SCHIZOPHRENIASCHIZOPHRENIA

SCHIZOPHRENIASCHIZOPHRENIADefinition: It refers to group of Definition: It refers to group of mental illness characterized mental illness characterized by specific psychological by specific psychological symptoms leading to symptoms leading to disorganization of personality disorganization of personality of an individual. The of an individual. The symptoms interfere with symptoms interfere with patients thinking, emotions patients thinking, emotions and behavior in a and behavior in a characteristic way.characteristic way.

DEFINITION_2DEFINITION_2

It is defined as a functional psychosis It is defined as a functional psychosis characterized by disturbances in characterized by disturbances in thinking, emotions, volition and thinking, emotions, volition and perception. Finally leads to perception. Finally leads to personality deterioration.personality deterioration.

HISTORYHISTORY

Previously (1896) Emil Kraeplin termed as Previously (1896) Emil Kraeplin termed as dementia praecox( dementia of puberty). dementia praecox( dementia of puberty).

Eugen bleuler, first termed the name Eugen bleuler, first termed the name schizophrenia (1911).schizophrenia (1911).

Schizophrenia derived from Greek words Schizophrenia derived from Greek words schizo means split and Phren means schizo means split and Phren means mind.mind.

EPIDEMIOLOGYEPIDEMIOLOGY

Prevalent in all the culturesPrevalent in all the cultures 4-5 per 1000 population suffer with 4-5 per 1000 population suffer with

schizophreniaschizophrenia Most of the cases are in 15-30 years of age Most of the cases are in 15-30 years of age

groupgroup More common in low socio-economic classesMore common in low socio-economic classes Prevalence is common in women compare to Prevalence is common in women compare to

men.men. Life time risk to develop the illness is about Life time risk to develop the illness is about

1%.1%.

ETIOLOGYETIOLOGY

IdiopathicIdiopathic Genetic factorsGenetic factors: if one parent is affected : if one parent is affected

with schizophrenia, a 12% rate is with schizophrenia, a 12% rate is demonstrated in the children. If both are demonstrated in the children. If both are affected the rate of occurrence will be more affected the rate of occurrence will be more upto 35-39%.upto 35-39%.

Research is focused on genes on Research is focused on genes on chromosomes 6,13,18 & 22 are related to chromosomes 6,13,18 & 22 are related to the development of schizophrenia.the development of schizophrenia.

Hebephrenic and catatonic subtypes of Hebephrenic and catatonic subtypes of have greater genetic vulnerability.have greater genetic vulnerability.

ETIOLOGY Cont…..ETIOLOGY Cont…..Biochemical and structural brain factorsBiochemical and structural brain factors: :

dopamine hypothesis suggests that schizophrenia is dopamine hypothesis suggests that schizophrenia is caused by functional hyperactivity of dopamine. caused by functional hyperactivity of dopamine. Amphetamine and cocaine which release dopamine Amphetamine and cocaine which release dopamine at central synapses induce schizophrenia like at central synapses induce schizophrenia like symptoms in normal people.symptoms in normal people.

Anti-psychotic medications act by blocking Anti-psychotic medications act by blocking dopamine receptors and reducing the dopamine over dopamine receptors and reducing the dopamine over activityactivity

Dopamine receptors of D-2 type are dense in the Dopamine receptors of D-2 type are dense in the brains of schizophrenia (postmortem studiesbrains of schizophrenia (postmortem studies))

Nor epinephrine hypothesisNor epinephrine hypothesis: : increased nor increased nor epinephrine is associated with increased epinephrine is associated with increased dopamine activity.dopamine activity.

GABA hypothesisGABA hypothesis: it is decreased leading to : it is decreased leading to increase dopamine activity.increase dopamine activity.

Serotonin hypothesisSerotonin hypothesis: : excess causes- excess causes- excitement and perceptual disturbances, excitement and perceptual disturbances, deficiency causes retardation and stupor as deficiency causes retardation and stupor as seen in catatonia.seen in catatonia.

ETIOLOGY cont…ETIOLOGY cont…Structural anomalies of brainStructural anomalies of brain: brains of : brains of

patients with schizophrenia are lighter patients with schizophrenia are lighter and smaller.and smaller.

