Schizophrenia and schizophrenia-like disorders

Transcription

1 Schizophrenia and schizophrenia-like disorders Dr: Weibo Liu The Second Affiliated Hospital Zhejiang University College of Medicine

2 Category of psychotic disorders Schizophrenia (SC) Schizoaffective disorder Schizophreniform disorder Brief psychotic disorder Delusional disorder

3 Introduction The definition of schizophrenia The symptom of schizophrenia Diagnostic criteria of schizophrenia (DSM-IV and ICD-10) The therapeutic principle of schizophrenia The factors influencing prognosis of schizophrenia The concept and diagnostic significance of insight

4 Big Names associated with SC (1) Kraepelin ---Dementia praecox (2)Eugen Bleuler-- formal thought disorder(splitting) (3)Kurt Schneider-first-rank symptoms

5 Definition of SC Schizophrenia is a disorder characterized by apathy, absence of initiative (avolition), and affective blunting Patients have alterations in thoughts, perceptions, mood, and behavior Many schizophrenics display delusions, hallucinations and misinterpretations of reality

6 Epidemiology gender and age SC is equally prevalent in men and women. On set is earlier in men (in the teens or 20s) than in women (in the 20s or early 30s). It's uncommon for children to be diagnosed with SC and rare for those older than 40.

7 Moises HW, Zoega T, Gottesman II. The glial growth factors deficiency and synaptic destabilization hypothesis of schizophrenia. BMC Psychiatry Jul 3;2(1):8.

8 Epigenetic Code

9 Etiology of SC Genetic factors Biochemical factors Neuropathology Neural circuits Psychoneuroimmunology Psychoneuroendocrinology

10 Genetic factors A genetic contribution to SC, and a high proportion of the variance in the liability to SC is due to additive genetic effects But, Most patients have no family history of SC, is a complex genetic disease Multiple genes (epistasis) and environmental exposures (interaction) are involved in risk.

11 Biochemical factors Dopamine hypothesis Serotonin Glutamate Norepinephrine GABA Neuropeptides Acetylcholine and nicotine

12 Dopamine hypothesis in CNS

13 Brain Structure & Brain Function Ventricle Enlargement (MRI) Hypofrontality (fmri)

14 Clinical feature of Schizophrenia Positive Negative Mood Cognitive symptoms symptoms symptoms impairment

15 Positive symptoms Hallucinations are most commonly auditory or visual, but hallucinations can occur in any sensory modality Delusions--fixed false beliefs that cannot be corrected by reason Thought disorder is characterized by loose associations, tangentiality, incoherent thoughts, neologisms, thought blocking, thought insertion, thought broadcasting, and ideas of reference Disorganized behavior

16 Negative symptoms Poverty of speech (alogia) or poverty of thought content Flat affect Loss of motivation (avolition)

17 Mood symptoms Common and severe Depression or mood swings People with schizophrenia often seem inappropriate and odd, causing others to avoid them, which leads to social isolation

18 Cognitive impairment Exhibit subtle cognitive dysfunction in the domains of attention, executive function, working memory, and episodic memory such as: Problems with making sense of information Difficulty paying attention Memory problems The cognitive impairment seems already to be present when patients have their first episode and appears largely to remain stable over the course of early illness

19 Classification of schizophrenia A paranoid type schizophrenia B disorganized type schizophrenia C catatonic type schizophrenia D undifferentiated type schizophrenia E residual type schizophrenia

20 Paranoid type schizophrenia Characterized by preoccupation with one or more delusions or frequent auditory hallucinations No prominent disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect Best prognosis

21 Disorganized type schizophrenia Characterized by prominent disorganized speech, disorganized behavior, and flat or inappropriate affect worse prognosis

22 Catatonic type schizophrenia Characterized by at least 2 of the following: Motoric immobility Excessive motor activity Extreme negativism or mutism Peculiar voluntary movements such as bizarre posturing Echolalia or echopraxia

23 Undifferentiated type schizophrenia Meets criteria for SC, but can not be Characterized by paranoid, disorganized, or catatonic type

24 Residual type schizophrenia Characterized by the absence of prominent delusions, disorganized speech and grossly disorganized or catatonic behavior and continued negative symptoms or two or more attenuated positive symptoms Once a Schizophrenic, Always a Schizophrenic?

25 DSM-Ⅳ diagnostic criteria for schizophrenia A. Two or more of the following symptoms present for one month: 1.Delusions 2.hallucinations 3.disorganized speech 4.grossly disorganized or catatonic behavior 5.negative symptoms (ie,affective flattening,alogia,avolition) B. Decline in social and/or occupational functioning since the onset of illness C. Continuous signs of illness for at least six months with at least one month of active symptoms

26 DSM-Ⅳ diagnostic criteria for schizophrenia D. Schizoaffective disorder and mood disorder with psychotic features have been excluded E. The disturbance is not due to substance abuse or a medical condition F. If history of autistic disorder or pervasive developmental disorder is present, schizophrenia may be diagnosed only if prominent delusions or hallucinations have been present for one month

27 ICD-10 diagnositic criteria for schizophrenia 1. At least one of the following: Thought echo, insertion, withdrawal, or broadcasting. Delusions of control, influence, or passivity; clearly referred to body or limb movements or specific thoughts, actions, or sensations; and delusional perception. Hallucinatory voices giving a running commentary on the patient's behavior or discussing him/her between themselves, or other types of hallucinatory voices coming from some part of the body. Persistent delusions of other kinds that are culturally inappropriate or implausible, (e.g. religious/political identity, superhuman powers and ability).

