“It’s almost as if a demon has passed from one host to another.” – John Forbes Nash, Jr., 1994 Nobel Prize Winner in Economics
Overview
Unwise to stereotype people with schizophrenia as “homeless bums on the street”. It can happen to anyone, can come on at any age, and can be very difficult for patients and families to deal with.
Changes from DSM IV to DSM V
- Schizoaffective disorder: A major mood episode (MDD) must be present for the majority of the disorder’s duration once the patient has satisfied the psychotic criteria
- Delusional disorder: Delusions no longer have to be non-bizzare. It’s difficult to distinguish between what is bizarre and non-bizzare. Bizarre type specifiers for delusional disorders have been introduced.
- In order to dx delusional disorder the pt must not fit the diagnostic criteria for schizophrenia, schizoaffective disorder
- Delusional disorder is no longer separated from shared delusional disorder (folie a deux)
DSM-V Criteria for Schizophrenia
A. 2 or more of the following must be present for at least 1 month. And a least one must be 1, 2, or 3
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behaviour
- Negative symptoms
B. Must cause significant social, occupational, or self-care functional deterioration
C. Duration of illness for at least 6 months (including prodromal or residual periods in which the above full criteria may not be met)
D. Symptoms not due to effects of a substance or another medical condition.
General Principles
Generally, men have an earlier onset than women (15-25y vs 25-35y) for psychotic disorders. Several drugs can cause hallucinations or delusions, so r/o with urine tox screen. Medical conditions to r/o include epilepsy, stroke/TIA, encephalitis, and SOLs (tumour, trauma). Assess safety and hospitalize the patient if they pose a risk to themselves and others. Schizophrenia is degenerative. Some days the patient may be symptom-free, but over time they are only getting worse.
All psychotic patients are at an INCREASED RISK OF SUICIDE
- Psychotic disorders
- Schizophrenia (>6mos)
- Schizophreniform disorder (1-6mos)
- Brief psychotic event (1day – 1mo)
- Schizoaffective disorder
- The delusional disorders
Hallucinations
- Hallucinations
- A sensory perception that is not real
- Something the patient hears, feels, smells etc. that isn’t heard, felt, or smelt by others.
- Auditory, command, visual, tactile, gustatory, autoscopic, change in perception
- Causes of hallucination
- In healthy people: Sensory deprivation, Sleep deprivation, Religion. Isolation
- Organic brain disorders: Epilepsy (Temporal lobe epilepsy), Charles Bonnet syndrome (with vision loss), Neurocognitive disorders (delirium, dementia). Brain tumours
- Drug use:
- Psychedelics: LSD, Psilocybin (shrooms), Mescalin (peyote), DMT (ayahuasca)
- Dissociatives: ketamine, PCP, dextromethorphan
- Deliriants: diphenhydramine, benztropine, atropine
- Stimulants: cocaine, methamphetamine
- Mental illness
Delusions
Delusions are typical and can be diagnostic on its own for Schizophrenia. Delusions can also be seen in Bipolar disorder, MDD, Substance use and Major NCDs.
- Delusion
- An interpretation of real stimuli that is contradictive to what is generally held to be reality
- A different interpretation of reality
- Types of delusions
- Systematized delusions: delusions organized around a common theme (typical of delusional disorder and paranoid schizophrenia)
- Bizzare and non-bizarre delusions
- Bizarre delusion: something that is totally impossible…
- Non-bizarre delusion: something that is possible but is contradictory to reality (e.g. the president saying my name in a UN General meeting)
- Delusion of guilt
- Delusions of grandiosity
- Delusions of jealousy (eg. Othello syndrome)
- Persecutory delusion
- Delusions of reference
- Nihilistic delusion
- Delusions of infestation/parasistosis
- Eponymous/named delusion
- Capgras syndrome: delusion that a close family member, spouse, relative, friend or pet etc. has been replaced by a double (misidentification syndrome)
- Othello syndrome: morbid jealousy (delusion of infidelity)
- De Fregoli syndrome: belief that different people are in fact a single person who changes appearance or is in disguise
- Folie a deux: shared delusional disorder (”Folly of two”)
- Cotard syndrome: delusional belief that the individual is dead, does not exist, is putrefying, has lost blood, or has lost internal organs.
- de Clerambault syndrome: erotomania
Antipsychotic drugs
The mainstay of treating psychotic disorders is atypical antipsychotics. Typical antipsychotics are used for acute agitation. Antipsychotics antagonize dopamine. Chlorpromazine (Largactil, Thorazine), the first antipsychotic, was developed for WWII and introduced in 1952.
- Typical (classical, older) antipsychotics
- Haloperidol*, procholrperazine, chlorpomazine*, pimozide
- It has major side effects. Typically do not want to use them if can avoid them.
