Transcript SCHIZOPHRENIA

SCHIZOPHRENIA
History
 Emil Kraeplin - dementia precox
 Eugen Bleuler - schizophrenia
 4A’s : associational disturbances
affective disturbances
ambivalence
autism
- Secondary Symptoms: hallucinations &
delusions
 Other Theorists:
 Adolf Meyer - founder of psychobiology;
schizophrenic reaction
 Harry Stack Sullivan - founder of
interpersonal psychoanalytic school; social
isolation
 Gabriel Langfeldt - 2 groups: with true
schizophrenia & schizophreniform
psychosis
 Kurt Schneider - first rank symptoms
Epidemiology
 Lifetime prevalence (US) = 0.6 - 1.9%
 Annual incidence of 0.5 - 5.0 per
10,000
1. Age & Sex: M=F
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M: early onset (15-25 yrs), > (-) sxs
F: peak onset=25-35 yrs, better outcome
90% of cases - between 15-55 years old
Onset before 10yrs & after 50 yrs=rare
Medical Illness
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Have higher mortality rate from accidents
and natural causes
80% - have significant concurrent
medical illness
3. Suicide - 50% attempt suicide
50% attempt suicide
10-15% die by suicide
M=F, likelihood to commit suicide
Major risk factors: (+) depressive sxs,
young age, high levels of premorbid
functioning
4. Associated Substance Use & Abuse
cigarette smoking
substance abuse
5. Cultural and Socioeconomic
Consideration
a. Downward Drift Hypothesis
b. Social Causation Hypothesis
Etiology
Stress-Diathesis Model
2. Biological Factors - limbic system,
basal ganglia, frontal cortex
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Dopamine Hypothesis - too much
dopaminergic activity
Other Neurotransmitters
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5HT
NE
Amino Acids
 Neuropathology
 Limbic system
 Basal ganglia
 Brain Imaging - CT scan, MRI
 EEG
3. Genetics
4. Psychosocial Factors
a. Psychoanalytic theories
b. Psychodynamic theories
c. Expressed emotions (EE)
5. Social Theories
Diagnosis
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DSM IV SUBTYPES
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Paranoid type
Disorganized/Hebephrenic type
Catatonic type
Undifferentiated type
Residual type
Type I : (+) symptoms, N brain structures on
CT scan, good response to tx
Type II: (-) symptoms, structural brain abN,
poor response to tx
Clinical Features
 History is important
 Symptoms change with time
 Premorbid sxs : schizoid or schizotypal
personalities
 Consider px’s educational level,
intellectual ability and cultural
background
Mental Status Examination
1. General Description : broad
2. Mood, Feelings, Affect : secondary
depression or post-psychotic
depression; flat or blunted affect
3. Perceptual disturbances :
hallucinations, illusions
4. Thought : content - delusions
form of thought
thought process
5. Impulsiveness, suicide, homicide
6. Sensorium & Cognition : intact
7. Judgment & Insight ; poor
8. Reliability : poor
Differential Diagnosis
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Secondary & Substance-Induced
Pscyhotic Do
Malingering & Factitious DO
Other Psychotic Dos
Mood DO
Personality DO
Course and Prognosis
 Course : retrospective recognition of
symptoms
 Each relapse of psychosis is followed by a
further deterioration in the px’s baseline
functioning
 Exacerbations and remissions
 (+) symptoms tend to become less severe
with time, (-) symptoms may increase in
severity
 Prognosis :
 Study : 10-20% good outcome
>50% poor outcome
 Literature - range of recovery rate= 1060%
20-30% lead normal lives
20-30% moderate sxs
40-60% significantly impaired
Treatment
 CONSIDERATIONS
Unique individual, familial, social,
psychological profile
2. Environmental and psychological factors
3. Complex disorder
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 Hospitalizations
 Indications: diagnostic purposes
stabilization on medications
patient safety
grossly disorganized or
inappropriate behavior
 Somatic Treatment
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Antipsychotic/Neuroleptics
Dopamine-Receptor antagonist
2. Remoxipride
3. Risperidone
4. Clozapine
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 Therapeutic Principles
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Define target symptoms to be treated
AP that worked in the past should be used
for the patient again
Minimum length of an AP trial = 4-6 wks
Use of monopharmacology
Maintain on lowest possible effective
dosage
2. Psychosocial Treatment
 Behavior therapy
 Family-oriented therapy
 Group therapy
 Individual psychotherapy