Schizophrenia and Related Psychotic Disorders

Schizophrenia and Related Psychotic Disorders Diana O. Perkins, MD, MPH Associate Professor of Psychiatry Director, Schizophrenia Treatment and Evaluation Program

Schizophrenia and Related Psychotic Disorders • Clinical characteristics • Epidemiology • Etiology

Psychotic Disorders Clinical Characteristics

Schizophrenia is Heterogeneous... • A syndrome defined by a constellation of clinical symptoms • With multiple causes, that are similarly expressed

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Schizophrenia: Clinical Features • Positive Symptoms a distortion or excess of normal function • Negative Symptoms a decrease or loss in normal function • Disorganization of thoughts and behavior • Cognitive Impairments • Mood Symptoms

Features of Schizophrenia Positive symptoms Negative symptoms Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits Mood symptoms Disorganization

Positive Symptoms (Psychosis) • Disturbance of Perception (Hallucinations) • Disturbance of Thought Content (Delusions)

Positive Symptoms Disturbance of Perception • may effect any sensory modality

Positive Symptoms: Hallucinations Auditory Hallucinations • involve voices or sounds • single or multiple • familiar or unfamiliar • may make insulting remarks or be pleasant • may comment on behavior • may command person to perform acts

Positive Symptoms: Hallucinations Other Sensory Modalities • Tactile: may involve electrical, tingling, or burning sensations • Visual • Gustatory • Olfactory

Positive Symptoms: Delusions Delusions • fixed false beliefs • examples: • persecutory delusions • delusions of reference • delusions of being controlled • thought broadcasting/insertion/withdrawal • grandiose • religious • nihilistic • somatic

Features of Schizophrenia Positive symptoms- Hallucinations - Delusions Negative symptoms Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits Mood symptoms Disorganization

Negative Symptoms Negative symptoms include: • decreased expression of feelings • diminished emotional range • poverty of speech • decreased interests • diminished sense of purpose • diminished social drive

Differential Diagnosis of Negative Symptoms Negative Symptoms primary to schizophrenia: The “Deficit Syndrome”: primary and enduring negative symptoms in individuals with schizophrenia • The Deficit Syndrome occurs in about 20% of treated patients

Differential Diagnosis of Negative Symptoms Negative Symptoms may be secondary to: • antipsychotic EPS side effects • decreased emotional expression and apathy may be due to Parkinsonian side effects • lack of initiation of activity may be due to bradykinesia • psychosis • depression or anxiety • demoralization

Features of Schizophrenia Negative symptoms-emotional range -  expression of emotion -  motivation/drive -  interests -  social drive - poverty of speech Positive symptoms- Delusions- Hallucinations- Disorganization Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits Mood symptoms Disorganization

Positive Symptoms: Disorganization • Disorganization of Speech • tangential or circumstantial speech • looseness of associations • Disorganization of Behavior • odd mannerisms • catatonic stupor

Video Tape • Positive symptoms: • Hallucinations • Delusions • Disorganization • Speech • Behavior • Negative symptoms:

Features of Schizophrenia Negative symptoms-emotional range -  expression of emotion -  motivation/drive -  interests -  social drive - poverty of speech Positive symptoms- Delusions- Hallucinations- Disorganization Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits Mood symptoms Disorganization - speech - behavior

Cognitive Domains: Severe Impairment in Schizophrenia Moderate Impairment • Delayed recall • Distractibility • Immediate memory span • Visuomotor skills • Working memory Severe Impairments • Serial learning • Executive functioning • Vigilance • Motor speed • Verbal Fluency

Working Memory • Aspects of Working Memory • Temporary storage and manipulation of information • “workspace” for holding items of information in mind as recalled, manipulated, and associated with other ideas and information • Tests • patients with schizophrenia tend to perform 1-2 standard deviations below the mean • Tests: visual, spatial, auditory working memory

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Executive Function • Aspects of Executive Function • Focus attention • Distinguish the important aspect of a task or a situation from unimportant • Prioritize • Perform mental or physical activities proper sequence • Modulate behavior based on social cues • Tests: • Patients perform 2-3 standard deviations below mean • Examples: Trail Making Tests, Wisconsin Card Sort, Tower of London

The Wisconsin Card Sorting Test

Vigilance • Ability to monitor target stimuli over an extended duration of time • inability to attend to relevant stimuli and ignore irrelevant stimuli • inability to concentrate • increased susceptibility to distractions • inability to sustain effort and attention • Tests of Vigilance: • patients perform 2-3 standard deviations below the mean • example: CPT

Cognitive Functions: Mild or No Impairment in Schizophrenia No Impairment • Word recognition • Long-term factual memory Mild Impairment • Perceptual Skills • Delayed recognition memory • Confrontation naming

Features of Schizophrenia Negative symptoms-Decreased experience and expression of emotions - Decreased motivation/drive - Decreased initiative - Social withdrawal Positive symptoms- Delusions- Hallucinations- Disorganization Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficits-Attention- Memory - Verbal fluency - Motor function- Executive function Disorganization - speech - behavior Mood symptoms

Mood Symptoms • Dsyphoric • anger, hostility, fear, irritability, depression, anxiety • high risk of suicide • Euphoric • sense of power, control, exhilaration

Mood Symptoms • Primary to schizophrenia • “Reactive” • psychosis is frightening • reality of illness is demoralizing • Co-morbid disorder • major depressive episode

Features of Schizophrenia Negative symptomsAnhedonia Affective flatteningAvolitionSocial withdrawal Alogia Positive symptomsDelusionsHallucinationsDisorganized speech Functional ImpairmentsWorkInterpersonal relationshipsSelf-care Cognitive deficitsAttentionMemory Verbal fluencyExecutive function (eg, abstraction) Mood symptomsDepression/AnxietyAggression/Hostility Suicidality Disorganization - speech - behavior

Diagnosis of Schizophrenia Symptoms Severity/Impairment/Distress Duration

Differential Diagnosis of Schizophrenia • Significant psychotic symptoms for at least one week • Continuous signs of the disturbance for at least six months • Markedly impaired ability to function • Without known etiology

Differential Diagnosis of Schizophrenia Differential Diagnosis: related disorders • Schizophreniform Disorder • Brief Psychotic Disorder • Delusional Disorder • Schizoaffective Disorder • Schizoid Personality • Schizotypal Personality Disorder • Paranoid Personality Disorder

Differential Diagnosis of Schizophrenia Differential Diagnosis:Mood Disorders with Psychotic Features • Major Depression • Bipolar Disorder

Differential Diagnosis of Schizophrenia Organic Mental Disorders • substance induced (e.g. PCP, amphetamine, cocaine, hallucinogens, cannabis, alcohol, a variety of prescribed medications • most diseases affecting the central nervous system

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Schizophrenia and Related Psychotic Disorders

Schizophrenia and Related Psychotic Disorders

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