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Schizophrenia

Department of psychology
The first affiliated hospital of ZZU
Huirong guo
Preface
♦ schizophrenia is much the most difficult
to define and describe
 over the past 100 years, many widely divergent
concepts of schizophrenia have been held in
different countries by different psychiatrists
 Radical differences of opinion persist to the
present day
Preface
♦ a simple comparison between two basic
concepts-acute schizophrenia and chronic
schizophrenia
 in acute schizophrenia the predominant clinical
features are delusions, hallucinations and interference
with thinking. Features of this kind are often called
’positive’ symptoms
 the main features of chronic schizophrenia are apathy,
lack of drive, slowness, and social withdrawal. These
features are often called ‘negative’ symptoms
Epidemiology
♦ The lifetime prevalence of schizophrenia is
usually estimated to be between 0.5% and
1%
♦ Incidence rates are considerably lower than
prevalence rates and are estimated to be
approximately 1 per 10,000 per year
Etiology
♦ Genetics
♦ Neurological abnormalities
♦ Biochemistry and
psychopharmacological factors
♦ Psychosocial factors
Genetics -Family studies

♦ The first systematic family study of dementia


praecox was carried out in Kraepelin’s
department by Ernst Rudin, who showed that
the rate of dementia praecox was higher
among the siblings of probands than in the
general population (Rudin 1916)
Genetics -Family studies
♦ Kallmann (1938) found increased rates not
only among the probands’siblings but also
among their children. There was quite a lot
studies afterwards. Although the morbidity
risks vary somewhat from one another but
that the general pattern is consistent
Genetics -Twin studies
♦ These studies compare the concordance rates
for schizophrenia in monozygotic (MZ) and
dizygotic (DZ)
♦ Luxenberger (1928), who found concordance in
11 of this 19 MZ pairs and none of his 13 DZ
pairs carried out the first substantial twin
study in Munich
♦ Representative figures for concordance are
about 50 per cent for MZ pairs and about 17
per cent for DZ pairs
Genetics -Adoption studies
♦ Heston (1966) studied 47 adults who had been
born by schizophrenic mothers and separated
from them within three days of birth
 Amongst the offspring of schizophrenic mothers,
five were diagnosed as schizophrenic as against
none of the controls
 There was also an excess of antisocial personality
and neurotic disorders among the children of
schizophrenic mothers
Genetics -Adoption studies
♦ Denmark, which has national registers of
psychiatric cases and adoptions, confirmed
those of Heston described above (1971)
♦ Wender et al found no increase in
schizophrenia amongst adoptees that had
normal biological parents and a schizophrenic
adoptive parent
Genetics -Mode of inheritance
♦ As the rations of the frequencies of
schizophrenia in different relatives do not fit
any simple Mendelian pattern
♦ The polygenic theory proposes a cumulative
effect of several genes
Neurological abnormalities
♦It is possible that some of these signs
resulted from coincidental neurological
disease
 In the past, investigators searched for gross
pathological changes in the brains of
schizophrenics, but found none
 Recent research is concerned with four issues: non-
localizing (soft) neurological signs; possible
abnormalities of the corps callosum; evidence of
ventricular enlargement and changes in the EEG
Biochemistry and
psychopharmacological factors
♦ Most attention has been paid to those
concerned with dopaminergic transmission
 Carlsson and Lindqvist (1963) show that such
drugs increase dopamine turnover. This effect was
interpreted as a feedback response of the
presynaptic neuron to blockade of postsynaptic
dopamine receptors
 much additional evidence that antipsychotic drugs
block postsynaptic dopamine receptors
Biochemistry and
psychopharmacological factors

