Schizophrenia Lecture Notes PDF

Schizophrenia Dr. Asmaa Elrakaybi gu.edu.eg  Hollywood’s John Nash John Forbes Nash was an American mathematician who made fundamental contributions...

Schizophrenia Dr. Asmaa Elrakaybi gu.edu.eg  Hollywood’s John Nash John Forbes Nash was an American mathematician who made fundamental contributions to game theory, differential geometry, and the study of partial differential equations In 1994, he received the Nobel Memorial Prize in Economic Sciences In 1959, Nash began showing clear signs of mental illness, and spent several years at psychiatric hospitals being treated for paranoid schizophrenia  Split Mind Describe the fragmented thinking of people with the disorder (NOT split personality). ❑ Schizophrenia is a devastating, chronically debilitating disorder. ❑ Schizophrenia is one of the most leading cause of disability among adults ❑ Schizophrenia most commonly has its onset in late adolescence or early adulthood (from 15 to 40) and rarely occurs before adolescence or after the age of 40 years. Epidemiology and etiology: ❑ Prevalence is equal in men and women, but symptoms appear earlier in men with first hospitalization typically occurring at 15 to 24 years compared to 25 to 34 years in women. ❑ The etiology remains unknown. Environmental stimuli Genetics ❑ Intrauterine exposure ❑ First-degree relatives to significant stress, of patients with viral or bacterial schizophrenia carry infections a 10% risk of ❑ Immune/ developing the autoimmune disorder. disorders Pathophysiology: Dopamine hypothesis ❑ Psychosis is caused by excessive dopamine in the brain ❑ Chlorpromazine, the first antipsychotic medication, was a postsynaptic dopamine antagonist. ❑ Drugs that cause an increase in dopamine (eg, cocaine and amphetamines) worsen or cause psychotic symptoms, Pathophysiology: Dysregulation hypothesis ❑ Data reveal a more complicated picture with both hyperdopaminergic and hypodopaminergic brain regions in schizophrenia. ❑ The positive symptoms are possibly more closely associated with DA-receptor hyperactivity in the mesolimbic pathway, whereas negative symptoms and cognitive impairment are most closely related to DA-receptor hypofunction in the mesocortical pathway. Pathophysiology: Other neurotransmitters ❑ Malfunctioning N-methyl-d-aspartate (NMDA) receptors, impacts dopaminergic activity in the mesolimbic and mesocortical pathways. ❑ NMDA antagonists such as phencyclidine and ketamine can elicit state resembling schizophrenia, including positive and negative symptoms and cognitive impairments. Pathophysiology: Other neurotransmitters ❑ There is speculation regarding a role for serotonin receptor antagonism in antipsychotic efficacy because many second-generation antipsychotics (SGAs) are active at serotonin receptors. ❑ Serotonin receptor binding may be important to drug action, possibly by modulating dopamine activity in mesocortical pathways.  Clinical presentation Presence of Absence of abnormal normally behaviors Negative expected (something Positive symptoms behavior symptoms that should (absence not be of there something that should be Cognitive present ) impairment Clinical presentation Positive symptoms Psychotic symptoms Hallucinations (distortions or exaggeration of perception) ✓ Most frequently auditory, can also be visual, olfactory, gustatory, and tactile. ✓ Voices may be threatening or commanding (eg, commanding the person to perform a particular action). Clinical presentation Positive symptoms Psychotic symptoms Delusions (fixed false beliefs) Ideas of influence ✓ Beliefs despite ✓ (beliefs that one’s invalidating evidence actions are ✓ May be bizarre in controlled by nature external ✓ Often paranoid in influences). nature which may cause suspiciousness Clinical presentation Positive symptoms Psychotic symptoms Delusions ✓ Delusions of reference: thinking that random events convey a special meaning to you. ✓ Religious delusions: you are Jesus, God, a prophet. ✓ Grandiosity: the belief that you have an important mission, special purpose, or have an unrecognized genius ✓ Paranoid delusions: an exaggerated sense of self-importance, intense feeling that people are talking about you, looking at you. ✓ Delusion of Persecution (part of paranoid delusions): belief that one is being targeted or harmed by others (very common) ✓ Thought broadcasting: thinking that others are capable of hearing one’s private thoughts. ✓ Thought insertion: thoughts are being placed into one’s mind by an outsider. Clinical presentation Positive symptoms Psychotic symptoms Thought disorder (illogical thought and speech) ✓ Loosening of associations: the person going from one topic to another as though the topics were connected. ✓ Tangentiality ✓ Word salad: random words or phrases linked together ✓ Disorders of the stream or speed of thoughts, such as "pressure of thought," involve rapid and continuous thinking with an inability to focus on one idea for long. The speech associated with this condition is referred to as "pressured speech." Clinical presentation Negative symptoms: ✓ Lack of social drive (avolition): No motivation for anything even eat or sleep…. catatonic like ✓ Apathy: no emotional response to any thing ✓ Anhedonia: Inability to experience pleasure or interest in activities that one used to enjoy ✓ Asociality: Patient does not want to interact and may be withdrawn Clinical presentation