1 / 72

The Essence of Schizophrenia

The Essence of Schizophrenia. Originally called “dementia praecox” Produces severe incapacity – “dementia” Typically begins in adolescence – “praecox”. The Tragedy of Schizophrenia. A catastrophic illness Tends to persist chronically 10% suicide rate Very common -- 0.5-1% of population

kermit
Télécharger la présentation

The Essence of Schizophrenia

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Essence of Schizophrenia Originally called “dementia praecox” Produces severe incapacity – “dementia” Typically begins in adolescence – “praecox”

  2. The Tragedy of Schizophrenia • A catastrophic illness • Tends to persist chronically • 10% suicide rate • Very common -- 0.5-1% of population • The “cancer of mental illness”

  3. The Complexity of Schizophrenia • No single defining feature • Multiple characteristic symptoms • Symptoms from multiple domains • Emotion • Personality • Cognition • Motor Activity • Probably a multisystem disorder, analogous to syphilis

  4. Simplifying the Complexity of Schizophrenia • Division of symptoms into two broad groups • Positive: distortions or exaggerations of normal functions • Negative: diminution of normal functions

  5. Hughlings-Jackson: Positive and Negative Symptoms • Disease that is said to “cause the symptoms of insanity.” I submit that disease only produces negative mental symptoms answering to the dissolution, and that all elaborate positive mental symptoms (illusions, hallucinations, delusions, and extravagant conduct) are the outcome of activity of nervous elements untouched by any pathological process; that they arise during activity on the lower end of evolution remaining.

  6. Positive Symptoms

  7. Negative Symptoms

  8. The Importance of Negative Symptoms • Impair ability to function in daily life • Holding a job • Attending school • Forming friendships • Having intimate family relationships

  9. Subdivision of Symptoms into Three Dimensions • Psychotic Delusions Hallucinations • Disorganized Disorganized speech Disorganized behavior Inappropriate affect • Negative Poverty of speech Avolition Affective Blunting Anhedonia

  10. Types of Hallucinations • Auditory • Visual • Tactile • Olfactory

  11. Types of Delusions • Persecutory • Grandiose • Religious • Jealous • Somatic

  12. Historical Concepts • Emil Kraepelin • Eugen Bleuler • Kurt Schneider • Others (e.g., Leonhard, Kleist, Langfeldt)

  13. Emil Kraepelin: Dementia Praecox “Dementia praecox consists of a series of states, the common characteristic of which is a peculiar destruction of internal connections of the psychic personality....the majority of the clinical pictures are the expression of a single morbid process, though outwardly they often diverge very far from one another.”

  14. Kraepelin: Course and Outcome • Split “dementia praecox” from manic-depressive illness • Early onset • Marked deterioration • Chronic course • Diversity of signs and symptoms • Importance of volition and affect

  15. Eugen Bleuler: Loosening of Associations “Of the thousands of associative threads that guide our thinking, this disease seems to interrupt, quite haphazardly, sometimes single threads, sometimes a whole group, and sometimes whole segments of them.”

  16. Bleuler: Fundamental Symptoms • Renamed the disorder “schizophrenia” • Focused on the characteristic symptoms • Emphasized fragmenting of thinking • Partial recovery possible • No full “restitutio ad integrum” • A broader concept • Heterogeneity: the “group of schizophrenias”

  17. Bleuler’s Fundamental Symptoms • Associations • Affective Blunting • Avolition • Autism • Ambivalence • Attention

  18. Bleuler’s Description of Fundamental Symptoms • Certain symptoms of schizophrenia are present in every case and at every period of the illness even though, as with every other disease symptom, they must have attained a certain degree of intensity before they can be recognized with any certainty…for example, the peculiar association disturbance is always present, but not each and every aspect of it…besides these specific permanent or fundamental symptoms, we can find a host of other, more accessory manifestations such as delusions, hallucinations, or catatonic symptoms…as far as we know, the fundamental symptoms are characteristic of schizophrenia, while the accessory symptoms may also appear in other types of illnesses.

  19. Kurt Schneider

  20. Schneider: The Psychotic Experience • Interested in pathognomonic symptoms • “First Rank Symptoms” (FRS) E.g., voices commenting Voices arguing Thought insertion • Involve a loss of the sense of autonomy of self, or “ego boundaries”

  21. Importance of Schneiderian Ideas • Discrete phenomena—clearly pathological or “bizarre” • Discontinuous from normality • Potentially for good reliability • Ideal for objective criterion-based systems

  22. Schneiderian Influences on Diagnostic Systems • Incorporated into Present State Examination (PSE) • Used in International Pilot Study of Schizophrenia (IPSS) • Influenced the International Classification of Disease (ICD) • Influenced the US Diagnostic and Statistical Manual (DSM)

  23. Fundamental Questions about Schizophrenia • What are the characteristic symptoms? • What are the boundaries of the concept? • Is the disorder a single illness or multiple disorders? • If multiple, what are the subtypes?

