schizophrenia :The latest news By Dr. Gamal Suliman Elgorashi MB BS,DPM, MRCpsych Consultant psychiatrist Kent & Medway NHS Trust UK

Transcription

1 schizophrenia :The latest news By Dr. Gamal Suliman Elgorashi MB BS,DPM, MRCpsych Consultant psychiatrist Kent & Medway NHS Trust UK

2

3

4 The argument Schizophrenia has for too long been known as a single clinical entity illness. The treatment approach continues to be universal despite the variation in presentation, psychopathology, course of illness and indeed the causes behind the symptoms. In the last few years there have been major advances in understanding schizophrenia and other psychosis. This presentation will attempt to provide some of the new ways of thinking about schizophrenia. This will include the many faces of schizophrenia and whether it is one illness or many and also include new research, causes and possible new treatment approaches.

5 THE MANY FACES OF SCHIZOPHRENIA Schizoaffective Schizophreniform Delusional disorder Brief psychotic disorder Shared psychotic disorder Drug induced psychosis Prodromal schizophrenia Acute schizophrenia Residual schizophrenia Paranoid schizophrenia Hebephrenic schizophrenia Catatonic schizophrenia Simple schizophrenia Disorganised schizophrenia Undifferentiated schizophrenia Just unsocial people

6 Where is the damage Thinking Feelings Behaviour Motor Perception Cognition functioning

7 Problems defining schizophrenia Heterogeneity of symptoms Definitions are based on qualitative judgement (paranoid. catatonic) Same pt might be classified at different times by different clinicians as belonging to different subtype Absence of identifiable cause (medical model)

8 New approach to the definition It has been shown that closely related individuals to schizophrenics are at greater risk developing schizophrenia (Byrne et al 2003) Therefore the stress model may be useful in understanding schizophrenia It is a life time illness because communication disturbance not affected by treatment While symptoms may resolve

9 The new approach to subtypes Cortical subtype ( thought disorder and absence of delusions) Subcortical subtype (diffuse positive symptoms,negative symptoms and cognitive difficulties) Composite subtype (unimpaired group) lesser symptoms and mild course Turetsky et al 2002

10 Is it a one illness? Service user labelling? Pressure group? Government (Deprt of work)? Stigma? Relation to violence? Relation to crime?

11 Yes it is Schizophrenia is a single disease which can have different effects depending on which brain region most affected An illness based in the brain s physiology which is partially genetically heritable

12 One illness and has a gene Hannes Petursson (Iceland) reported the association of the gene neuregulin 1,on chromosome 8 with schizophrenia These results were replicated by David St Clair in Aberdeen and also similar results came from other groups including Tao Li from the Institute of psychiatry This is the first susceptibility gene for schizophrenia

13 The gene research continues A US-Irish group led by Ken Kendler reported another susceptibility gene dysbindin on chromosome 6 This has been replicated by a number of independent groups There are now more than six promising candidate genes for schizophrenia that are being investigated

14 The effect on neurodevelopment Susceptibility genes exert their effect by causing deviant neurodevelopment. Schizophrenics suffer deviant neurodevelopment either through inheriting genes that impair development or through some insult to the brain early in life or a combination of both This may explain childhood difficulties and then psychosis in adolescence or early life

15 The challenge Many people (particularly women) schizophrenia happens at 30,40or even 50 years of age ( not a brain maturation issue) Only 40% of people who have developmental problems. Some have no cognitive difficulties whatsoever( Noble prize winner John Nash) portrayed in the film beautiful mind

16 Immune protein linked to abnormal brain development In the October Journal of Neuroimmunology Daniel Kaufman described the protein called Major Histocompatability It has two functions : it helps the immune system to identify infected cells and it enables neuron make the right connection with each other In case of an infection the brain produce more MHC

17 Environmental factors Drug consumption Amphetamines and cocaine the ( Swedish army study) Social isolation (previously believed to be due to inheritance of schizoid or schizotypal personality Increasing evidence that isolation itself increases the risk of schizophrenia

18 Understanding symptoms If negative symptoms persist consider depression and give antidepressants If thought disorder and disorganisation persist consider mania and give a mood stabiliser This interventions can produce dramatic improvement(murray,r)

19 Understanding auditory hallucinations Misinterpretation of inner speech Sub vocal speech can be picked up from the larynx Speaking back or moving lips if responding During inner speech Broca's area is activated (Study by Phil McGuire) carried out SPET-scan during hallucinations

20 Understanding auditory hallucinations Sukhi Shergill has shown that during hallucinations beside Broca s area auditory cortex in the temporal lobe and other sub cortical structures are also activated In schizophrenia inner speech is processed by the system that is normally involved in processing external speech

21 Dopamine system in highly creative people New research by Fredrick Ullen from Karolinska Insitute manged to show that the dopamine system in healthy highly creative people is similar in some respect to that seen in schizophrenic Bizarre association Divergent thoughts Break the rules but goes back to reality(omda)

22 Brain abnormalities in schizophrenia In a paper published by AJP research led by John Gilmore University of North Carolina and Colombia University provide first evidence that brain abnormalities associated with schizophrenia risk are detectable in babies only a few weeks old

23 Brain signs of schizophrenia found in babies Image provided by John Gilmore, MD

24 Brain signs of schizophrenia There also exists a very-late-onset group in which degenerative brain disorder is implicated (Murray R,)

25 Molecular link between diabetes and schizophrenia Gallis Group Vanderbilt University Medical centre found that insulin also regulate the brain supply of dopamine They pieced together the molecular pathway between perturbed insulin and dopamine dysfunction leading to schizophrenia like symptoms

26 The sugar pill Out of Cambridge recently Prof Sabine Bahn said we suspect people with mental illness may have problems transporting glucose across the brain barrier and we are working on medication which can convert this This is likely if brain cells were made to effectively use glucose

27 Why some schizophrenics deteriorate In recent years it has become evident that subtle brain structural changes may occur after the onset of psychosis This include loss of temporal lobe grey matter Some antipsychotic may be implicated in these changes Stress hypothesis suggest that hormonal influence may affect the brain morphology

28 Why some schizophrenics deteriorate The HPA axis and the resultant high cortisol levels may cause further brain changes The longer person is psychotic the less likely are to recover, because of the neurochemical toxic effect e.g. cortisol However it is thought that being psychotic for a long period fill up the individual consciousness with bizarre memories

29

30 Conclusion Schizophrenia is no longer the illness we learned about in the last century Symptoms alone are no longer a salient diagnostic tool Genetic research is promising Mapping the brain pathophysiology is likely Understanding the origin of presenting symptoms can improve the outcome

31