Cognitive impairment ✓ Impaired attention ✓ Impaired processing speed ✓ Impaired verbal, visual memory, and working memory (does not learn from mistakes) ✓ Impaired problem solving and executive functioning ✓ Decreased IQ, Clinical presentation Others ✓ People with schizophrenia may appear uncooperative, suspicious, hostile, anxious, or aggressive. ✓ Mood changes: it can be normal or depressed or euphoric. ✓ Psychotic and depressive symptoms may lead to poor hygiene and impaired self-care. ✓ Bizarre behaviour ✓ Sleep and appetite are often disturbed, ✓ Comorbid medical disorders, such as obesity, type 2 diabetes and chronic obstructive pulmonary disease, are prevalent in people with schizophrenia because of sedentary lifestyles, poor dietary habits ✓ Cigarette smoking. ✓ Approximately 50% use illicit drugs (cannabis, and cocaine) and alcohol.  Course and prognosis ❑ Most patients fluctuate between acute episodes and remission. ❑ Complete remissions without symptoms are uncommon. ❑ Periods between episodes may include some residual symptoms. ❑ The onset of symptoms in most cases is insidious, usually preceded by a prodromal phase Prodromal Acute Stabilization Stable Phase Phase Phase phase  Course and prognosis Prodrome: (non-psychotic) ❑ Characterized by the gradual development of symptoms that may go unnoticed until a major symptom occurs. ❑ Social withdrawal, loss of interest, dysphoria ❑ Deterioration in hygiene and grooming ❑ Unusual behavior Acute phase (Active phase) ❑ This is the full-blown episode of psychotic behavior. ❑ Patients suffer from hallucinations and delusions and might have disordered thinking.  Course and prognosis Stabilization phase ❑ The acute symptoms begin to decrease ❑ This phase may last for several months. Stable phase ❑ During this phase, symptoms have markedly declined and may not be present. ❑ Non-psychotic symptoms such as anxiety and depression may be present (Residual symptoms). ❑ Life expectancy is shortened primarily because of suicide, cardiovascular disease, accidents, and compromised self-care. ❑ Lifetime risk of suicide for people with schizophrenia is 5% to 10%.  Diagnosis ❑ A diagnosis of schizophrenia is made clinically because there are An initial psychotic work up no psychological assessments, includes a thorough neurologic, brain imaging, or laboratory medical and laboratory examinations that confirm the evaluation to rule out other diagnosis. causes ❑ The diagnosis is made by ruling out ✓ Electrolytes other causes of psychosis and ✓ Blood urea nitrogen ✓ Serum creatinine meeting specified diagnostic ✓ Urinalysis criteria “Diagnostic and Statistical ✓ Liver and thyroid function Manual of Mental Disorders, 5th profile edition(DSM-5)”. ✓ Syphilis serology ✓ Urine toxicology phase symptoms Diagnosis Symptom Monitoring ❑ Many assessments are available to objectively rate positive and negative symptoms, level of function, and life satisfaction. The most commonly used scales include: ✓Positive and Negative Symptom Scale (PANSS) ✓Brief Psychiatric Rating Scale (BPRS) ✓Clinical Global Impression (CGI) Scale ❑ Using these scales on a regular basis, particularly when switching medications or changing doses, is a more reliable means of monitoring symptoms. ❑ Symptom assessments cannot capture the full range of possible improvements, but they can be useful in deciding whether a medication is having substantial benefit. 30 items included in the PANSS: A Positive Scale of 7 items A Negative Scale of 7 items A General Psychopathology Scale of 16 items Filled by the physician while interviewing with the patient 31 32 33 34 35 36 37 38 Case 1: A 23-year-old man presents with a history of hearing voices for the past six months. He believes these voices belong to people who are trying to control his thoughts and monitor his every move. He also reports isolating himself from friends and family, feeling emotionally flat, and struggling to focus on daily tasks. He denies any history of substance use. Question: Which of the following symptoms is considered a negative symptom in this case? A) Hearing voices B) Emotional flatness C) Belief of thought control D) Inability to focus Case 2: A 27-year-old woman has been experiencing significant difficulty in concentrating on her studies over the last few months. She reports that she often feels disconnected from her surroundings and that her thoughts are “all over the place.” She expresses unusual ideas, including a belief that she is being monitored by the government because of her unique ability to send thoughts to others. She has also stopped interacting with her friends and seems indifferent about her personal hygiene. Question: Which of the following is a cognitive symptom in this case? A) Belief of being monitored by the government B) Disconnection from surroundings C) Difficulty concentrating D) Lack of interaction with friends Case 3: A 29-year-old man presents with a history of being withdrawn, lacking motivation, and displaying a noticeable decline in his ability to perform daily activities. He has also developed an unusual belief that he is being followed by secret agents who want to steal his ideas. Despite reassurance, he remains suspicious and increasingly isolated. Question: Which type of delusion is this patient experiencing? A) Grandiose delusion B) Persecutory delusion C) Somatic delusion D) Referential delusion Thank You gu.edu.eg