Psychosis

Optimism in the Treatment of Schizophrenia and Other Psychosis Dr. Anselmo Tronco

49 41

39

35

30 25

19 90

19 80

19 70

19 60

19 50

10

19 40

12

19 30

20

19 20

50 45 40 35 30 25 20 15 10 5 0 <1 91 0

Mean % Improvement at follow up

The State of Treatment of Schizophrenia for the Past Century

Decade * Hogarty, 1995

Stress-Diathesis Model Vulnerability ---------------- Clinical Schizophrenia (Neurodevelopmental)

Stress

The Diagnosis of Schizophrenia • Symptoms of Schizophrenia A. Positive Symptoms – Delusions – Hallucinations – Disorganized Behavior – Disorganized thinking

The Diagnosis of Schizophrenia • Symptoms of Schizophrenia B. Negative Symptoms – Anhedonia – Amotivation – Alogia

The Diagnosis of Schizophrenia • Duration: – at least 6 months , inclusive of prodromal period

• Exclusion of:

– medical cause – Drug Abuse

• Function:

– Insiduous and progressive deterioration

Change in Phenomenology of Schizophrenia (DSM) 1900 to Present

Kraepelinian 1900

Schneiderian

1970 Positive s/s

Neo-Kraepelinian

1980

1990

2004

Chronicity/ Dysfunction

? Negative S/S

DSM I & II

DSM III

DSM IV

DSM IV TR

DOPAMINERGIC PATHWAY

SUBSTANTIA NIGRA

VENTRAL TEGMENTAL AREA

STRIATUM

D1

E M

OR C SO

FRONTAL LOBE DLPFC

autoreceptors D2/D3

BIC LIM SO

D2

D2 D3

ME

L

CA TI

NUCLEUS ACUMBENS (NA)

EPS THALAMUS DM

Raphe Tegmental 5HT

NEGATIVE SYMPTOMS

POSITIVE SYMPTOMS

Biological Model: Dopaminergic

B. Psychosocial Model Family as Cause ----- Family as Allies Schizophrenic Course Mother

Impact on of illness (EE)

The Treatment of Schizophrenia Atypical vs Atypical Antipsychotics Family Care (E.E.) Supportive Psychotherapy

Summary of Treatments for Schizophrenia (1900 to present)

Psychoanalysis sychodynamic Psychotherapy

1900

1910

EE Family Care Intervention

1920

1930

ECT (Bernini)

1940

1950

Typical Lithium AP (Cade)

CPZ

1960

1970

1980

1990

Atypical AP (oral) Atypical Parenteral

00

Expressed Emotion (E.E.) 1. Anger 2. Criticism 3. Over-involvement 4. Absence of warmth and empathy

Effect of Family Care Intervention • 9 months post-discharge Type of Intervention Rate Medication Alone Medication + Family Intervention

Relapse 60% 9%

Atypical vs Typical Antipsychotics, Efficacy. Are they different?

• ATYPICAL, Oral – – – –

Clozapine Risperidone Olanzapine Amisulpride

• Effect Size: 0.21 0.49

Davis, 2003

>

• TYPICAL – Haloperidol – Chlorpromazin e

Remission in Schizophrenia Improvement Progression Acute

Severity

Response Resolution Remission Symptom Focus

Recovery Functional Focus

Time

Remission in Schizophrenia Symptoms in DSM IV and PANSS DSM IV PANSS Delusions

Delusions (P1) Unusual thought content (G9)

Hallucinations

Hallucinatory behavior (P3)

Disorganized Speech Conceptual Disorganization (P2) Grossly disorganized or catatonic behavior

Mannerisms/Posturing (G5)

Negative Symptoms

Blunted Affect (N1) Social Withdrawal (N4) Lack of Spontaneity (N6)

RISPERDAL CONSTA: 1 Year Study 55 (14%)

Achieve remission (Low severity, <6 months)

394 (68.1%)

82 (21%)

No Remission

71 (87%)

Achieve remission (Low severity, >6 months)

Stable Patients 0

3

6

Keep Remission (Low severity, 6months

9

12 Months

RISPERDAL CONSTA: 1 Year Study Stable Patients

Remission 184 (31.9%)

0

3

6

9

12 Months

Keep Remission (Low severity, 6 months) 156 (85%)

RISPERDAL CONSTA: 1 Year Study Achieve remission (Low severity, <6 months)

394 (68.1%) No Remission

Achieve remission (Low severity, <6 months)

Stable Patients 0 Remission

184 (31.9%)

3

6

Keep Remission (Low severity, 6months

9

12 Months

Keep Remission (Low severity, 6 months)

Risperdal Consta: 1 Year Study Kane (2003)

No Remmission 394 (68.1%)

Achieve Remission (low severity =>6 months, 18%)

44%

Stable Patient s Remission 184 (31.9%)

Keep Remission (85%)

49 41

39

35

30 25

19 90

19 80

19 70

19 60

19 50

10

19 40

12

19 30

20

19 20

50 45 40 35 30 25 20 15 10 5 0 <1 91 0

Mean % Improvement at follow up

The State of Treatment of Schizophrenia for the Past Century

Decade * Hogarty, 1995

Summary • The Stress Diathesis Model is still the most coherent model to encompass hippocampal neurodevelopmental abnormality and psychosocial variables in Schizophrenia.

Summary • The Dopaminergic abnormality is the most consistent finding in Schizophrenia: 1. Hyperdopaminergia in the mesolimbic system 2. Hypodopaminergia in the mesocortical system

Summary • Expressed Emotion (EE) highlights the role of the family NOT in the etiology but in determining the course of Schizophrenia

1. The treatment Expectation for

Schizophrenia had shifted towards optimism for the past five years! From relapse prevention towards Remission From Remission towards Recovery

1) The biological and psychosocial

interface remains to be elusive. However, more is not known than known about biology. Little is known about how psychosocial intervention shapes recovery in the long term

Remission in Schizophrenia • Severity: – At worst a score of (+) 1, i.e., presence of symptoms with mild disability

• Duration – At least 6 months