Lecture 5: Clinical Features of Schizophrenia Flashcards
September 11
Jeannette Dagam, DO
Psychiatrist
Diagnostic Criteria: A
A) Two or more of the following, each present for a significant portion of the 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)
Diagnostic Criteria: B
For a significant portion of the time since the onset of the
disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood
or adolescence, there is a failure to achieve expected level of interpersonal, academic or occupational functioning).
Diagnostic Criteria: C
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 2 or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
Diagnostic Criteria: D
Schizoaffective disorder and depressive disorder in bipolar
disorder with psychotic features have been ruled out because either
1: no major depressive or manic episodes have occurred
concurrently with active-phase symptoms, or
2: they have been present
for a minority of the total duration of the active and residual periods of the illness
Diagnostic Criteria: E
The disturbance is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication) or another medical condition
Diagnostic Criteria: 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)
Positive Symptoms
Delusions
Hallucinations
Disorganized speech
Disorganized behavior
Negative Symptoms
Affective Flattening – reduction in range and intensity of
emotional expression, including facial expression, voice tone, eye contact, and body language
Alogia – poverty of speech, the lessening of speech fluency and productivity
Avolition – reduction, difficulty or inability to initiate and persist
in goal-directed behavior; is often mistaken as disinterest or
depression
Prevalence, Development and
Course
Lifetime prevalence approximately 0.3%-0.7%
Onset prior to adolescence is rare
Psychotic features typically emerge between the late teens and mid-30s
Peak age of onset is early to mid 20s for males and late 20s for females
Earlier age of onset is traditionally seen as a worse predictor for prognosis
Age of onset is likely related to gender, with males having worse premorbid adjustment, lower educational achievement, more prominent negative symptoms and cognitive impairment, and in general worse outcomes
Development and Course continued…
Psychotic symptoms tend to diminish over the life course, perhaps in association with normal age-related declines in dopamine activity.
The essential features of schizophrenia are the same in childhood, but it’s more difficult to make the diagnosis. In children, delusions and hallucinations may be less elaborate than in adults and visual hallucinations are more common and need to be distinguished from normal fantasy play.
Late onset cases (after 40 years) are overrepresented in females.
Often the course is characterized by a predominance of psychotic
symptoms with preservation of affect and social functioning
Familial Clustering of Schizophrenia
80%-85% of persons with schizophrenia have NO
1st-degree relatives with schizophrenia
60% of persons with schizophrenia have NO 1st or
2nd degree relatives with schizophrenia
Nevertheless, family studies consistently show increased risk in relatives of probands
HISTORY OF PRESENT
ILLNESS
49-yr-old single African American female presented
to a local psychiatric emergency room with her sister
for worsening paranoid delusions that her phone is
bugged, people are following her, that her ex-fiance is trying to kill her, referential delusions of death threats in license plates and AH of music/ex-fiance
Paranoia has resulted in insomnia, decreased food/
water intake, decreased attention to activities of daily living, missed work without calling in
Paranoia has intensified over the last several days but
per family reports, the patient has had an insidious onset of paranoia for the past year
Patient suspected her fiancé at the time of cheating, so she began tape-recording him at night because she believed he was revealing whom he was cheating with. When she played the recordings for her family, all
that was audible was his snoring but she was convinced she was hearing incriminating information.
Complicating factors in obtaining a better history of
onset/quality of symptoms:
a) patient refused to sign a release of information for ex-fiance
b) patient had been living alone since her fiance moved out
HOSPITAL COURSE
of that crazy lady
Upon evaluation by the treatment team, patient was
extremely paranoid/delusional that staff were trying to gas her by manipulating the light switches. Walked around with a napkin over her nose claiming to smell the gas
Paranoid that her ex would send people to find and hurt her on the unit
Auditory hallucinations of voices saying they were going to shoot her through the heart
Patient was observed to be distracted by her hallucinations at times. Also endorsed paranoia that the food was tainted.
Initially, very paranoid about starting medications but
agreed to start Geodon (patient was already morbidly obese, so
neuroleptic-induced weight gain was a concern).
Geodon was gradually titrated up with good tolerability but the patient continued to be delusional, irritable, reading her Bible and rebuking the
medications and staff. Believed that demons were controlling her
Prolixin was added to the patient’s regimen with the hope of hastening her recovery
Patient eventually began sleeping better, became less paranoid, isolated less, was eating adequately and began to report that she felt the medication was helping
The patient’s insight also improved, gradually able to entertain the notion that her fears may be originating from within her
FOLLOW-UP AFTER
DISCHARGE
(of that crazy lady)
Patient developed some side affects to the Prolixin which was tapered as an outpatient and eventually dc’ed.