- Extrapyramidal symptoms, neuroleptic malignant syndrome (fever, muscle rigidity)
- Atypical (newer) antipsychotics
- Ziprasidone, Olanzapine, Quetiapine, Aripiprazole, Clozapine
- Clozapine is used as a last resort since it is associated with Agranulocytosis
- Ziprasidone is notorious for causing weight gain
Schizophrenia
Schizophrenia is characterized by two or more psychotic symptoms for 6 months or more. Symptoms can be delusions, hallucinations (mainly auditory), disorganized speech, disorganized or catatonic behaviour, and negative symptoms (affective flattening, avolition, mutism). They severely impact daily life (social and occupational) and lead to a downward drift (low SES)
Affects 1% of the population, peak onset is 18-25yo. 14% slow sustained recovery after treatment for 5 years. The rest show relapse (85%, very difficult to treat)
6% die by suicide with or w/o treatment. 20% attempt suicide (bizarre, not planned for, males more like – 20% higher incidence rate than the general population)
Diagnosis is clinical.
- Treatment
- Atypical antipsychotics: Risperidone, Olanzapine, Quetiapine/Aripiprazole
- Regular psychotherapy
- Social workers help the patient maximize function in the outside world.
- Outpatient review
- Factors for good prognosis (25%)
- Female gender
- Older age of onset
- Significant mood component
- Family Hx of mood disorder
- Premorbid high IQ and robust, resourceful personality
- A significant mood component
- Nil or minimal cognitive impairment
- Compliance with treatment (pt should continue meds w/side effects or w/o side effects)
- Sudden onset (if caused by a stressor, remove it)
- Rapid response to treatment
- Treatment early in the course of the disorder (acute psychosis is ‘toxic’, causing progressive brain damage)
- Compliance with treatment
- Rejection of illegal substances
- Prevention
- Genetics
- Personality change
***Brief Psychiatry Rating scale (BPRS) for monitoring progress
Historical perspective
- Emil Kraeplin (1893, Germany)
- Manic depressive insanity & Dementia praecox
- To identify schizophrenia and isolate it
- Eugene Bleuler (Early 20th century Sweden)
- Coined the term ‘Schizophrenia” which means “split mind”
- Kurt Schneider (1959, Germany)
- Symptoms of the first-rank
Symptomatology
- Kurt Schneider’s Symptoms of the First Rank (Still applicable in Europe)
- Auditory hallucinations
- Audible thoughts (Thought echo): voices repeating the subject’s thoughts aloud (Echo de la pensee)
- Voices arguing: Two or more hallucinatory voices discussing the subject in third person
- Voices commenting on subject’s thoughts/behaviour: usually as a running commentary
- Thought alienations/control
- Thought withdrawal: thoughts cease and the subject simultaneously experiences them as removed by an external force
- Thought insertion: Alien thought put into the subject’s mind
- Thought broadcasting: feeling that the subject’s thoughts are public
- Delusions of being controlled
- Somatic passivity: Influence playing on the body, the experience of bodily sensations imposed by an external agency
- Made feelings: feelings do not seem to be own, attributed to external force
- Made impulses: drive or impulse seem to be alien and external
- Made volitional acts: actions and impulses seem to be alien and external
- Delusional perception: normal perception has private and illogical meaning (experiences a normal sensory perception but assigns a false meaning to it)
- Auditory hallucinations
- Positive symptoms
- Hallucinations (Remarkable, mainly auditory)
- Delusions (Bizzare)
- Formal thought disorder
- Disorganized speech
- Grossly Disordered or Catatonic Behavior
- Negative symptoms
- Flat affect
- Anhedonia
- Asociality
- volition
- Alogia
- Self-neglect
- Cognitive dysfunction in schizophrenia
- 60-78% of pts with schizophrenia have cognitive impairment. Which came first? Impaired cognition or schizophrenia? (Probably schizophrenia)
- Social cognition
- Difficulty inferring other people’s thoughts (thus unable to predict other’s reactions etc.)
- Catatonia
- Decreased motor activity; Decreased engagement during interview; Excessive and peculiar motor activities
- Disorganised/Chaotic behavior
- Classical “mad person”
- Goes hand in hand with self-neglect
- Negativism
- The patient typically goes against what you say
- Other findings in the MSE
- Grimacing
- Echolalia
- Echopraxia
Subtypes of Schizophrenia
Classified in the DSM-IV. Not important to differentiate these 5 types because treatment is the same. But be aware they exist. Disorganized schizophrenia has the worst prognosis.
- Paranoid type
- Preoccupation with:
- delusions of persecution
- generally bizarre delusions and hallucinations (auditory hallucinations that are speaking about the pt in a negative manner)
- delusions of grandeur (also seen in mania but mania will not have hallucinations among other psychotic symptoms)
- Preoccupation with:
- Disorganized type
- The most severe type with disorganized speech and no association with reality
- Highly unkempt
- Confused
- Child-like
- Difficult to maintain interview
- Catatonic type
- Prominent psychomotor symptoms (fixed positions, in the ward staring at the wall not moving)
- Mutism (don’t talk much, difficult to interview)
- Echolalia (repeat what you say)
- Echopraxia (repeat what you do)
- Undifferentiated type
- Does not fit into any of the types above.
