Schizophrenia

=Reading= Andreason Kaplan & Sadok'c pocket handbook of licnical psychiatry, pp100-127 Carpenter, WT Jr, Buchanan RW (1994) Schizophrenia, NEJM Jibson MD, Glick ID, Tnadon R. (2004) Schizophrenia and other psychic disorders, Focus

=Goals=

Describe schizoaffective disoorder, b rief psychotic disorder, delusional disorder, and common substances and medical illnesses associated with psychosis
Psychsis almost always pathological usually represent relatively severe disorder run through diff diag talk about b/c mpotant: public health,

Description: impairment in reality testing interacting with world around us evidenced by specific symptoms

hallucinations: false sensory perceptions hearing, feeling things w/o sensory inputs

delusions: fixed ideas cannot be supported with environmental evidene when confronted, person doesn't change

thought disorganization: usually cognitive or emotional content circumstances in which occur need to spot connections if thinking repreatedly fails....

hallucination where happening? not in ear or inner ear...in sensory cortex in last area where sound is processed experienced the same by looking at brain activity > most frequent hallucination, no matter the cause > visual or olfactory may be more common in neurological problems > relative frequency > not pathognomonic
 * auditory

> face occupied facial lesions
 * visual
 * tactile
 * olfactory

> think physilogical imbalances also multimodal..see and hear //example: schizophrenic man hears and sees...can smell aftershave//
 * gustatory
 * None are pathognomonic for anything!!**

Delusion: False belief that is... ((doesn't necessarily have to be false)) //example: young man brought in by parents parents more concerned explained hearing voices pressed: knew why hearing voices... find evidence for whatever you want pile of evidence....implantaiton of metallic electrodes in brain...can broadcast voices directly to brain development of cochlear implants...really did affect hearing undergraduate roommates had secretly implanted electrodes during night talked...persuaded...try antipsychotic medication pressing for MRI scan predicted that he would not believe resultes of MRI resolution...sneaked in and remove wire...records switched sent back report patient returns "Remind me what the resolution of the MRI is? And what assurance do we have that the records weren't switched?" tried antipsychotic started on medication...2 out of 3 chances came back 1 month later...said...almost with resignation..'alright', you're right...the voices are gone...it was the medicine....Tell me about schizophrenia//
 * based on incorrecte inference about external reality
 * firmly held despite obvious evidence to the contrary
 * not sanctione by the indvidual's culture or group

not sanctioned by the indivdual's clture or group otherwise start treating people who don't need, won't benefit. common in society otherwise... (example: dropping two objects)

schizophrenics are unable to do that when presented with evidence, still believe it

Delusions: Persecutory: belief that one is being malevolently treated in some way //example: persecution by KGB...changed after fall of soviet russia...usually still tied to reality//

Referential: AKA Ideas of Reference, idea that neutral things in the environment are seen as directed towards oneself...For example...Television //example: Weather report said it as going to be in the 50s, but windy message for me that I'm supposed to have yogurt for lunch// other questions: are you hearing voices? Are you concerned about people spying on you? Are you getting special messages? Are you reading people's thoughts? Are you reading their thoughts? "Psychiatric equivalent of a rectal exam" Sometimes can be fairly subtle //Example: was sent to county jail... wife was police officer guy came in... booking oficer sent down note saying...'spychotic, hearing voices, please evaluate' went to see him....no hint of any of the things... not disorganized, no delusional material, denied voices... told credible story of being harassed by police beause girlfriend was former girlfriend of drug lord says story of police harassment searching car, following wife, arrested on courthouse steps parabolic reflector... "Are they able to read your thoughts with that device? They try. but I resist. I'm one of only 2 or 3 people who can. I can resisthem because of the receiver implanted in my jaw. I am receiving infrared messages from jupider//

Religious: delusion beliefs of a spiritual or religious nature Were all these people in biblical accounts psychotic? Authentic religious experience is very different than psychotic disorder psych disorder usually chronic

//example: legitimate religious experience...reading bible, etc//

//example: 2 weeks ago, the heavens open, the angels come down...can't do work now...personal relationships fallen apart...when mention this to other religious members, think I'm crazy//

Grandiose: inflated sense o fwroth, power, accomlishment

Somatic: beliefe ones body is defective, changed, or disease

jealous: beliefe that ones sexual partner is unfaithufl

Erotomanic: belief that another (often famous) person is in love with the patient

//example: john hinkly thought Jodie Foster wanted him to kill the president//

//example: rebecca shaefer was killed by a man with delusions who thought she had dumped him//

disorganization

meaninngless or chaotic speach.....more

History
Madness goes back thousands of years

Kraepelin--Demential Praecox... 1896, //Dementia Praecox and Paraphrenia// dementia refers not to psychosis, but loss of memory and cognitive function friends iwth Alzheimer

