• Schizophrenia-In a nutshell

Key points – a brief history

• Schizophrenia was first clearly identified in the 1890s.• Its characteristic features were an early onset and a

chronic course.• Kraepelin described two characteristic

psychopathological processes. • Bleuler introduced the concept of primary and

secondary symptoms.

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Schneider’s first-rank symptoms of schizophrenia

• Thought insertion, withdrawal or broadcasting : The experience of one’s thoughts being put into or taken out of one’s head, or broadcast to others. Collectively known as ‘thought interference’

• Passivity experiences :Experience that one’s thoughts or actions are physically being controlled by an external force: ‘made actions’

• Delusional perception :A normal perception followed suddenly by a seemingly unrelated, fully formed delusion

• Echo de la pensée: Hallucination of a voice repeating one’s own thoughts Rare

• Running commentary Hallucination describing one’s current actions • Third-person auditory hallucinations Voices describing patient as ‘he’ or ‘she’

Well-established predictors of outcomeGood outcome Poor outcome

Demographic Female • Married • Male • Single •

Genetic Family history of mood disorder Symptoms

Family history of schizophrenia

Onset: Acute onset , Life event at onset

Slow onset • Long duration of untreated psychosis • Onset under 17 years old

Psychosocial • Good response to treatment •Prompt treatment

High expressed emotion • Substance misuse • Poor adherence to treatment

symptoms Good • premorbid adjustment Affective symptoms

Schizoid traits • Negative symptoms • Obsessions • Bizarre delusions • Poor insight

Key points – genetics

Having a close relative with schizophrenia increases one’s own risk 15-fold. Identical twins show a 45% concordance rate. Individual vulnerability genes exist. Genes are each of small effect and act additively. So far, 4– 6 susceptibility genes have been identified, some of which also predispose to bipolar disorder. There are likely to be 15– 20 genes in all.

• Early neurodevelopmental, non-genetic risk factors exist for schizophrenia.

• Birth complications increase the child’s risk of schizophrenia in later life fourfold.

• Psychosocial risk factors are being re-established as important risk factors.

• Cannabis use appears to increase the risk of schizophrenia as well as relapse.

• Evidence for specific gene– environment interactions is beginning to emerge.

Key points – developmental theories and environmental factors

Key points – neurochemistry• The dopamine hypothesis remains the major neurochemical

hypothesis of schizophrenia.• Positive symptoms are hypothesized to be due to increased

activity of the mesolimbic dopamine pathway. • Negative symptoms are hypothesized to be due to decreased

activity of the mesocortical dopamine pathway. • Altered glutamate activity may be involved in the pathophysiology

of negative and positive symptoms and cognitive impairments.• Disturbances in the cholinergic and GABAergic systems have been

hypothesized to underlie cognitive impairments in schizophrenia.

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Key points – pharmacological treatment

• The depot forms of conventional and second-generation antipsychotics are useful for patients who are non-adherent to their medications.

• Clozapine is the only second-generation antipsychotic that is effective for positive symptoms resistant to conventional antipsychotics.

• Second-generation antipsychotics other than clozapine have become the first-line treatments for acute psychotic episodes and maintenance therapy.

• Conventional and second-generation antipsychotics are relatively effective for treating secondary, but not primary, negative symptoms.

• Conventional antipsychotics have limited effects on the cognitive impairments of schizophrenia.

• Second-generation antipsychotics may have modest benefits for multiple cognitive processes.

Key points – psychosocial interventions and non-drug treatments

• Family interventions are known to be effective in reducing relapse.

• Cognitive-behavioral therapy (CBT) in addition to drug treatment reduces persistent positive symptoms. CBT can also abort relapses if targeted at early signs.

• Motivational intervention techniques can reduce street drug use and enhance treatment compliance.

• Cognitive remediation reduces some cognitive deficits in chronic schizophrenia.

Key points – early intervention

Duration of untreated psychosis is usually 3– 6 months.

The longer the delay in treatment the worse the clinical outcome.

Early detection has been shown to be possible. Second-generation drugs are preferred. Treatment of prodromal cases with cognitive-

behavioral or drug therapy may prevent or delay schizophrenia.