Schizophrenia

Description:

·         Chronic debilitating psychotic disorder with residual symptoms and deepening destruction of the original personality

·         Start in young adulthood

·         Rapid deterioration in mental functions & behavior

·         Gross impairment of reality testing (psychosis)

·         Alterations in sensory perceptions (hallucinations mainly verbal)

·         Abnormalities in thought process (delusions)

·         Ambivalence, ambitendency

·         Emotional decoloration

·         autism

Definitions:

            Delusion:

1.      Unshakeable false idea

2.      Not explained by cultural tradition or background

3.      Presence of psychosis should be established

(Explanation: everyone has false ideas from time to time, but we are able to correct our incorrect ideas and we have the appropriate insight to do so. Delusions main attribute that they are absolutely unshakeable and incorrigible. To consider the cultural or traditional background is important, because for example the idea of so many goddesses is normal for a Hindu person, but a Muslim person considers it an unshakeable false idea. However, in the Indian Hindu culture it is the norm. It is also important to always trying to find presence of other symptoms of psychosis.)

Hallucination: Perception with all distinctive characteristic of reality, without any external or internal stimulus. Hallucinations may arise from all our sensory organs: acoustic, visual, tactile, gustatory, olfactory, somatic, vestibular. Combinations of those listed are called complex hallucinations. Rare form is the extracampine hallucination: for example someone sees someone behind his head. ‘As if’ hallucinations are frequent in normal persons. Illusions are falsifications of normal sensory stimuli, are also present in normal persons. Synaesthesia when for example smelling something elicits another sensory organ sensation, for example taste.

The Bleulerian 4 ‘A’

·         Autism

·         Ambivalence

·         Associations (loosening of associations)

·         Affects (blunt of affects or incongruous affects)

What are the Positive & Negative symptoms?

Positive symptoms are for e.g. delusions, hallucination and any other symptom, which are normally not present, therefore we can describe as if something (pathological) added

Negative symptoms are losses of the original personality, as to distract something which is normally present. The resulting symptoms are for example decoloration of personality, autism etc

Course of schizophrenia

·         Prodromal symptoms (the world changed, going to end etc). It is a very particular experience, also called ‘Wahn’

·         reaction

·         Episode,

·         Phase,

·         Process,

·         Residual symptoms

Subtypes

1.      undifferentiated (Simplex)

2.      disorganized (Hebephren)

3.      Catatonic

4.      Paranoid

5.      Residual

Symptoms

Perception:

lIllusion

lHallucination (Auditory in schizophrenia)

Thought process:

lLoss of ego boundaries

lImpaired abstraction

lMagical thinking

lEcholalia

lLoose associations

lNeologisms

lPerseverations

lVerbigerations

lTangentiality

lThought blocking

lThought insertions

lPrimary incoherentia

lWord salad

lSide chain association

Thought content:

lIdeas of reference

lIdeas of persecution

lDelusions

Emotional:

lAmbivalentia

lAmbitendencia

lAnxiety

lPathologic antipathy and sympathy feelings

lDecoloration

lFlattened affects

lImpending end of the world

Behavior

lMannerism

lBizarreness

lAutism

lRestlessness

lKatatonia

nStupor

nAgitation

lWaxy flexibility

Pathology: supporting evidences of organic origin

·         Frontal lobe

·         Decreased glucose utilization in prefrontal lobe

·         Lateral and III ventricle enlargement

·         Asymmetry

·         Decreased volume of hippocampus, amygdala, parahyppocampal gyrus

·         Poor smooth and visual pursuit

Neurotransmitter abnormalities

Increased dopeminergic, serotoninergic, noradrenergic activity, abnormal GLU transmission

