deficiency during neonatal/brain development
- Two-fold increase in risk for urban births
- More common among lower socioeconomic classes & more prevalent in lower class districts of many cities of the industrial world (? drift hypothesis)
- Schizophrenia: Developmental course
see diagram slide 28-29
- TREATMENT: Medication
Medication is primary intervention:
• 60% of clients with positive symptoms respond: Block dopamine receptors
10%-20% do not show symptom improvement in response to medication
Relapse rates high with 40% relapsing within one year
- Side effects of medication: NEUROLEPTICS Medication non-compliance given common side effects:
Sedation
Extra pyramidal side effects (EPS resembling Parkinson’s Disease):
- Tardive dyskinesia (abnormal movements, facial grimacing, lip smacking)
- Finger tremors, shuffling gait, drooling, chewing, twisted posture
Weight gain, diabetes, heart disease
Clozapine additional side effects:
- blood abnormalities
- reduced white blood count
- TREATMENT:
Psychological Interventions
§ Need to be tailored to the stage of illness
§ Designed to target specific deficits or objectives:
• social skills training for interpersonal deficits
• medication compliance
• managing delusions/hallucinations
• stress management
• Important to work from the patient perspective
Systematic reviews & Meta-analyses
§ Lutgens et al (2017): Psychological and psychosocial
interventions for negative symptoms (72 studies)
• CBT, skills-based training, exercise, music treatment found
beneficial
§ Jauhar et al (2014):
• Evidence for only small effects on overall symptoms
What does CBT help patients to do?
- Notice early signs of relapse
- Understand relationship between external stressors/activating events and internal thoughts, feelings & behaviours
- Challenge beliefs about not being able to manage one’s thoughts & behaviours
- Learn strategies to cope with symptoms & stressors
- Evaluate evidence supporting delusional beliefs versus alternative beliefs (e.g., recognize inner experiences such as ‘thoughts’ can be misattributed to external sources, like ‘voices’)
“If your voices came from the radiator, why can’t anyone else hear them?
What is the suicide rate like in schizophrenia?
- 30% of patients attempt suicide
* 5-10% complete suicide
