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The Essence of The Essence of SchizophreniaSchizophrenia

• Originally called “dementia Originally called “dementia praecox”praecox”

• Produces severe Produces severe incapacity – “dementia”incapacity – “dementia”

• Typically begins in Typically begins in adolescence – “praecox”adolescence – “praecox”

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The Tragedy of The Tragedy of SchizophreniaSchizophrenia

• A catastrophic illnessA catastrophic illness

• Tends to persist chronicallyTends to persist chronically

• 10% suicide rate10% suicide rate

• Very common -- 0.5-1% of Very common -- 0.5-1% of populationpopulation

• The “cancer of mental illness”The “cancer of mental illness”

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The Complexity of The Complexity of SchizophreniaSchizophrenia

• No single defining featureNo single defining feature• Multiple characteristic symptomsMultiple characteristic symptoms• Symptoms from multiple domainsSymptoms from multiple domains

• EmotionEmotion• PersonalityPersonality• CognitionCognition• Motor ActivityMotor Activity

• Probably a multisystem disorder, Probably a multisystem disorder, analogous to syphilisanalogous to syphilis

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Simplifying the Complexity Simplifying the Complexity of Schizophreniaof Schizophrenia

• Division of symptoms into Division of symptoms into twotwo broad groups broad groups

• Positive:Positive: distortions or distortions or exaggerations of normal exaggerations of normal functionsfunctions

• Negative:Negative: diminution of diminution of normal functionsnormal functions

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Hughlings-Jackson: Positive Hughlings-Jackson: Positive and Negative Symptomsand Negative Symptoms

• Disease that is said to “cause the symptoms of Disease that is said to “cause the symptoms of insanity.” I submit that disease only produces insanity.” I submit that disease only produces negative mental symptoms answering to the negative mental symptoms answering to the dissolution, and that all elaborate positive dissolution, and that all elaborate positive mental symptoms (illusions, hallucinations, mental symptoms (illusions, hallucinations, delusions, and extravagant conduct) are the delusions, and extravagant conduct) are the outcome of activity of nervous elements outcome of activity of nervous elements untouched by any pathological process; that untouched by any pathological process; that they arise during activity on the lower end of they arise during activity on the lower end of evolution remaining.evolution remaining.

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Positive SymptomsPositive Symptoms

SymptomSymptom

HallucinationsHallucinations

DelusionsDelusions

Disorganized Disorganized SpeechSpeech

Bizarre BehaviorBizarre Behavior

Function DistortedFunction Distorted

PerceptionPerception

Inferential thinkingInferential thinking

Thought/LanguageThought/Language

Behavioral Behavioral monitoringmonitoring

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Negative SymptomsNegative SymptomsSymptomSymptom

AlogiaAlogia

Affective bluntingAffective blunting

AvolitionAvolition

AnhedoniaAnhedonia

Function DiminishedFunction Diminished

Fluency of Fluency of speech/thoughtspeech/thought

Emotional expressionEmotional expression

Volition and driveVolition and drive

Hedonic capacityHedonic capacity

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The Importance of The Importance of Negative SymptomsNegative Symptoms

• Impair ability to function in daily Impair ability to function in daily lifelife

• Holding a jobHolding a job• Attending schoolAttending school• Forming friendshipsForming friendships• Having intimate family Having intimate family

relationshipsrelationships

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Subdivision of Symptoms Subdivision of Symptoms into Three Dimensionsinto Three Dimensions

• PsychoticPsychoticDelusionsHallucinations

• DisorganizedDisorganizedDisorganized speechDisorganized behaviorInappropriate affect

• NegativeNegativePoverty of speechAvolitionAffective BluntingAnhedonia

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Types of Types of HallucinationsHallucinations

• AuditoryAuditory

• VisualVisual

• TactileTactile

• OlfactoryOlfactory

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Types of DelusionsTypes of Delusions

• PersecutoryPersecutory• GrandioseGrandiose• ReligiousReligious• JealousJealous• SomaticSomatic

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Historical ConceptsHistorical Concepts

• Emil KraepelinEmil Kraepelin• Eugen BleulerEugen Bleuler• Kurt SchneiderKurt Schneider• Others (e.g., Others (e.g.,

Leonhard, Kleist, Leonhard, Kleist, Langfeldt)Langfeldt)

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Emil Kraepelin: Dementia Praecox Emil Kraepelin: Dementia Praecox

““Dementia praecox consists of Dementia praecox consists of a series of states, the a series of states, the common characteristic of common characteristic of which is a peculiar which is a peculiar destruction of internal destruction of internal connections of the psychic connections of the psychic personality....the majority of personality....the majority of the clinical pictures are the the clinical pictures are the expression of a single expression of a single morbid process, though morbid process, though outwardly they often diverge outwardly they often diverge very far from one another.”very far from one another.”