Neurotransmitter abnormalities

lThe Dopamine hypothesis = excessive DA activity

lAmphetamine, cocaine cause psychotic symptom

lElevated HVA (DA metabolite)

lRole of 5-HT

lHallucinogens which increase 5-HT availability (LSD) cause psychosis similar to schizophrenia

lAtypical antipsychotics have anti-5-HT2 activity and they are very effective

lNE:

l Proposed in paranoid type

lGLU

lAntagonists of NMDA receptors (phencyclidine) increase symptoms

lAgonists of NMDA receptors (glycine, D-serine, cycloserine) decrease symptoms

Differential diagnosis

1.      Psychosis caused by medical condition (delirium)

lHallucinations are visual and changing fast

lAcute confusional state

lAcute medical illness is present (pneumonia, fever, malaria, erysipelas,)

lOr: drug withdrawal

2.      Brief psychotic disorder

lPsychotic symptoms last less than 1 month

lPrecipitating factors are present

3.      Schizophreniform disorder

lPsychotic with residual symptoms last only for 1-6 month

4.      Schizoaffective disorder

lCriteria for mood disorder and sch are present simultaneously

5.      Delusional disorder (paranoia)

lFixed, structured bizarre delusional system

lNo thought disorder otherwise

lNormal social and occupational functioning

6.      Shared delusional disorder (folie a deux)

7.      Manic phase of bipolar disorder

lElated mood, rapid onset, hyperactivity, rapid speech

lDelusions of grandeur or mood congruent delusions

lLittle or no impairment between episodes

8.      Schizoid personality disorder

lVoluntary social withdrawal

lNo thought disorder

9.      Schizotypal personality disorder

lNegative symptoms only

lBizarre behavior

lOdd thought patterns

lNo frank psychosis

10.  Borderline personality disorder

lExtreme mood swings

lUncontrollable anger

lEpisodic suic. Ideation

lShort lasting mini’ psychotic episodes

11.  Substance induced psychosis

Prognosis is unfavorable

Repeated episodes

Lifelong impairment

Chronic, downhill course

Stabilizes in midlife (burns out)

50% attempt suicide

10% dies in suicide

Post psychotic depression

Imperative hallucination (commanding hallucination)

Better prognosis:

Older age at onset

Married

Female

Persisting social interactions

Employed

Mood symptoms present

Positive symptoms present/Negative symptoms absent

Relatively few episodes

Therapy

Traditional antipsychotics: D2 receptor antagonists

Haloperidol

Chlorpromazine

Atypical agents

Less neurological adverse effect (e.g. parkinsonism; tardive dyskinesia)

Clozapine

Risperidone

Olanzapine

Ziprasidone

Quietapine

Aripriprazole

ECT

‘Depot’ treatment

Haloperidol decaonate

Fluphenazine decaonate

70% of patients on pharmacotherapy significantly improve

Other psychotic disorders

1.      Brief psychotic disorder (symptoms present for less than 1 month)

2.      Schizophreniform disorder (sometimes reaction following severe life event!) (symptoms present for 1-6 month)

3.      Schizoaffective disorder

4.      Delusional (psychotic) disorder

5.      Shared psychotic disorder (folie a deux)

Schizoaffective disorder

a.       Significant mood symptoms are present along with schizophreniform symptoms

b.      Better premorbid functioning

c.       Better prognosis

Delusional disorder (Paranoia)

Highly systematized delusion system

Non-bizarre but very organized in content

Delusions present at least for 1 month

No other symptoms of schizophrenia

Start at middle age

Occupationally and socially remains functional

Subtypes

Erotomanic type

Jealous type

Persecutory type

Shared delusional disorder (folie a deux)

Case Studies

v  A 27-year-old man complains that he has felt “down in the dumps” for months and is feeling guilty because he has been having an extramarital affair. In recent weeks, he has started to believe that his wife is poisoning his food and the rest of his family is involved in an elaborate plot to drive him from the house.

1.      Assuming his thinking is delusional, how would his delusions be best characterized?

(A) Ego-syntonic

(B) Bizarre

(C) Somatic

(D) Mood congruent

(E) Mood incongruent

2. What diagnosis would these delusions most likely accompany?

(A) Schizophrenia

(B) mania

(C) MDD

(D) Dysthymia

(E) Adjustment disorder

1. (D) Mood-congruent delusions are compatible and consistent with the state of mind of the patient. In this case, the patient feels guilty and presumably believes he deserves punishment.

