Schizophrenia

1
Schizophrenia related psychoses
2
Schizophrenia
3
Schizophrenia psychosocial
4
Schizophrenia neurobiology
5
Schizophrenia neurobiology
6
Schizophrenia epidemiology
7
SCZ neurodevelopmental model of aetiology
8
Neurodevelopmental Pantelis
Figure 1.  Illustration of our proposed model.
Shaded areas represent periods of structural
brain change associated with the disorder, with
functions maturing at these times shown below. We
suggest that the functional consequences of
structural brain changes in schizophrenia are
developmentally moderated such that the later in
life a functional component comes 'online', the
more likely it is to be defective
Pantelis, Christos, Yücel, Murat, Wood, Stephen
J., McGorry, Patrick D. Velakoulis, Dennis?arly
and late neurodevelopmental disturbances in
schizophrenia and their functional
consequences.?Australian and New Zealand Journal
of Psychiatry 37 (4), 399-406.
9
Pantelis neurodevelopmental

• Early neurodevelopmental/structural insult
• Compensation in infancy
• More brain plasticity
• Functions that come online earlier e.g. motor are
  saved
• Impairment of functions that develop later
• Multi-circuit functions involving the frontal
  lobe e.g. working memory, executive functions lt
• Less brain plasticity to deal with developmental
  functional demands in adolescence
• 2nd insult/maturational abnormality e.g. as
  reflected in hippocampal volume
• Long term neurodevelopmental/cognitive effects of
  illness possibly reflected in ongoing structural
  damage

10
More evidence for neurodevelopmental model
This multi-stage, multi-influence model may
account for heterogeneity of schizophrenia
11
Schizophrenia Aetiology
doomed from the womb second hit or
hits
12
Cannabis SCZ
13
Cannabis SCZ theories
14
Course
15
Schizophrenia Early onset
16
Schizophrenia Good prognosis
17
Schizophrenia

• A. Characteristic symptoms Two (or more) of the
  following, each present for a significant portion
  of time during a 1-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
• Note Only one Criterion A symptom is required if
  delusions are bizarre or hallucinations consist
  of a voice keeping up a running commentary on the
  person's behaviour or thoughts, or two or more
  voices conversing with each other.

18
Schizophrenia

• B Social/occupational dysfunction or failure to
  achieve expected function
• C Duration 6 months incl. 1/12 active phase (NB
  ICD doesnt have 6 months)
• D Schizoaffective/mood disorder exclusion mood
  episodes brief relative to overall illness no
  concurrent MDD, mania, mixed affective episode
• E Substance/general Med exclusion
• F Relationship with PDD additional prominent
  delusions, hallucinations for 1/12

19
Schizophrenia symptom complexes
20
Schizophrenia types
Hierarchical i.e. catatonic trumps disorganized
21
Schizophrenia types
22
Old age gt45 onset schizophrenia
23
Schizophrenia DDx
-ve symptoms vs. MDD AFFECT intensely painful
in MDD vs. blunted in scz
24
Management of schizophrenia at different stages
of illness

• From the college CPG 2004

OPTIMISM is evidence-based And is the
fundamental guideline
25
Prodromal schizophrenia
26
First episode psychosis
If first episode is schizoaffective use
adjunctive mood-stabiliser for manic and
antidepressant (SSRI ? SNRI ? TCA ? ECT) for
depressed type DUP worse symptoms at
admission, poorer response to tx in medium term,
poorer social re-integration BUT no evidence it
increases impairment on cognitive testing
27
First episode psychosis
28
Why reduce DUP/DUI?

• Decreased
• Readmission
• Suicide
• DA abuse
• Homelessness
• Negative symptoms
• Increased
• Recovery (more rapid resolution of Sx)
• Family support
• Social support and Fx
• QOL

29
Mx - FEP

• 5 Ss
• Safety assess risks
• Setting aim for home, avoid PICU if hospital
  needed
• Status least restrictive
• Sx early assertive Rx
• Specific instructions - family, pt, GP
• - in-pt minimise trauma, 11 nursing
  for highly agitated young patients
• Dx and Fx clarification
• Detailed history pt and other informants
  prodromal Sx and DUI/DUP, presence of mood
  symptoms, substance use, developmental Hx
• Early family meeting education, engagement,
  information
• Liaison with other key informants GP
• Physical examination esp. neuro (movement
  disorder), also wt/BMI
• Investigations
• MRI, ECG
• Fasting Lipids / glucose, FBE, UE, TFT, UDS
• MDT Neuropsych, OT ax