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Kraepelin: Course and Kraepelin: Course and OutcomeOutcome

• Split “dementia praecox” from Split “dementia praecox” from manic-depressive illnessmanic-depressive illness

• Early onsetEarly onset• Marked deteriorationMarked deterioration• Chronic courseChronic course• Diversity of signs and symptomsDiversity of signs and symptoms• Importance of volition and affectImportance of volition and affect

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Eugen Bleuler: Loosening Eugen Bleuler: Loosening of Associationsof Associations

““Of the thousands of Of the thousands of associative threads associative threads that guide our that guide our thinking, this disease thinking, this disease seems to interrupt, seems to interrupt, quite haphazardly, quite haphazardly, sometimes single sometimes single threads, sometimes a threads, sometimes a whole group, and whole group, and sometimes whole sometimes whole segments of them.”segments of them.”

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Bleuler: Fundamental Bleuler: Fundamental SymptomsSymptoms

• Renamed the disorder “schizophrenia”Renamed the disorder “schizophrenia”• Focused on the characteristic Focused on the characteristic

symptomssymptoms• Emphasized fragmenting of thinkingEmphasized fragmenting of thinking• Partial recovery possiblePartial recovery possible• No full “restitutio ad integrum”No full “restitutio ad integrum”• A broader conceptA broader concept• Heterogeneity: the “group of Heterogeneity: the “group of

schizophrenias”schizophrenias”

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Bleuler’s Fundamental Bleuler’s Fundamental SymptomsSymptoms

• AssociationsAssociations

• Affective BluntingAffective Blunting

• AvolitionAvolition

• AutismAutism

• AmbivalenceAmbivalence

• AttentionAttention

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Bleuler’s Description of Bleuler’s Description of Fundamental SymptomsFundamental Symptoms

• Certain symptoms of schizophrenia are present in Certain symptoms of schizophrenia are present in every case and at every period of the illness even every case and at every period of the illness even though, as with every other disease symptom, they though, as with every other disease symptom, they must have attained a certain degree of intensity before must have attained a certain degree of intensity before they can be recognized with any certainty…for they can be recognized with any certainty…for example, the peculiar association disturbance is example, the peculiar association disturbance is always present, but not each and every aspect of it…always present, but not each and every aspect of it…besides these specific permanent or fundamental besides these specific permanent or fundamental symptoms, we can find a host of other, more symptoms, we can find a host of other, more accessory manifestations such as delusions, accessory manifestations such as delusions, hallucinations, or catatonic symptoms…as far as we hallucinations, or catatonic symptoms…as far as we know, the fundamental symptoms are characteristic of know, the fundamental symptoms are characteristic of schizophrenia, while the accessory symptoms schizophrenia, while the accessory symptoms may also appear in other types of illnesses.may also appear in other types of illnesses.

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Kurt SchneiderKurt Schneider

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Schneider: The Schneider: The Psychotic ExperiencePsychotic Experience

• Interested in pathognomonic Interested in pathognomonic symptomssymptoms

• ““First Rank Symptoms” (FRS)First Rank Symptoms” (FRS)E.g., voices commentingVoices arguingThought insertion

• Involve a loss of the sense of Involve a loss of the sense of autonomy of self, or “ego autonomy of self, or “ego boundaries”boundaries”

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Importance of Importance of Schneiderian IdeasSchneiderian Ideas

• Discrete phenomena—clearly Discrete phenomena—clearly pathological or “bizarre”pathological or “bizarre”

• Discontinuous from Discontinuous from normalitynormality

• Potentially for good reliabilityPotentially for good reliability• Ideal for objective criterion-Ideal for objective criterion-

based systemsbased systems

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Schneiderian Influences Schneiderian Influences on Diagnostic Systemson Diagnostic Systems

• Incorporated into Present State Incorporated into Present State Examination (PSE)Examination (PSE)

• Used in International Pilot Study of Used in International Pilot Study of Schizophrenia (IPSS)Schizophrenia (IPSS)

• Influenced the International Influenced the International Classification of Disease (ICD)Classification of Disease (ICD)

• Influenced the US Diagnostic and Influenced the US Diagnostic and Statistical Manual (DSM)Statistical Manual (DSM)

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Fundamental Questions Fundamental Questions about Schizophreniaabout Schizophrenia

• What are the characteristic symptoms?