His delusions express these thoughts. If he described delusions of grandiosity, that would be an example of a mood-incongruent delusion. Bizarre delusions describe a circumstance that is virtually impossible to be true, for example, a schizophrenic patient believing a computer chip is implanted in his brain. The delusions in this question, however unlikely, are in some sense conceivable. Somatic delusions focus on bodily functions and integrity. Ego-syntonic delusions are experienced by the sufferer as acceptable; for example, the manic patient believing he is the greatest actor in the world. This patient’s delusions are ego-dystonic, that is, experienced as unacceptable and unpleasant. Often, the nature of the delusion and its relation to mood state provide clues to a diagnosis. Delusions arising out of a severe depression, as in this case, are frequently mood congruent.

2. (C) The delusions of schizophrenic patients can be bizarre and are often unrelated to mood state. Mania produces delusions that are grandiose, usually related to a sense of inflated self-esteem. The presence of delusions rules out dysthymia and adjustment disorder because these affective illnesses do not reach an intensity that includes delusional thinking.

v  A19-year-old man is admitted to a psychiatric hospital for the first time and discharged with a diagnosis of schizophrenia. When he returns to the hospital a month later for follow-up, the patient’s speech is logical and he is able to sit and talk with the interviewer becoming relatively engaged in the examination. He says that he has been hearing voices since his discharge and he believes his every word is being recorded by a tape recorder inside his mouth. What is the most likely type of schizophrenia in this patient?

(A) paranoid

(B) disorganized

(C) catatonic

(D) undifferentiated

(E) residual

(A) Schizophrenia is commonly classified according to types, which try to capture descriptively the symptoms that predominate the clinical picture. In the paranoid type, the patient is preoccupied with delusions, typically persecutory in nature, and often has auditory hallucinations. Speech and behavior appear relatively organized.

The disorganized type is characterized by disorganized speech and behavior as well as flat or inappropriate affect. In catatonic type, motor activity is retarded to the point of immobility, or excessive, yet purposeless and unrelated to external events. A diagnosis of undifferentiated type means that the patient meets criteria for schizophrenia, but does not meet criteria for paranoid, disorganized, or catatonic types. The residual type describes an absence of positive symptoms and a preponderance of negative symptoms.

v  A33-year-old woman with a history of paranoid schizophrenia tells you she has been hearing voices. What is the most important information to obtain regarding her auditory hallucinations?

(A) Whether the voices come from inside or outside her head

(B) How loud the voices are

(C) How long she has been hearing voices

(D) What the voices are saying

(E) Whether she recognizes the voices

(D) The most important aspect of voices heard by a patient with schizophrenia is the nature of what the voices are saying. Command auditory hallucinations telling a patient to harm or kill him or herself or someone else is almost always a psychiatric emergency, and the patient requires hospitalization to be safe or to keep someone else safe. The only possible exception is the case in which an experienced clinician knows the patient well and believes the situation to be safe; even then, hospitalization is probably necessary. All of the other choices in this question speak to important characteristics of auditory hallucinations and should be evaluated but the presence of command auditory hallucinations requires immediate attention.

v  A37-year-old man presents to your office complaining of auditory hallucinations that have worsened over the last several months. He notes that the Devil has been telling him that he is “no good,” and that he will not “amount to anything.” During the last several months, the patient also reports feeling “depressed” and has been sleeping poorly. He has no desire to get out of bed and has lost interest in even watching sports (normally one of his favorite activities). The patient states that even when his mood is improved, he still cannot “get the voices out of my head.” He denies using any drugs or alcohol.

