Exploring schizophrenia

Psychiatrist Dr Eugene Allers recently presented an update on schizophrenia. This event was made possible by Dr. Reddy’s.

To watch the replay and still earn a CPD point, go to: https://event.webinarjam.com/go/ replay/401/10wo0u59uyou0gh4. The following article is based on Dr Allers’ presentation.

Dr Eugene Allers

Specialists Psychiatrist

"S CHIZO’ MEANS SPLIT in Greek, while ‘phrene’ refers to mind, to describe fragmented thinking associated with the condition.

Schizophrenia models are grouped into three categories • Developmental • Drug induced • Genetic.

Lifetime prevalence of schizophrenia is approximately 0.4% worldwide. Positive symptoms include delusions, hallucinations, and thought disorders. Negative symptoms include anhedonia, avolition, social withdrawal and poverty of thought. Its aetiology is still poorly understood but the following play a role: • Dopamine • Glutamate • Multiple neurotransmitters and neuromodulators, including 5-hydroxytryptamine (5-HT) • Gamma-aminobutyric acid (GABA) • Glycine • D-serine • Neuroactive steroids.

PROGNOSIS

The prognosis is very varied. Studies show the following disability rates: • 41% (Chestnut Lodge) • 91% (Columbia) • 39% (Vaillant) • 30% (Phipps) Dr Allers’ unit has a 25% disability rate in schizophrenic patients.

DETERMINANTS OF GOOD OUTCOME

Determinants of good outcome that has been researched longer symptom duration, later age of onset, higher total PANNS score (patients are more ill), greater positive symptoms, fewer negative symptoms, higher general psychopathology scores, lower mood scores on HamD, positive employment status, and independent living.

Schizophrenia is not only a disorder of the brain, but also a metabolic disorder. Many physical illnesses occur with increased frequency in patients with serious mental illness.

Mortality rates are higher across multiple causes of death. Patients with schizophrenia had consistently increased mortality rates compared to controls. The increased burden of comorbidities is particularly high in younger patients. Schizophrenia has a considerable negative impact on survival. In younger patients with schizophrenia the mortality risk may be up to 13 times greater than controls.

SUICIDE RISK

The following criteria indicate an increased suicide risk: • Poor adherence to medication • Male • Previous suicide attempts • Higher education • Higher IQ • Living alone • Family history of depression • Paranoia • Agitation • Worthlessness • Hopelessness • Depression • Drug abuse (other than alcohol).

The following decrease suicide risk: • Hallucinations • Negative symptoms.

The following have no influence on risk: • Race • Religion • Divorce • Not being a parent • Unemployed • Coming from a broken home • Raised by a single parent • Alcohol abuse.

Schizophrenia is a progressive disease that worsens with repeated relapses.

DIAGNOSTIC CHALLENGES WITH SCHIZOPHRENIA

The DSM III narrowed down the diagnosis of schizophrenia, however the DSM 5 placed it on the spectrum with affective disorders and bipolar disorder.

Challenges include: • Early detection • The time delay before the diagnosis can be made • To differentiate from other psychotic disorders • The stigma attached to the disorder • Life long illness • No biomarker • Fairly rare disorder.

Can schizophrenia be diagnosed in the prodromal phase?

PRODROMAL SYMPTOMS

The following are prodromal phase symptoms: • Marked social isolation or withdrawal • Marked impairment in role functioning • Markedly peculiar behaviour • Marked impairment in personal hygiene and grooming • Blunted or inappropriate affect • Digressive, vague, over-elaborate or circumstantial speech, or poverty of speech, or poverty of content of speech • Odd beliefs or magical thinking • Unusual perceptual experiences • Marked lack of initiative, interests or energy.

NEURODEVELOPMENTAL

Neurodevelopmental hypotheses show major structural brain abnormalities relating to: • Cingulum • External capsule • Fornix • Corona radiata • Thalamic radiation • Body and genu of the corpus callosum • Superior fronto-occipital fasciculus • Superior longitudinal fasciculus • Uncinate fasciculus.

DRUG-INDUCED SCHIZOPHRENIA

Drug-induced schizophrenia shows a correlation with the use of cannabis. Six genes have been identified that give a much higher chance of developing schizophrenia with the use of cannabis.

GENETIC STUDIES

This is a multifactorial disease in terms of genetics. Genetic studies are still inconclusive.

PSYCHOMETRIC TESTING

• Rorschach test may indicate a more psychotic than depressive process • WAISS/SSAIS-R.

VIRAL HYPOTHESIS

Growing evidence that viruses and inflammation play a part in the aetiology of schizophrenia. Inflammation and viral infections have also been shown to play a role, with more patients being born in the winter months being diagnosed with schizophrenia. There is a higher incidence of schizophrenia after pandemics. We have seen with Covid-19 that there is a neuronal aspect.

OBSTACLES

Obstacles in the treatment of schizophrenia include: • How is remission defined? We don’t have a standard global definition • Medication doesn’t offer a cure • Medication has several side effects, such as metabolic and neurological.

TREATMENT

Early intervention is possible and critical, after the first psychotic episode. Prevent any further relapses. You should treat patients as you would treat patients with myocardial infarctions, to give you an idea of severity. The aim is to prevent another attack at all costs. Do all that you can to ensure compliance, especially in the early phases of the disease.

Other therapy areas, such as multiple sclerosis, also advocate early intervention in order to prevent further decline in patient functioning. In the natural course of schizophrenia, each relapse is linked to brain tissue loss and functional decline.

Relapse is the rule rather than the exception for people living with schizophrenia without effective treatment.

Discontinuation of antipsychotic medication shows a one-year recurrence rate of 77% and at two years, the risk of recurrence >90%. Continuation of antipsychotic medication has one-year recurrence rate of only 3%.

TREATMENT

Treatment involves medication, psychotherapy and electroconvulsive therapy (reserved for patients who don’t react quickly to medication).

Medication is divided into longacting injectable antipsychotics and oral antipsychotics. In terms of mortality risk reduction, any antipsychotic is better than no treatment at all.

Therapy includes psychotherapy such as family interventions or cognitive behavioural therapy, and occupational therapy, being cognitive rehabilitation and work hardening.

7 COGNITIVE DOMAINS TESTED IN SCHIZOPHRENIA

1. Speed of processing 2. Attention/ vigilance 3. Working memory 4. Verbal learning and memory 5. Visual learning and memory 6. Reasoning and problem solving 7. Social cognition.

KEY POINTS

• The first six months of treatment is crucial • Ensure compliance • Treat schizophrenia as a metabolic illness.