SYMPTOMS OF SCHIZOPHRENIA

Diagnosis of schizophrenia comes after the symptoms have lasted for six months. There is a marked deterioration from the person’s previous level of functioning at work, in social relations and in self-care.  The symptoms cannot be explained by physical illness, prescription medications, street drugs or brain injury.  There must be a gross distortion of reality (psychosis) and the disturbance must affect more than one of the following processes: thought, perception, emotion, communication or psychomotor behavior.

Note the five symptom criteria on page 357: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior and negative symptoms.

Delusions:  false and bizarre beliefs that resist all attempts to correct by evidence; the most striking symptoms of schizophrenia.  Delusions in schizophrenia are most often incongruent with the presented emotional responses of the person.  Most common types of delusions:

·        Delusions of prosecution

·        Somatic delusions

·        Bizarre delusions

·        Delusions of control

·        Delusions of reference

·        Delusions of grandiosity

Can you provide examples of each of the above?

Hallucinations:  perceptual signs of psychosis involving false sensory perceptions without external stimuli that would provoke such perceptions.  Most common: auditory hallucinations.  May also be visual, tactile, olfactory; PET scans note that actual visual or auditory cortex activity accompanies hallucinations.

Disorganized speech:  There are terms used to describe the disorganized speech of people with schizophrenia.

·        derailment (shifting from one topic to another without connection);

·        tangential responses that bear no relationship to the question asked;

·        incoherence (making no sense to the listener);

·        loose association refers to more subtle irregularities in a patient’s statement;

·        clang association refers to the lists of rhyming words the patient may inject into a sentence;

·        neologisms are words that are created that may have a private meaning to the patient.  Impoverished speech suggests that there is little meaningful content in the speech of the individual.

Disorganized/Catatonic Behavior:  behaviors range from bizarre silliness and hyperarousal to extreme irritability and agitation: laughing, pacing, wringing hands in distress, wearing inappropriate clothing, poor hygiene; catatonic behavior is the most bizarre: the appearance of being frozen in place, rigid body posture, waxy flexibility, non-communicative; catatonia has diminished with more effective medications.

Negative Symptoms: reduction in normal behaviors; usually appear before the positive symptoms noted above. These symptoms include

·        blunted or flattened affect (emotion)

·        alogia (decrease in speech production)

·        avolition (loss of energy, interest, will)

·        anosognosia (unawareness of symptoms)

Five Subtypes of Schizophrenia: paranoid, disorganized, catatonic, undifferentiated and residual

Paranoid Schizophrenia:  longest-standing of the types: delusions of persecution and grandeur, and hallucinations present, in often remarkably systematized and complex.  May include delusional jealousy; seldom are these people disorganized in their behavior, incoherent or loose in speech, nor do they display blunted or inappropriate affect.

Disorganized Schizophrenia:  silliness and incoherence; inappropriate affect; bizarre and often scary behaviors; somatic delusions are more often present, rather than complex delusions or hallucinations; poor hygiene and grooming.

Catatonic Schizophrenia:  excited motor behavior or catatonic state, or an alternation between the two states; onset is sudden and the person is hard to control, very agitated and may be dangerous to self or others; difficult to settle down without strong sedative medication.  In a catatonic state, the person is often hallucinating and may explain that lack of movement will save them from some impending danger.  In a catatonic state the patient will often resist all instructions or attempts to be moved; negativism defines the category.

Undifferentiated Schizophrenia:  a diagnosis given when the patient doesn’t meet the criteria for the three above, but still shows psychotic symptoms and poor interpersonal adjustment

Residual Schizophrenia:  no delusions or hallucinations, incoherence or disorganized behaviors.  Minor symptoms: social isolation, withdrawal, impairment in role functioning, peculiar behaviors, impairment in personal hygiene and grooming, blunt affect, odd thinking, apathy, and unusual perceptual experiences; these behaviors may appear after an active episode and will decrease as time passes. 