♦ This effect is produced in vitro by the different


antipsychotic drugs correlates closely with their
clinical potency
♦ The antipsychotic drugs do not have effects
specific to schizophrenia; they are equally
effective in mania
♦ Also, it is important to recall the analogy of
Parkinsonism
Biochemistry and
psychopharmacological factors
♦ In this condition, anticholinergic drugs have
therapeutic effects even though the
biochemical lesion is not an excess of
acetylcholine but a deficiency in dopaminergic
neurons due to selective degeneration
 Because of these difficulties of interpretation, more
direct evidence has been sought by biochemical
studies of post-mortem brains from schizophrenic
patients . (Owen et al (1978) )
 Further studies of unmedicated patients are needed
before definite conclusions can be reached.
Psychosocial factors
♦ Personality
 Abnormal personality is common among people who
later become schizophrenic
 Schizoid personality (But such ideas must be treated
with caution since it is difficult to distinguish between
premorbid personality and the prodromal phase of a
slowly developing illness )
♦ Social factors
 Low socioeconomic status, unsatisfactory living
conditions, migration, social isolation etc
Clinical features
♦The acute syndrome (‘positive’ symptoms )
 appearance and behavior: awkward
 though disorder (speech ; disorders of the stream
of though; Loosening of association )
 Abnormalities of mood :anxiety, depression,
irritability, or euphoria ; blunting of affect
;incongruity of affect
 Auditory hallucinations ; Visual hallucinations ;
Tactile, olfactory, gustatory, and somatic
hallucinations
Clinical features
 Delusions :Persecutory delusions ; delusions of
reference and of control, and delusions about the
possession of thought
 Orientation (normal); Concentration(impaired);
memory(nrmal)
 Insight: impaired
 It should be kept in mind that
schizophrenic patients do not necessarily
experience all these symptoms, and the
clinical picture is variable
Clinical features
♦ The chronic syndrome (‘negative’ symptoms )
 underactivity :diminished volition
 lack of drive:motor disturbance (catatonic, stupor ,
waxy flexibility , stereotypy )
 social withdrawal :Social behavior may deteriorate
(collect and hoard objects ; break social conventions by
talking intimately to strangers, or shouting obscenities
in public )
 and emotional apathy :blunted , incongruous
Clinical features
 Speech is often abnormal, showing evidence of
thought disorder of the kinds found in acute
syndrome
 Hallucinations are common, again in any of the
forms occurring in the acute syndrome described
above
 Delusions are often systematized. In chronic
schizophrenia, delusions may be held with little
emotional response
Clinical features
 Orientation is normal
 Attention and concentration are often poor
 Memory is not generally impaired though some
patients have difficulty in giving their age correctly
 Insight is impaired : the patient does not recognize
that his symptoms are due to illness
 Also, the symptoms and signs are
combined in many ways so that the
clinical picture is variable
Subgroups of schizophrenia
♦ Hebephrenic( 青春型 )
♦ Catatonic (紧张型)
♦ Paranoid (偏执型)
♦ And simple schizophrenia (单纯型)
Subgroups of schizophrenia
♦ Patients with hebephrenic schizophrenia
often appear silly and childish in their
behavior. Affective symptoms and thought
disorder are prominent. Delusions are
common, and not highly organized.
Hallucinations also are common, and not
elaborate
Subgroups of schizophrenia
♦ In catatonic schizophrenia is characterized
by motor symptoms and by changes in
activity varying between excitement and
stupor. Hallucinations, delusions and
affective symptoms occur but are usually
less obvious
Subgroups of schizophrenia
♦ In paranoid schizophrenia the clinical
picture is dominated by well-organized
paranoid delusions. Thought processes and
mood are relatively spared, and the patient
may appear normal until his abnormal
beliefs are uncovered
Subgroups of schizophrenia

♦ Simple schizophrenia is characterized by


the insidious development of odd behavior,
social withdrawal, and declining
performance at work
Subgroups of schizophrenia

