SCHIZOPHRENIA class Final RK and Bobby.pptx

Class notes on Schizophrenia. Reference from Kaplan and Shaddocks.

1. SCHIZOPHRENIA Ronit Kumar - 20210615 Bobby Trevor

2. Table Of Contents Definition History Epidemiology Etiology Pathophysiology

3. Definition Schizophrenia is a chronic and severe mental health disorder that affects how a person thinks, feels, and behaves Schizophrenia is a disabling psychiatric condition impacting around 1% of people worldwide

4. Definition Schizophrenia is characterized by positive psychotic symptoms, negative symptoms and cognitive impairments affecting executive function, memory, and mental processing speed. Positive symptoms Negative symptoms Cognitive symptoms Hallucinations Delusions Disorganized thinking Disorganized speech Disorganized or catatonic behaviour Movement disorders   Flat affect; Reduced emotional expression Avolition: Lack of motivation or initiative Anhedonia: Reduced ability to experience pleasure Asociality: Social withdrawal Alogia: Reduced speaking Poor executive functioning (difficulty understanding information and using it to make decisions) Trouble focusing or paying attention Problems with working (difficulty using information immediately after learning it) Difficulties with memory, learning and understanding

5. History

6. Epidemiology

7. Epidemiology Worldwide lifetime prevalence of schizophrenia is about 0.7-1 % This means about 1 person out of 100 will develop schizophrenia during life time 1-year incidence rate: 15-50 per 100 000. Lifetime risk: 1%. Age of onset: between 15 years and 55 years. Male to female ratio: 1:1. Women tend to have a later age of onset. Symptoms in men tend to be more severe.

8. Epidemiology

9. Etiology

10. Etiology – Genetic Factors Family studies: 10% chance of developing schizophrenia if a first-degree relative has it 50% chance of developing schizophrenia if both parents have it Twin studies: 10% chance in dizygotic twins, 45-50% chance in monozygotic twins; Adoption studies: 10% chance of developing schizophrenia if a biological parent has it; Cannabis use may increase the risk of schizophrenia in people who are homozygous for Val/Val alleles in COMT genotypes. Patients born from fathers older than the age of 60 are vulnerable to developing the disorder. This suggests the likelihood of spermatogenesis in older men to be subjected to greater epigenetic damage than in younger men

11. Etiology – Biochemical Factors Dopamine hypothesis : this states that schizophrenia is the result of dopaminergic hyperactivity in the mesolimbic- mesocortical pathway; evidence in support of the dopamine hypothesis: antipsychotics are dopamine D2 receptor antagonists and cause a reduction in the positive symptoms of schizophrenia, drugs that increase cerebral dopamine levels (e.g. amphetamines and cocaine) can cause psychosis; Serotonin : excess serotonin has been linked to schizophrenia; evidence in support of serotonin’s involvement in schizophrenia: clozapine (a serotonin antagonist) is very effective in treatment resistant schizophrenia and has an affinity for 5HT2 and 5HT3 receptors while binding only weakly to D2 receptors, drugs that increase cerebral serotonin levels such as LSD (lysergic acid diethylamide) can induce psychotic symptoms.

12. Etiology – Biochemical Factors

13. Dopaminergic Neural Pathways Dopamine Hypothesis for symptoms and side effects The pathophysiology of schizophrenia remains indirect and undetermined, but theories such as the dopamine hypothesis helps to explains the possible reason for signs and symptoms of schizophrenia Dopamine hypothesis states that schizophrenia is result of dopaminergic hyperactivity in the mesolimbic- mesocortical pathway

14. The Tuberoinfundibular Pathway It plays a crucial role in regulating the secretion of prolactin hormone from anterior pituitary gland. Dopamine released from neurons in the pathway inhibits prolactin secretion Reduced dopamine activity in the tuberoinfundibular pathway leads to hyperprolactinemia. Tuberoinfundibular pathway is associated with the hyperprolactinemia observed with D2 receptor blocker use.

15. The Nigrostriatal Pathway Reduction of dopamine activity in nigrostriatal pathway by antipsychotic drugs such as D2 receptor antagonism, leads to EPS. EPS  tardive dyskinesia, parkinsonism symptoms, akathisia and dystonia.

16. Neuroanatomical abnormalities Neurodevelopmental Theory Infections Environment lateral and third ventricular enlargement, atrophy of prefrontal cortex and temporal lobe, smaller thalamus, enlarged caudate nucleus, reduction in overall brain volume. The total number of neurons, oligodendrocytes and astrocytes us reduced by 30-45% Increasing evidence that suggests schizophrenia is a neurodevelopmental disorder Abnormal neuronal migration during the second trimester of fetal development. classical schizophrenia symptoms emerge in adolescence and these include abnormal eye (saccadic) tracking movements, neuropsychological deficits, soft neurological signs [e.g. clumsiness & incoordination] and abnormal behaviors; Evidence of slow virus etiology includes neuropathological changes consistent with past infections: gliosis, glial scarring and antiviral antibodies in the serum and CSF of schizophrenia patients Epidemiological data shows a high incidence of schizophrenia after prenatal exposure to influenza during several epidemics Environmental factors also pose risk to development of schizophrenia and these include Adverse obstetric complications such as birth complications or Trauma after delivery Prenatal exposure to viral infections nutritional deficiencies Cannabis smoking during adolescence Any other factors that negatively affect healthy developmental Other Etiological Factors

17. Schizophrenia Clinical Features

18. Clinical features Three main key issues when discussing clinical features. No clinical sign or symptom is pathognomonic for schizophrenia as some symptoms can be seen in other psychiatric and neurological disorders , MSE alone cannot be used to diagnose the patient , but thorough history taking is the key to a accurate diagnosis. Secondly the patient’s symptoms change with time ,so significant symptoms may come and go during the course of schizophrenia. Thirdly , it is important to take into account the patients educational level , intellectual ability ,cultural and subcultural membership ,as impaired ability to understand abstract concepts may reflect either the patient’s education or his or her intelligence .

