Schizophrenia

Schizophrenia

·        Key features: positive symptoms, negative symptoms, deterioration in functioning over time

·        It is not a split personality (ie multiple personality disorder)

·        Epidemiology:

o   1% (30,000) NZers have or have had schizophrenia

o   Median age of presentation: males 19, female 24

·        Symptoms:

o   Positive symptoms:

§  Hallucinations: comes from external space.  Typically 2^nd or 3^rd person auditory hallucinations 

§  Delusions: fixed false beliefs out of cultural context

§  Thought disorder: „loss of syntax‟, non-linear.  Different to confusion or incoherence 

§  Bizarre and/or disorganised behaviour: eg aggressive, disinhibited, violent (often in „self-defence‟ if paranoid - rare but possible). 

§  Catatonic behaviour: if long term, untreated psychosis then may assume odd positions, waxy flexibility, totally unresponsive

o   Negative symptoms: 

§  Deficiency of mental function - Cognitive symptoms: difficulty concentrating, learning, hard to assemble thoughts. Not a decline in intelligence. Will still remember. Don‟t try to pull the wool over their eyes 

§  Alogia: poverty of speech or speech content

§  Affective flattening: including reduced intensity of emotional response 

§  Anhedonia: don‟t care about their lack of interest, cf depression where they want to enjoy themselves but can‟t 

§  Asociality - uninterested in the company of others, unresponsiveness, withdrawal

o   Prodrome = gradual change prior to first episode of frank psychosis.  Look for: 

§  ¯Concentration, attention drive, motivation

§  Depression, anxiety

§  Sleep disturbance

§  Social withdrawal, suspiciousness

§  These are common in adolescence: you‟re looking for marked change over previous function

·        Associated problems:

o   Suicide in 10 – 15% 

o   Lack of insight (® non-compliant with medication)

o   Substance abuse: co-morbid problem, ?self medication

o   Depression in schizophrenia: diagnosed as Depressive Disorder NOS 

o   Neurological symptoms: abnormalities in balance, proprioception, graphesthesia, disorder in smooth eye pursuit, decreased blinking 

o   EPS (extra-pyramidal side effects) in 20% of drug naïve people suffering from schizophrenia (Þ it‟s not always due to drugs)

·        Subtypes:

o   Paranoid: delusions, hallucinations

o   Disorganised: disorganised speech, behaviour, flat/inappropriate affect 

o   Catatonic: motor immobility, excessive motor activity, negativism, stereotypies (repeated monotonous movements), echolalia, echopraxia

o   Undifferentiated

o   Residual

·        Aetiology:

o   Multi-factorial: don‟t know about relative loadings for predisposing and precipitating factors 

o   Genetic: one parent affected ® 5% chance, two parents ® 45% chance, sibling affected ® 10% chance 

o   Neurodevelopment: brain injury at birth and perinatal complications (eg low Apgar), born in winter, ?viral influences. Insults at this age not causal – but some correlation 

o   Social causation: eg Shift and Drift or Breeder theory to try and explain higher incidence in lower socio-economic groups, Expressed Emotion theory (a lot of critical comment and high expectations from parents) 

o   Vulnerable personality: schizoid, schizotypal, paranoid

o   Head injury

o   Precipitating factors: life events, drug abuse, etc

·        Differential Diagnosis: 

o  Psychiatric disorders: Bipolar (manic phase), Major Depression with Psychotic Features, Brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, delusional disorder, depersonalisation disorder 

o  Medical illness: Temporal lobe epilepsy, tumour, trauma, infectious (syphilis, HIV), SLE 

o  Drugs: amphetamines, cocaine, cannabis, PCP (Angel dust), alcohol withdrawal, benzo withdrawal, barbiturate withdrawal

·        Assessment: 

o  Establish rapport: this will be the first encounter of a lifetime of encounters with mental health services. Try to get off to a good start!

o  Domains for assessment: home, employment/study, activities, drugs, sexuality, suicide

o  Assess social situation, and family views and functioning

·        Recovery from psychotic illness:

o  20% - no further episodes

o  10 – 15 % die: suicide/early death

o  60 % ongoing, 20% with serious disability