30
Mx - FEP

• 3. Barriers to Rx
• Cognitive /negative Sx
• Adverse effects
• Personality
• Specific Sx / Substances
• Insight
• Chaotic lifestyle
• Under influence others
• Means / money
• 4. Engagement strong working alliance with pt
  and carers
• Attitudes
• Early engagement (ideally in prodrome) incl.
  carer/consumer gps
• Roles
• Others involve family early educate, support,
  build alliance
• Boundaries confidentiality NB as far as
  possible
• Information education, MHL
• Negotiated Rx plan
• Goals

31
Specific interventions Dx and co-morbidity

• Bio start low, go slow, provide info, general
  prescribing principles
• 24-48 hr BDZ only
• Use of benzos for behavioural agitation,
  insomnia, distress
• Start atypical slowly over 1 week (R2, O10, Q300,
  As400, Ar15)
• Wait 3 weeks
• ?to R4, O20, Q600, As800, Ar 30 over 4 weeks
• Use clozapine if 2 agents for 6 weeks each have
  failed (including 1 atypical) or prominent
  suicidal ideation
• Continue for 12 -24 months then wean over
  several months if in remission (but 70-90 will
  relapse difficult to predict)
• Co-morbidity / Diff Dx
• Mood stabiliser in maniform psychosis,
  Antidepressant in depressive S-A-D
• Substance abuse
• Other common co-morbidities OCD, PTSD, Panic,
  Social Phobia

32
Specific interventions Dx and co-morbidity

• Psychosocial target at key problems/issues
• Manage trauma minimise, screen for PTS Sx,
  allow opportunity to ventilate and debrief,
  provide info on admission
• MDT Social work finances, accommodation
• Active use of NGOs, consumer and carer
  consultants and groups
• PE Key intervention improve MHL, improve
  adherence, improve pt satisfaction with Rx
• CBT promote recovery, decrease relapse,
  decrease Sx, more rapid discharge
• Also for co-morbidity
• CT Motivational interviewing, PE
• FI building alliance
• General PE and relapse prevention
• Specific individualised FT- eg EE
• OTHER- SST, CR, VR

33

• Discharge planning
• Sx reduction
• Accommodation
• Follow-up early engagement with CM
• Available support
• Risks ameliorated
• Insight / adherence
• Crisis plan
• Rehab / Recovery early (lt1year) and
• late phases (gt1 year)
• Housing / Health
• ADLs
• Vocation
• Education
• Relapse prevention
• Self-mx, social activities

34
Long-term interventions
35
(No Transcript)
36
Persistent Negative Sx

• Affective blunting, Abulia (amotivation),
  Anhedonia, Alogia, ADLs impaired, Autism (social
  isolation)
• Any phase of illness prodrome, acute, chronic
• Significant impact on Fx
• 20 Depression
• Positive symptoms eg voices, persecutory
  delusions
• Lack of social stimulation, institutionalisation
• Medications EPSE, sedation
• Substance abuse eg THC
• Standardised scales for Ax - PANSS
• Rx of 10 Negative Sx atypical APs- esp.
  amisulpiride 100-300mg
• Aim for lower doses of atypicals (R 1-4, OLZ
  5-12.5)

37
Management of schizophrenia specific
interventions

• From College CPG 2004

38
CPG psychopharmacology
39
CPG psychopharmacology
No haloperidol for acute agitation/emergencies
40
ECT for schizophrenia
41
Schizophrenia models of psychosocial care
Therapist Optimism has evidence for modulating
outcome
42
CPG psychosocial interventions
43
CPG psychosocial FI
44
CPG psychosocial FI
45
Assessing families in SCZ

• Adjustment how have your family adjusted to
  having a family member with SCZ?
• Boundaries / Roles what roles do you think the
  various family members take on in the family?
• Communication- how does your family communicate?
• Conflict How are disagreements dealt with?
• Discipline who is in charge of laying down the
  rules of the home?
• Difficulties how does your family go about
  resolving difficulties
• Emotion is yours a family that expresses
  feelings very openly? What about negative
  feelings? When you are worried or frustrated with
  _, do you tend to be critical or overinvolved?
• Expectation- how do you see _s future? What do
  you hope for him to achieve
• Function How does your family function as a
  whole?

