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Diagnosis and Management of Schizophrenia

Diagnosis and Management of Schizophrenia

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Diagnosis and Management of Schizophrenia

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  1. Diagnosis and Management of Schizophrenia Stephen R. Marder, M.D. Professor and Director, Section on Psychosis Semel Institute for Neuroscience at UCLA VA Desert Pacific Mental Illness Research, Education, and Clinical Center

  2. Diagnosis and Management of Schizophrenia • Process for diagnosing schizophrenia • Epidemiology • Genetics and environment • How to access severity • Capacity to Work • Current and future treatment

  3. DSM-IV criteria for schizophrenia • Characteristic Symptoms • Social/occupational dysfunction • Duration of 6 months • Schizoaffective and mood disorder exclusion • Substance/general medical exclusion • Relationship to pervasive developmental disorder

  4. Diagnostic Process for Schizophrenia • Physical and lab exams rule out psychotic disorder due to a medical condition and substance-induced psychosis • Imaging (CT, MRI, PET) are seldom helpful in diagnosis • The diagnosis is commonly made from history and the mental status exam • There are currently no reliable biomarkers for diagnosis or severity

  5. Characteristic Psychotic Symptoms in Schizophrenia • Audible thoughts • Voices arguing or commenting • Thought withdrawal or insertions by outside forces • Thought broadcasting • Impulses, volitional acts, or feelings imposed by outside forces • Delusional perceptions

  6. Psychotic Hallucinations Suspiciousness Delusions Negative Impoverished speech Lack of motivation Asociality Decreased Affect Neurocognitive – Impairments Memory Attention Motor skills Social cognition Executive skills Disorganized speech Symptom dimensions in schizophrenia

  7. Epidemiology of Schizophrenia • Lifetime prevalence of about 1% • No differences related to culture or race • Onset in men is usually earlier (15-24) than in women (25-34)

  8. Global Burden of Disease 2000(15-Disease-adjusted Life Years (DALYs) Top 10 Causes of DALYS in Adults (15-44 years) DALY=Sum of years of life lost due to premature mortality and years lost due to disability WHO. The World Health Report 2001. Available at

  9. Stable Relapsing Premorbid Progression Course of Schizophrenia Good Function Psycho- pathology Poor 15 20 30 40 50 60 70 Age (Years) Sheitman BB, Lieberman JA. The natural history and pathophysiology of treatment-resistant schizophrenia. J Psychiatr Res. 1998(May-Aug);32(3-4):143-150

  10. Severity in Schizophrenia • People with schizophrenia have different levels of disability varying from no disability to complete dependence on institutional care • The amount and type of disability is related to the symptoms of the individual’s illness and how responsive these symptoms are to treatment

  11. Severity in Schizophrenia • The severity of psychotic symptoms are related to • How distracting • Do they influence behavior – eg, command hallucinations • Do they cause suffering • Do they impair social functioning – eg, suspiciousness

  12. Severity • The severity of negative symptoms are related to • Social isolation • Apathy • Lack of expressiveness • The severity of cognitive impairments are related to • Poor concentration • Poor memory • Inability to make simple decisions • Inability to interpret social signals • Slower pace

  13. Pharmacological Treatment of Acute Schizophrenia • Antipsychotic medications are effective for decreasing the severity of psychotic symptoms • Nearly all patients on antipsychotic medications will experience some burden from side effects • Antipsychotics are relatively ineffective for negative symptoms and cognitive impairment

  14. Long-term treatment of schizophrenia • Antipsychotic medications are effective for preventing relapse in stabilized patients • Effective nonpharmacological treatments include patient and family education, skills training, supported employment, cognitive behavior therapies, and psychotherapies • For most individuals, antipsychotic medications control the symptoms while non-pharmacological treatments address the impairments in social, vocational, and educational functioning

  15. Clinical Challenges • Substance use disorders are common in people with schizophrenia • Insight can be impaired leading people with schizophrenia to refuse treatment • Adherence to treatments can be irregular