Schizophrenia
Kraepelin-dementia precox
 Bleuler-schism between thought, emotion
and behavior in affected patients
 4 A’s
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ambivalence
associations
affect
autism
Schizophrenia and DSM
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Disturbance of 6 months or more that
includes one month of 2 or more* of the
following active-phase symptoms
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Delusions
Hallucinations (3/4 @ some point)
Disorganized Speech
Grossly disorganized or catatonic behavior
Negative symptoms
Positive & Negative Sx.
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Delusions
Hallucinations
Disorganized thinking
Misperceptions
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Blunted affect
Poor initiation &
planning with tasks
Poverty of speech
Anhedonia
Delusions
Grandeur
 Guilt
 Jealousy
 Passivity
 Persecution
 Poverty
 Reference
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Other Symptoms of
Schizophrenia
Cognitive Dysfunction
 Dysphoria
 Absence of Insight
 Sleep disturbance
 Suicide
 Illusions
 Echopraxia
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Why accurate Dx is important?
 Frequency-1%
 Chronicity
– Schizophrenic patients die younger
 Males
5.1 greater mortality
 Suicide rate 10-13% higher overall
 2x MVAs; More disease & homelessness
 Severity
 Management*
– 80% vs. 30% relapse rate @ 1 year
Epidemiology
Gender-15-25 vs. 25-35
 Comorbid with substance abuse
 Deinstitutionalization (>2/3)
 Dx has increased with the onset of
neuroliptics
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Etiology
Many different problems that converge on
the same syndrome, not just a single disease
 >50% of Sx appear to be associated with
brain abnormalities (especially + Sx).
 Stress Diathesis Model
 Dopamine Hypothesis
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Genetics
G en eral P o p u latio n
1 .0 %
N o n tw in sib o f S ch z. p t.
8 .0 %
C h ild w ith 1 S ch z. p aren t
1 2 .0 %
D y zy g o tic tw in o f S ch z.
p aren t
C h ild o f 2 S ch z. p aren ts
1 2 .0 %
M o n o zy g o tic tw in
o f a S ch z. p aren t
4 7 .0 %
4 0 .0 %
Factors related to good
prognosis in Schizophrenia
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Late onset
Obvious precipitating factors
Acute onset
Good premorbid social, sexual, and work history
Married
Family/Personal history of mood disorders
Good support systems
Positive symptoms
Factors related to poor
prognosis in Schizophrenia
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Young and insidious onset
No precipitating factors
Poor premorbid social, sexual, and work histories
Withdrawn, autistic behavior; assaultive history
Single, divorced or widowed
Neurological signs and symptoms/prenatal trauma
Family history of schizophrenia
No remission in 3 years; many relapses
Medication Issues
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Chlorpromazine (Thorazine); Fluphenazine
(Prolixin); Haloperidol (Haldol); Thiothixene
(Navane); Thioridazine (Mellaril) & Perphenazine
(Trilafon)
Benzodiazepines
– Valium (diazepam)
– Librium (chordiazepoxide)
Tardive dyskenesia
Newer drugs (Risperdal, Clozaril & Zyprexa)
Tablet or liquid form with “depot formulations”
Common antipsychotic
medication side effects
Dry mouth
 Constipation
 Blurred vision
 Drowsiness
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Less common antipsychotic
medication side effects
Decreased sexual desire
 Menstrual changes
 Stiff muscles on one side of the neck or jaw
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Serious antipsychotic
medication side effects
Restlessness
 Muscle stiffness
 Slurred speech
 Extremity tremors
 Agranulocytosis
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Ethnicity and Antipsychotic
medication efficacy
(Frackiewicz, et al., 1997)
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Asians responded to lowest dosages
Limited AfA results, with differences apparently due to
prescribing practices
Authors highlight the problem of this line of cross-cultural
research where Western ethnic groups are seen as
homogenous
AfA are diagnosed significantly more with Scz than EA
and less with depression
Satcher (2001) AfAs and Latinos…
AfA more likely to receive medication and less likely to be
referred for therapy (Richardson, 2001)
Work Behavior Strengths
Minimal physical limitations
 Generally have at least average IQ
 Medications provide good control over
symptoms for most
 If onset in late 20s, the consumer may have
a work history of > HS education
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Work Behavior Limitations
Difficulty multitasking
 Difficulty interacting with co-workers
 Difficulty accepting criticism or supervision
 May have difficulty with customer service
or customer contact
 Cyclic symptoms lead to inconsistent perf.
 Needs work space with limited stimulation
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Common types of work
accommodations
Flexible schedule to allow time off during
times when symptoms exacerbate or need
“treatment”
 Loss stress, low stimulation work
environment
 Training and education staff
 Modifying simple job tasks
 Developing on site services (e.g. EAP)
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Comorbidity
91% with accompanying substance abuse or
mental health disorders (Judd, 1989)
 Strongest relationship with mood disorders
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81.4% with comorbid mood disorder
59% with comorbid unipolar depression
22% with comorbid bipolar depression
38% with comorbid mood disorder made at least one
suicide attempt
– 28.9%% suicide attempts in pts. with comorbid bipolar
disorder
Cultural variants
Women are less vulnerable to cognitive
deficits than men (particularly verbal
processing) Goldstein, et al., 1998
 Sx. Expression on the BSI were
significantly higher in HA compared to EA
Coelho, et al., 1998
 Cognitive differences must be covaried by
premorbid language functioning
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Catatonic Schizophrenia
Meets basic criteria for Schizophrenia
 At least 2 catatonic symptoms predominate:
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– Stupor or motor immobility (catalepsy or waxy
flexibility)
– Hyperactivity w/o apparent purpose or not
influenced by external stimulation
– Mutism or marked negativism
– Peculiar posturing, stereotypes, or mannerisms
– Echolalia or echopraxia
Disorganized Schizophrenia
Meets all of the basic criteria for
Schizophrenia plus
 Disorganized behavior
 Disorganized speech
 Affect is flat or inappropriate
 Not meet criteria for Catatonic Schz.
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Undifferentiated
Schizophrenia
Meets basic criteria for Schizophrenia but
not Paranoid, Disorganized or Catatonic
types
 Diagnosis of exclusion..what is left
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Residual Type
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At one time met criteria for Schizophrenia,
Catatonic, Disorganized, or Undifferentiated Type
No longer has pronounced catatonic behavior,
delusions, hallucinations, or disorganized speech
or behavior
Still ill as indicated by either
– Negative symptoms
– Attenuated form of at least 2 symptoms of Schz
Paranoid Schizophrenia
Meets basic criteria for Schizophrenia
 Preoccupied with delusions or frequent
auditory hallucinations
 None of these symptoms is prominent:
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Disorganized speech
Disorganized behavior
Inappropriate of flat affect
Catatonic behavior
Schizophreniform Disorder
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“A” criteria symptoms for at least a month
Delusions (only 1 required, if bizarre)
Hallucination(s)*
Incoherent, derailed, or disorganized speech
Severely disorganized or catatonic behavior
Negative symptom
From prodromal to active and residual, symptoms
last at least one month but no longer than six
months
Factors related to good
prognosis of
Schizophreniform Disorder
Actual psychotic features begin within 4
weeks of the 1st noticeable change in the
patient’s functioning or behavior
 Pt. confused or perplexed when psychotic
 Good premorbid social or job functioning
 Affect is neither blunt nor flattened
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DSM-IV - College of Public Health & Health Professions