Other subtypes:  acute schizophrenia is characterized by quick onset of symptoms and usually a specific precipitating crisis; good premorbid condition; and chronic schizophrenia involved a gradual and prolonged period of decline, and no specific stressor is identified.  In chronic schizophrenia, social withdrawal, poor school adjustment and interpersonal problems are noted in childhood history; therefore, poor premorbid condition.

Type I schizophrenia:  predominance of positive symptoms; more responsive to medication because it comes from a disturbance of brain chemistry (dopamine transmission); more often associated with acute schizophrenia

Type II schizophrenia:  predominance of negative symptoms; associated with chronic schizophrenia and poorer long-term prognosis; related to structural changes in the brain and intellectual impairment

CHILDHOOD ONSET SCHIZOPHRENIA (COS)

General Characteristics:   Incidence of childhood schizophrenia is less than 1/10,000 births

1.       Slight male predominance

2.       Less educated and professionally successful families

3.       Patients have low-average to average range of intelligence

4.       Patterns of behavior before a formal diagnosis:  attention/conduct problems, earlier patterns of inhibition, withdrawal and sensitivity

5.       Disease is rarely observed before age 5

6.       80% of children have auditory hallucinations; 50% have delusional beliefs

7.       Can be observed with additional conditions such as:  conduct disorder, learning disabilities, mental retardation, and autism

8.       Poor prognosis if onset before age 10 with above personality difficulties

The behavior of children and adolescents with schizophrenia may differ from that of adults with this illness. Child and adolescent psychiatrists look for several of the following early warning signs in youngsters with schizophrenia:

• seeing things and hearing voices which are not real (hallucinations),
• odd and eccentric behavior, and/or speech,
• unusual or bizarre thoughts and ideas,
• confusing television and dreams from reality,
• confused thinking,
• extreme moodiness,
• ideas that people are "out to get them," or talking about them,
• behaving like a younger child,
• severe anxiety and fearfulness,
• confusing television and dreams with reality,
• difficulty relating to peers, and keeping friends.
• withdrawn and increased isolation,
• decline in personal hygiene

Since 1990 there has been an ongoing study of childhood onset schizophrenia (COS) of 49 patients at the National Institute of Mental Health (NIMH) which most of the following findings are based on.

-          55% had language abnormalities

-          57% had motor abnormalities

-          55% had social abnormalities

-          63.3% either failed a grade or required placement in special education

-          overall poor neuropsychological functioning in attention, working memory and executive function (i.e. making and carrying out appropriate decisions on a day to day basis)

-          findings were more striking than those in adult patients which indicates a more severe early disruption of brain development in COS – also indicates greater familial vulnerability (possibly a greater likihood of a genetic component to the disease)

Family Characteristics:

-          high rate of spectrum personality disorders (schizoaffective, schizotypal, paranoid) 45% had at least one relative with a disorder

-          increased schizophrenia in relatives (1.8%) vs. control group (0.5%)

-          77.3% of patients with family members with spectrum disorders had prediagnosis language abnormalities which was more striking than adult patients

Obstetric/Environmental Characteristics:

-          NIMH study doesn’t show an increase in obstetrical complications in COS vs. adults patients (though there have been studies that have found a link between obstetrical complications and schizophrenia in general)

-          No association of socioeconomic status, psychological trauma with an earlier age of onset

-          Study at UCLA of Finnish patients showed an increase in early onset schizophrenia with perinatal hypoxia (each event increased the risk 2 fold)

-          No correlation has been shown b/w onset of puberty and onset of psychosis

Treatment of Schizophrenia

Early treatments for schizophrenia that were proven ineffective: insulin coma therapy, prefrontal lobotomy and ECT

Presently, the medications for the disorder are more effective and have fewer side effects and the therapy or rehabilitation programs are more structured and target more specific impairments.  Patients do not self-refer, but are often sent to treatment by families, or occasionally by court order.

DRUG TREATMENT:  Introduction to antipsychotic drugs in the early 50s has had a tremendous influence in the lives of those with schizophrenia.  Inpatient care has diminished dramatically, and the focus presently is on community-based programs, like Dove Point, Go-Getters and Lower Shore Sheltered Workshop in our own community.

