1. SCHIZOPHRENIA

2. History  Emil Kraeplin - dementia precox  Eugen Bleuler - schizophrenia  4A’s : associational disturbances affective disturbances ambivalence autism - Secondary Symptoms: hallucinations & delusions  Emil Kraeplin - dementia precox  Eugen Bleuler - schizophrenia  4A’s : associational disturbances affective disturbances ambivalence autism - Secondary Symptoms: hallucinations & delusions

3.  Other Theorists:  Adolf Meyer - founder of psychobiology; schizophrenic reaction  Harry Stack Sullivan - founder of interpersonal psychoanalytic school; social isolation  Gabriel Langfeldt - 2 groups: with true schizophrenia & schizophreniform psychosis  Kurt Schneider - first rank symptoms  Other Theorists:  Adolf Meyer - founder of psychobiology; schizophrenic reaction  Harry Stack Sullivan - founder of interpersonal psychoanalytic school; social isolation  Gabriel Langfeldt - 2 groups: with true schizophrenia & schizophreniform psychosis  Kurt Schneider - first rank symptoms

4. Epidemiology  Lifetime prevalence (US) = 0.6 - 1.9%  Annual incidence of 0.5 - 5.0 per 10,000 1. Age & Sex: M=F M: early onset (15-25 yrs), > (-) sxs F: peak onset=25-35 yrs, better outcome 90% of cases - between 15-55 years old Onset before 10yrs & after 50 yrs=rare  Lifetime prevalence (US) = 0.6 - 1.9%  Annual incidence of 0.5 - 5.0 per 10,000 1. Age & Sex: M=F M: early onset (15-25 yrs), > (-) sxs F: peak onset=25-35 yrs, better outcome 90% of cases - between 15-55 years old Onset before 10yrs & after 50 yrs=rare

5. 2. Medical Illness Have higher mortality rate from accidents and natural causes 80% - have significant concurrent medical illness 2. Medical Illness Have higher mortality rate from accidents and natural causes 80% - have significant concurrent medical illness

6. 3. Suicide - 50% attempt suicide 50% attempt suicide 10-15% die by suicide M=F, likelihood to commit suicide Major risk factors: (+) depressive sxs, young age, high levels of premorbid functioning 3. Suicide - 50% attempt suicide 50% attempt suicide 10-15% die by suicide M=F, likelihood to commit suicide Major risk factors: (+) depressive sxs, young age, high levels of premorbid functioning

7. 4. Associated Substance Use & Abuse cigarette smoking substance abuse 5. Cultural and Socioeconomic Consideration a. Downward Drift Hypothesis b. Social Causation Hypothesis 4. Associated Substance Use & Abuse cigarette smoking substance abuse 5. Cultural and Socioeconomic Consideration a. Downward Drift Hypothesis b. Social Causation Hypothesis

8. Etiology 1. Stress-Diathesis Model 2. Biological Factors - limbic system, basal ganglia, frontal cortex Dopamine Hypothesis - too much dopaminergic activity Other Neurotransmitters 5HT NE Amino Acids 1. Stress-Diathesis Model 2. Biological Factors - limbic system, basal ganglia, frontal cortex Dopamine Hypothesis - too much dopaminergic activity Other Neurotransmitters 5HT NE Amino Acids

9.  Neuropathology  Limbic system  Basal ganglia  Brain Imaging - CT scan, MRI  EEG  Neuropathology  Limbic system  Basal ganglia  Brain Imaging - CT scan, MRI  EEG

10. 3. Genetics 4. Psychosocial Factors a. Psychoanalytic theories b. Psychodynamic theories c. Expressed emotions (EE) 5. Social Theories 3. Genetics 4. Psychosocial Factors a. Psychoanalytic theories b. Psychodynamic theories c. Expressed emotions (EE) 5. Social Theories

11. Diagnosis  DSM IV SUBTYPES 1. Paranoid type 2. Disorganized/Hebephrenic type 3. Catatonic type 4. Undifferentiated type 5. Residual type  Type I : (+) symptoms, N brain structures on CT scan, good response to tx Type II: (-) symptoms, structural brain abN, poor response to tx  DSM IV SUBTYPES 1. Paranoid type 2. Disorganized/Hebephrenic type 3. Catatonic type 4. Undifferentiated type 5. Residual type  Type I : (+) symptoms, N brain structures on CT scan, good response to tx Type II: (-) symptoms, structural brain abN, poor response to tx