1. Which diagnosis best accounts for this patient’s symptoms?

(A) major depression

(B) schizophrenia

(C) schizoaffective disorder

(D) bipolar II disorder

(E) schizoid personality disorder

2. What medication combination could be used to adequately treat this patient’s symptoms?

(A) mirtazapine (Remeron) and citalopram (Celexa)

(B) fluoxetine (Prozac) and diazepam (Valium)

(C) chlorpromazine (Largactil) and sertraline (Zoloft)

(D) haloperidol (Haldol) and perphenazine (Trilafon)

(E) divalproex sodium and lorazepam (Ativan)

1. (C) The most likely diagnosis in this case is schizoaffective disorder. The patient has prominent psychotic symptoms, including auditory hallucinations and paranoid ideation, but also has concurrent mood symptoms, including depressed mood, decreased sleep, anhedonia, and decreased motivation. Also important, the patient’s hallucinations have occurred in the absence of mood symptoms, and his mood symptoms appear to have been present for a substantial portion of the total duration of his symptoms in the absence of mood symptoms makes major depression unlikely. A diagnosis of schizophrenia alone would not adequately account for this patient’s mood symptoms. Bipolar II disorder is not a valid choice since there is no clear history of a hypomanic episode. Schizoid personality disorder is unlikely because that diagnosis would not account for the patient’s psychotic and mood symptoms.

2. (C) In schizoaffective disorder, it is important to treat both the mood and psychotic symptoms. Because the patient’s symptoms mainly consist of depression and psychosis, a combination of an antipsychotic and antidepressant medication would be a reasonable approach. Mirtazapine, citalopram, fluoxetine, and sertraline are antidepressant medications, while chlorpromazine, ziprasidone, haloperidol, and perphenazine are antipsychotic medications. Lorazepam and diazepam are benzodiazepines. Divalproex sodium is the only mood stabilizer listed.

v  A29-year-old man with a history of chronic paranoid schizophrenia comes to the emergency department with a temperature of 102.9°F, labile blood pressure rising to 210/110 mm Hg, a pulse of 110/min, and a respiratory rate of 22 breaths/min. This patient’s medications include haloperidol, benztropine (Cogentin), and clonazepam (Klonopin). He cannot correctly identify the day, date, or year, and believes himself to be in a city from which he moved 10 years ago. A family member indicates that 3 days ago he was healthy and completely oriented and that he has no significant medical or surgical history.

1. Physical examination reveals that he is in acute distress with hypertonicity. Laboratory examination reveals a creatine phosphokinase (CPK) of 45,000 Iµ/L, a white blood cell count of 14,000/µL and no left shift, a sodium of 145 mEq/L, and a creatinine of 2.5 mg/dL. Lumbar puncture produces clear fluid with   slightly elevated protein count. What is the most likely diagnosis?

(A) anticholinergic syndrome

(B) malignant hyperthermia

(C) central nervous system (CNS) infection

(D) prolonged immobilization

(E) neuroleptic malignant syndrome (NMS)

2. With appropriate treatment, the patient recovers completely and returns home. In a month’s  he is stating that the “voices in the walls” are telling him to kill himself. He has taken no medications since he left the hospital. His vital signs are stable and a medical workup is negative. Initial therapy may include which of the following?

(A) ECT

(B) Haloperidol depot injections

(C) Olanzapine

(D) Safety monitoring only

(E) Physical restraints

1. (E) NMS is characterized by severe (“lead pipe”) rigidity, change in mental status, autonomic instability, elevated CPK, and elevated white blood count; a slight elevation in cerebrospinal fluid protein count is possible. NMS may be induced by any neuroleptic including the newer atypicals. No one symptom is necessary for the diagnosis; instead, a constellation of symptoms and their severity, in a setting of neuroleptic exposure, makes the diagnosis more or less likely.  Anticholinergic syndrome, resulting from overdosing on anticholinergic medications, does not produce rigidity and an elevated CPK.  Malignant hyperthermia, an acute muscular pathologic process, resembles NMS, but follows the administration of inhaled anesthetic agents, as in general surgery.  A diagnosis of CNS infection would be better supported by findings on the lumbar puncture and CT or MRI scan; an elevated CPK would be possible if the CNS infection caused seizures. Prolonged immobilization could result in an elevated CPK, but would not account for the other findings.