Thorazine, Stelazine, Mellaril, Prolixin( called Phenothiazines) and Haldol were among the earliest antipsychotic drugs (received at D-2 receptors), and they both worked to relieve the positive symptoms of schizophrenia—hallucinations, delusions, disorganized speech and behaviors—but did not affect the negative symptoms—alogia, anhedonia, avolition; negative side effects of these drugs (extrapyramidal effects) made them unpleasant and unpopular: dry mouth, drowsiness, visual disturbances, weight gain, drooling, sexual dysfunction, depression, menstrual problems in women and constipation and depression are the less serious side effects; the most serious are the Parkinson-like effects: stiffness of muscles, stiffness in moving, reduced flexibility of facial muscles, tremors and spasms of limbs and akathesia (an itchiness and restlessness that keeps people pacing).  The most serious side effect: tardive dyskinesia: a movement disorder consisting of sucking, lip-smacking, tongue movements and cheek puffing.  TD affects about 20% of patients using these drugs more than a year; it is seldom reversible, even if the medication is terminated. Lowering the dosage to “maintenance dose” alleviates some of these side effects.

The new, “atypical”, antipsychotics (received at D-1 and D-4 receptors): Clozaril, Risperdal, Zyprexa, Zeldox, Seroquel: fewer side effects (but still dizziness, nausea, sedation, seizures, hypersalivation, weight gain and tachycardia) and affecting both positive and negative symptoms of the disorder. The differences in effect are related to the chemical reactions of the drugs in the brain.  The atypical antipsychotics block fewer dopamine receptors and also block as many or more serotonin receptors.  A side effect noted is agranulocytosis, a precipitous drop in white blood cells.  These medications are very expensive.

Potential for relapse after an initial episode of schizophrenia is related to the following variables:  environmental stress, poor premorbid functioning, being male, and adherence to medication regimen (if drugs are discontinued 75% of people will relapse with one year, compared to 33% of those who continue with their medication).

Revolving Door Phenomenon:  hospitalization is increasing after a period of radical decline in the 50s.  This increase is evidence that drugs do not cure schizophrenia and that community-based programs are often inadequate to meet the needs of this population.  Other factors include unemployment and lack of social skills and noncompliance with taking medication.

Psychological Treatment:  Review the history of institutional case with discussions of state mental institutions, milieu therapy and behavioral therapy (the token economy).  The current goal is adaptive functioning for the individual, and the means to that end seem to focus on cognitive skill building (attention, abstraction, concept formation, memory, reasoning skills) and social skill building (role-playing of social interactions, social problem-solving).  Family therapy educates family members about the disorder and how best to interact with the patient, to increase tolerance, to recognize and manage warning signs that an episode is imminent.  Stress management and conflict-resolution skills are also taught to both the patient and the family members.  An example of the objectives for teaching basic conversational skills might include:

  learning effective verbal and nonverbal listening techniques

  learning where to meet people and how to determine whether another is willing to engage in conversation

  learning how to sustain conversations

  learning how to end conversations gracefully

  integrating all skill areas into natural and spontaneous conversations

Community-based Programs:  an ideal program for people with schizophrenia includes careful monitoring of medication regimens and cognitive and social skill-building within the framework of a community.  In a residential community, a group home that provides effective treatment and opportunities to work productively in a sheltered work environment, seems to increase the independent living and normalizing activities of the person with schizophrenia.  An effective program would include:

  helping members gain material resources for food, shelter, clothing, medical care

  helping them gain coping skills to meet the demands of community life, such as using public transportation, preparing simple meals, budgeting money, running a household

  motivating them to persevere and remain involved in life even when their lives become stressful

  lessening their dependence on family members

  educating family members and community members about the kind of support they need

  discouraging inappropriate behaviors and encouraging healthy behaviors

These community-based programs have proven to be very effective in reducing rehospitalization and increasing employment, decreasing emotional distress and psychotic symptoms, and increasing overall quality of life for these people.  Despite such success, there are only about 800 such programs now operating (often underfunded and understaffed), about one-third of the number needed.