46
CPG psychosocial PE CBT
47
CPG psychosocial SST
Cognitive adaptation is like SST but tailored to
particular cognitive deficits
48
CPG psychosocial VR
49
Other psychosocial
50
Treatment resistance
51
Treating treatment resistance

• DO NOT lose optimism
• Exclude/treat mimickers
• Use depot if non-adherent
• USE CBT in everyone
• Use clozapine
• If clozapine fails go back to most effective past
  antipsychotic and add lithium
• DO NOT use combined antipsychotics

52
Schizophrenia emergencies
53
Schizophrenia emergencies
54
Scz CPG odds ends

• Private services 2001
• 7.5 used inpatient
• 13 had private insurance (vs. 30 in comm.)
• 25 saw private psychiatrist

55
The CATIE trial Sep 05 NEJM Lieberman et al.
56
Schizophreniform disorder

• Prodromal, active, and residual phases lt6 gt1 m
• Impaired sociooccupational is not required for
  dWith Good Prognostic Features
• 2
• (1) onset of prominent psychotic symptoms within
  4 weeks of the first noticeable change in usual
  behavior or functioning(2) confusion or
  perplexity at the height of the psychotic
  episode(3) good premorbid social and
  occupational functioning(4) absence of blunted
  or flat affect

DSM 2/3 progress to schizophrenia/schizoaffective
disorder
57
Schizoaffective disorder

• A. B C
• Psychotic mood episode superimposed for a
  substantial portion of the total period of active
  residual illness with 2 weeks
  delusions/hallucinations without mood.
• D. Gen med/substance exclusion
• Bipolar Type or Depressive Type

58
Schizoaffective disorder
59
Delusional disorder

• Non-bizarre delusions 1 m
• Criterion A for Schizophrenia has never been met.
  Note Tactile and olfactory hallucinations may be
  present in Delusional Disorder if they are
  related to the delusional theme.
• Functioning behaviour fine
• Any mood is brief in relation to total period of
  delusions
• Gen med/substance exclusion

60
Delusional disorder

• Erotomanic Type delusions that another person,
  usually of higher status, is in love with the
  individual. Most clinical cases female, most
  forensic cases male.
• Grandiose Type delusions of inflated worth,
  power, knowledge, identity, or special
  relationship to a deity or famous person
• Jealous Type delusions that the individual's
  sexual partner is unfaithful
• Persecutory Type (most common) delusions that
  the person (or someone to whom the person is
  close) is being malevolently treated in some way
• Somatic Type delusions that the person has some
  physical defect or general medical condition
• Mixed Type delusions characteristic of more than
  one of the above types but no one theme
  predominates
• Unspecified Type

61
Brief psychotic disorder

• 1
• (1) delusions
• (2) hallucinations
• (3) disorganized speech (e.g., frequent
  derailment or incoherence)
• (4) grossly disorganized or catatonic behavior
• gt1d lt1m with eventual full return to premorbid
  level of functioning.
• Other psychot/substance/gen med excl.
• With Marked stressors
• Without Marked stressors
• With Postpartum onset (within 28 days)

62
Shared Psychotic Disorder (Folie a Deux)

• A delusion develops in an individual in the
  context of a close relationship with another
  person(s), who has an already-established
  delusion.
• The delusion is similar in content to that of the
  person who already has the established delusion.
• C. Other psychot/gen med/substance excl

63
Psychotic disorder due to a GMC

• Prominent hallucinations or delusions.
• B. There is evidence from the history, physical
  examination, or laboratory findings that the
  disturbance is the direct physiological
  consequence of a GMC.
• C. Not other MI.
• D. Not delirium.

64
Psychotic disorder due to GMC
NEMO
65
Substance-induced psychotic disorder

• A. Prominent hallucinations or delusions. Note
  Do not include hallucinations if the person has
  insight that they are substance induced.
• B. Within 1 mo or intox/withdraw OR substance use
  aetiologically related to sx
• C. Not other psychosis i.e. sx NOT
• Precede drug use
• In excess of whatd be expected with drug
• Prolonged (gt 1month)
• Part of previously known psychosis
• D. Not delirium.

intoxication with the following classes of
substances alcohol amphetamine and related
substances cannabis cocaine hallucinogens
inhalants opioids (meperidine) phencyclidine
and related substances sedatives, hypnotics, and
anxiolytics withdrawal from the following
classes of substances alcohol sedatives,
hypnotics, and anxiolytics
66
Substance-induced psychotic disorder

