SCHIZOPHRENIASCHIZOPHRENIA

What is Schizophrenia?What is Schizophrenia?

Schizophrenia is a medical illness that Schizophrenia is a medical illness that causes strange thinking, abnormal causes strange thinking, abnormal feelings, and unusual behavior. feelings, and unusual behavior.

It is uncommon in children and hard to It is uncommon in children and hard to recognize in its early stages.recognize in its early stages.

Adult behavior often differs from that of Adult behavior often differs from that of teens and children.teens and children.

Symptoms of DiagnosisSymptoms of Diagnosis

In children, Schizophrenia is preceded by In children, Schizophrenia is preceded by developmental disturbances. (speech developmental disturbances. (speech problems, lacking needed motor skills…)problems, lacking needed motor skills…)

Diagnostic criteria is the same for both Diagnostic criteria is the same for both children and adults, only symptoms must children and adults, only symptoms must appear prior to 12 years of age.appear prior to 12 years of age.

May see or hear things that do not existMay see or hear things that do not exist May be paranoid or have bizarre beliefsMay be paranoid or have bizarre beliefs

Other SymptomsOther Symptoms

Problems paying attentionProblems paying attention Impaired memoryImpaired memory Inappropriate expressions (laughing Inappropriate expressions (laughing

something is not funny such as some something is not funny such as some one being hurt)one being hurt)

Poor social skillsPoor social skills Depressed moodDepressed mood

Diagnosis ProblemsDiagnosis Problems

Often misdiagnosed in childrenOften misdiagnosed in children Mistaken for autism, personality disorders, Mistaken for autism, personality disorders,

bipolar disorder and dissociative disordersbipolar disorder and dissociative disorders Abused children may hear voice of abuser Abused children may hear voice of abuser

or see visions of abuseror see visions of abuser Bottom Line:Bottom Line: Schizophrenia is hard to Schizophrenia is hard to

diagnose in children!diagnose in children!

Early Warning SignsEarly Warning Signs

Trouble discerning dreams from realityTrouble discerning dreams from reality Seeing things and hearing voices that are Seeing things and hearing voices that are

not realnot real Extreme moodinessExtreme moodiness Concept that people are “out to get them”Concept that people are “out to get them” Confusing television with realityConfusing television with reality Severe problems making friendsSevere problems making friends

DSM IVDSM IV

Characteristic Symptoms: Two or more of the following present for a Characteristic Symptoms: Two or more of the following present for a significant portion of time during a 1 month period (less if successfully significant portion of time during a 1 month period (less if successfully treated):treated):

DelusionsDelusions HallucinationsHallucinations Disorganized speechDisorganized speech Grossly disorganized or catatonic behaviorGrossly disorganized or catatonic behavior Negative symptoms (affective flattening)Negative symptoms (affective flattening)

Social/Occupational dysfunctionSocial/Occupational dysfunction Duration: Continuous signs of disturbance persist for at least 6 months. This Duration: Continuous signs of disturbance persist for at least 6 months. This

6 month period must include 1 month of symptoms.6 month period must include 1 month of symptoms. Type:Type:

Paranoid typeParanoid type Disorganized typeDisorganized type Catatonic typeCatatonic type Undifferentiated type Undifferentiated type Residual typeResidual type

EpidemiologyEpidemiology

Less than 1% for children under 19 years of ageLess than 1% for children under 19 years of age Never diagnosed under the age of 5 and rarely before Never diagnosed under the age of 5 and rarely before

age 15age 15 Boys are at 2:1 advantage of an early onset compared to Boys are at 2:1 advantage of an early onset compared to

girlsgirls Boys first psychotic break between 15-24Boys first psychotic break between 15-24 Girls first psychotic break between 20-29Girls first psychotic break between 20-29 Levels out for older adolescents and adultsLevels out for older adolescents and adults Children: No SES ties or racial/ethnic tiesChildren: No SES ties or racial/ethnic ties Adults: Over diagnosed in African AmericansAdults: Over diagnosed in African Americans World wide Schizophrenia is very evenly spreadWorld wide Schizophrenia is very evenly spread

