11 schizophrenia.ppt

Teaching and Research office of Psychiatry,
West China medical school S.U.
What is it?
n Schizophrenia is a chronic, severe, and What is it?
n Research is gradually leading to new and safer medications and unraveling the complex causes of the disease General Considerations
n Eugen Bleuler: a more appropriate name than dementia praecox( autism, ambivalence, flat affect, and disturbance of volition ) n Kurt Schneider: first-rank symptoms (e.g., thought diffusion, thought insertion, voices arguing and commenting) Criteria:
n The Diagnostic and Statistical Manual of Mental Disorder, 4th edition (DSM-IV)
n International Classification of Diseases (ICD)
Criteria of Mental Disease, the third version
DSM-IV Diagnostic Criteria
A. Characteristic symptoms:
(3) disorganized speech (e.g., frequent derailment (4) Grossly disorganized or catatonic behavior (5) Negative symptoms, i.e., affective flattening, B. Social/occupational dysfunction:
DSM-IV Diagnostic Criteria
C. Duration: Continuous signs of the disturbance
persist for at least 6months.This 6 month period must include at least 1month 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. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in CriterionA present in an attenuated form ( eg , odd beliefs, unusual perceptual experience) DSM-IV Diagnostic Criteria
D. Schizoaffective and mood disorder
Schizoaffective disorder and mood disorder
with psychotic features have been ruled out
because either (1) no major depressive,
manic, or mixed episodes have occurred
concurrently with the active-phase symptoms,
or (2)if mood episode have occurred during
active-phase symptom, their total duration
has been brief relative to the duration of the
active and residual periods.
DSM-IV Diagnostic Criteria
E. Substance/general medical condition exclusion: The
disturbance is not due to the direct physiological effect of a substance (e.g., a drug of abuse, a medication)or a general medical condition.
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) The three core syndromes
n Positive symptoms: delusions,
hallucinations, and formal thought disorder. n Disorganization: incoherence, loose
associations, inappropriate affect, and poverty of thought content. n Negative symptoms: affective flattening,
loss of spontaneity, lack of initiative or willed action, anergia, and anhedonia.
Subtype in Schizophrenia
n Paranoid schizophrenia: prominent persecutor
n Undifferentiated schizophrenia:delusions and
hallucinations are prominent, and are accompanied by incoherence disorganized behavior.
n Disorganized schizophrenia: absence of
systematized delusions and the presence of Subtype in Schizophrenia
n Residual schizophrenia: in which positive
symptoms are minimal and negative symptoms n Catatonic schizophrenia: motor disturbance in
the dominant feature, consisting of either agitated hyperactivity or decrease in gross motor activity with Major Etiologic Theories
n Dopamine hypothesis
n Serotonin hypothesis
n Glutamate hypothesis
n Neurodevelopmental hypothesis
Major Etiologic Theories
n Dopamine hypothesis
n The excess activity of DA in some brain area: eg, limbic, nucleus accumbens, striaterminalis, lateral septum and olfactory tubercle n Antipsychotics decreased DA activity by Major Etiologic Theories
n Serotonin hypothesis
n There are at least 15 types of 5-HT receptors; most of these relevant to schizophrenia are the 5-HT1, 5-HT1D, 5-HT2, 5-HT3, 5-HT6, and 5-HT7 receptors. n Schizophrenia was that it was due to an excess of n The potency of some agents as hallucinogens is highly correlated with their 5- HT2A-receptor antagonist affinity.
n Newer antipsychotic drugs are potent antagonists of Major Etiologic Theories
n Glutamate hypothesis
n Decreased levels of glutamate in the CSF of patients n Some antagonists of NMDA receptors can produce a range of positive and negative symptoms and cognitive dysfunction in normal control subjects and in schizophrenic patients.
n Neuroleptics can block some of the clinical effects of PCP(a noncompetitive antagonists of NMDA receptors ).
Major Etiologic Theories
n Neurodevelopmental hypothesis
Obstetric and perinatal complications.
Structural abnormalities based on in vivo brain imaging.
Adverse environmental events in uterus.
Developmental neurologic and biopsychosocial Epidemiology
n Schizophrenia affects 1% of the adult population.
The incidence is comparable in all societies.
n Lower income:
n Gender: slightly more common in males than in
n Age at onset:
n The mean age for female patients is 25 years with a n For male patients, the mean age is 20 years with a Genetics
n Complex mode of inheritance n Inheritance: 60-80%n Candidate gene:DR,5-HTR,NGF,NT-3n Linkage study: chromosome6, 11, 22,1 Clinic Findings
n Obtain as much information as possible: n medical and psychiatric history, mental status examination, family and social history, other pertinent information from n Progressive behavioral disturbances in n social withdrawal and academic and personal problems Clinic Findings
n Personality changes, withdrawal, decreased academic performance, less interest, obsessive- compulsive, ritualistic behavior, poor hygiene, moodiness, flat affect, magical thinking, Clinic Findings
n Thoughts loosen, delusion, hallucination, n Behavior: stereotyped behavior, repeat various functions n Echopraxia: They may imitate others’ movements.
n Catatonic stupor: remain motionless for a long time n Waxy flexibility or catalepsy: and maintain their limbs or trunks in unusual positions for various lengths of time Clinic Findings
n It is based on diffuse rather than localized brain disease.
n It is independent of three core syndromes.
n Small percentage of patient reach to severe level. Treatment
n Pharmacological Treatments:
n Electroconvulsive (ECT) Treatment
n Psychosocial Treatment:
n Pharmacologic Treatments:
n Initiation of treatment
n Rapidly dosage raising induce side effects n Typical antipsychotic drugs
n Atypical antipsychotics
Commonly used antipsychotic drugs
Approximate Oral
Class and Drug Name
Dose Equivalents
Range (mg}
Conventional Drugs
Haloperidol decanoate
25-100 every,1-4
Loxapine succinate
Pimozide (Orap)
Molindone hydrochloride
Atypical Drugs
n Pharmacological Treatments:
n Electroconvulsive (ECT) Treatment
maintenance treatment, which is difficult to provide on an outpatient. A short course of Treatment
n Psychosocial Treatment:
Besides the treatment of antipsychotic drugs, Psychosocial treatment is also important, especially for the patients in convalescence.
Prognosis & Course of Illness
occupational record, family history of mental illness, length of course, clinic symptoms, treatment n Relapse rate more than 50% if no any therapy n Relapse reduce to 10% with both continuing antipsychotic drugs and psycho-social rehabilitation. Summary:

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