28 ICD-10 diagnositic criteria for schizophrenia 2. Or, at least two of the following: Persistent hallucinations in any modality, when accompanied by fleeting or half-formed delusions without clear affective content, persistent over-valued ideas, or occurring every day for weeks or months on end. Breaks of interpolations in the train of thought, resulting in incoherence or irrelevant speech or neologisms. Catatonic behavior such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor. Negative symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses. A significant and consistent change in the overall quality of some aspects of personal behavior, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

29 A case of SC What s the symptoms? How to make a diagnose?

30 Differential diagnosis with SC Psychotic disorder due to a general medical condition CNS infections, lupus, multiple strokes, HIV Substance-induced psychotic disorder Amphetamines, cocaine, phencyclidine(pcp) Mood disorder with psychotic features

31 Therapeutic approach of SC UCLA Recovery Criteria Recovery criteria must be met in each of 4 domains Improvement in each domain must be sustained concurrently for 2 y Level of recovery in these 4 domains is measured by: - Symptom remission - Appropriate role function - Ability to perform day-to-day living tasks without supervision - Social interaction Liberman RP et al. Int Rev Psychiatry. 2002;14;

32 Therapeutic goals Reduce or eliminate symptoms Maximize quality of life and adaptive functioning Promote and maintain recovery from the debilitating effects of illness to the maximum extent possible

33 Treatment of SC Treatment Pharmacotherapy antipsychotic medication *Electroconvulsive (ECT) Psychosocial interventions Family interventions Supported employment Assertive community treatment Social skills training Cognitive behaviorally oriented psychotherapy

34 Phases of treatment in SC Acute Phase 4-8weeks Stabilization phase 6 weeks Maintenance Phase 1-2 years Three steps in whole treatment phases

35 Acute Phase Treatment Reducing the severity of psychosis and associated symptoms (e.g., agitation, aggression, negative symptoms, affective symptoms) Ensuring the safety of the patient and others because of socially damaging behaviour

36 Stabilization Phase If the patient has improved with a particular medication regimen, continuation of that regimen and monitoring are recommended for at least 6 months Reducing stress on the patient and provide support to minimize the likelihood of relapse, enhance the patient s adaptation to life in the community Consolidation of remission, and promote the process of recovery

37 Maintenance phase Ensuring that symptom remission is sustained, continuation rehabilitation that the patient is maintaining or improving his life quality Most patients are at very high risk of relapse in the absence of antipsychotic treatment. It is generally recommended that multiepisode patients receive maintenance treatment for at least 5 years

38 Indication for hospitalization Psychotic symptoms prevent the patient from caring for his basic needs Suicidal ideation secondary to psychosis Dangerous to self or others With command hallucinations to harm self or others, especially with a history of acting on hallucinations

39 Medication Treatment Antipsychotics can help control the hallucinations, delusions, and thinking problems associated with the illness. Patients may need to try several different antipsychotic medications before they find the medicine or combination of medicines that works best for them.

40 Binding profile of antipsychotics BINDING PROFILE OF ANTIPSYCHOTICS OLANZAPINE CLOZAPINE HALOPERIDOL RISPERIDONE D1 D2 D4 5HT2A 5HT2C Musc α1 α2 H1 SERTINDOLE SEROQUEL ZIPRASIDONE ZOTEPINE DATA FROM BYMASTER ET AL., 1996 & SCHOTTE ET AL., 1996 Fig. 1.

41 Conventional/typical Antipsychotics The antipsychotics in longest use are called conventional antipsychotics. Examples are: Haldol (haloperidol) Stelazine (trifluoperazine) Mellaril (thioridazine) Thorazine (chlorpromazine) Navane (thiothixene) Trilafon (perphenazine) Prolixin (fluphenazine) Conventional antipsychotics are becoming obsolete. Because of side effects, experts usually recommend using a newer atypical antipsychotic rather than a conventional.

42 Extrapyramidal side effects (EPS) More often be seen in the patients with the medication of conventional antipsychotics Due to blockade of dopamine receptors in the nigrostriatal pathway of the basal ganglia in the brain Manifestation as: acute dystonia, drug-induced parkinsonian syndrome, akathesia

43 Atypical Antipsychotics Atypical antipsychotics work in a different way than the conventional antipsychotics. Examples are: Aripiprazole (Abilify) Clozapine (Clozaril) Olanzapine (Zyprexa) Paliperidone (Invega) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon) much less likely to cause the distressing movement side effects. Common side effects include weight gain, diabetes and high blood cholesterol. The experts recommend the newer atypical medications as the treatment of choice for most patients with schizophrenia.

44 Natrual History of Schizophrenia Stages of Illness Healthy Worsening Severity of Signs and Symptoms Gestation/Birth 10 Puberty Years

45 Separate Components of Schizophrenia? Constitutional Vulnerability Neurodevelopmental Prodromal State Psychosis Neurodegeneration Deterioration

46 Risk factors of SC Having a family history of schizophrenia Exposure to viruses, toxins or malnutrition while in the womb Stressful life circumstances Older paternal age Taking psychoactive drugs during adolescence and young adulthood

47 The factors influencing prognosis of SC Concise textbook of clinical psychiatry, third edition,p163

48 Judgment and Insight Insight conscious recognition of one s condition, in psychiatry, it refers to the conscious awareness and understanding of one s psychodynamics and symptoms of maladaptive behavior Patients with Sc are described as having poor insight into the nature and the severity of their disorder Lack of insight is associated with poor compliance with treatment

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