19. Clinical Features The symptoms of schizophrenia can usually be considered as falling into 6 main symptoms Positive Negative Disorganized domains Cognitive Depressive Anxiety

20. Clinical Features Mental Status Examination Appearances of a schizophrenia patient ranges from screaming ,dishevelled and agitated person to someone that is obsessively groomed ,completely silent and immobile person. Can be violent or agitated ,in contrast patients may display catatonic stupor where it can be more evident in characteristics as waxy flexibility , social withdrawal and egocentricity ,can be immobile and speechless on the chair and response with short answers and move only when directed to move , other obvious behaviour may include odd clumsiness and stiffness in the body movements. All this signs now seen as possibly indicating a disease process in the Basal ganglia

21. Symptoms of Schizophrenia Positive - are symptoms that are added abnormal behaviours or changes to the firstly normal behaviours that the patient normally have before onset. Delusions Persecutory, Referential, Grandiose, Erotomaniac, Nihilistic and somatic Hallucinations- Auditory , visual and olfactory Bizarre behaviour Positive formal disorder Inappropriate affect

22. Cont’l Negative– absence of typical physical , emotional and psychological behaviours that the patient should normally have. Restricted affect Passive social withdrawal Apathy Avolition Alogia Anhedonia Asociality Primary – Part of disease process Secondary - Depression, Positive symptoms and Antipsychotics

23. Disorganization Disorganised actions Formal though disorder Inappropriate affect Cognitive - Executive functioning Verbal fluency Motor speed Working memory

24. Cognitive – Orientation Cognitive impairment Judgement and Insight Reliability Executive functioning Verbal fluency Motor speed Working memory Depressive - Major depression Demoralization

25. Cont’l Anxiety Panic Generalized anxiety Social anxiety Obsessive compulsive Somatic Comorbidity Neurological findings- localizing and non-localizing neurological signs have been reported to be more common in patients with schizophrenia than in other psychiatric patient . Non-localizing neurological signs- dysdiachokinesia , astereognosis , primitive reflexes and diminished dexterity Eye Examination – In addition to the disorder of smooth ocular pursuit , patients with schizophrenia have an elevated blinked which is believed to reflect hyper-dopaminergic activity Speech

26. Clinical Features Other Comorbidity Obesity – patients with schizophrenia appears to be obese, higher BMI than age and gender-matched cohorts in the general population ,largely due anti-psychotic medications as well as poor nutritional balance and decreased motor activity. Diabetes Mellitus – schizophrenia is associated with an increased risk of type 2 diabetes mellitus ,there is evidence that some antipsychotic medications cause diabetes through a direct mechanisms. Cardiovascular disease – many antipsychotic medications have direct effects on cardiac electrophysiology HIV – Patients have risk of infection that is 2 times than the general population such association is due to increased risk behaviours, such as unprotected sex , multiple partners and increased drug use. Chronic obstructive pulmonary Disease- increased rate compared to the general population , smoking is an obvious contributor to this problem and may be the only cause.

27. Diagnosis So for the diagnostic criteria, atleast two or more present during a 1-month period for a diagnosis to be made. 1. Delusions 2. Hallucinations 3. Disorganised speech 4. grossly disorganised or catatonic behaviour 5. Negative symptoms B. Level of function in one or more major areas are below level achieved prior to the onset these areas can include work, interpersonal relations or self-care. C. Persistent continuous signs of disturbance for atleast 6 months ,these 6months must include 1month of symptoms criterion A (active-phase symptoms) D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out E. Disturbance is not attributed to the physiological effects of substance or another medical condition. F. If there is a history of autism spectrum disorder or a communication disorder 0f childhood onset , the diagnosis of schizophrenia is made only if prominent delusions or hallucinations in addition to the other required symptoms of schizophrenia .

28. Diagnosis Specifiers – only to be used after 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria First episode ,currently in partial remission- first manifestation of the disorder and if they are in contradiction to the diagnostic course criteria, an acute episode is a time period in which the symptom criteria are fulfilled. First episode ,currently in full remission – full remission is a period after a previous during which no disorder-specific symptoms are present. Multiple episodes , currently in acute episode – Multiple episodes may be determined after a minimum of two episodes . Multiple episodes , currently in partial remission Multiple episodes , currently in full remission

29. Diagnosis Continuous – symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course , with sub-threshold symptom period being very brief relative to the overall course. Specify if with catatonia Specify current severity - rated by a qualitative assessment of the primary symptoms of psychosis which includes delusions ,hallucinations ,disorganized speech , abnormal psychomotor behaviour and negative symptoms .

30. Diagnosis Diagnostic features – ranges from cognitive , behavioural and emotional dysfunctions , should be noted that no single symptom is pathognomonic. Criteria A symptoms must be present for a significant portion of time during a 1-month period or longer. Criteria A1 – Hallucinations Criteria A2 – disorganized speech Criteria A3 – Grossly disorganised or catatonic behaviour. Criteria A4 – Negative symptoms Criteria B- involves impairment in one or more major areas of functioning Criteria C – some signs of the disturbance must persist for a continuous period of at least 6 months ,can be described as prodromal symptoms.