ComorbidityComorbidity

Substance abuse disorderSubstance abuse disorder Common substances are alcohol, stimulants such as cannabis, Common substances are alcohol, stimulants such as cannabis,

cocaine and amphetaminescocaine and amphetamines 33.7% of people with Schizophrenia disorder or 33.7% of people with Schizophrenia disorder or

schizophreniform met criteria for alcohol abuseschizophreniform met criteria for alcohol abuse 47% met criteria for any substance abuse47% met criteria for any substance abuse 43% in 125 male patients consumed cannabis43% in 125 male patients consumed cannabis 20% for cocaine, 3% heroin, and nicotine between 70-90%20% for cocaine, 3% heroin, and nicotine between 70-90% 80% out of 62 adolescents with schizophrenia had comorbidity 80% out of 62 adolescents with schizophrenia had comorbidity

with substance use in New Zealandwith substance use in New Zealand 69% of children with Schizophrenia met criteria for another 69% of children with Schizophrenia met criteria for another

psychiatric disorderpsychiatric disorder

ComorbidityComorbidity

Obsessive-Compulsive disorderObsessive-Compulsive disorder 7.8% with schizophrenia had OCD7.8% with schizophrenia had OCD 26% out of 50 patients met criteria for OCD26% out of 50 patients met criteria for OCD

DepressionDepression 25% prevalence rate with Schizophrenia25% prevalence rate with Schizophrenia

SuicideSuicide 10% of patients commit suicide10% of patients commit suicide Suicide attempts are 5 times higher than suicide rateSuicide attempts are 5 times higher than suicide rate

ComorbidityComorbidity

Other comorbid disordersOther comorbid disorders Social phobiaSocial phobia Generalized anxietyGeneralized anxiety Avoidant personality disorderAvoidant personality disorder Eating disorderEating disorder Conduct disorderConduct disorder

EtiologyEtiology

Strong evidence of genetic Strong evidence of genetic component to development of component to development of Schizophrenia.Schizophrenia.

The stronger the genetic The stronger the genetic compatibility between individuals, compatibility between individuals, the higher the concordance rates. the higher the concordance rates. Cont…Cont…

ConcordanceConcordance RatesRates

Non twin siblings:Non twin siblings: 9%9% One biological parentOne biological parent 13%13% Dizygotic twinsDizygotic twins 17%17% Both parentsBoth parents 46%46% Monozygotic twinsMonozygotic twins 48%48%(Also children of Schizophrenic mothers (Also children of Schizophrenic mothers

are at greater risk regardless of who are at greater risk regardless of who raises them)raises them)

Etiology cont…Etiology cont…

Evidence of prenatal and biological factors that Evidence of prenatal and biological factors that lead to Schizophrenia.lead to Schizophrenia. Disruptions in brain development during prenatal Disruptions in brain development during prenatal

periodperiod Complications during pregnancyComplications during pregnancy Studies suggest that brain abnormalities are evident Studies suggest that brain abnormalities are evident

in children/adolescents with Schizophreniain children/adolescents with Schizophrenia Decrease in grey matter in frontal and temporal Decrease in grey matter in frontal and temporal

regions regions

Developmental PathwaysDevelopmental Pathways

Delayed developmental milestones such Delayed developmental milestones such as walking or talkingas walking or talking

Poor academic workPoor academic work High levels of impulsivityHigh levels of impulsivity High levels of social withdrawlHigh levels of social withdrawl

When Schizophrenia appears in childhood it When Schizophrenia appears in childhood it is often a life long disorder.is often a life long disorder.

Developmental PathwaysDevelopmental Pathways

First psychotic break in childhood First psychotic break in childhood often is followed by multiple other often is followed by multiple other breaks throughout life.breaks throughout life.

