There are 3 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
Patients may become socially withdrawn
and irritable during this phase.
Next, they have the psychotic symptoms.
This is where there are perceptual
process and content.
And then, there is a residual phase.
This occurs between episodes of psychosis
and it’s marked by a flat affect, 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 the 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 are 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
The specific subtype is
the paranoid subtype.
This has the best treatment
outcome, short and long-term.
Earlier in this lecture, I have referenced
positive and negative symptoms a lot.
So you might 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 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withdrawn type of symptoms.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,
Negative symptoms are things
like blunted or flat affect,
apathy and anhedonia.
What are Schneider’s first-rank
symptoms of psychosis?
Well, the answers are hallucinations,
delusions, thought insertion,
thought withdrawal and
Well, who is Schneider?
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 5 A’s of schizophrenia
that tend to be associated
with negative symptoms.
anhedonia, flat affect,
allogia or in other words
poverty of thought,
avolition, in other words apathy,
and attention being very poor.
Well, who defined the 5
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
Kraeplin coined another term
to refer to patients
Do you know what that term was?
It’s dementia praecox.
We talked earlier a little bit about
head imaging in schizophrenia
and how hypofrontality is very
important and a prominent sign.
And so just to reiterate,
schizophrenia can appear on a head
CT scan as ventricular enlargement
and also cortical atrophy, although keeping
in mind, these are nonspecific findings.
Let’s consider this case of Mr. B.
He is 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 is talking nonsense when his
parents ask him what’s wrong.
The only thing they can decipher
from him is that he is 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 is having both positive and
negative symptoms of psychosis.
He appears to be having paranoid
delusions about his professor
and he is not making much sense
as parents say he is nonsensical,
which indicates he may have a
thought disorder happening.
He also seems to be withdrawn.
He is staying in his room.
He is unmotivated.
He is not going to class.
His room is a mess and he has 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 overemphasize
The suicide risk assessment is
important for every patient
including the patient with
schizophrenia or psychotic disorder.
Approximately 10% of patients with
schizophrenia will actually commit suicide.
And so, what are the risk factors for
suicide in a patient with schizophrenia?
Well, we consider these to
be some of the risk factors:
Male gender, being
under the age of 30,
having college education
or being in college,
being paranoid, having a comorbid substance
abuse problem, be it drugs or alcohol,
having associated depressive
frequent recurrences or exacerbations
of their disease and symptoms,
any prior suicide attempt, living alone
and maybe having a recent hospitalization.
These are all the some of the risk factors
that you want to make sure to ask about.
So, what is at the core of schizophrenia?
Well, 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 patient needs to have two or
more of the following symptoms,
each have to be present for
significant amount of time
over a consecutive
one month period.
So, that’s delusions, hallucinations,
disorganized speech, grossly
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 ones social and
extends for at least
6 months or longer.
Also, the other disorders
associated with psychotic features
such as schizoaffective disorder and
mood disorder 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 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 in A of schizophrenia.
However, a difference is that the symptoms
only persists for less than a month
and the disruption to social and occupational
functioning is for less than a month.
is very important and is often
a precursor to schizophrenia.
In schizophreniform 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
we are talking about brief psychotic
disorder, schizophreniform 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 a treatment options
geared towards helping Mr. B
experience relief from his symptoms
and to help him function within society.