Schizophrenia Flashcards
What schizophrenia is not
- 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.
Schizophrenia and psychosis
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
History of schizophrenia
- 4 A’s
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
DSM diagnostic criteria for schizophrenia
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)
- Delusional disorder
- Brief psychotic disorder
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)
Schizophreniform disorder
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
- Schizoaffective disorder
- Substance/medication induced psychotic disorder
- Psychotic disorder due to another medical problem
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
Positive symptoms in schizophrenia spectrum disorders
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
Negative symptoms in schizophrenia spectrum disorders
Negative symptoms –> deficit symptoms; may be either primary or secondary (e.g. related to anti-psychotic side effects, environmental deprivation, or positive symptoms)
- Blunted affect –> decreased expressiveness, constrained, dampened emotional tone
- Alogia –> poverty of speech
- Avolition –> lack of will and motivation to do things
Relational and cognitive problems in schizophrenia spectrum disorders
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
Deficit syndrome of schizophrenia
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
Key points to remember about schizophrenia
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
Diagnosis
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)
Possible etiologies
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.
Pathophysiology - neurotransmitters
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