- No characteristics are prominent
- Residual type
- Attenuated positive psychotic symptoms (eg. hallucinations), only negative symptoms
Theories of schizophrenia (Etiology)
The theory goes that Dopaminergic activity increases so much in a pt with schizophrenia that it essentially “burns out” the basal ganglia. Hence the findings in neuroumaging and the need to inhibit DA as pharmacotherapy. Schizophrenia has a very strong genetic linkage.
- Dopamine theory
- Increased amount or activity of dopamine
- The nigrostriatal pathway affects the limbic system (hippocampus, amygdala, thalamus, parts of the cortex) and Ventral striatum (nucleus accumbens)
- Forms the basis for treatment
- Histology
- Smaller and densely packed pyramidal cells (esp of the hippocampus and dorsolateral prefrontal cortex; Delayed neuronal migration?)
- Reduced synapses in the hippocampus and prefrontal cortex
- NO dysplasia or gliosis in cortical regions
- Neuroimaging ***Which came first? Changes in the brain to cause schizophrenia OR schizophrenia to cause changes in the brain?
- Cortical atrophy – Reduction of cortical volume, especially around the basal ganglia
- Enlarged lateral ventricles
- Hypoactive frontal lobe (on PET)
- Hyperactive basal ganglia (on PET)
- Genetics
- 85% hereditability (about similar to T1DM)
- 47% monozygotic concordance
- 16% dizygotic concordance
- 12% primary concordance (1st degree relative)
- 6% secondary concordance (2nd degree relative)
- 1% lifetime risk (affects 1% of the population)
- Epigenetics
- miRNA modifies gene expression
- 40% of schizophrenics have an immune reaction (tied with viral theory)
- Environmental modifiers
- Familial theory/Double-blind/”Mother’s mixed messages”; high expression of emotions in the family, conflicting parental messages)
- Viral theory (High number of schizophrenics born in winter or early spring)
- Stress (can precipitate onset, lead to relapse, or sustain symptoms)
Phases of Schizophrenia
The risk phase is crucial for prevention. The prodrome is crucial for early detection, especially in children.
- Risk phase
- Genetic factors: 85% herediability, 47% monozygotic concordance etc.
- Intrauterine factors: viral infections
- Obstetric factors: hence the need for efficient perinatal care
- Substance use: Psychoactive (Cannabis-induced psychosis)
- Prodrome
- Isolation: Pt simply withdraws (important to differentiate from Autism-Spectrum disorder)
- Poor school performance
- Poor work output
- Odd thinking
- Psychiatric phase
- Positive symptoms
- Chronic phase (Disability)
- Irreversible
- Negative symptoms
Schizophreniform disorder
Meets all the clinical criteria for schizophrenia BUT symptoms last less than 6 months (but greater than one month) Diagnose and manage just like schizophrenia w/atypical antipsychotics. May need to be hospitalized acutely. Diagnosis shifts to schizophrenia if the patient has not recovered and still meets the criteria after 6 months. Not all patients progress to schizophrenia (about 50%)
Brief Psychotic Episode
Meets all the clinical criteria for schizophrenia BUT symptoms last for less than 1 month. Hospitalization is acutely psychotic. Atypical antipsychotics are the mainstay. Benzos may be useful. Diagnosis shifts to schizophreniform disorder if the patient has not recovered and still meets criteria after 1 month.
- Adjustment disorder vs Brief Psychotic Episode
- After stressful events, pt will not have psychotic symptoms in brief psychotic episode
Schizoaffective Disorder
The patient has symptoms of mood disorders (MDD, Manic episodes, mixed depressive/manic episodes) and symptoms of schizophrenia (delusions, hallucinations etc.). Better prognosis than schizophrenia. 50% of pts with schizophrenia have depression.
Schizophrenic (Psychotics) symptoms must be present for at least two weeks without mood symptoms (mood symptoms can clear but psychotic symptoms remain for 2 weeks) 50% of patients with Schizophrenia have depression
F>M. 30% of cases start 25-35y. 0.3% lifetime prevalence. 10-30% of inpatient admissions.
- Differentials
- Schizophrenia
- MDD w/psychotic features
- Major Mood Disorde (BPD1 and BPD2)
- Treatment
- Psychotic symptoms first (atypical antipsychotics)
- Mood symptoms (mood stabilizers, SSRIs/Antidepressants; depending on symptoms)
- Family therapy
- Psychotherapy
- Individual therapy
- ECT
Delusional Disorder
Characterized by delusions for at least one month. Can have hallucinations**. NO IMPAIRMENT IN FUNCTION** (although people may think the patient is “crazy”). Remember to keep culture in mind. If the “delusion” is an accepted cultural view in that patient’s culture then it is not a delusion.
Can have hallucinations (not marked); undifferentiated; shared psychotic disorders