Non-progressive cortical atrophy is seen Non-progressive cortical atrophy is seen in 10-35% of patients, particularly in the in 10-35% of patients, particularly in the frontal and temporal lobes of the left frontal and temporal lobes of the left side. The lateral and third ventricles are side. The lateral and third ventricles are enlarged in about half of the patients.enlarged in about half of the patients.

Cerebral atrophy and resultant Cerebral atrophy and resultant ventricular dilatation are attributed to ventricular dilatation are attributed to the viral infection.the viral infection.

ETIOLOGY cont…ETIOLOGY cont…

Family as a cause of schizophrenia: Family as a cause of schizophrenia: broken homes, unstable parents broken homes, unstable parents and eccentric child raring practices and eccentric child raring practices were seen in many cases.were seen in many cases.

Two anomalous family situations Two anomalous family situations leading to the onset of illness have leading to the onset of illness have been described:been described:

a)a) Deviant role relation shipDeviant role relation shipb)b) Disordered communication.Disordered communication.

ETIOLOGY cont…ETIOLOGY cont…

Lack of warm, nurturing relationship in Lack of warm, nurturing relationship in early years of life contributes to the lack early years of life contributes to the lack of self identity, reality misconception of self identity, reality misconception and relation ship withdrawal.and relation ship withdrawal.

Migration and life changesMigration and life changes: rates of : rates of schizophrenia are high among migrants schizophrenia are high among migrants which could be attributed to the effects which could be attributed to the effects of the new environment and life of the new environment and life changes.changes.

ETIOLOGY cont…ETIOLOGY cont…

Psycho-social stresses and social Psycho-social stresses and social changeschanges: it will precipitate illness in : it will precipitate illness in susceptible individual.susceptible individual.

Classification of Classification of schizophreniaschizophrenia

F20.0 Paranoid schizophreniaF20.0 Paranoid schizophrenia

F20.1 Hebephrenic schizophreniaF20.1 Hebephrenic schizophrenia

F20.2 Catatonic schizophreniaF20.2 Catatonic schizophrenia

F20.3 Undifferentiated schizophreniaF20.3 Undifferentiated schizophrenia

F20.4 Post schizophrenic depressionF20.4 Post schizophrenic depression

F20.5 Residual schizophreniaF20.5 Residual schizophrenia

F20.6 simple schizophrenia F20.6 simple schizophrenia

F20.8 others schizophreniaF20.8 others schizophrenia

F20.9 unspecified schizophreniaF20.9 unspecified schizophrenia

Paranoid schizophreniaParanoid schizophrenia

ParanoidParanoid schizophreniaschizophrenia::Commonest typeCommonest typeCore symptoms are paranoid delusionsCore symptoms are paranoid delusionsThought disorders of the formal type are Thought disorders of the formal type are

usually absentusually absentAffect is preserved and is neither shallow Affect is preserved and is neither shallow

nor inappropriatenor inappropriateHallucinations are common with paranoid Hallucinations are common with paranoid

themes.themes. it has good prognosis if treated early.it has good prognosis if treated early.

Hebephrenic schizophrenia:Hebephrenic schizophrenia:Early onset occurring around at or Early onset occurring around at or

around puberty which is insidious but around puberty which is insidious but may be acute.may be acute.

It may progress rapidly leading to It may progress rapidly leading to personality deterioration and negative personality deterioration and negative symptoms.symptoms.

Thought is disorganized, speech Thought is disorganized, speech incoherent and rambling.incoherent and rambling.

Mood is shallow and inappropriate with Mood is shallow and inappropriate with occasional euphoria- marked silly occasional euphoria- marked silly giggling, smiling and laughter.giggling, smiling and laughter.

Hallucinations may be presentHallucinations may be present.. Recovery never occurs and it has worst Recovery never occurs and it has worst

prognosis among all sub types.prognosis among all sub types.

Catatonic schizophrenia:Catatonic schizophrenia: Motor and volition disturbances are most Motor and volition disturbances are most

prominent features. This may take the prominent features. This may take the form of catatonic excitement and stupor.form of catatonic excitement and stupor.

In excitement, increase psychomotor In excitement, increase psychomotor activity, [stereotyped and purposeless over activity, [stereotyped and purposeless over activity and impulsive behavior is seen]activity and impulsive behavior is seen]

Increase in speech productionIncrease in speech production Alternatively in stupor all motor activity is Alternatively in stupor all motor activity is

reduced in the form of mutism and stupor.reduced in the form of mutism and stupor. Posturing, negativism, echolalia and Posturing, negativism, echolalia and

echopraxia are common.echopraxia are common.

