1. Schizophrenia Radovan Přikryl, Hana Kučerová Department of Psychiatry Medical Faculty Masaryk Univerzity Brno 2004

2. Definition of schizophrenia Schizophrenia is a disorder of unknown causes. It is characterized by psychotic symptoms that significantly impair functioning and that involve disturbances in feeling, thinking and behaviour. Disorder is chronic and generally has a prodromal phase, an active phase with delusions, hallucinations, or both, and a residual phase in which the diorder may be in remission.

3. History 1852: schizophrenia was first formally described by Belgian psychiatrist Benedict Morel, who called it „demence precoce“ 1896: Emil Kraepelin, a German psychiatrist, applied the term „dementia praecox“ to a group of illnesses that began in adolescence and ended in dementia 1911: Swiss psychiatrist Eugen Bleuler introduced the term „schizophrenia“, he postulated the cluster of symptoms pivotal for schizophrenia, there are called 4A: association, ambivalence, anhedonia, autizmus

4. Diagnosis Diagnosis is based on observation and description of the patients DSM IV diagnostic criteria for schizophrenia

5. A. characteristic symptoms: two or more of the following, each present for a significant portion of time during a 1 month period Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behaviour Negative symptoms (affective flattening, alogia, avolition) B. social or occupational dysfunction C. duration of B at least for 6 month D. schizoaffective and mood disorder exclusion E. Substance/ general medical condition exclusion

6. Symptoms of schizophrenia Impaired overall functioning The level of patients functioning declines or fails to achieve the expected level Abnormal content of thought For example delusions, ideas of reference, poverty of content Illogical form of thought Loosening of associations, incoherence, tangentiality, neologism, blocking, echolalia Distorted perception Hallucinations: visual, olfactory, tactile, and most frequently auditory

7. Symptoms of schizophrenia Changed affect Flat, blunted, labile, inappropriate Impaired sense of self Loss of ego boundaries, gender confusion, inability to distiquish internal from external reality Altered volition Inadequate motivation or marked ambivalence Impaired interpersonal functioning Social withdrawal and emotional detachment, aggressiveness, sexual inappropriateness Change of psychomotor behaviour Agitation, withdrawal, grimacing, posturing, rituals, catatonia

8. Types Paranoid Preoccupation with systematized delusions or with frequent auditory hallucinations Disorganized Incoherence, marked loosening of associations or grossly disorganizes behavior Flat or grossly inappropriate affect

9. Types Catatonic Stupor or mutism Negativism Rigidity Excitement Posturing Echolalia or echopraxia

10. Types Undifferentiated type Prominent delusions, hallucinations, incoherence or grossly disorganized behavior Does not meet the criteria for paranoidm catatonic or disorganized type Residual type Absence of prominent delusions, hallucinations, incoherence or grossly disorganized behavior Continuing evidence of the disturbance through two or more residual symptoms Simple schizophrenia Primary symptom is the withdrawal of the patient from social and work related situations

11. The division of schizophrenia into the positive and the negative symptoms according to Nancy Andreasen Positive symptoms of schizophrenia: the presence of abnormal behaviour Hallucinations Delusions Disorganised speech and/or thinking Grossly disorganised behaviour Catatonic behaviour Negative symptoms of schizophrenia: the absence of normal behaviour Social withdrawal Isolation Poor self care Blunted mood and facial expression Lack of spontaneous thinking

12. Epidemiology Prevalence Approximately 1-1,5% Sex ratio The male to female ratio is 1:1 Age of onset Most common between ages 15 and 35 Cost in USA approximately 100 bilion dolars a year

13. Dopamine hypothesis Schizophrenic symptoms are in part a result of hypersensitive dopamine receptors or increased dopamine activity Antipsychotics bind dopamine D2 receptors and cause functional decrease in dopamine activity The mesocortical and mesolimbic CNS dopamine tracts ate rhose most implicated in schizophrenia Drugs that increase dopamine worsen or trigger psychosis

14. Brain imaging MRI Cortical atrophy in 10-35% Enlargement of the lateral or third ventricle in 10- 50% Findings may correlate with the presence of negative symptoms PET Decreased frontal and pariental lobe metabolism Abnormal laterality Increased temporolimbic metabolism

15. Neuropsychology I. A neuropsychological evaluation is recommended for any case in which brain- based impairment in cognitive function or behavior is suspected. Typical referrals are made to diagnose or rule out the following conditions, and to describe their impact on a person's cognitive functioning:  Traumatic brain injury; Strokes; Developmental learning disabilities; Attention deficit disorders; Psychiatric or neuropsychiatric disorders; Seizure disorders; Medical illness or treatments; Effects of toxic chemicals or chronic substance abuse; Dementing conditions (e.g., Alzheimer's Disease)

16. Neuropsychology II. A neuropsychological evaluation is particularly useful for tracking progress in rehabilitation after brain injury or other neurological disease. Neuropsychological evaluation can assist greatly in planning educational and vocational programs. It can also be invaluable for disability determination or for forensic (legal) purposes.

