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. Characteristic Symptoms
B. Social/occupational dysfunction
C. Duration of 6 months
D. Schizoaffective and mood disorder exclusion
E. Substance/general medical exclusion
F. 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)
Both Sexes
%
Total Male
%
Total Female
%
Total
HIV/AIDS 13.0 HIV/AIDS 12.1 HIV AIDS 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 3.0 Tuberculosis 4.5 Schizophrenia 2.8
Self-inflicted Injuries 2.7 Violence 3.7 Obstructed labor 2.7
Iron-deficiency anemia 2.6 Self-inflicted Injuries 3.0 Bipolar disorder 2.5
Schizophrenia 2.6 Schizophrenia 2.5 Abortion 2.5
Bipolar disorder 2.5 Bipolar disorder 2.4 Self-inflicted injuries 2.4
Violence 2.3 Iron deficiency anemia 2.1 Maternal sepsis 2.1
Top 10 Causes of DALYS in Adults (15-44 years)
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
Age (Years)
Good
Function
Psycho-
pathology
Poor
15 20 30 40 50 60 70
Premorbid Progression
Stable
Relapsing
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