• What are the boundaries of the concept?

• Is the disorder a single illness or multiple disorders?

• If multiple, what are the subtypes?

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Characteristic SymptomsCharacteristic Symptoms

• Schneider: specific types of Schneider: specific types of delusions and hallucinationsdelusions and hallucinations

• Bleuler: fragmented thinking, Bleuler: fragmented thinking, inability to relate to external inability to relate to external worldworld

• Kraepelin: emotional dullness, Kraepelin: emotional dullness, avolition, loss of inner unityavolition, loss of inner unity

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Schizophrenia as a Schizophrenia as a “Polythetic Construct”“Polythetic Construct”

• No single characteristic symptomNo single characteristic symptom

• Many symptoms, all present in Many symptoms, all present in some, not present in allsome, not present in all

• Manifestations in thinking, emotion, Manifestations in thinking, emotion, interpersonal relationshipsinterpersonal relationships

• A multisystem diseaseA multisystem disease

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What are the Characteristic What are the Characteristic Symptoms of Schizophrenia?Symptoms of Schizophrenia?• Depends upon whom you askDepends upon whom you ask

• Depends upon theoretical Depends upon theoretical constructconstruct

• Depends upon what you mean by Depends upon what you mean by characteristiccharacteristic

Common?Common?

Specific?Specific?

CoreCore?

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Kraepelin: The Borders Kraepelin: The Borders of Schizophreniaof Schizophrenia

……it is certainly possible that it is certainly possible that its borders are drawn at its borders are drawn at present in many directions present in many directions too narrow, in others perhaps too narrow, in others perhaps too wide.too wide.

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Boundaries of the ConceptBoundaries of the Concept

• Schizoaffective DisorderSchizoaffective Disorder

• Psychotic Mood DisordersPsychotic Mood Disorders

• Nonpsychotic disordersNonpsychotic disordersSchizotypal PersonalitySchizotypal Personality

Simple SchizophreniaSimple Schizophrenia

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““Good Prognosis Good Prognosis Schizophrenia”Schizophrenia”

• Prominent affective symptomsProminent affective symptoms

• Acute onsetAcute onset

• Family history of affective disorderFamily history of affective disorder

• Good premorbid function Good premorbid function

• Presence of insightPresence of insight

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Narrowing of Concept: Narrowing of Concept: RationaleRationale

• Risk of tardive dyskinesiaRisk of tardive dyskinesia• Risk of erroneously treating Risk of erroneously treating

mood disorders with mood disorders with neurolepticsneuroleptics

• Risk of self-fulfilling Risk of self-fulfilling prophesies of poor outcomeprophesies of poor outcome

• Risk of political abuseRisk of political abuse

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Single or Multiple Single or Multiple IllnessesIllnesses

• Whether dementia praecox in the Whether dementia praecox in the extent here delimited represents extent here delimited represents one uniform disease, cannot be one uniform disease, cannot be decided at present with certainty.decided at present with certainty.

-- Emil Kraepelin-- Emil Kraepelin

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Heterogeneity: Heterogeneity: Competing ModelsCompeting Models

• Single disease entity: multiple Single disease entity: multiple sclerosissclerosis

• Multiple disease entities: mental Multiple disease entities: mental retardationretardation

• Multiple domains of Multiple domains of psychopathologypsychopathology

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Single Disease EntitySingle Disease Entity

• A single illnessA single illness

• A single cause that produces A single cause that produces diverse manifestationsdiverse manifestations

• Possible mechanism: Possible mechanism: process producing multiple process producing multiple brain lesionsbrain lesions

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Multiple Disease EntitiesMultiple Disease Entities

• ““The group of schizophrenias”The group of schizophrenias”

• Multiple causesMultiple causesPurely genetic forms, e.g. phenylketonuriaPurely genetic forms, e.g. phenylketonuria

