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. Symptom dimensions in schizophrenia
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

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)
Both Sexes
% Total
Male
Female
HIV/AIDS
13.0
12.1
HIV AIDS
13.9
Depressive disorders
8.6
Road traffic accidents
7.7
10.6
4.9
6.7
Tuberculosis
3.2
3.9
Alcohol Use Disorders
5.1
Iron deficiency anemia
3.0
4.5
Schizophrenia
2.8
Self-inflicted Injuries
2.7
Violence
3.7
Obstructed labor
Iron-deficiency anemia
2.6
Bipolar disorder
2.5
Abortion
2.4
Self-inflicted injuries
2.3
2.1
Maternal sepsis
DALY=Sum of years of life lost due to premature mortality and years lost due to disability
WHO. The World Health Report Available at

9. Course of Schizophrenia
Good
Premorbid
Progression
Stable
Relapsing
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):

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