• Hallucinations may occur in any modality, but, in
  the absence of delirium, they are usually
  auditory. Alcohol-Induced Psychotic Disorder,
  With Hallucinations, usually occurs only after
  prolonged, heavy ingestion of alcohol in people
  who apparently have Alcohol Dependence. The
  auditory hallucinations are usually voices. The
  Psychotic Disorders induced by intoxication with
  amphetamine and cocaine share similar clinical
  features. Persecutory delusions may rapidly
  develop shortly after use of amphetamine or a
  similarly acting sympathomimetic. Distortion of
  body image and misperception of people's faces
  may occur. The hallucination of bugs or vermin
  crawling in or under the skin (formication) can
  lead to scratching and extensive skin
  excoriations. Cannabis-Induced Psychotic Disorder
  may develop shortly after high-dose cannabis use
  and usually involves persecutory delusions. The
  disorder is apparently rare. Marked anxiety,
  emotional lability, depersonalization, and
  subsequent amnesia for the episode can occur. The
  disorder usually remits within a day, but in some
  cases may persist for a few days.
  Substance-Induced Psychotic Disorders may at
  times not resolve promptly when the offending
  agent is removed. Agents such as amphetamines,
  phencyclidine, and cocaine have been reported to
  evoke temporary psychotic states that can
  sometimes persist for weeks or longer despite
  removal of the agent and treatment with
  neuroleptic medication. These may be initially
  difficult to distinguish from non-substance-induce
  d Psychotic Disorders. Some of the medications
  reported to evoke psychotic symptoms include
  anesthetics and analgesics, anticholinergic
  agents, anticonvulsants, antihistamines,
  antihypertensive and cardiovascular medications,
  antimicrobial medications, antiparkinsonian
  medications, chemotherapeutic agents (e.g.,
  cyclosporine and procarbazine), corticosteroids,
  gastrointestinal medications, muscle relaxants,
  nonsteroidal anti-inflammatory medications, other
  over-the-counter medications (e.g.,
  phenylephrine, pseudoephedrine), antidepressant
  medication, and disulfiram. Toxins reported to
  induce psychotic symptoms include
  anticholinesterase, organophosphate insecticides,
  nerve gases, carbon monoxide, carbon dioxide, and
  volatile substances such as fuel or paint

67
Psychotic Disorder Not Otherwise Specified

• Postpartum psychosis that does not meet criteria
  for Mood Disorder With Psychotic Features, Brief
  Psychotic Disorder, Psychotic Disorder Due to a
  General Medical Condition, or Substance-Induced
  Psychotic Disorder
• Psychotic symptoms that have lasted for less than
  1 month but that have not yet remitted, so that
  the criteria for Brief Psychotic Disorder are not
  met
• Persistent auditory hallucinations in the absence
  of any other features
• Persistent nonbizarre delusions with periods of
  overlapping mood episodes that have been present
  for a substantial portion of the delusional
  disturbance

68
Schneiders FRS (c. 1959)

• 1. Auditory hallucinations
• hearing thoughts spoken aloud (echo de la pensee
  gedankenlautwerden)
• Two or more voices talking to each other
  referring to the patient as a third person
• Commentary on ones actions
• 2. Delusions
• Passivity
• thought withdrawal/insertion
• feelings or actions experienced as made or
  influenced by external agents as if one was
  hypnotised or a robot
• Thought broadcasting
• 3. somatic passivity
• sensations passively and reluctantly experienced
  as imposed by outside agencies
• 4. delusional perception
• a normal perception interpreted delusionally

69
Schneiders FRS (c. 1959)

• No prognostic significance
• 1 in 5 patients have never experienced a 1st rank
  symptom
• 1 in 10 non-schizophrenic patients have
  experienced a 1st rank symptom
• twin studies have shown that Schneiders 1st rank
  symptoms defined a form of schizophrenia with the
  least evidence of inheritance

70
Beyond the episode
71
Recovery model

• Hope
• Purpose/meaning/spirituality
• Perspective on disorder (as part not whole of
  oneself)
• Engagement community/work/new roles
• Self-esteem
• Self-care/basic functioning
• Self-responsibility (e.g. relapse prevention,
  destructive habits)
• Self-empowerment
• Self-advocacy