Purely environmental forms, e.g. virally inducedPurely environmental forms, e.g. virally induced

Multifactorial formsMultifactorial forms

• Manifestations reflect site of injury Manifestations reflect site of injury and time of the maturational and time of the maturational processprocess

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Multiple DomainsMultiple Domains• Multiple dimensions of Multiple dimensions of

psychopathology psychopathology e.g., psychotic, disorganized, negativee.g., psychotic, disorganized, negative

• Different mechanism for each dimensionDifferent mechanism for each dimension

• Disease process A Disease process A dimension A dimension A

• Disease process B Disease process B dimension B dimension B

• Disease process C Disease process C dimension C dimension C

• Mixed clinical presentation due to Mixed clinical presentation due to multiple disease processesmultiple disease processes

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Methods for SubtypingMethods for Subtyping

• Traditional subtypes based Traditional subtypes based on clinical presentationon clinical presentation

• Phenomenotype vs. biotypePhenomenotype vs. biotype

• Positive vs. mixed vs. Positive vs. mixed vs. negativenegative

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Traditional SubtypesTraditional Subtypes

• ParanoidParanoid

• DisorganizedDisorganized

• CatatonicCatatonic

• UndifferentiatedUndifferentiated

• ResidualResidual

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Traditional SubtypesTraditional Subtypes

• Divide patients based on Divide patients based on their prominent presenting their prominent presenting symptomssymptoms

• Useful for predictionUseful for predictionPrognosisPrognosis

Social and occupational functionSocial and occupational function

Response to treatmentResponse to treatment

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PhenomenotypePhenomenotype

• Types of symptomsTypes of symptoms• Severity of symptomsSeverity of symptoms• Longitudinal courseLongitudinal course• Mode of onsetMode of onset• Cognitive functionCognitive function• Psychosocial adaptationPsychosocial adaptation• Response to treatmentResponse to treatment

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BiotypeBiotype

• Genetic loading and linkageGenetic loading and linkage• Birth and pregnancy Birth and pregnancy

complicationscomplications• Viral risk factorsViral risk factors• Neurophysiological measuresNeurophysiological measures• Neuropsychological measuresNeuropsychological measures• Neuroimaging measuresNeuroimaging measures• Neurochemical measuresNeurochemical measures

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Positive vs. NegativePositive vs. Negative

PositivePositive NegativeNegative

Poor premorbidPoor premorbid

Acute onsetAcute onset

Psychotic symptomsPsychotic symptoms

Intact cognitionIntact cognition

Poor treatment responsePoor treatment response

Neurochemical mechanismNeurochemical mechanism

ReversibleReversible

Good premorbidGood premorbid

Insidious onsetInsidious onset

Negative symptomsNegative symptoms

Impaired cognitionImpaired cognition

Good treatment responseGood treatment response

Structural mechanismStructural mechanism

IrreversibleIrreversible

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DSM-IV Criteria for DSM-IV Criteria for Schizophrenia: The BasicsSchizophrenia: The Basics• Characteristic symptoms for one Characteristic symptoms for one

monthmonth

• Social/Occupational DysfunctionSocial/Occupational Dysfunction

• Overall Duration > 6 monthsOverall Duration > 6 months

• Not attributable to mood disorderNot attributable to mood disorder

• Not attributable to substance use Not attributable to substance use or general medical conditionor general medical condition

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Criterion A: Characteristic Criterion A: Characteristic SymptomsSymptoms

• At least two of the following, each present for At least two of the following, each present for a significant portion of time during a one a significant portion of time during a one month period (or less if successfully treated):month period (or less if successfully treated):

• (1) delusions(1) delusions• (2) hallucinations(2) hallucinations• (3) disorganized speech (e.g., frequent (3) disorganized speech (e.g., frequent

derailment or incoherence)derailment or incoherence)• (4) grossly disorganized or catatonic behavior(4) grossly disorganized or catatonic behavior• (5) negative symptoms, I.e., affective (5) negative symptoms, I.e., affective

flattening, alogia, or avolitionflattening, alogia, or avolition

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Criterion A: Criterion A: Parenthetical NoteParenthetical Note

• [Note: Only one “A” symptom is [Note: Only one “A” symptom is required if delusions are bizarre required if delusions are bizarre or hallucinations consist of a or hallucinations consist of a voice keeping up a running voice keeping up a running commentary on the person’s commentary on the person’s behavior or thoughts, or two or behavior or thoughts, or two or more voices conversing with more voices conversing with each other.]each other.]