♦ As to undifferentiated schizophrenia, the


psychotic conditions exhibiting more than
one group of symptoms without a clear
predominance of a particular set of
diagnostic characteristics
Diagnosis
♦ Here the diagnosis criteria for schizophrenia of
ICD-10 were outlined
♦ G1. Either at least one of the syndromes, symptoms
and signs listed under (1) below or at least two of
the symptoms and signs listed under (2) should be
present for most of the time during an episode of
psychotic illness lasting for at least 1 month (or at
some time during most of the days)
Diagnosis
♦ (1)At least one of the following must be present
 Thought echo, thought insertion or withdrawal, or thought
broadcasting; delusions of control, influence or passivity,
clearly referred to body or limb movements or specific
thoughts, actions or sensations; delusional perception;
hallucinatory voices giving a running commentary on the
patients’ behavior, or discussing the patient between
themselves, or other types of hallucinatory voices coming
from some part of the body; persistent delusions of other
kinds that are culturally inappropriate and completely
impossible (e.g. being able to control the weather, or being in
communication with aliens from another world)
Diagnosis
♦ (2)Or at least two of the following
 Persistent hallucinations in any modality, when occurring
very day for at least 1 month, when accompanied by
delusions (which may be fleeting or half-formed) without
clear affective content, or when accompanied by persistent
overvalued ideas.
 Neologism, breaks or interpolations in the train of thought,
resulting in incoherence or irrelevant speech;
 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
(it must be clear that these are not due to depression or to
neuroleptic medication)
Diagnosis
♦ G2 Most commonly used exclusion clauses
 If the patient also meets the criteria for manic episode
or depressive episode,
 The criteria listed under G (1) and G (2) above must
have been met before the disturbance of mood
developed.
 The disorder is not attributable to organic brain
disease or to alcohol- or drug- related intoxication
dependence or withdrawal
Diagnosis
♦ Criteria for simple schizophrenia
 There is slow but progressive development, over a
period of at least 1 year, of all three of the
following:
 A significant and consistent change in the overall
quality of some aspects of personal behavior,
manifest as loss of drive and interests, aimlessness,
idleness, a self absorbed attitude and social
withdrawal;
Diagnosis
♦ Criteria for simple schizophrenia
 Gradual appearance and deepening of ‘negative’
symptoms such as marked apathy, paucity of
speech, under-activity, blunting of affect, passivity
and lack of initiative, and poor non-verbal
communication (by facial expression, eye contact,
voice modulation and posture)
 Marked decline in social, scholastic or occupational
performance
Diagnosis
 At no time are there any of the symptoms referred to in
criterion G1 nor are there hallucinations or well-
formed delusions of any kind, i.e. the individual must
never have met the criteria for any other types of
schizophrenia, or for any other psychotic disorder.
 There is no evidence of dementia or any other organic
mental disorder
The diagnostic criteria of schizophrenia in
CCMD-3
♦ Symptom criteria :Two of the following criteria are
met
 (1) Repeated auditory hallucinations that are usually
not mood congruent;
 (2) Loosening of association, derailment,
incoherence in thinking or poverty of thought;
 (3) Thought insertion or withdrawal, though block
or forced thinking;
 (4) Delusion of control, influence or passivity,
though broadcasting;
The diagnostic criteria of schizophrenia in
CCMD-3
♦ Symptom criteria :
 (5) Primary delusions including delusional
perception, delusional mood or other bizarre
delusion;
 (6) Incongruous emotion, symbolic thought or
neologism;
 (7) Alexithymia or apathy;
 (8) Catatonic syndrome, unusual or silly behavior;
 (9) Avolition.
The diagnostic criteria of schizophrenia in
CCMD-3
 Course criteria :(1) Clinical picture satisfying with both
symptom criteria and severity criteria persists for more
than one month. But there are separate course criteria
of simple type of schizophrenia;
(2) If there are concurrent schizophrenic and affective
symptoms satisfying the diagnostic criteria of both
schizophrenia and mood disorders, with the duration of
schizophrenia symptoms being 2 weeks longer than the
affective component after the duration of both
concurrent symptoms for at least 2 weeks, a single
diagnosis of schizophrenia should be made
The diagnostic criteria of schizophrenia in
CCMD-3

 Severity criteria :The patients ‘s insight into the


illness is partial or absent and accompanied by
marked impairment in social functioning and
communication skill
 Exclusion: Organic mental disorders,
psychoactive substance and non-addictive
substance induced mental disorders
Diagnostic criteria of subgroups of
schizophrenia

Paranoid schizophrenia

(1) Conditions meeting the general symptom


criteria of schizophrenia;
(2) Predominance of delusions usually
accompanied by hallucinations, often auditory
hallucination.
Diagnostic criteria of subgroups of
schizophrenia
Hebephrenic schizophrenia
(1) Conditions meeting the general symptom
criteria of schizophrenia;
(2) It is often adolescent in onset;
(3)Predominance of thought disorders, shallow
affection and behavioral disturbance. For
instance, loosening of affection, incongruity of
affection, childish behavior
Diagnostic criteria of subgroups of
schizophrenia
Catatonic schizophrenia

(1) Conditions meeting the general


symptom criteria of schizophrenia;
(2) Predominance of catatonic symptoms
(usually stupor)
Diagnostic criteria of subgroups of
schizophrenia
Simple schizophrenia
(1) Predominance of poverty of thought,
apathy and abulia, lack of positive psychotic
symptoms;
(2) Severe impairment in social functioning
with gradual decline;
(3) The onset is insidious and progression is
gradual with duration of at least 2 years
Diagnostic criteria of subgroups of
schizophrenia

