Schizophrenia

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Schizophrenia

• Greg Chick
• SHO Psychiatry, Royal Manchester Childrens
  Hospital

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What do I Really Have to Know?

• Prevalence (quoted as 1 worldwide)
• Age of onset 20ish, (40ish, 70ish)
• Differential Diagnosis
• Think ORGANIC!
• Drug-induced psychosis, Psychotic depression,
  mania, (schizoaffective disorder), schizotypal
  personality disorder
• Psychopathology
• Define Delusion, Hallucination

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WHY do I need to know about Sz?

• GP
• Front line service
• Early detection improves prognosis!
• worried relatives asking you to section people
• Increased burden
• Surgeons / Obs Gynae delusional pts insisting
  on unnecessary operations
• AE pts present with overdose, bizarre
  behaviour complaints
• Paediatrics child protection issues early
  onset psychosis
• Psychiatry bread butter!
• frequent LONG admissions

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Definition of Schizophrenia

• a severe and enduring mental illness
• A clinical syndrome
• a collection of features which tend to occur
  together
• Refined over last 200 years or so
• Recognised pattern of outcome
• Same methods of treatment
• Biological basis severe psychosocial
  consequences
• No definitive cause or mechanism yet identified
  (multifactorial see Theory Lecture)
• Neurochemical imbalance
• reality testing and theory of mind defective
• loss of ego boundaries (what is Me and what
  is Outside)
• BUT there is still no single concise definition!

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Myths Misconceptions

• Schizophrenia does literally mean separated
  mind
• Greek applied by Bleuler in 1911
• BUT is nothing to do with split personality
• Let alone multiple personality (very rare)
• HAS to do with the brains functions separating
• Eg. Hear a voice but dont recognise its come
  from your own mind

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Heritable Risk
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Risks for family members with schizophrenia

• Single parent 10 risk
• Both parents 25 risk
• Sibling 10 risk
• Twin 50 risk
• Clear-cut genetic loading proven by adopted away
  twin studies
• Not 100 genetic since risk with identical twins
  is only 50.
• Multifactorial with multiple genes and
  environmental factors (viral, toxins, drugs,
  alcohol, psychological stressors)

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Clinical features

• Prevalence 1 in all countries
• Gradual onset
• Onset at late adolescence/early adulthood
• But can occur AT ANY AGE
• Smaller peak around 40yrs (late onset)
• Even smaller peak around 70yrs! (late late onset)
• Progressive decline in function
• Deficit symptoms predominate
• Family history of schizophrenia

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Age of Onset Bimodal Distribution
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Historical spotting the patterns, grouping the
symptoms

• 1900s Kraepelin and Bleuler
• Kraepelins Dementia praecox
• premature loss of mind inevitable decline (13
  recovered)
• Bleulers 4 As
• Autism (withdrawal into own fantastic world)
• Associations loosened (eg chaotic thinking
  speech)
• Affect (blunted or incongruous)
• Ambivalence (love hate, want / not want)

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Historical spotting the patterns, grouping the
symptoms

• 1950s - Schneiders 1st Rank Symptoms
• Primary Delusion delusional percept
• Own thoughts spoken aloud thought echo
• Voices arguing or discussing
• running commentary voices
• thought withdrawal and/or thought block
• Thought insertion
• thought broadcasting (others are thinking it at
  the same time as you)
• Made to feel passivity of affect
• Made to want passivity of impulse
• Made to do passivity of volition
• Done to my body somatic passivity eg probed by
  aliens
• Some may occur in illnesses other than
  schizophrenia eg mania, dementia, delusional
  disorder

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Natural History Prognosis

• Often poor
• Commonly leads to social disability
• Many long admissions to hospital
• Unemployment, reliance on benefits
• Homelessness (though not usually on the
  streets)
• Isolation loss of contact with friends, not
  making new ones
• stigma
• Lack of insight gt non-compliance with meds,
  despite need for life-long treatment in most
  cases. psycho-education, relapse prevention,
  family work
• Tardive dyskinesia
• Occurs even without drug Rx but seems worse with
  Dopamine antag
• (involuntary facial / truncal twitching /
  writhing movements essentially untreatable)
• Much more physical disease
• Also side effects of medication

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5 Year Outcome after First Presentation
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Medication is vital to recovery

• Delay of treatment is correlated with worsening
  outcome
• The earlier antipsychotic medication is started,
  the better the ultimate outcome
• D.U.P. Duration of Untreated Psychosis

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Types of Schizophrenia ICD-10

• F20 Schizophrenia
• F20.0 Paranoid Schizophrenia
• F20.1 Hebephrenic Sz
• F20.2 Catatonic Sz
• F20.3 Undifferentiated Sz
• F20.4 Post-Schizophrenic Depression\
• F20.5 Residual Sz
• F20.6 Simple Sz

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Types of Schizophrenia ICD-10

• F20.0 Paranoid Schizophrenia
• most common type hallucinations delusions
• paranoia from the Greek reference to the Self
  
• (its ME theyre out to get, not anyone else)
• Hebephrenic Sz
• Cartoon mad person laughing inappropriately,
  crying, chaotic
• Only seen in young people
• Catatonic Sz
• Historical asylum cliché strange postures /
  muteness / manerisms
• Less commonly seen now, more common in mania or
  severe depression
• Residual Sz chronic low-grade oddness
• Simple Sz hermit-like retreat from society

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Prodromal / Early Symptoms

• Symptoms one month to one year before psychotic
  crisis
• Person feels something strange or weird is
  happening to them
• Perplexity, delusional atmosphere
• Misinterprets things in the environment
• Feelings of rejection, lack of self-respect,
  loneliness,hopelessness, isolation, withdrawal,
  and inability to trust others.