The patient reported doing well on the Geodon –acknowledging that she had been hospitalized for mental illness, denied many previous paranoid thoughts, and reunited with her ex-fiance.
However, the pt still required assistance from family
regarding medication administration and had not yet
been able to return to work.
Later Onset Schizophrenia
More likely to have been married but nonetheless
more socially isolated and impaired when contrasted
with general population
Presentation more likely to include persecutory
delusions and hallucinations and less likely disorganized and negative symptoms
Often there is a predominance of positive symptoms w/ preservation of affect and social functioning
Good Prognostic Indicators
Later onset means better premorbid functioning
Women with schizophrenia tend to express more affective symptomatology, paranoid delusions, and hallucinations, whereas men tend to express more negative symptoms
(flat affect, avolition, social withdrawal)
In general, women have been found to have a better prognosis as defined by number of hospitalizations, lengths of hospital stays, overall duration of illness, time to relapse, response to neuroleptics, and social and work functioning
Gender advantage lessens with age
The Role of Estrogens in
Schizophrenia
Estrogen, like all gonadal steroids, are fat soluble –easily entering nerve cells and binding to specific receptor proteins either within the cell nucleus or in the cellular cytoplasm
Mechanism of estrogen’s actions is through gene
expression but it may also act directly on neurotransmitter systems.
Estrogens are known to modulate the dopamine system.
Estrogens stimulate nerve growth factors and enhance neuronal survival
Long-term studies (15+ years after illness onset) globally do not support outcome differences between men and women
However at 2, 5, and 10 years into the illness, most research shows that women as a group doing significantly better than men
This ‘doing better’ during the first decade may be more
related to premorbid competence, decreased substance abuse, and compliance with treatment than to hormones (although such behaviors may be hormone-dependent to some extent)
Estrogens, Age, and
Schizophrenia
It is thought that the initiation of cyclical hormone fluxes in women may serve as a protective function against the development of adolescent psychosis
This is reinforced by the bimodal age of onset peak in
women – the 2nd peak being in the early to mid 40s, a time when estrogen levels are falling
Also supportive of the protective effects of estrogen
is how the severity of illness in women approximates that of men in later years after the onset of menopause
When the role of Estrogen does
not seem to confer an Advantage
Studies have confirmed the absence of gender effect on the age of onset for patients with familial schizophrenia
There is a trend toward decreasing familial risk for
schizophrenia with increasing age of onset
Data indicate that women with a positive family history of schizophrenia do not have the reported delay in age of onset, suggesting the effect of
estrogen cannot play its protective role in the presence of genetic factors
Overview of Post Mortem Findings
Reduced brain size and weight in some, not all, studies
Tissue reduction and neuronal disarray in many regions
Limbic system most extensively involved
Possible involvement of cortex, corpus callosum, basal ganglia
Generally, absence of gliosis
gliosis
an increase in the size and number of astrocytes of the brain.
Excessive proliferation of the neuroglia.
Gliosis is a process leading to scars in the central nervous system that involves the production of a dense fibrous network of neuroglia (supporting cells) in areas of damage. Gliosis is a prominent feature of many diseases of the central nervous system, including multiple sclerosis and stroke. After a stroke, neurons die and disappear with replacement gliosis.
Brain Size, Volume, and Weight
Compared to controls matched for age & sex, many studies
find no differences.
But…Some studies find:
5% to 8% reduction in weight
4%-5% reduction in anterior-posterior length
Neuroleptic drug effects may be present
Adults with schizophrenia have head (skull) circumference
similar to controls
Infants who meet criteria for schizophrenia in adulthood have
slightly reduced head circumference (in early infancy)
Conclusion: more evidence for focal than generalized
abnormalities
Ventricular Enlargement
Compared to age- and sex-matched controls, 15%-20% of patients with schizophrenia show mild to moderate increase in size of lateral ventricles, inferior (temporal) horns, and 3rd ventricle (but not the 4th)
Enlargement of 3rd ventricle generally found more
frequently and to a greater degree
Enlargement is bilateral, symmetric, and diffuse
Ventricle-to-brain ratio (VBR) is abnormally high in about 20% of patients