Undifferentiated schizophrenia
(1) Conditions meeting the general symptom
criteria of schizophrenia with marked positive
psychotic symptoms;
(2) The clinical feature does not satisfy the full
criteria of any of the subtypes mentioned above;
(3) This type is also called mixed type or
unclassified type
Treatment
♦ Antipsychotic drugs
 Treatment of acute schizophrenia
 Treatment after the acute phase
Interaction of maintenance treatment
and social treatment
ECT
Antipsychotic drugs
♦ Treatment of acute schizophrenia
 The effectiveness of antipsychotic medication in
the treatment of acute schizophrenia has been
established by several well-controlled, doubled-
blind studies( the NIMH collaborative project (Cole et
al. 1964) compared chlorpromazine, fluphenazine, and
thioridazine with placebo. Three-quarters of the patients
receiving antipsychotic treatment for six weeks
improved, whatever the drug, whilst a half of those
receiving placebo worsened )
Antipsychotic drugs
 Treatment of acute schizophrenia
 Drug treatment has most effect on the positive
symptoms of schizophrenia, such as hallucinations
and delusions, and least effect on the negative
symptoms
 The various antipsychotic drugs do not differ in
therapeutic effectiveness, although their side-
effects vary
Antipsychotic drugs
♦ Treatment after the acute phase
 It has also become clear that some chronic
schizophrenics do not respond even to long-term
medication, and that others remain well without drugs
 Since long-continued antipsychotic madication may
lead to irreversible dyskinesias, it is important to
known how long such treatment needs to be given
 Hogarty and Ulrich (1977) reported that, over a three-
year period, maintenance anti-psychotic medication
was 2.5 to 3 times better than the placebo in
preventing relapses of schizophrenia, depot injections
are more successful than continued oral medication
Antipsychotic drugs
♦ Treatment after the acute phase
 Schooler et al. (1980) found that depot injections
offered no such advantage
 Davis et al (1980), in the long-term management of
schizophrenia there is no difference in the usefulness
of the various antipsychotic drugs available
Interaction of maintenance
treatment and social treatment
♦ Since both medication and social casework
appear effective in the management of
schizophrenia, it is reasonable to enquire
whether the two kinds of treatment interact
 Hogarty et al. (1974) studied the use of ‘major role
therapy’ (i.e. social casework) with and without
drugs. Given alone, social casework had only a small
effect in reducing relapse rate; combined with
medication, it had a larger effect
Interaction of maintenance
treatment and social treatment
♦ In a study of the effect of adding day
hospital treatment to continued medication,
Linn et al (1980) found that day care
conferred extra benefit on patients when it
was of low intensity and based on
occupational therapy, but not when it
included more active treatments such as
group therapy
ECT
In the treatment of schizophrenia, the
indications for ECT are catatonic stupor
and severe depressive symptoms
accompanying schizophrenia. The effects
ECT are often rapid and striking in both
these conditions
Some clinical cases
A 31-year-old male vocational nurse

 A 59-year-old divorced power


company engineer
Summary
 Schizophrenic disorders are a complex
syndrome characterized by a disturbance in reality
testing, marked impairment of social functional,
and severe personality disorganization involving
disturbances in though, affect, and behavior
 There is no single cause, although in many cases
there do appear to be medical and biological bases
present within early childhood
 Psychosocial factors play an important part in
the development and in the treatment of the
schizophrenic disorders
Summary
 Treatment should consist of various combined
bio-psychosocial methods and should include the
formation of a therapeutic alliance with the
schizophrenic person, as well as contact with friends
and family, if needed and available
 Although schizophrenia has remained the most
serious psychiatric illness known for the past 200
years, a comprehensive approach to the care and
treatment of schizophrenic disorders has improved
the quality of life for patients and their families and
also greatly improved the treated outcome as
compared to the natural course
Summary
 We might have reached the point at which early
intervention to arrest the deterioration that comes
from successive psychotic episodes has become a
possibility and a goal
 If efforts at prevention are to be successful for the
next generation of young people with schizophrenia,
we have to begin treatment as early as possible and
keep the psychotic episodes as brief as possible
New medications hold promise for better
treatment with fewer side effects, particularly when
coupled with effective psychosocial treatments and
support.
Thank you

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