  24. Characteristic Symptoms • Schneider: specific types of delusions and hallucinations • Bleuler: fragmented thinking, inability to relate to external world • Kraepelin: emotional dullness, avolition, loss of inner unity

  25. Schizophrenia as a “Polythetic Construct” • No single characteristic symptom • Many symptoms, all present in some, not present in all • Manifestations in thinking, emotion, interpersonal relationships • A multisystem disease

  26. What are the Characteristic Symptoms of Schizophrenia? • Depends upon whom you ask • Depends upon theoretical construct • Depends upon what you mean by characteristic Common? Specific? Core?

  27. Kraepelin: The Borders of Schizophrenia …it is certainly possible that its borders are drawn at present in many directions too narrow, in others perhaps too wide.

  28. Boundaries of the Concept • Schizoaffective Disorder • Psychotic Mood Disorders • Nonpsychotic disorders Schizotypal Personality Simple Schizophrenia

  29. “Good Prognosis Schizophrenia” • Prominent affective symptoms • Acute onset • Family history of affective disorder • Good premorbid function • Presence of insight

  30. Narrowing of Concept: Rationale • Risk of tardive dyskinesia • Risk of erroneously treating mood disorders with neuroleptics • Risk of self-fulfilling prophesies of poor outcome • Risk of political abuse

  31. Single or Multiple Illnesses • Whether dementia praecox in the extent here delimited represents one uniform disease, cannot be decided at present with certainty. -- Emil Kraepelin

  32. Heterogeneity: Competing Models • Single disease entity: multiple sclerosis • Multiple disease entities: mental retardation • Multiple domains of psychopathology

  33. Single Disease Entity • A single illness • A single cause that produces diverse manifestations • Possible mechanism: process producing multiple brain lesions

  34. Multiple Disease Entities • “The group of schizophrenias” • Multiple causes Purely genetic forms, e.g. phenylketonuria Purely environmental forms, e.g. virally induced Multifactorial forms • Manifestations reflect site of injury and time of the maturational process

  35. Multiple Domains • Multiple dimensions of psychopathology e.g., psychotic, disorganized, negative • Different mechanism for each dimension • Disease process A  dimension A • Disease process B  dimension B • Disease process C  dimension C • Mixed clinical presentation due to multiple disease processes

  36. Methods for Subtyping • Traditional subtypes based on clinical presentation • Phenomenotype vs. biotype • Positive vs. mixed vs. negative

  37. Traditional Subtypes • Paranoid • Disorganized • Catatonic • Undifferentiated • Residual

  38. Traditional Subtypes • Divide patients based on their prominent presenting symptoms • Useful for prediction Prognosis Social and occupational function Response to treatment

  39. Phenomenotype • Types of symptoms • Severity of symptoms • Longitudinal course • Mode of onset • Cognitive function • Psychosocial adaptation • Response to treatment

  40. Biotype • Genetic loading and linkage • Birth and pregnancy complications • Viral risk factors • Neurophysiological measures • Neuropsychological measures • Neuroimaging measures • Neurochemical measures

  41. Positive vs. Negative

  42. DSM-IV Criteria for Schizophrenia: The Basics • Characteristic symptoms for one month • Social/Occupational Dysfunction • Overall Duration > 6 months • Not attributable to mood disorder • Not attributable to substance use or general medical condition

  43. Criterion A: Characteristic Symptoms • At least two of the following, each present for a significant portion of time during a one 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

  44. Criterion A: Parenthetical Note • [Note: Only one “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.]

  45. Criterion 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 is 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

  46. Criterion C: Overall Duration • Continuous signs of the disturbance persist for at least six months • This six-month period must include at least one month of symptoms that meet criterion A (i.e., active phase symptoms), and may include periods of prodromal or residual symptoms • During these prodromal or residual period, 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)

  47. Criterion D: Schizoaffective and Mood Disorder Exclusion • Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out because of either: • No major depressive or manic episodes have occurred concurrently with the active phase symptoms; or • 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

  48. Criterion E: Substance / General Medical Condition Exclusion The disturbance is not due to the direct effects of a substance (e.g., drugs of abuse, medication) or a general medical condition

  49. ICD 10 Criteria for Schizophrenia: The Basics • Characteristic symptoms for one month • If mood disorder is present, one month of characteristic symptoms must antedate it • Not attributable to organic brain disease or substance abuse

More Related