schizophrenia

19.03.2012
 Schizophrenia and schizophrenia-
like disorders
• The most difficult to define and describe;
• Many widely divergent concepts of
schizophrenia;
• Two basics concepts- acute/ chronic
schizophrenia
• Many varieties of clinical picture
encountered in clinical practice
 Schizophrenia and schizophrenia-
like disorders
• Predominant clinical features in acute
schizophrenia are delusions, hallucinations,
interference with thinking
• Often called “positive” symptoms;
• Some recover from the acute illness, whilst
others progress to the chronic syndrome. Main
features: -apathy, lack of drive, slowness, social
withdrawal = “negative” symptoms.
• Once the chronic syndrome is established, few
patients recover completely.
 Schizophrenia and schizophrenia-
like disorders
• Most of the disagreements about the diagnosis
of schizophrenia are concerned with the acute
syndrome.
• The criteria for diagnosis are concerned with
both the pattern of symptoms and the course of
the disorder;
• The disagreements are the range of symptoms
that are required and the length of time these
symptoms should have been present in order to
make the diagnosis.
 Schizophrenia and schizophrenia-
like disorders- epidemiology
• The onset between the ages of 15 and 45.
• Occurs equally in men and women, but the
mean age of onset is about five years
earlier in men( Hafner et al 1989).
• The lifetime risk of developing
scizophrenia is probably between 7,0 and
9,0 per 1000( Jablensky1986).
 Acute syndrome(WHO1973)
• Lack of insight
• Auditory hallucinations
• Ideas of references
• Suspiciousness
• Flatness of affect
• Voices speaking to the patient
• Delusional mood
• Delusions of persecution
• Thought alienation
• Thoughts spoken aloud
 Chronic schizophrenia( CREER
and WING 1975)
• Social withdrawal
• Under-activity
• Lack of conversation
• Few leisure interests
• Slowness
• Over-activity
• Odd ideas
• Depression
 Chronic schizophrenia( CREER
and WING 1975)
• Odd behaviour
• Neglect of appearance
• Odd postures and movements
• Threats or violence
• Poor mealtime behaviour
• Socially embarrassing behaviour
• Sexually unusual behaviour
• Suicidal attempts
• incontinence
 Subtypes DSM-IV TR
• Paranoid
• Catatonic
• Dezorganized=hebephrenic
• Undifferentiated
• rezidual
 CROW
• TYPE I- POSITIVE – good prognosis
• TYPE II- NEGATIVE- bad
• TYPE III- MIXT- bad

• N.
 catatonia
• DSM-IV recognizes catatonia as a subtype
of schizophrenia
• Characterized by at least 2 of the folowing:
• 1. motor immobility/ excessive motor
activity not influenced by external stimuli
• 2. peculiarities of voluntary movement
 catatonia
• May also occur secondary to mania,
depression, general medical condition
such encephalitis,focal neurological
lesions,metabolic disturbances and drug
intoxications and withdrawals.
 catatonia
• First described in 1874 by Kahlbaum as
being a cyclic disease mixing motor
features and mood variations.
• Kraepelin recognized catatonia as a form
of dementia praecox because most cases
ended in dementia.
• Bleuler included it within his wide group of
schizophrenias.
 catatonia
• Catatonia was recently reconsidered
because of the definition of more precise
diagnosis criteria, the discovery of a
striking association with mood disorders
and the emphasis on effective
therapeutics.
 catatonia
• Peralta et al empirically developed a
performant diagnostic instrument with the
11 most discriminant signs among
catatonic features
• Diagnostic threshold is 3 or more signs
 catatonia
• 1. immobility/ stupor= extreme passivity,
marked hypokinesia
• 2. mutism= include inaudible wihisper
• 3. negativism= resistance to instructions,
contrary comportment to whose asked;
• 4.Oppositionism= gegenhalten= resistance
to passive movement which increases with
the force exerted;
 catatonia
• 5.posturing=patient adopts spontaneously odd
postures;
• 6. catalepsy= patient retains limb posiyions
passively imposed during examination= waxy
flexibility;
• 7. automatic obedience= exaggerated
cooperation to instructed movements;
• 8. echo phenomena= movements, mimic and
speech of the examiner are copied with
modification and amplification
 catatonia
• 9. rigidity= increased muscular tone;
• 10. verbigeration= continuous and
directionless repetition of single words or
phrases;
• 11. withdrawal/ refusal to eat or drink=
turning away from examiner, no eye
contact, refusal to take food or drink when
offered.
 catatonia
• Other signs also common but less specific:
• Staring, ambitendance, iterations,
stereotypes, mannerism,
overactivity/excitement, impulsivity,
combativeness.
 catatonia
• Clinical forms are differentiated according
to evolution: acute/ chronic and periodic
forms.
• According to symptomatology: excited/
retarded catatonias; best/ worst prognosis.
 catatonia
• Malignant catatonia: severe, highrates of
mortality(25%) Stauder.
• Catatonic patients develop autonomic
disturbances with labile blood pressure,
hyperthermia, diaphoresis,…
• Requires ECT intervention in emergency.
• Treatment with lorazepam first..
 Circuitele dopaminegice din SNC