Term schizofpherenia was coined by bleuler...four As...Dementia Praecox, or, the Group of Zhchizophernias//, 1911 Split is not personality, but is in emotional and cognitive funcitons, external and internal realities Four A's:// >> Preoccupied with internal stuff >>Loose >> how communicate with people...usually blunting >> difficulty in making decisions
 * Autism
 * Associations
 * Affective disturbance
 * ambivalence

By 1950s, turned on head.... Schneider not about destruction of personality really about being psychotic 10 first-ran symptoms he thought they were pathognomonic...now not cnsidered so, but still used 1) audible thoughts 2) more than one voice arging or discussing the patient he needs ot stop pacing on the stage, and why doesn't he put his glasses on? //quite maddening3) Voices commenting on patient's activities 4) thought insertion 5) thought withdrawal 6) thought broadcasting 7) made feelingsimpusles 8) made voltion 2 more

in america....split the difference/incorporated everything A and B criteria A criteria are schneider's criteria need active B criteria are Kraeplin's criteria need to be loss in function, in the fabric of our lives

DSM-IV At least two psychotic symptoms for one month (or one psychotic and one negative symptom) for a sustained paeriod of time social or cocupational dysfunction

six month duration of symptoms schizoaffective and mood disorders have eben excluded

This is the hardest part get a call from someone in graduate schools "I dont' know if should be talking to you, but have student, very concerned baout....first tow years very productive...last six months, just kinda dropped off...research hasn't gone bad. Not coming into lab, hard to engage, talk to roommate, not doing anything else, not a lot of social stuff....talked to her a couple of weeks ago...talking aboutw eird stuff"//
 * Social dysfunction**

Example: woman possessed by spirit entities that stuck to her like velcro balls if didn't go out, less upsetting gradual deterioration professor was willing to cover for her for a while 1 year later got a call from her could you prescribe for me a tank of oxygen and an oxygen mask? why? because going to be doing work in a wind tunnel kind of on my own. The entities are stuck to me, and I discover if I stick my head out the window of my car, the entities are blown off. If I could get in a wind tunnel, I think I could blow them off. But I'm afraid I won't be able to breathe. No oxygen mask... Didn't come see typical course

//General deterioration

<> active psychosis functional deterioration//

Subtypes
limited validity, but still used

Paranoid types
not specifically about having paranoia! about having delusions or hallucinations as primary sumpoms mainly psychosis, relatively preserved social function maintain employment, family relationships...John Nash subtype no catatonia or as much deterioration of speeh

Disorganized
Prominent disorganized speech disorganized behavior flat or inappropriate affect wandeirng around inner city, screaming incoherently// virtually never are able to maintain relationships terrible prognosis

Catatonic
rarest subtype motor immobility catalepsy...'waxy flexibility'...poseable....move into new posture...sit there a long time excessie, purposeless motor activity extreme negativisim...motiveless reeistance ot instructions or mutism peculaiarities of coluntary movement...sterotypes movenments, prminent mannerisms, or prominent grimacing Echolalia echoing words echopraxia mimicking gestures when not in catatonic episode...goes away when properly treated unlike being obnoxious! more common with mood disorders

Undifferentiated
None of the above most common Maybe should be 'elements of all of the above' or 'more than one of the bove' some delusions, motor, degredation of speech prognosis in the middle

Residual
Active psychosis gone, still noticeably imparired absence of prominet delusions, hallucinations, disorganized speech, and grossly disorganized catatonic behavior continueing evidence of disturbance....negative symptoms, ablated psychoses

Symptom Descriptions empirically validated added on to normal experience synonymous w/ active psychosis > hallucinations, delusions...ideas of refernce
 * Positive symptoms

things missinng from normal experience > Blutned affect > Alogia--thougth blocking, long latency, reducted amount or content > Avolition/apathy: poor grooming, hygiene, impersistence, at schol or work, low energy
 * Negative Symptoms

Affect: amygdala...subcortical pathways translate thought into facial expression non-conscious if try ot do it, it looks fake fake lauging or fake crying as soon as walk up to someone...can read facial expression, walk the other way can do dangerous things, more often victims than perpetraters of crime

Avolition: in everything no drive to be creative, productive...just fades away Reagan: how do we know they're not lazy? No enjoyment of sports, leisure activity, fun activities Anhedonia--little social drive inattention: socially uninoled, spacey cognitive impairments: IQ ~ 1 standard dev below average memory,executive function language, attention... had no trouble spotting schizophrenic abnormal affect

