Schizophrenia

Schizophrenia

TOM SIEGFRIED
A BEAUTIFUL MATH

• JOHN NASH,
• GAME THEORY,
• AND THE
• MODERN QUEST
• FOR A CODE
• OF NATURE

Diagnostic Criteria

• Two or more of the following present for a significant portion of the time during a 1 month period:
  • Delusions
  • Hallucinations (See link on website for examples)
  • Disorganized speech
  • Grossly disorganized or catatonic behavior
  • Negative symptoms (affect flattening, alogia, avolition, apathy)

Denotes positive symptoms.

• Only one criterion needed if delusions are bizarre or hallucinations consist of a voice keeping a running commentary or two voices talking to each other.
• Must cause significant social/occupational dysfunction.
• Continuous signs of disturbance for 6 months.
• < 6 months = Schizophreniform.

Schizophrenia Subtypes

• Paranoid: Preoccupation with one or more delusions or frequent auditory hallucinations.
• Disorganized: Disorganized speech, behavior, and flat or inappropriate affect are all present.
• Catatonic: Motoric immobility or excessive activity, extreme negativism, peculiar movements, echolalia, or echopraxia.

Epidemiology

• It affects 1-2% of the population.
• Onset symptoms in males peak 17-27 years.
• Onset symptoms in females: 17-37 years.
• Only 10% new cases have onset after 45 years.
• Presence of proband with schizophrenia significantly increases the prevalence of schizoid and schizotypal personality disorders, schizoaffective disorder, and delusional disorder.

Etiology

• Studies of monozygotic twins suggest approximately 50% schizophrenia risk genetic as there is 40-50% concordance.
• Estimated: the other 50% due to as of yet unidentified environmental factors including in utero exposure.

Pathophysiology

• Possibly due to aberrant neuro-developmental processes such as increase in normal age-associated pruning frontoparietal synapses that occur in adolescence and young adulthood.
• Excessive activity in mesocortical and mesolimbic dopamine pathways.

Schizophrenia and Addiction

• 47 percent have met criteria for some form of drug/ETOH abuse/addiction.
• The odds of having an alcohol or drug use disorder are 4.6 times greater for people with schizophrenia than the odds are for the rest of the population: the odds for alcohol use disorders are over three times higher, and the odds for other drug use disorders are six times higher.

Regier et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990 Nov 21;264(19):2511-8.

Schizophrenia Illness Course

• Negative symptoms thought to be more debilitating in regards to social and occupational impairment.

• >90% of patients do not return to pre-illness level of social and vocational functioning.

• 10% die by suicide.

• Generally marked by chronic course with superimposed episodes of symptom exacerbation.

• 1/3 have severe symptoms & social/vocational impairment and repeated hospitalizations.

• 1/3 have moderate symptoms & social/vocational impairment and occasional hospitalizations.

• 1/3 have no further hospitalizations but typically have residual symptoms, chronic interpersonal difficulties, and most cannot maintain employment.

Treatment

• Positive symptoms respond better than negative. Antipsychotics are the mainstay of treatment.
• Atypical antipsychotics: Used first to reduce risk of Tardive Dyskinesia (TD) but can have weight gain, metabolic syndrome including elevated lipids and type 2 diabetes.
• Risk of TD approximately 3-5% per year for typical antipsychotics. Highest in older women with affective disorders.
• Risk of dystonic reaction highest in young males.