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Criterion B: Social/Occupational Criterion B: Social/Occupational DysfunctionDysfunction

• For a significant portion of the time For a significant portion of the time since the onset of the disturbance, one since the onset of the disturbance, one or more major areas of functioning such or more major areas of functioning such as work, interpersonal relations or self-as work, interpersonal relations or self-care is markedly below the level care is markedly below the level achieved prior to the onsetachieved prior to the onset

• OR when the onset is in childhood or OR when the onset is in childhood or adolescence, failure to achieve expected adolescence, failure to achieve expected level of interpersonal, academic, or level of interpersonal, academic, or occupational achievementoccupational achievement

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Criterion C: Overall DurationCriterion C: Overall Duration

• Continuous signs of the disturbance persist for at Continuous signs of the disturbance persist for at least six monthsleast six months

• This six-month period must include at least one This six-month period must include at least one month of symptoms that meet criterion A (i.e., active month of symptoms that meet criterion A (i.e., active phase symptoms), and may include periods of phase symptoms), and may include periods of prodromal or residual symptomsprodromal or residual symptoms

• During these prodromal or residual period, the signs During these prodromal or residual period, the signs of the disturbance may be manifested by only of the disturbance may be manifested by only negative symptoms or two or more symptoms listed negative symptoms or two or more symptoms listed in criterion A present in an attenuated form (e.g. in criterion A present in an attenuated form (e.g. odd beliefs, unusual perceptual experiences)odd beliefs, unusual perceptual experiences)

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Criterion D: Schizoaffective Criterion D: Schizoaffective and Mood Disorder Exclusionand Mood Disorder Exclusion• Schizoaffective Disorder and Mood Schizoaffective Disorder and Mood

Disorder with Psychotic Features have Disorder with Psychotic Features have been ruled out because of either:been ruled out because of either:(1)(1) No major depressive or manic episodes have No major depressive or manic episodes have

occurred concurrently with the active phase occurred concurrently with the active phase symptoms; or symptoms; or

(2)(2) If mood episodes have occurred during active If mood episodes have occurred during active phase symptoms, their total duration has been phase symptoms, their total duration has been brief relative to the duration of the active brief relative to the duration of the active and residual periodsand residual periods

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Criterion E: Substance / Criterion E: Substance / General Medical Condition General Medical Condition

ExclusionExclusion

The disturbance is not due to the The disturbance is not due to the direct effects of a substance direct effects of a substance (e.g., drugs of abuse, (e.g., drugs of abuse, medication) or a general medical medication) or a general medical conditioncondition

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ICD 10 Criteria for ICD 10 Criteria for Schizophrenia: The BasicsSchizophrenia: The Basics

• Characteristic symptoms for one Characteristic symptoms for one monthmonth

• If mood disorder is present, one If mood disorder is present, one month of characteristic symptoms month of characteristic symptoms must antedate itmust antedate it

• Not attributable to organic brain Not attributable to organic brain disease or substance abusedisease or substance abuse

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ICD 10: Characteristic ICD 10: Characteristic SymptomsSymptoms

•At least one of the following:At least one of the following:Thought echo, insertion, withdrawal, or Thought echo, insertion, withdrawal, or broadcastingbroadcastingDelusions of control, influence, or passivity; Delusions of control, influence, or passivity; delusional perceptdelusional perceptVoices commenting or discussing; voices Voices commenting or discussing; voices coming from some part of the bodycoming from some part of the bodyPersistent delusions that are culturally Persistent delusions that are culturally inappropriate and completely impossible, such inappropriate and completely impossible, such as religious or political identity, superhuman as religious or political identity, superhuman powerspowers

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ICD 10: Characteristic ICD 10: Characteristic SymptomsSymptoms

•Or at least two of the following:Or at least two of the following:Persistent hallucinations in any modality when accompanied by delusionsNeologisms, breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speechCatatonic behavior“Negative” symptoms such as marked apathy, paucity of speech, and bluntingor incongruity of emotional responses

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Similarities Between ICD Similarities Between ICD and DSMand DSM

• Both require one month of active Both require one month of active symptomssymptoms

