Diagnosis and Management of Schizophrenia

Stephen R. Marder, M.D.Professor and Director, Section on Psychosis

Semel Institute for Neuroscience at UCLAVA Desert Pacific Mental Illness Research, Education,

and Clinical Center

Diagnosis and Management of Schizophrenia

• Process for diagnosing schizophrenia• Epidemiology• Genetics and environment• How to access severity• Capacity to Work• Current and future treatment

DSM-IV criteria for schizophrenia

A. Characteristic SymptomsB. Social/occupational dysfunctionC. Duration of 6 monthsD. Schizoaffective and mood disorder exclusionE. Substance/general medical exclusionF. Relationship to pervasive developmental

disorder

Diagnostic Process for Schizophrenia

• Physical and lab exams rule out psychotic disorder due to a medical condition and substance-induced psychosis

• Imaging (CT, MRI, PET) are seldom helpful in diagnosis

• The diagnosis is commonly made from history and the mental status exam

• There are currently no reliable biomarkers for diagnosis or severity

Characteristic Psychotic Symptoms in Schizophrenia

• Audible thoughts• Voices arguing or commenting• Thought withdrawal or insertions by outside

forces• Thought broadcasting• Impulses, volitional acts, or feelings imposed

by outside forces• Delusional perceptions

Symptom dimensions in schizophrenia

• Psychotic– Hallucinations– Suspiciousness– Delusions

• Negative– Impoverished speech– Lack of motivation– Asociality– Decreased Affect

• Neurocognitive – Impairments – Memory– Attention– Motor skills– Social cognition– Executive skills– Disorganized speech

Epidemiology of Schizophrenia• Lifetime prevalence of about 1%• No differences related to culture or race• Onset in men is usually earlier (15-24) than in

women (25-34)

Both Sexes%

Total Male %

Total Female%

Total

HIV/AIDS 13.0 HIV/AIDS 12.1 HIV AIDS 13.9

Depressive disorders 8.6 Road traffic accidents 7.7 Depressive disorders 10.6

Road traffic accidents 4.9 Depressive disorders 6.7 Tuberculosis 3.2

Tuberculosis 3.9 Alcohol Use Disorders 5.1 Iron deficiency anemia 3.2

Alcohol Use Disorders 3.0 Tuberculosis 4.5 Schizophrenia 2.8

Self-inflicted Injuries 2.7 Violence 3.7 Obstructed labor 2.7

Iron-deficiency anemia 2.6 Self-inflicted Injuries 3.0 Bipolar disorder 2.5

Schizophrenia 2.6 Schizophrenia 2.5 Abortion 2.5

Bipolar disorder 2.5 Bipolar disorder 2.4 Self-inflicted injuries 2.4

Violence 2.3 Iron deficiency anemia 2.1 Maternal sepsis 2.1

Top 10 Causes of DALYS in Adults (15-44 years)

DALY=Sum of years of life lost due to premature mortality and years lost due to disability

WHO. The World Health Report 2001. Available at http://www.who.int/whr/2001/en/index.html

Course of Schizophrenia

Age (Years)

Good

Function

Psycho-pathology

Poor

15 20 30 40 50 60 70

Premorbid Progression StableRelapsing

Sheitman BB, Lieberman JA. The natural history and pathophysiology of treatment-resistant schizophrenia.J Psychiatr Res. 1998(May-Aug);32(3-4):143-150

Severity in Schizophrenia

• People with schizophrenia have different levels of disability varying from no disability to complete dependence on institutional care

• The amount and type of disability is related to the symptoms of the individual’s illness and how responsive these symptoms are to treatment

Severity in Schizophrenia

• The severity of psychotic symptoms are related to– How distracting– Do they influence behavior – eg, command

hallucinations– Do they cause suffering– Do they impair social functioning – eg,

suspiciousness

Severity• The severity of negative symptoms are related to – Social isolation– Apathy– Lack of expressiveness

• The severity of cognitive impairments are related to – Poor concentration– Poor memory– Inability to make simple decisions– Inability to interpret social signals– Slower pace

Pharmacological Treatment of Acute Schizophrenia

• Antipsychotic medications are effective for decreasing the severity of psychotic symptoms

• Nearly all patients on antipsychotic medications will experience some burden from side effects

• Antipsychotics are relatively ineffective for negative symptoms and cognitive impairment

Long-term treatment of schizophrenia• Antipsychotic medications are effective for

preventing relapse in stabilized patients• Effective nonpharmacological treatments include

patient and family education, skills training, supported employment, cognitive behavior therapies, and psychotherapies

• For most individuals, antipsychotic medications control the symptoms while non-pharmacological treatments address the impairments in social, vocational, and educational functioning

Clinical Challenges

• Substance use disorders are common in people with schizophrenia

• Insight can be impaired leading people with schizophrenia to refuse treatment

• Adherence to treatments can be irregular