Diagnosis and Management of Schizophrenia Stephen R. Marder, M.D. Professor and Director, Section on Psychosis Semel Institute for Neuroscience at UCLA VA 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. B. C. D. E. F. Characteristic Symptoms Social/occupational dysfunction Duration of 6 months Schizoaffective and mood disorder exclusion Substance/general medical exclusion 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) Top 10 Causes of DALYS in Adults (15-44 years) Both Sexes HIV/AIDS % Total 13.0 Male HIV/AIDS % Total 12.1
Female HIV AIDS % Total 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
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 Good Function Psychopathology Premorbid Stable Relapsing Progression Poor 15 20 30
40 50 60 70 Age (Years) 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 individuals 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
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