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there are three essential phases of
schizophrenia so the first phase is
called the prodromal this is where a
person has a decline in functioning that
precedes the first psychotic episode
patients may become socially withdrawn
and irritable during this phase next
they have the psychotic symptoms this is
where there are perceptual disturbances
delusions disorganized thought process
and content and then there is a residual
phase this occurs between episodes of
psychosis and it's marked by a flat
effect social withdrawal and odd
thinking or behaviors another question
to consider what is the strongest
predictor of treatment outcome in a
first episode of a psychotic break or a
first diagnosis of schizophrenia the
answer is a duration of presenting
symptoms before treatment so for example
if somebody gets into treatment very
early when they've only had symptoms for
a brief period of time they're much more
likely to have a good treatment response
and outcome than somebody who's
languishing with psychotic symptoms for
weeks months or even years before ever
getting into treatment here's another
question what subtype of schizophrenia
is associated with a better short and
long term outcome the specific subtype
is the paranoid subtype this has the
best treatment outcomes short and long
term earlier in this lecture I
referenced positive and negative
symptoms a lot so you may be asking
yourself what are these positive and
negative symptoms well there are way
that we classify the symptoms associated
with schizophrenia and there are several
different types as you can see here
maybe take a moment and try to think to
yourself which category each symptoms
falls under the positive symptoms
usually being the more active expansive
type symptoms and
negative symptoms being the more quiet
withdrawn type of symptoms so see if you
can assign the correct symptom to the
correct category this is the answer
positive symptoms of schizophrenia
include things like disorganized
thoughts bizarre behavior delusions and
hallucinations negative symptoms are
things like blunted or flat effect in
attentiveness apathy and anhedonia what
our snipers first rank symptoms of
psychosis well the answer are
hallucinations delusions thought
insertion thought withdrawal and thought
broadcasting well who is shinai der Kurt
Schneider was a German psychiatrist
known largely for his writing on the
diagnosis and understanding of
schizophrenia back in the 1970s he
coined the first rank symptoms that we
just reviewed another important history
lesson is the five days of schizophrenia
that tend to be associated with negative
symptoms
these include anhedonia a flat effect a
loggia or in other words poverty of
thought a volition in other words apathy
and attention being very poor well who
define the five A's of schizophrenia
the answer is Eugen Bleuler who was the
one to coin the term schizophrenia in
1908 but prior to him emil kraepelin
coined another term to refer to patients
with schizophrenia do you know what that
term was it's dementia praecox so we
talked earlier a little bit about head
imaging in schizophrenia and how
hypofrontality is very important in a
prominent sign and so just to reiterate
schizophrenia can appear on a head CT
scan as ventricular a Lardon enlargement
and also cortical atrophy although
keeping in mind these are nonspecific
findings let's consider this case of mr.
B he's a 22 year old man who's having
trouble in college rather than
graduating on time
he has had to repeat a few years due to
inability to get to class because he's
low on motivation his parents come out
to college to visit him and they find
that his dorm room is a mess their son
mr. B is malodorous he hasn't been
showering or taking care of his hygiene
he's talking nonsense when his parents
ask him what's wrong the only thing they
can decipher from him is that he's
saying my professor wants to kill me
based on your knowledge of the different
types of thought disorder and delusions
what types of symptoms are most
prominent in mr. B well he's having both
positive and negative symptoms of
psychosis he appears to be having
paranoid delusions about his professor
and he's not making much sense his
parents say he's nonsensical which
indicates he may have a thought disorder
happening he also seems to be withdrawn
he's staying in his room he's
unmotivated he's not going to class his
room is a mess
and he's also neglected his personal
hygiene really important to note that
someone like mr. B or any patient with
schizophrenia must be assessed for
suicide risk
I can't over emphasize that enough the
suicide risk assessment is important for
every patient including the patient with
schizophrenia or a psychotic disorder
approximately 10% of patients with
schizophrenia will actually commit
suicide and so what are the risk factors
for suicide in the patient with
schizophrenia
well we consider these to be some of the
risk factors male gender being under the
age of 30 being paranoid having a
comorbid substance abuse problem be it
drugs or alcohol having associated
depressive symptoms unemployment
frequent recurrences or exacerbations of
their disease and symptoms any prior
suicide attempt living alone and maybe
having a recent hospitalization these
are all just some of the risk factors
that you want to make sure to ask about
so what
is at the core of schizophrenia while
negative symptoms of schizophrenia are
considered the core of the disease and
unfortunately they're also the most
difficult to treat let's go through the
diagnostic criteria for schizophrenia so
a patient needs to have two or more of
the following symptoms each have to be
present for a significant amount of time
over a consecutive one-month period so
that's delusions hallucinations
disorganized speech grossly disorganized
behavior and negative symptoms
furthermore that patient also has to
have been affected by the disorder in
various domains of their life including
social and occupational functioning and
the signs of the disturbances have
persisted for at least six months so
even if the criterion a is only active
for a month the impact to one's social
and occupational functioning extends for
at least six months or longer also there
the other disorders associated with
psychotic features such as
schizoaffective disorder and mood
disorders with psychotic features have
to have been ruled out before somebody
can be diagnosed with schizophrenia the
person has to be ruled out for having
symptoms that could be attributed to
substances or a general medical
condition and a final criteria is that
if the patient has a history of autistic
disorder or other pervasive
developmental disorder the additional
diagnosis of schizophrenia is made only
if prominent delusions or hallucinations
are also present for at least a month or
less if successfully treated I'd like to
make a note here of some other psychotic
disorders so another disorder would be
brief psychotic disorder which basically
includes criterion a of schizophrenia
however
a difference is that the symptoms only
persist for less than a month and the
disruption to social and occupational
functioning is for less than a month
another disorder schizophrenia form
disorder is very important and is often
a precursor to schizophrenia in
schizophrenic form disorder a patient
will meet criterion a for schizophrenia
however the symptoms and the disruption
to social and occupational functioning
are actually for under six months so
it's very important when thinking about
schizophrenia to know that this is
really a very serious disorder that has
impacted someone's life for six months
or more
thinking back to this case study of mr.
B I want you to think about what would
your diagnosis be of him
so of course you've ruled out all
substance issues all medical conditions
that could be contributing to his
presentation and also other psychiatric
disorders would need to be ruled out
before you can attribute his condition
to schizophrenia and again when I say
other psychiatric disorders were talking
about brief psychotic disorder
schizophrenic form disorder
schizoaffective disorder or mood
disorder with psychotic features also
his symptoms would have to be confirmed
as present for at least six months
before it could be attributed to
schizophrenia if schizophrenia is
diagnosed mr. B and his family should be
engaged actively in the treatment
options geared towards helping mr. B
experience relief from his symptoms and
to help him function within society
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