• Cinci tracturi neuronale (4 dintre ele cu functii binecunoscute)

• Neuroanatomia lor si variatiile nivelului
neuromediatorilor la nivelul sinapselor explica:
– Simptomatologia in schizofrenie
– Efectele terapeutice
– Efectele secundare ale medicatiei

Stahl 2003
Principalele 4 circuite dopaminegice
la nivelul SNC

Limbic
cortex

Dopamine pathways
1 Nigrostriatal
2 Mesolimbic
3 Mesocortical
4 Tuberoinfundibular

Adaptat - Stahl 2003

 Insight in schizophrenia
• Degree of awareness of illness or
manifestations of it.
• Insight into cognitive symptoms of both the
patients and their relatives is important for
compliance and adherence to treatment
 Cognitia in schizofrenie
• Criterii de diagnostic viabile, larg acceptate sunt
necesare pentru o ingrijire clinica buna cat si
pentru cercetare; altfel oricare doua mostre,
loturi nu vor putea fi comparate.
• Provocarea in domeniul psihiatriei este
reprezentata de nevoia de formulare de criterii
diagnostice acceptate de toti, in pofida stadiului
timpuriu ca stiinta relevanta si a absentei testelor
de laborator obiective.
 Cognitia in schizofrenie
• Datorita absentei reperelor biologice,
consensul comunitatii a jucat un rol
supraevaluat in dezvoltarea criteriilor de
diagnostic si a facut dificila justificarea
schimbarii criteriului de diagnostic.
• Exista un echilibru fin intre actualizarea
utila a criteriilor de diagnostic si creearea
unei confuzii de diagnostic.
• Cu toate acestea , legiferarea criteriilor
DSM (a caror intentie a fost de provizorat),
impiedica cercetarea si dezvoltarea
terapiei.
• De exemplu, criteriile pentru schizofrenie
incepand cu DSM-III subliniaza importanta
simptomelor psihotice, cum sunt halucinatiile si
ideile delirante, fara sa mentioneze simptomele
cognitive, cum sunt deficitele memoriei de lucru.
• Desi simptomele cognitive sunt atat dizabilitante
cat si rezistente la tratamentele existente putine
incercari au fost fost din partea industriei
farmaceutice de a dezvolta noi medicamente
datorita faptului ca nu exista indicatii
recunoscute pentru care sa primeasca aprobare.
• O singura posibila cale de a focaliza
aceste simptome “orfane” importante a
fost aceea de a “destructura” tulburarile in
complexe simptomatice cu substraturi
neurale si etiologice diferite.
• Schizofrenia poate fi practic descompusa
in urmatoarele patru clustere de
simptome: pozitive, negative, cognitive si
de dispozitie.
• Mai mult, aceste simptome pot fi intelese
mai bine ca dimensiuni ce se continua cu
starea “normala”- multe rude nonpsihotice
ale indivizilor cu schizofrenie prezinta
forme usoare de anomalii cognitive ca si
deficite asociate structurale sau
functionale, observate cu neuroimagistica.
• Strategia a fost focalizarea dezvoltarii
tratamentului nu pe entitatile nozologice
existente DSM-IV ci pe dimensiuni, cum
sunt simptomele cognitive din
schizofrenie, in care exista ipoteze
construite despre circuitele neuronale
implicate si farmacologie.
• Sub conducerea Wayne Fenton, Institutul
National de Sanatate Mintala a dezvoltat
Measurement and Treatment Research to
Improve Cognition in Schizophrenia MATRICS
Project, cu scopul de a dezvolta tratamente
pentru simptomele cognitive ale schizofreniei.
• Scopul a fost acela de a facilita acordul larg intre
domeniul academic, industrie si legislativ( FDA),
acela ca simptomele cognitive pot fi indicatie de
tratament si sa dezvolte masuratori prin care
eficacitatea terapeutica sa poata fi judecata.
 MATRICS
• A generat la ora actuala un consens de lucru
avand drept rezultat initierea unui numar crescut
de studii clinice.
• Pe masura ce stiinta progreseaza vom avea
oportunitatea in identificarea cailor neuronale ce
vor naste simptome semnificative, chiar daca
acestea nu se conformeaza pe deplin
clasificarilor actuale.
• Identificarea circuitelor neuronale atrage atentia
asupra modului celulelor si sinapselor, cat si
targhetului molecula ce poate conduce la noi
terapii.