Onset, Course: Prodrome: deterioration, negative symptoms an be present from birth, or for months or years
 * poor social adjustment; few firends
 * poor school and work performance, low IQ
 * negatie symptoms
 * peculiarities of thought or behavior

Age of onset is onset of psychosis Men: 17-30 Women: 20-40 can occur before or later

Prognostic features < > GOod prognosis: sudden onset, later onset Poor prognosis

Positive symptoms tend to occur episodically acute episodes are the most common cause of hospialitzation, and respond well to antipsychotic medication

Negative symptoms tend to be chronic and progressive little improvements

residual symptoms are those that never go away < >

5-10% commit suicide generally higher functioning schizophernics most often when are on the way down from a psychotic episode depression: 50% of casses, often after an acute episode Homelessness Crime: 4 fold increase in acts of violence ompared with the general populations almost all use psychoactive substances

Incidence is about 1% in all populations Annual incidence is 15-20 per 100,000 overrepresentation of lower economic groups...downward drift
 * Remember**

Epidemiology: 10% risk to first-degree relatives 50% risk to monozygotic twins no specific gene linkage has been demonstrated probably common final pathways of many problems in brain

Environmental.... if 50% of twins don't develop... 2nd trimester viral infections toxic exposure perinatal anoxia winter births > puts second trimester at peak of influenza season

Pathopsyiology we don't know exactly
 * Dopamine Hypothesis
 * Structural Hypothesis
 * Other Hypotheses

Major Dopamine Pathways: Nigrostriatal tract: extrpyramidal pathway begins in the substantia nigra and ends in the caudate nucleus and putamen....etc

evidence: more dopamine receptors at autopsy dopamine agonsits worsen psychotics all effetive neurleptics work via dopamine pathway...block post-synaptic dopamine actions good respondes have a response in metabolism of dopamine increaesd subcortical... <<>>

Structural correlates: increased ventricle-to-brain ratio 10% smaller than everyone else reflected in large sulci and large ventricles general loss of neuronal tissue not specific enough to be used as diagnosis

Treatment: antipsychotic medications atypical vs conventional 70% of pts repond clozapine is 'ace in hole'

Psychosocial interventions: social skills trianing vocational rehabilitaiton Family psychoeducation-especially for families with high levels of expressed emotion supportive psychotherapy

Manic Episode: occurs in 80% of manic episodes have psychotic symptoms manic episodes: antipsychotic, mood stabilizers

Depressive disorders: 10% develop psychosis often congruent: ECT is effective in about 90% of patients

'big three: depression, bipolar, schizophrenia'

can't always tell difference

Schizoaffective sdisorder... acute disorders are mood disorder psychotic without mood symptoms voices, delusions, no mania, no depression other times, manic episodes and depressive episodes independent of each other roughtly equal contribution

<> less common that schizophernia treatment antipsychotic plus mood stabilizer or antidepressant

Delusional Disorder much more cirucumscribed only delusion no deterioration in social function non-bizarre delusion bizarre: the receiver in my tooth is picking up infrared beams from Jupiter Non-bizarre: My wife is having an affair //story: couple comes in, husband is falling apart, don't know what to do with him, not aking care of business well dressed, professional husband has head down wife marching along wife "We have a title company, my husband is not taking care of business, not paying attention to contracts, afraid going to come back to haunt us...concerned." goes on 20 minutes "So, are you depressed?" "I don't think I'm depressed" We have a boilerplate contract. We run them off 5000 at a time. we fill in the blank with the names and addresses. she is sure someone has broken into theoffice and and changed one word from an 'or' to an 'and' I don't think so, and I'm not going to read those contracts "The good news is, your husband isn't depressed." gently try to ... "Are you sure your concerns are realistic?" "You have no idea...our competitors would do anything...." never came back. delusional disorder// tendency to assume that everything starts with the mildest form not true with psychosis not particulary comon Onset is middle or late life should **not** be preferentially diagnosed over big 3 lifetime risk 0.05% course is variable treatment is antipschtoic, response not very good

brief psychotic disorder...totally psychotic...recover within 30 days //classic case: come in, looking totally manic, give one dose of antipsychotic see next morning, completely normal// major predisposing factor is a personality disorder: especially paranoid, borderline hisrionic, narcissitic, schizotypal often get better with supportive care rapid onset, rapid resolution

Shared psychotic disoders....'folie a deux'

Other psychotic dirodrs: Substance-Induced Psychosis Disorder almost anything < >

WIthdrawal: alcohol, sedatives, hypnotics, anxiolytics //I've gotten burned...need to get withdrawal under control// delerium tremens

Other substances high-dose steroids L-dopa

Lots and lots of medical ilnesses context of delirium, dementia