Schizophrenia

What is Schizophrenia• Schizophrenia is a chronic and disabling brain

disorder that has been recognized throughout recorded history.

• Symptoms usually emerge for men in late teens to early 20’s. In females mid 20’s to early 30’s.

• Many people with this disorder have difficulty holding a job or caring for themselves. This creates a great burden for their families and for society.

• Those with the disorder may hear voices that others don’t hear. They may believe that others are reading their minds, controlling their thoughts, or plotting to harm them.

• They may not make sense when they talk or they may seem perfectly fine until they start talking about what they are really thinking.

What are the symptoms?

• The symptoms of schizophrenia fall into three broad categories.

• Positive Symptoms are unusual thoughts or perceptions, including hallucinations, delusions, thought disorder and disorder of movement. Auditory hallucinations are the most common.

• Negative Symptoms refers to reductions in normal emotional and behavioral states such as:

• Flat affect with immobile facial expression, monotonous voice.

• Lack of pleasure in everyday life.• Diminished ability to initiate and sustain planned

activity.• Speaking infrequently even when forced to interact• People with the disorder often neglect basic hygiene

and need help with ADL.

• Cognitive Symptoms are subtle and often detected only when neuropsychological test are performed.

• Poor executive functioning. (the ability to absorb and interpret information and make decisions based on that information).

• Inability to sustain attention.• Problems with working memory (the ability to keep

recently learned information in mind and use it right away).

Etiology of Schizophrenia

• The etiology and pathogenesis of schizophrenia is not known

• It is accepted, that schizophrenia is „the group of schizophrenias“ which origin is multifactorial:– internal factors – genetic, inborn, biochemical– external factors – trauma, infection of CNS, stress

Causes

• The disorder is believed to result from a combination of environmental and genetic factors.

• It is well known that the disease runs in families, and is seen in 10% of people with a first degree relative.

• Identical twins have 40 to 60% chance of developing the disorder.

Causes

• Although there is a genetic risk for schizophrenia, it is not likely that genes alone are sufficient to cause the disorder.

• Interactions between genes and the environment are thought to be necessary for the disorder to develop.

• Many risk factors have been identified such as exposure to viruses or malnutrition in the womb, problems during birth, and psychosocial factors such as stressful environmental conditions.

Brain Function

• Scientist feel it is likely that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate plays a role in schizophrenia.

• Neurotransmitters allow the brain cells to communicate with one another.

The Criteria of DiagnosisFor the diagnosis of schizophrenia is necessary • presence of one very clear symptom - from point a) to d)• or the presence of the symptoms from at least two groups - from point e) to

h)for one month or more:

a) the hearing of own thoughts, the feelings of thought withdrawal, thought insertion, or thought broadcasting

b) the delusions of control, outside manipulation and influence, or the feelings of passivity, which are connected with the movements of the body or extremities, specific thoughts, acting or feelings, delusional perception

c) hallucinated voices, which are commenting permanently the behavior of the patient or they talk about him between themselves, or the other types of hallucinatory voices, coming from different parts of body

d) permanent delusions of different kind, which are inappropriate and unacceptable in given culture

The Criteria of Diagnosise) the lasting hallucination of every formf) blocks or intrusion of thoughts into the flow of thinking and resulting

incoherence and irrelevance of speach, or neologismsg) catatonic behaviorh) „the negative symptoms”, for instance the expressed apathy, poor speech,

blunting and inappropriatness of emotional reactionsi) expressed and conspicuous qualitative changes in patient’s behavior, the

loss of interests, hobbies, aimlesness, inactivity, the loss of relations to others and social withdrawal

• Diagnosis of acute schizophorm disorder (F23.2) – if the conditions for diagnosis of schizophrenia are fulfilled, but lasting less than one month

• Diagnosis of schizoaffective disorder (F25) - if the schizophrenic and affective symptoms are developing together at the same time

Genetics of Schizophrenia

• Many psychiatric disorders are multifactorial (caused by the interaction of external and genetic factors) and from the genetic point of view very often polygenically determined.

• Relative risk for schizophrenia is around:– 1% for normal population– 5.6% for parents– 10.1% for siblings– 12.8% for children

Antipsychotics

• In the 1990’s, new drugs, called atypical antipychotics, were developed.

• These medications appear to be equally effective for helping reduce the positive symptoms like hallucinations and delusions - but may be better than the older medications at relieving the negative symptoms of the illness, such as withdrawal, thinking problems, and lack of energy.

Antipsychotics

• The atypical antipsychotics include aripiprazole (Abilify), risperidone (Risperdal), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon).

• Current treatment guidelines recommend using one of the atypical antipsychotics other than clozapine as a first line treatment option for newly diagnosed patients.

Suicide in Schizophrenia

• People with schizophrenia attempt suicide much more often than people in the general population. About 10% (especially young adult males) succeed. It is hard to predict which patients with the disorder are prone to suicide. Listen when they talk about harming themselves.

Monitoring

• On monthly visits monitor for things such as over eating, weight gain, polyuria (increase urination), polydipsia (increased thirst).

• When each of you see your clients, if they have recently been put on an antipsychotic, discuss the above symptoms with them.

• Have them notify the practitioner if they are having problems with any of these symptoms.

Treatment of Schizophrenia• The acute psychotic schizophrenic patients will respond usually

to antipsychotic medication.• According to current consensus we use in the first line therapy

the newer atypical antipsychotics, because their use is not complicated by appearance of extrapyramidal side-effects, or these are much lower than with classical antipsychotics.

conventional antipsychotics(classical neuroleptics)

chlorpromazine, chlorprotixene, clopenthixole, levopromazine, periciazine, thioridazine

droperidole, flupentixol, fluphenazine, fluspirilene, haloperidol, melperone, oxyprothepine, penfluridol, perphenazine, pimozide, prochlorperazine, trifluoperazine

atypical antipsychotics

amisulpiride, clozapine, olanzapine, quetiapine, risperidone, sertindole, sulpiride

Summary

• Relapses occur most often when people with schizophrenia stop taking their antipsychotic medication.

• They may feel better, or their side effects or so bad they stop the medication.

• At times they don’t feel taking their medication regularly is important.

• It is our responsibility to education our patient to be compliant and monitor them to keep them healthy.

References

• Department of Psychiatry, 1st Faculty of Medicine, Charles University, Prague, Head: Prof. MUDr. Jiří Raboch, DrSc.

• Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In: Schizophrenia, Hirsch S.R. and Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995