2. (C) Command auditory hallucinations are a psychiatric emergency and most clinicians would agree that this patient should be restarted on a neuroleptic. Long acting (i.e., hard to stop), depot injections of a neuroleptic are not a first choice. Because the patient is not violent, physical restraints should be avoided. ECT has some efficacy in treatment-resistant schizophrenia but is not a first-line therapy.

v  A 21-year-old man is brought to the emergency department by police after an episode in which he ransacked the office where he works looking for “evidence.” He started this job 2 months ago after graduating from college. He lives with four roommates and he believes they are jealous of him because of his job and have been poisoning his food. His family reveals that once before when he went away to college he went through a period of “acting crazy” but got better without treatment and has done well since. In the emergency department, he is shouting that he has been up for a week writing a “classic” book about accounting and someone at the office stole it from him. He needs to be physically restrained by emergency department security. Physical examination and complete laboratory workup and toxicology screen prove to be negative.

1. Initial medications should include which of the following?

(A) lithium

(B) a neuroleptic and a benzodiazepine

(C) an SSRI

(D) carbamazepine (Tegretol)

(E) buspirone (BuSpar)

2. Three months later, the patient sees his doctor for follow-up. He is taking lithium and haloperidol. He is doing well, except he complains of muscle stiffness. His lithium level is 0.8 mEq/L. A reasonable intervention is which of the following?

(A) increase the lithium dose

(B) decrease the lithium dose

(C) start baclofen (Lioresal)

(D) decrease the haloperidol dose

(E) increase the haloperidol dose

1. (B) Initial medications in this case are aimed at the target symptoms of agitation, delusional thinking, and disruptive behavior and could reasonably include a neuroleptic and a benzodiazepine. Although he clearly needs a mood stabilizer such as lithium or carbamazepine as well, these are not expected to start showing an effect for at least a week and are not the critical medications to start emergently. SSRIs must be used with extreme caution in bipolar illness because they can incite or exacerbate mania. Buspirone is an anxiolytic used mostly in GAD. It is of extremely limited use in bipolar disorder and does not adequately address the target symptoms seen in this case.

2. (D) When the patient returns for his first follow-up visit, his lithium level is therapeutic at 0.8 mEq/L and is not in need of adjustment. However, his muscle stiffness is a parkinsonian side effect of haloperidol. This is normally treated by lowering the dose of the neuroleptic or with anticholinergic medication not with a muscle relaxant such as baclofen. The patient would have to be followed closely for reemergence of psychotic symptoms.

v  A patient is admitted to a psychiatric hospital. Her medications include an SSRI and a benzodiazepine, which are both discontinued on admission. A neuroleptic and a mood stabilizer are started. Two days after admission, she calls the nursing staff to her bed. She is extremely frightened and complains excitedly that she cannot stop looking up. On examination, her eyes are noted to be deviated upward bilaterally.

This specific reaction is called which of the following?

(A) torticollis

(B) trismus

(C) oculogyric crisis

(D) retrocollis

(E) NMS

(C) Oculogyric crisis is a specific example of an acute dystonic reaction in which there is spasm of the muscles of extraocular motion. Torticollis and retrocollis refer to muscle spasms that cause abnormal positioning of the head. Trismus is a spasm of the jaw muscles. NMS, also a reaction to neuroleptic medications, is characterized by dystonia, autonomic instability, and usually some degree of delirium.

v  A 22-year-old single man is referred to you for a 1-year history of strange behavior characterized by talking to the television, accusing local police of bugging his room, and carrying on conversations with himself. His mother also describes a 3- to 4-year history of progressive withdrawal from social activities. The patient dropped out of college in his final year and since then has been living in his room at home. Attempts to hold a job as a busboy at a local restaurant and as a night janitor have abruptly ended after disputes with the employers.