17. What is a Neuropsychological Evaluation? A neuropsychological evaluation is a comprehensive assessment of cognitive and behavioral functions using a set of standardized tests and procedures. Various mental functions are systematically tested, including, but not limited to:  Intelligence; Problem solving and conceptualization; Planning and organization; Attention, memory, and learning; Language; Academic skills; Perceptual and motor abilities; Emotions, behavior, and personality

18. Course Prodromal symptoms Anxiety, depression, suspicious May be present for months before the onset of schizophrenia Acute stage Is generally in the late teens and early 20s Precipitating events, such as emotional trauma, drugs, separations, may trigger schizophrenia in predisposed persons

19. Course Course of schizophrenia is deteriorating over time with acute exacerbations superimposed on a chronic picture Vulnerability to stress is lifelong Postpsychotic depressive episodes may occur in the residual phase Over the course, the more florid positive psychotic symptoms tend to diminish in intensity, while the more residual negative symptoms may actually increase

20. Prognosis The rule of thirds Approximately one third of patients lead somewhat normal lives One third continue to experince significant symptoms but can function within society The remaining one third are markedly impaired and require frequent hospitalizations Approximately 10% of this final third of patients require long-term hospitalization

21. Treatment Antipsychotic drugs are available to control acute psychosis, but unfortunately many of the older agents are associated with a high rate of undesirable side effects However, this is being improved by the newer antipsychotic drugs Effective treatment of schizophrenia extends well beyond drug therapy and includes psychotherapy and support from family and friends Up to 20% of people who experience a psychotic episode may not experience any further episodes and will not require lifelong treatment.

22. Treatment People with schizophrenia have an excess of the neurotransmitters like dopamine and serotonin The conventional, first-generation antipsychotics are dopamine antagonists The newer, atypical, second-generation antipsychotics are dopamine and serotonin antagonists. The first-generation antipsychotics are associated with a high risk of side effects, which can be inconvenient, disabling and dangerous and occur in 40-50% of those treated. Second-generation antipsychotics are generally more widely prescribed to treat schizophrenia, as they cause fewer side effects.

23. Treatment Schizophrenia can be characterised by three phases of treatment: Acute Stabilisation Maintenance

24. Acute treatment The acute phase of treatment is from the start of the psychotic episode until remission or significant improvement of the psychotic symptoms This usually takes 4 to 6 weeks During this short period, people with schizophrenia are often admitted to psychiatric hospitals or enrolled in a day care hospital programme, and are treated with the optimal dose of antipsychotic medication and may be sedated initially.

25. Stabilisation This phase lasts from 6 weeks to 6 months after the onset of an acute episode and during this time, acute psychotic symptoms decrease in severity The affected individual is discharged from hospital and antipsychotic medication is stabilised at a dose where the side effects are minimised while preventing recurrence of the psychotic symptoms Psychotherapy should be started at this phase.

26. Maintenance After 6 months of antipsychotic treatment symptoms should be relatively stable and the psychiatrist should begin to reduce the dose of antipsychotic medication to a level that still prevents the reoccurrence of a psychotic episode Continued support is needed during this time and psychoeducation and compliance- improving measures are very important.

27. How long should treatment continue? minimum of 1 to 2 years maintenance treatment is recommended for people who have experienced one psychotic episode People who have experienced multiple psychotic episodes should receive treatment for up to 5 years to prevent further episodes People with a history of suicidal or dangerously aggressive behaviour should be treated for longer than 5 years. In severe cases, people should receive life- long treatment.

28. Psychosocial treatments Psychosocial treatments are vital forms of therapy and should be implemented alongside medication. Psychosocial treatments include: Psychotherapy - individual and group therapies that focus on practical life problems associated with schizophrenia, eg life skills training. Family interventions - programmes that educate families about schizophrenia, provide support and crisis intervention and offer training in communication.

29. Psychosocial treatments Psychosocial rehabilitation and skills development - training that teaches people verbal and nonverbal interpersonal skills, such as listening and conversation skills and medication management, to allow them to live successfully in the community. Coping and self-monitoring - training to enable people to manage distressing symptoms and the effects of their illness. Vocational rehabilitation - training on employment, self-esteem and personal purpose in life to teach people with schizophrenia the values of employment.

30. Prevention Schizophrenia cannot be prevented However, there are measures that can be taken to prevent schizophrenic relapses Although antipsychotic medications can provide effective relief from the symptoms of schizophrenia, at least 50% of people with schizophrenia will suffer one or more relapses within one year.

31. Prevention One of the major reasons that people relapse is because they stop taking their medication This may be because they experience inconvenient and distressing side effects, or because they do not fully understand the importance of their treatment People with schizophrenia, and their families, should be given extensive and well-prepared information to enable them to fully understand the nature of the symptoms of schizophrenia, the course of the disease and the importance of taking their medication