Schizophrenic Disorders

History

Emil Kraepelin: This illness develops relatively early in life, and its course is likely deteriorating and chronic; deterioration reminded dementia (Dementia praecox), but was not followed by any organic changes of the brain, detectable at that time. Eugen Bleuler: He renamed Kraepelins dementia praecox as schizophrenia (1911); he recognized the cognitive impairment in this illness, which he named as a splitting of mind. Kurt Schneider: He emphasized the role of psychotic symptoms, as hallucinations, delusions and gave them the privilege of the first rank symptoms even in the concept of the diagnosis of schizophrenia.

Schizophrenic Disorders

Schizophrenia

Catatonic Disorganized Paranoid Residual Undifferentiated

Definition

The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time. The most important psychopathological phenomena include

thought echo thought insertion or withdrawal thought broadcasting delusional perception and delusions of control influence or passivity hallucinatory voices commenting or discussing the patient in the third person thought disorders and negative symptoms.

Schizophrenia

Essential features: a mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1month period.

Positive symptoms: appear to reflect an excess or distortion of normal functions.

Delusions, hallucinations, disorganized speech, grossly disorganized behavior

Negative symptoms: restrictions in the range and intensity of emotional expression.

Affective flattening, alogia (fluency and productivity of thought & speech), avolition (initiation of goal-directed behavior)

Positive and Negative Symptoms

Negative Positive

Alogia Affective flattening Avolition-apathy Anhedonia-asociality Attentional impairment

Hallucinations Delusions Bizarre behaviour Positive formal thought disorder

4 A (Bleuler)
Bleuler maintained, that for the diagnosis of schizophrenia are most important the following four fundamental symptoms:

affective blunting disturbance of association (fragmented thinking) autism ambivalence (fragmented emotional response)

These groups of symptoms, are called four A s and Bleuler thought, that they are primary for this diagnosis. The other known symptoms, hallucinations, delusions, which are appearing in schizophrenia very often also, he used to call as a secondary symptoms, because they could be seen in any other psychotic disease, which are caused by quite different factors from intoxication to infection or other disease entities.

Schizophrenia

Research suggests that diagnoses of childhood onset schizophrenia can be made with the adult criteria Early age of onset requires special considerations for diagnoses, educational needs, as well as treatment.

Course of Illness

Course of schizophrenia:

continuous without temporary improvement episodic with progressive or stable deficit episodic with complete or incomplete remission

Typical stages of schizophrenia:

prodromal phase active phase residual phase

Schizophrenia
A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): (1) delusions (2) hallucinations

(3) disorganized speech (e.g., frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior (5) negative symptoms, i.e., affective flattening, alogia, or avolition Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

Schizophrenia
B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).

Schizophrenia
C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Schizophrenia
D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

Schizophrenia
E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Schizophrenia
Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):

Episodic With Interepisode Residual Symptoms (episodes are defined by the reemergence of prominent psychotic symptoms); also specify if: With Prominent Negative Symptoms Episodic With No Interepisode Residual Symptoms Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With Prominent Negative Symptoms Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms Single Episode In Full Remission Other or Unspecified Pattern

Diagnostic Definitions

Delusions: erroneous beliefs that usually involve a misinterpretation of perceptions or experiences.

Bizarreness is a characteristic of schizophrenic delusions; need to keep cultural issues in mind when making the bizarre determination

Hallucinations: may occur in any sensory modality (e.g., auditory, visual, olfactory, gustatory, tactile).

May be a normal part of some religious experiences in some cultural contexts.

Disorganized thinking: may be present in the speech of individuals with schizophrenia

Derailment or loose associations, tangentiality, incoherent, word salad

Grossly disorganized behavior: dress in an unusual manner, inappropriate sexual behavior Catatonic motor behaviors: waxy flexibility, catatonic agitation

Schizophrenia: Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:
(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor (2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli) (3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism (4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing (5) echolalia or echopraxia

Schizophrenia: Disorganized Type

A type of Schizophrenia in which the following criteria are met:
A. All of the following are prominent:
(1) disorganized speech (2) disorganized behavior (3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.

Schizophrenia: Paranoid Type

Paranoid schizophrenia is characterized mainly by delusions of persecution, feelings of passive or active control, feelings of intrusion, and often by megalomanic tendencies also. The delusions are not usually systemized too much, without tight logical connections and are often combined with hallucinations of different senses, mostly with hearing voices.

Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous.

Schizophrenia: Paranoid Type

A type of Schizophrenia in which the following criteria are met:
A. Preoccupation with one or more delusions or frequent auditory hallucinations. B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Schizophrenia: Residual Type

A type of Schizophrenia in which the following criteria are met:
A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Schizophrenia: Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Associated Features

Inappropriate affect Anhedonia Poor insight likely due to a manifestation of the illness rather than a coping strategy Anxiety disorders Motor abnormalities (e.g., facial grimacing separate from Tardive Dyskinesia) Suicide attempts (10% complete, 20% to 40% attempt) Some history of violent or assaultive behavior puts individual at risk for violent behavior in active phase of schizophrenia Comorbid Substance-Related Disorders (80% to 90% of individuals with SZ are regular cigarette smokers) OCD and Panic Disorder elevated

Cultural Features

Ideas that may be delusional in one culture (e.g., sorcery or witchcraft) may be commonly held in another culture. Visual or auditory hallucinations may be part of a cultural belief as well. Overdiagnosing common in African-American and Asian-American ethnic groups not sure if this represents true differences or cultural insensitivity and/or bias.

Age Features

Onset typically between late teens and mid-30s Onset prior to adolescence is rare Essential features are same in children as they are in adults; however, may be difficult to make the diagnosis in children.
Hallucinations & delusions less elaborate Visual hallucinations more common in children

Early Warning Signs for Child-Onset Schizophrenia

1. trouble telling dreams from reality, 2. seeing things and hearing voices which are not real, 3. confused thinking, 4. vivid and bizarre thoughts and ideas,

Early Warning Signs for Child-Onset Schizophrenia

5. extreme moodiness,
6. odd behavior, 7. ideas that people are "out to get them," 8. behaving like a younger child, 9. severe anxiety and fearfulness,

Early Warning Signs for Child-Onset Schizophrenia

10. confusing television with reality,
11. severe problems in making and keeping friends.

Often children show their signs gradually, such a child may become shy or withdrawn. These signs are often first noticed by teachers. Children may begin talking about odd fears or ideas.
In children or adolescents there is a failure to achieve what is expected of the individual, rather than a deterioration in functioning. Comparing the child with unaffected siblings is helpful in making a decision. Their education is usually disrupted, and in adolescence many individuals can't hold onto a job for long (American Academy of Child & Adolescent Psychiatry, 1995).

Gender Features, Prevalence

Modal age of onset differs between males and females:

Males: 18-25yrs Females: 25yrs to mid 30yrs; another peak later in life

Adult prevalence: 0.5% to 1.5% Childhood prevalence: 1 in 40,000 before age 13

Familial Pattern

10x greater risk among first-degree relatives of SZ positive probands Twin studies and adoption studies support a genetic link; however, substantial discordance rate among monozygotic twins strongly suggests an environmental factor as well.

Differential Diagnosis

Psychotic Disorder Due to a General Medical Condition Substance-Induced Psychotic Disorder Mood Disorder with Psychotic Features Schizophreniform Disorder

Duration: SZ 6+mos; Schizophreniform, 1-6mos

Brief Psychotic Disorder Delusional Disorder Psychotic Disorder NOS PDD