1. Historical figures Emil Kraepelin –Separated schizophrenia (which he called dementia praecox) from bipolar disorder (which he called manic- depressive psychosis) largely on the basis of the clinical course of the syndromes. Eugen Bleuler –Coined the term schizophrenia, meaning splitting (or more accurately, fracturing) of the mind. Note this is NOT intended to imply “split personalities”. –He also is associated with the “four A’s” of schizophrenia: autism, affect, association, ambivalence. Sanders A. Don't confuse schizophrenia with multiple personality. Tex Med. 1993 Mar;89(3):8. PMID: 8451749

2. Diagnosis of Schizophrenia - I A.Characteristic symptoms: > 2 of 5 of the following symptoms: (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 bizarre delusions or running commentary voices or voices conversing with each other. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). American Psychiatric Press; 1994 ISBN: 0890420629

3. Diagnosis of Schizophrenia - II B.Social/occupational dysfunction. C.Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. D.Schizoaffective and Mood Disorder exclusion. E.Substance / general medical condition exclusion. F.Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated). American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). American Psychiatric Press; 1994 ISBN: 0890420629

4. Subtypes DSM-IV Subtypes - hierarchy in the order of consideration –Catatonic Catatonic behavior dominates Less common nowadays Medical supportive care, benzodiazepines may help, consider ECT –Disorganized (previously called hebephrenic) Disorganized speech, behavior, and affect (flat or inappropriate) –Paranoid Delusions and/or auditory hallucinations Not limited to persecutory themes Tends to have a later onset and better course –Undifferentiated - not above, but Criterion A still met –Residual - Criterion A not currently met American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). American Psychiatric Press; 1994 ISBN: 0890420629

5. Epidemiology - I Lifetime prevalence ~1%; male = female Seen in all cultures at similar frequency (refutes "myth" concept), though a few geographical pockets of higher prevalence exist Onset usually late adolescence to young adulthood, earlier in males than females Increased chance of being born in the winter or early spring Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309

6. Epidemiology - II Increased mortality rate from accidents and natural causes: –life span is shortened by about a decade –some under-diagnosis of medical illness is present ~10-15% suicide; ~50% attempt; prominent risks: –early in illness and young age –high premorbid function –depression –the latter two often contributing to demoralization Illness seems concentrated in urban settings, i.e., it is somewhat correlated with population density in larger cities. Illness seems concentrated in lower socioeconomic classes. –downward drift vs. social causation Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309

7. Epidemiology - III Increased use vs. abuse vs. dependence: –~75% nicotine; ~40% alcohol; ~20% marijuana; ~10% cocaine –Substance use comorbidity worsens prognosis. ~1/3 or more of homeless population Disabling (over 50% unemployed) High number years of productive life lost 2.5% of all health care expenditures 50% of all inpatient psychiatry beds 30% of all hospitalizations $50 billion annual cost to US (direct + indirect) Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309 Kandel ER, Schwartz JH, Jessell TM (eds). Principles of Neural Science. McGraw-Hill Professional Publishing. 2000, ISBN: 0838577016.

8. Clinical course Prodrome Acute index episode (~first hospitalization) Relapsing, remitting course Positive and negative symptoms Social and family effects Violence

9. Prodrome Generally, there are some prodromal signs & symptoms prior to the first acute episode These most commonly appear as attenuated “Criterion A” symptoms of schizophrenia They can also be thought of as the symptoms of Cluster A (“odd & eccentric”) Personality Disorders, e.g., Paranoid, Schizoid, and/or Schizotypal Personality Disorders Schizoid Personality Disorder fits well with attenuated forms of “negative symptoms” Schizotypal Personality Disorder fits well with attenuated forms of “positive symptoms” American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). American Psychiatric Press; 1994 ISBN: 0890420629

10. Acute index episode Often, but not always, preceded by months to years of prodromal symptoms Usually no “stressor” is identifiable Patient develops Criterion A symptoms, i.e, an acute psychosis This usually leads to behavior seen as serious enough by family or other social supports to initiate some sort of medical contact Often some form of impetus (other than the patient) is needed, up to the point of legal coercion, e.g., involuntary hospitalization Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309

11. Course Classically, course consists of exacerbations and remissions, though often not to “baseline” premorbid level of functioning Illness progression often plateaus at about 5 years after initial diagnosis Antipsychotic medications improve acute and long-term outcome About 1/4 have a good outcome, 1/4 continue to have moderate symptoms, and 1/2 remain significantly impaired with current treatment Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309

12. Positive and negative symptoms “Positive symptoms” of schizophrenia mean something is present which should not be there: –Delusions; hallucinations; disorganized speech; grossly disorganized or catatonic behavior –Some investigators put the latter two groups into a third category: disorganized “Negative symptoms” of schizophrenia mean something is missing which should be there: –Affective flattening, alogia, avolition Positive symptoms tend to decrease in severity with time, while negative symptoms tend to increase in severity over the years American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). American Psychiatric Press; 1994 ISBN: 0890420629 Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309

13. Social and family effects Better prognosis for patient: –Married –Good social support system –Good premorbid social and other functioning –Low levels of “expressed emotion” (hostile, critical, intrusive over-involvement) Previous discredited and harmful psychoanalytic hypotheses blamed the family, especially mothers, for causing the illness. Education is sometimes still needed to help correct this misconception. Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309

14. Treatment Psychopharmacologic –Classical (= typical = conventional) antipsychotics –“Atypical” antipsychotics –Other agents Psychosocial –Supportive therapy –Social skills training –Case management –Working with families Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309

15. Classical (typical) antipsychotics - I Synonyms for antipsychotics are neuroleptics or major tranquilizers Henri Laborit, an anesthesiologist, discovered that chlorpromazine had a marked calming effect Their introduction in the 1950’s was a major revolution in psychiatry Classical antipsychotics are dopamine receptor antagonists They are most effective for positive symptoms Depot (long acting) forms are available Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309 Kandel ER, Schwartz JH, Jessell TM (eds). Principles of Neural Science. McGraw-Hill Professional Publishing. 2000, ISBN: 0838577016.

16. Classical (typical) antipsychotics - II They are divided into a high potency and a low potency group. Potency refers to the amount (mg) of drug to give the antipsychotic effect. Examples of high potency antipsychotics include haloperidol (Haldol) and of low potency antipsychotics include chlorpromazine (Thorazine). The high potency group is worse with extrapyramidal symptom (EPS) side effects, and the low potency group is worse with most of the other side effects (anticholinergic, sedation, orthostatic hypotension). A minimum therapeutic trial is 4-6 weeks of adequate dose. Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309

17. “Atypical” antipsychotics “Atypical” antipsychotics are serotonin-dopamine receptor antagonists They are as effective for positive symptoms and more effective for negative symptoms Clozapine is notable in particular: –It is effective in treatment refractory cases –It is worse for most non-EPS side effects –It has a ~1-2% risk of inducing agranulocytosis The others (e.g., risperidone) generally produce fewer side effects than classical antipsychotics Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309

18. Psychosocial Supportive therapy –This is well supported as an adjunct to medication. (Insight- oriented approaches are contraindicated.) Social skills training –This especially focuses on amelioration of negative symptoms by means of cognitive-behavioral methods. Case management –This greatly aids in coordination of care and optimization of treatment compliance. Working with families –Besides education, the primary goal is to reduce high levels of expressed emotion to improve illness course. –The National Alliance for Mental Illness (NAMI) is a key support and advocacy group. Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry, 8 th Edition. Lippincott, Williams & Wilkins. 1998, ISBN: 0683303309