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Categories of Symptoms

• Symptoms may be classified as
• Positive symptoms i.e. hallucinations,
  delusions, bizarre behavior, disorganized speech
• Negative lack of normal experiences
• apathy, lack of motivation, anhedonia (inability
  to enjoy normal pleasures)
• Cognitive - i.e. difficulty with selective
  attention, memory, planning and problem solving
• Disorganized i.e. disorganized speech,
  inappropriate affect

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Differential diagnosis

• THINK ORGANIC first!
• Delirium tremens, alcoholic hallucinosis, brain
  tumor, toxins
• Rare metabolic disorders
• Huntingtons Disease (psychiatric symptoms
  predominate!)
• Drug induced cannabis, amphetamines, Cocaine,
  LSD, PCP
• Mania depression with psychotic features
• Schizoaffective disorder (equal proportion of
  psychotic affective symptoms)

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Delusions - definition

• A delusion is a false, unshakeable idea or
  belief which is out of keeping with the patients
  educational, cultural and social background
  Simms
• we can never understand how they arrived at the
  belief defies normal logic
• BUT
• Need not be totally unshakeable cognitive
  therapy for delusions
• Need not be false (eg delusional jealousy then
  discover partner actually IS unfaithful)
• Wrongly ARRIVED at belief
• Primary Delusion out of the blue
• Secondary Delusion arises out of eg.
  hallucination

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Delusions - examples

• I am the son of George W Bush
• by a somali woman. They were on holiday there
  and left me behind.
• I have a microchip in my brain which transmits my
  thoughts to MI5
• Theres a man living in my loft whos trying to
  drive me out of my house. He kills pigeons and
  eats them.
• My family are poisoning my food. It tastes funny

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Hallucination

• A perception, which feels real, but has no real
  stimulus
• Modalities
• Auditory
• heard as if coming from outwith your head inc.
  from another part of the body!
• Visual (more indicative of organic pathology!)
• Somatic / Sexual
• Gustatory
• Olfactory
• Non-pathological
• Hypnagogic (going off to sleep)
• Hypnopompic (waking up)

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When its NOT a hallucination

• Illusion misperception of a REAL stimulus
• Daydream imagery
• Pseudohallucination
• Occurs in inner subjective space
• eg voices INSIDE your head
• May have quality of your own thoughts
• Distressed patients not interested in this
  distinction!

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Thought Disorder in Schizophrenia

• Circumstantiality (goal eventually reached but
  tortuously indirect and over-inclusive)
• Knights Move Thinking
• Illogical jumping between ideas. Listener cant
  follow train of thought.
• I cant go to the zoo, no money. Oh... I have a
  hat - these members make no sense, man Whats
  the problem?
• NOT the same as Flight Of Ideas, which you CAN
  follow
• Derailment (just losing the plot goal of speech
  not reached)
• Fusion (themes recur but in odd order, hard to
  follow)
• Thought Block (snapping off train of thought.
  No thoughts left)

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Case Vignette - 2

• Brian began to be a worry to his parents at the
  age of 17. After doing quite well in his GCSEs,
  he seemed to lose interest and his ability to
  concentrate on his studies. He began to spend
  more time alone in his room listening to music
  and when he went out with his friends, he
  appeared dazed and distant on returning home.
• His parents suspected he was taking drugs but he
  denied this. When his mother went into his
  bedroom to tidy up one day, she found that he had
  draped a cloth over the mirror. He explained this
  by saying that he avoided looking at his face
  because he had a strange look in his eyes, as
  though he had become hypnotised. His parents
  tried to persuade him to visit their GP, but he
  refused to go. He became very quarrelsome and one
  day he punched one of his friends without
  warning. That evening, he removed all the light
  bulbs from their sockets after complaining that
  they were emitting dangerous radiation. His
  parents took him to hospital and he was admitted.

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Negative Symptoms

• Develop over time
• May not be detected (masked by positive symptoms
• Negative symptoms include poverty of speech
  content, thought blocking, anergia, anhedonia,
  affective blunting, and lack of volition.

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Where can I find out more?

• Symptoms in the Mind Andrew Simms
• (the bible for descriptive psychopathology)
• NICE guidelines
• www.abpi.org.uk/publications/publication_details/t
  argetSchizophrenia-2003/section2.asp
• Bryan L. Roth, rothlab, (ppt presentation)
• Melinda Hermanns (ppt presentation)
• Douglas Ziedonis (ppt presentation)

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Quiz

• 2) Can you diagnose Sz in a patient who has been
  hearing voices for 2 weeks?
• No. Need gt 1 month of symptoms
• 3) do drugs cause Sz?
• Cannabis use in susceptible individuals increases
  risk X 6
• Amphetamine, cocaine/crack cause identical
  syndromes
• 4) do pts with Sz smoke more than other people?
• 70-90 are addicted to smoking
• Neuropsychological basis for this startle
  response
• Lack of other activities in hospital outside
• 5) Are pts with Sz more violent than the rest of
  the population?
• Essentially not. Paranoia hallucinations make
  pts frightened. Restraining people ditto. Sz pts
  have higher rates of drug alcohol problems,
  lower IQ in general
• 6) Psychotic nowadays refers to the bizarre
  phenomena described above (eg hallucinations,
  delusions), the perplexed state and being out of
  touch with reality. Not about being violent or
  cruel as per Hollywood usage.
• 1) still have other questions?