• Both include references to Both include references to negative symptomsnegative symptoms

• Both require presence of Both require presence of delusions and hallucinations for delusions and hallucinations for a diagnosis of schizophreniaa diagnosis of schizophrenia

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Differences Between ICD Differences Between ICD and DSMand DSM

• Characteristic symptoms (more Characteristic symptoms (more emphasis on FRS in ICD)emphasis on FRS in ICD)

• Overall duration of symptoms Overall duration of symptoms (one month for ICD vs. six months (one month for ICD vs. six months for DSM)for DSM)

• More specific and complex More specific and complex symptom list in ICDsymptom list in ICD

• Inclusion of Schizotypal Disorder Inclusion of Schizotypal Disorder and Simple Schizophrenia in ICDand Simple Schizophrenia in ICD

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ICD 10: Types of ICD 10: Types of SchizophreniaSchizophrenia

• ParanoidParanoid

• HebephrenicHebephrenic

• CatatonicCatatonic

• UndifferentiatedUndifferentiated

• Post-schizophrenic depressionPost-schizophrenic depression

• Simple schizophreniaSimple schizophrenia

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ICD 10: Categories of ICD 10: Categories of PsychosisPsychosis

• SchizophreniaSchizophrenia• Schizotypal DisorderSchizotypal Disorder• Persistent Delusional DisordersPersistent Delusional Disorders• Acute and Transient Psychotic Acute and Transient Psychotic

DisordersDisorders• Induced Delusional DisorderInduced Delusional Disorder• Schizoaffective DisordersSchizoaffective Disorders• Other Nonorganic Psychotic Other Nonorganic Psychotic

DisordersDisorders

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DSM IV: SubtypesDSM IV: Subtypes

• ParanoidParanoid

• DisorganizedDisorganized

• CatatonicCatatonic

• UndifferentiatedUndifferentiated

• ResidualResidual

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DSM IV: Categories of DSM IV: Categories of PsychosisPsychosis

• Schizophreniform DisorderSchizophreniform Disorder• SchizophreniaSchizophrenia• Brief Psychotic DisorderBrief Psychotic Disorder• Schizoaffective DisorderSchizoaffective Disorder• Delusional DisorderDelusional Disorder• Shared Psychotic DisorderShared Psychotic Disorder• Psychotic Disorder due to a General Medical Psychotic Disorder due to a General Medical

ConditionCondition• Substance-Induced Psychotic DisorderSubstance-Induced Psychotic Disorder• Psychotic Disorder Not Otherwise Psychotic Disorder Not Otherwise

SpecifiedSpecified

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Differential DiagnosisDifferential Diagnosis

• Mood DisordersMood Disorders• Nonpsychotic personality Nonpsychotic personality

disordersdisorders• Substance-induced psychotic Substance-induced psychotic

disordersdisorders• Psychotic disorders due to a Psychotic disorders due to a

general medical condition (i.e., general medical condition (i.e., “organic” disorders)“organic” disorders)

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Drugs That May Induce Drugs That May Induce PsychosisPsychosis

• AmphetaminesAmphetamines

• MarijuanaMarijuana

• HallucinogensHallucinogens

• CocaineCocaine

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Medical Conditions That May Medical Conditions That May Present with PsychosisPresent with Psychosis

• Temporal lobe epilepsyTemporal lobe epilepsy• TumorTumor• StrokeStroke• TraumaTrauma• Endocrine/metabolic abnormalitiesEndocrine/metabolic abnormalities• InfectionsInfections• Multiple SclerosisMultiple Sclerosis• Autoimmune diseasesAutoimmune diseases

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Evaluating Evaluating Psychosocial Psychosocial

FunctionFunction

• PremorbidPremorbid

• CurrentCurrent

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Aspects of Psychosocial Aspects of Psychosocial FunctionFunction

• Relationship to parentsRelationship to parents• Relationship to siblingsRelationship to siblings• Relationship to peersRelationship to peers• Sexual adjustmentSexual adjustment• Educational historyEducational history• Work functionWork function• Recreational activities and Recreational activities and

interestsinterests

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LaboratoryLaboratory WorkupWorkup

• No standard set of laboratory No standard set of laboratory teststests

• Test selected on basis of Test selected on basis of clinical presentation, mode of clinical presentation, mode of onset, and past historyonset, and past history

