Optimism in the

Treatment of
Schizophrenia and Other
Psychosis

Dr. Anselmo Tronco

The State of Treatment of
Schizophrenia for the Past
Century
Mean % Improvement at follow up

50 49
45 41
39
40
35
35 30
30 25
25
20
20
15 12 10
10
5
0
0

20

30

40

50

60

70

80

90
91

19

19

19

19

19

19

19

19
<1

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

Krae- Schneiderian Neo-Kraepelinian

pelinian

1900 1970 1980 1990 2004

Positive
s/s
Chronicity/
Dysfunction ?
Negative S/S

DSM I & II DSM III DSM IV DSM IV TR

 DOPAMINERGIC PATHWAY

SUBSTANTIA VENTRAL TEGMENTAL

NIGRA AREA

L D2 D3

ME
CA
TI

SO
D2 OR autoreceptors

LIM
C
SO

BIC
E
D2/D3
M
STRIATUM
D1
FRONTAL LOBE NUCLEUS ACUMBENS
DLPFC (NA)
EPS
THALAMUS DM
Raphe Tegmental
5HT

NEGATIVE POSITIVE
SYMPTOMS SYMPTOMS

Biological Model: Dopaminergic

B. Psychosocial Model

Family as Cause ----- Family as Allies

Schizophrenic Impact on
Course
Mother 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 EE
Psychotherapy Family Care
Intervention

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 00

ECT
(Bernini) Typical Atypical AP
Lithium AP (oral)
(Cade) CPZ

Atypical Parenteral
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 Relapse

Rate
Medication Alone 60%
Medication + Family 9%
Intervention
Atypical vs Typical Antipsychotics,
Efficacy. Are they different?

• ATYPICAL, Oral
> • TYPICAL
– Clozapine – Haloperidol
– Risperidone – Chlorpromazin
– Olanzapine e
– Amisulpride

• Effect Size: 0.21 -

0.49

Davis, 2003
 Remission in Schizophrenia
Improvement Progression

Acute

Response
Resolution
Severity

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 Mannerisms/Posturing (G5)
catatonic behavior

Negative Symptoms Blunted Affect (N1)

Social Withdrawal (N4)
Lack of Spontaneity (N6)
 RISPERDAL CONSTA: 1 Year
Study
55 (14%)

Achieve remission
394 (68.1%) (Low severity, <6 months)

82 (21%)
No Remission 71 (87%)
Achieve
remission
(Low severity, Keep Remission
>6 months) (Low severity, 6months
Stable
Patients
0 3 6 9 12 Months
RISPERDAL CONSTA: 1 Year
Study
Stable
Patients
0 3 6 9 12 Months

Remission Keep Remission

(Low severity,
6 months)
184 (31.9%)

156 (85%)
RISPERDAL CONSTA: 1 Year
Study
394 (68.1%) Achieve remission
(Low severity, <6 months)
No Remission
Achieve
remission Keep Remission
(Low severity, (Low severity, 6months
Stable <6 months)
Patients

0 3 6 9 12 Months

Remission Keep Remission

(Low severity, 6 months)

184 (31.9%)
 Risperdal Consta: 1 Year
Study
Kane (2003)
Achieve Remission
No Remmission (low severity
394 (68.1%) =>6 months, 18%)

Stable 44%
Patient
s
Remission Keep Remission
184 (31.9%) (85%)
The State of Treatment of
Schizophrenia for the Past
Century
Mean % Improvement at follow up

50 49
45 41
39
40
35
35 30
30 25
25
20
20
15 12 10
10
5
0
0

20

30

40

50

60

70

80

90
91

19

19

19

19

19

19

19

19
<1

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