12. Clinical Features  History is important  Symptoms change with time  Premorbid sxs : schizoid or schizotypal personalities  Consider px’s educational level, intellectual ability and cultural background  History is important  Symptoms change with time  Premorbid sxs : schizoid or schizotypal personalities  Consider px’s educational level, intellectual ability and cultural background

13. Mental Status Examination 1. General Description : broad 2. Mood, Feelings, Affect : secondary depression or post-psychotic depression; flat or blunted affect 3. Perceptual disturbances : hallucinations, illusions Mental Status Examination 1. General Description : broad 2. Mood, Feelings, Affect : secondary depression or post-psychotic depression; flat or blunted affect 3. Perceptual disturbances : hallucinations, illusions

14. 4. Thought : content - delusions form of thought thought process 5. Impulsiveness, suicide, homicide 6. Sensorium & Cognition : intact 7. Judgment & Insight ; poor 8. Reliability : poor 4. Thought : content - delusions form of thought thought process 5. Impulsiveness, suicide, homicide 6. Sensorium & Cognition : intact 7. Judgment & Insight ; poor 8. Reliability : poor

15. Differential Diagnosis 1. Secondary & Substance-Induced Pscyhotic Do 2. Malingering & Factitious DO 3. Other Psychotic Dos 4. Mood DO 5. Personality DO 1. Secondary & Substance-Induced Pscyhotic Do 2. Malingering & Factitious DO 3. Other Psychotic Dos 4. Mood DO 5. Personality DO

16. Course and Prognosis  Course : retrospective recognition of symptoms  Each relapse of psychosis is followed by a further deterioration in the px’s baseline functioning  Exacerbations and remissions  (+) symptoms tend to become less severe with time, (-) symptoms may increase in severity  Course : retrospective recognition of symptoms  Each relapse of psychosis is followed by a further deterioration in the px’s baseline functioning  Exacerbations and remissions  (+) symptoms tend to become less severe with time, (-) symptoms may increase in severity

17.  Prognosis :  Study : 10-20% good outcome >50% poor outcome  Literature - range of recovery rate= 10- 60% 20-30% lead normal lives 20-30% moderate sxs 40-60% significantly impaired  Prognosis :  Study : 10-20% good outcome >50% poor outcome  Literature - range of recovery rate= 10- 60% 20-30% lead normal lives 20-30% moderate sxs 40-60% significantly impaired

18. Treatment  CONSIDERATIONS 1. Unique individual, familial, social, psychological profile 2. Environmental and psychological factors 3. Complex disorder  CONSIDERATIONS 1. Unique individual, familial, social, psychological profile 2. Environmental and psychological factors 3. Complex disorder

19.  Hospitalizations  Indications: diagnostic purposes stabilization on medications patient safety grossly disorganized or inappropriate behavior  Hospitalizations  Indications: diagnostic purposes stabilization on medications patient safety grossly disorganized or inappropriate behavior

20.  Somatic Treatment 1. Antipsychotic/Neuroleptics 1. Dopamine-Receptor antagonist 2. Remoxipride 3. Risperidone 4. Clozapine  Somatic Treatment 1. Antipsychotic/Neuroleptics 1. Dopamine-Receptor antagonist 2. Remoxipride 3. Risperidone 4. Clozapine

21.  Therapeutic Principles 1. Define target symptoms to be treated 2. AP that worked in the past should be used for the patient again 3. Minimum length of an AP trial = 4-6 wks 4. Use of monopharmacology 5. Maintain on lowest possible effective dosage  Therapeutic Principles 1. Define target symptoms to be treated 2. AP that worked in the past should be used for the patient again 3. Minimum length of an AP trial = 4-6 wks 4. Use of monopharmacology 5. Maintain on lowest possible effective dosage

22. 2. Psychosocial Treatment  Behavior therapy  Family-oriented therapy  Group therapy  Individual psychotherapy 2. Psychosocial Treatment  Behavior therapy  Family-oriented therapy  Group therapy  Individual psychotherapy