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Some Common Some Common Laboratory TestsLaboratory Tests

• Complete blood countComplete blood count• UrinalysisUrinalysis• Endocrine testsEndocrine tests• Liver function testsLiver function tests• ElectroencephalogramElectroencephalogram• Computerized TomographyComputerized Tomography• Magnetic Resonance ImagingMagnetic Resonance Imaging• Neuropsychological testsNeuropsychological tests• Projective testsProjective tests

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Cross Cultural Issues: Cross Cultural Issues: Similarities Across CulturesSimilarities Across Cultures

• Schizophrenia is found Schizophrenia is found throughout the worldthroughout the world

• Some symptoms tend to be Some symptoms tend to be identical worldwideidentical worldwide

Negative symptomsNegative symptoms

Thought DisorderThought Disorder

Cognitive ImpairmentCognitive Impairment

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Differences Across Differences Across CulturesCultures

• Content of psychotic Content of psychotic symptomssymptoms

• OutcomeOutcome

• Frequency of acute psychotic Frequency of acute psychotic episodesepisodes

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Reasons for Reasons for Frequency of Acute Frequency of Acute

PsychosisPsychosis

• InfectionsInfections

• NutritionNutrition

• Delays in provision of Delays in provision of medical caremedical care

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Social Outcome in First Episode Social Outcome in First Episode Schizophrenia: NagasakiSchizophrenia: Nagasaki

Follow-up Follow-up after 2 years after 2 years

1981-19821981-1982

Follow-up Follow-up after 5 after 5

years 1984-years 1984-19851985

Follow-up Follow-up after 10 after 10

years 1989-years 1989-19901990

Number of cases at follow-upNumber of cases at follow-up 6464 6565 5858

Good OutcomeGood Outcome 34.434.4 44.644.6 36.236.2

Poor OutcomePoor Outcome 24.424.4 35.435.4 35.535.5

HospitalizedHospitalized 31.331.3 20.020.0 29.329.3

DAS overall evaluation (includes DAS overall evaluation (includes cases in the hospital)cases in the hospital)

With good outcomeWith good outcome 39.139.1 50.850.8 44.844.8

With poor outcomeWith poor outcome 60.960.9 49.249.2 55.255.2

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Poor Outcome: PredictorsPoor Outcome: Predictors

• Prominent negative symptomsProminent negative symptoms

• Early age of onsetEarly age of onset

• Insidious onsetInsidious onset

• Poor premorbid adjustmentPoor premorbid adjustment

• Low educational achievementLow educational achievement

• Low parental social classLow parental social class

• Male genderMale gender

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Comparison of Course in Developed Comparison of Course in Developed and Developing Countriesand Developing Countries

Pattern of Course *Pattern of Course * 11 22 33 44 55 66 77 88 99

Developed Countries (n-604)Developed Countries (n-604) 15.715.7 17.417.4 6.26.2 5.35.3 14.714.7 12.112.1 17.117.1 2.32.3 ----

Developing Countries (n-474)Developing Countries (n-474) 37.137.1 11.611.6 6.56.5 2.32.3 19.019.0 10.610.6 11.211.2 1.11.1 0.60.6

* 1. Single psychotic episode, complete remission* 1. Single psychotic episode, complete remission

2. Single psychotic episode, incomplete remission2. Single psychotic episode, incomplete remission

3. Single psychotic episode, non-psychotic episodes complete remission3. Single psychotic episode, non-psychotic episodes complete remission

4. Single psychotic episode, non-psychotic episodes incomplete remission4. Single psychotic episode, non-psychotic episodes incomplete remission

5. 2+ psychotic episodes, complete remission5. 2+ psychotic episodes, complete remission

6. 2+ psychotic episodes, incomplete remission6. 2+ psychotic episodes, incomplete remission

7. Continuous psychotic illness, no remission7. Continuous psychotic illness, no remission

8. Continuous non-psychotic illness8. Continuous non-psychotic illness

9. Not known9. Not known

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Reasons for Better Reasons for Better Outcome in Developing Outcome in Developing

CountriesCountries• Better social support from Better social support from

extended familiesextended families• Less social pressure to achieve Less social pressure to achieve

occupationallyoccupationally• Lower stress in rural Lower stress in rural

environments and small villagesenvironments and small villages• Less stigma toward mental Less stigma toward mental

illnessillness