After the disorder develops, more After the disorder develops, more noticeable complications arise:noticeable complications arise: Social isolationSocial isolation Economic impairmentEconomic impairment Academic deficitsAcademic deficits

Developmental PathwaysDevelopmental Pathways

Long term prognosis is generally related to age Long term prognosis is generally related to age of onset. (Earlier onset=poorer prognosis)of onset. (Earlier onset=poorer prognosis)

Childhood onset usually continues throughout Childhood onset usually continues throughout adulthood.adulthood.

Full recovery is Full recovery is rare.rare. Best hope is remission from active symptoms Best hope is remission from active symptoms

through intensive therapeutic interventions and through intensive therapeutic interventions and psychopharmacology.psychopharmacology.

TreatmentTreatment

Medication: “atypical” antipsychoticsMedication: “atypical” antipsychotics OlanzapineOlanzapine ClozapineClozapine Used to reduce symptoms such hallucinations Used to reduce symptoms such hallucinations

and delusionsand delusions New medicines help reduce chance of tardive New medicines help reduce chance of tardive

dyskinesiadyskinesia

TreatmentTreatment

Side effects of medication:Side effects of medication: Weight gainWeight gain Blood disorder (agranulocytosis)Blood disorder (agranulocytosis) NauseaNausea Urinary retentionUrinary retention ImpotenceImpotence Hyper salivationHyper salivation DyskinesiaDyskinesia DepressionDepression

TreatmentTreatment

Typically a combination of medication Typically a combination of medication (clozapine) and individual therapy, family (clozapine) and individual therapy, family therapy along with specialized programs is therapy along with specialized programs is necessary.necessary.

Medications can have many Medications can have many side effects.side effects. www.nimh.comwww.nimh.com

Case StudyReported is a case of an early onset of Schizophrenia with a translocation between

chromosomes 1 and 7. An 11 year old male was admitted to NIMH with symptoms including: disorganized speech, rambling, a 2 year history of agitation, beliefs that ghosts were talking to him

and could control his mind and that “rough hands” were pursuing him at night. His parents’ first concern came during day care at age 4 when it was reported to them their son was socially isolated and continually holding his genitals. At age 5 he began special programs for education. At age 9 an evaluation at a university hospital shows low intelligence and a language disorder. The patient has

hypotonia with gross and fine motor delays. He continued to have abnormal thoughts and an inability to focus. His symptoms from ages 9-11 showed symptoms of paranoid delusions,

grandiosity, mind control, auditory hallucinations, visual hallucinations, and tactile hallucinations. As for the patient’s developmental history, the mother had pregnancy complications with insulin-

dependant diabetes preceded by two trimesters of hypoglycemia that resulted in loss of consciousness and 6 hospitalizations. She also had a greater that 50 pound weight gain. The

patient walked by 14 months but did not have normal babbling and did not speak until age 3. He had a good temperament that did not include separation anxiety and no temper tantrums. At age

11 the NIH completed a physical that concluded the boy’s body was at a disproportion, having abnormally long limbs compared to his torso, a triangular face and small mouth. The patient

displayed inappropriate laughing and an inability to make eye contact. The patient met all criteria for the DSM-III-R for schizophrenia and was admitted to the NIMH at age 11 ½ years. Patient

responded well to clozapine.To further iterate, the patient had 3 other relatives whose DNA contained the 1 and 7

chromosome translocation, none of which were diagnosed with schizophrenia. They did have symptoms of drug/alcohol abuse and language delay. Another study showed an autistic boy with 7

and 21 translocation of chromosomes that also had a 1 chromosome in the same location of the patient discussed. The patient did show some early signs of autism but not enough to be

diagnosed. The relationship between autism and early childhood schizophrenia is still not clear, but studies have shown that 40% prepubertal schizophrenics did have autistic symptoms. At the time of this study it is hard to state the role of genetics in this patient’s schizophrenia. Certainly

more research needs to be conducted, but this is very good start.