1. How prevalent is this patient’s illness in the general population?

(A) 0.1%

(B) 0.5%

(C) 1%

(D) 3%

(E) 5%

2. The monozygotic (identical) twin concordance for this patient’s illness is which of the following?

(A) 10%

(B) 25%

(C) 50%

(D) 100%

(E) The same incidence as in the general population

1. (C) The patient’s 3- to 4-year history of bizarre behavior, delusions, and decline in social functioning strongly suggest that his illness is schizophrenia. Its prevalence is 1%

2. (C) In twin studies, schizophrenia’s monozygotic concordance is 50% suggesting that there is a strong genetic component to the illness.

v  A patient reports to you that for the past week or two he has had the belief that his intestines and his heart have been removed. When asked about his lack of getting out in the world, he responds “What world? There is no world!”

1. This aspect of the patient’s illness would best be referred to as which of the following?

(A) schizoaffective disorder

(B) Capgras syndrome

(C) folie à deux

(D) Cotard syndrome

(E) major depression

2. If this patient consistently reported to you the belief that his mother and father have been replaced by “cyborg alien robots” that look identical to his parents, this would be most indicative of which of the following?

(A) Delusional disorder

(B) Capgras syndrome

(C) folie à deux

(D) Cotard syndrome

(E) simple schizophrenia (simple deteriorative disorder)

1. (D) Nihilistic delusion content is classic for Cotard syndrome, a psychotic/delusional theme seen potentially in multiple psychotic illnesses. The belief that people have been replaced by imposters is the hallmark of Capgras syndrome. Folie à deux is a shared delusion aroused in one person by the influence of another. Although nihilism and negativism can be observed in patients with MDD, the predominance of psychosis in this patient makes that diagnosis unlikely. Similarly, this patient does not meet the criteria for delusional disorder, which is characterized by nonbizarre delusions.

2. (B) The belief that people have been replaced by imposters is the hallmark of Capgras syndrome. Simple schizophrenia is a disorder consisting entirely of negative symptoms with no positive symptoms.

v  A 32-year-old woman 6 days postpartum is brought into the emergency room at the encouragement of her husband. She is a poor historian, not believing that anything is wrong. He states that his wife has no past psychiatric history, although she does have an unknown family history of “some sort of mental illness.” He is very worried as over the last several days his wife has not been sleeping even while the newborn is. He has noticed her walking around their apartment in the middle of the night weeping while talking to no one in particular. She has begun ignoring their baby, but he brought her in today because earlier she volunteered that their child “is the Antichrist and must be destroyed.” Which of the following is her most likely diagnosis?

(A) bipolar disorder

(B) delusional disorder

(C) major depressive disorder (MDD) with psychotic features

(D) schizoaffective disorder

(E) schizophrenia

 (A) This case demonstrates an episode of postpartum psychosis characterized by depression, mood lability, delusions, and hallucinations. Although there can be different etiologies, most cases are a result of bipolar disorder. A less frequent underlying etiology is MDD. Primary psychotic illnesses, such as delusional disorder, schizoaffective disorder, and schizophrenia, are rarer.

v  An 18-year-old man, without a history of psychiatric illness is brought to the emergency department after being found on the roof of his dormitory. The police who brought him in report that he appeared to be dancing in a disorganized and agitated fashion, speaking angrily to someone that was not apparent to them, and accused the policemen of being “Satan’s horsemen” and “adulterers from the Court of King Herod.” On psychiatric examination, he reports to you that “Lucifer is telling me I’m an angel of death. He told me to flap my wings and soar to my death.” A careful history is obtained. His roommates report that for the past 5 weeks the patient has been delusional, mostly with persecutory content, and his thoughts seem disorganized. In talking with this patient’s family, you would be most likely to gather a history ofwhich of the following?

(A) Low intelligence

(B) Head trauma

(C) Progressive social withdrawal

(D) A neglectful mother

(E) Physical abuse

 (C) Progressive social withdrawal is commonly seen as part of the prodrome of schizophrenia; at this point the patient’s diagnosis must be schizophreniform disorder because his symptoms have lasted longer than 1 month but less than 6 months. All other choices—low intelligence, head trauma, a neglectful mother, and abuse—have not been proven in any conclusive way to be significantly linked to the disease, although early theories held that a history of one or more was a predisposing factor.