Catatonic stuporCatatonic stupor

Simple schizophrenia:Simple schizophrenia:Slow and progressive withdrawal from Slow and progressive withdrawal from

social and work situations.social and work situations.Has insidious onset presence of Has insidious onset presence of

negative symptoms, vague negative symptoms, vague hypochondriacal features wandering hypochondriacal features wandering tendency, self absorbed idleness and tendency, self absorbed idleness and aimless activity, except for lack of aimless activity, except for lack of drives, initiative and shallow emotions drives, initiative and shallow emotions patient does not exhibit any psychotic patient does not exhibit any psychotic features.features.

..

Residual schizophreniaResidual schizophrenia: chronic : chronic stage with incomplete remission and stage with incomplete remission and residual symptoms as lack of drive, residual symptoms as lack of drive, under activity, shallow affect and under activity, shallow affect and regressed behavior.regressed behavior.

Undifferentiated schizophreniaUndifferentiated schizophrenia: : when several psychotic symptoms when several psychotic symptoms are present and differentiation to any are present and differentiation to any clinical group is not possibleclinical group is not possible

Undifferentiated Undifferentiated schizophreniaschizophrenia

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONSPOSITIVE SYMPTOMS:POSITIVE SYMPTOMS:

DelusionsDelusions

HallucinationsHallucinations

Bizarre behaviorBizarre behavior

AggressionAggression

AgitationAgitation

SuspiciousnessSuspiciousness

ExcitementExcitement

GrandiosityGrandiosity

NEGATIVE SYMPTOMS:•Apathy, •Anhedonia, •Asociality, •A volition, •Alogia •Attention deficits,•Social withdrawal•Diminished emotional response•Blunted affect/ flat effect•Stereotyped thinking•Artificial gestures•Lack of spontaneity

Bleuler’s 4 A’sBleuler’s 4 A’sprimary\essential-primary\essential- Association defectAssociation defect Affect (blunt\flat)Affect (blunt\flat) Autism(thinking which is dominated by Autism(thinking which is dominated by

fantasies)fantasies) Ambivalence( simultaneous occurrence of Ambivalence( simultaneous occurrence of

contradictory feelings, wishes, attitudes or contradictory feelings, wishes, attitudes or ideas)ideas)

Secondary\accessorySecondary\accessory

DelusionsDelusions

HallucinationHallucination

Kurt schneider first rank Kurt schneider first rank symptomssymptoms

Audible thoughts or thought echoAudible thoughts or thought echo Voices commenting on him in the third person Voices commenting on him in the third person

or voices heard or voices heard Voices arguingVoices arguing Passivity feeling Passivity feeling Thought withdrawal or insertionThought withdrawal or insertion Thought broad casting Thought broad casting Delusional perceptionDelusional perception Other perceptual, motor and affective Other perceptual, motor and affective

symptoms are called second rank symptoms.symptoms are called second rank symptoms.

Disturbances of thinkingDisturbances of thinking

StreamStream: incoherence or absence of : incoherence or absence of link between ideas, crowding of link between ideas, crowding of ideas, thought block, thought ideas, thought block, thought withdrawal, flight of ideas etc..withdrawal, flight of ideas etc..

ContentContent: irrelevant and meaning : irrelevant and meaning less ideas, pseudo religious, less ideas, pseudo religious, neologism, delusions.neologism, delusions.

Disorders of speech:Disorders of speech:

Poverty of speechPoverty of speech

Poverty of ideationPoverty of ideation

EhcolaliaEhcolalia

Circumstantiality , TangentialityCircumstantiality , Tangentiality

PerseverationPerseveration

VerbigerationVerbigeration

Neologism, word saladNeologism, word salad

MutismMutism

Disturbances of emotionsDisturbances of emotionsEmotional blunting, unexplainable Emotional blunting, unexplainable

depression, elation, giggling.depression, elation, giggling.Mood incongruous that is Mood incongruous that is

inappropriate to thoughts and current inappropriate to thoughts and current situations.situations.

Disturbances of perceptions:Disturbances of perceptions: Hallucination are important Hallucination are important

perceptual disturbance. Auditory perceptual disturbance. Auditory hallucination are the commonest. hallucination are the commonest. Visual, tactile, olfactory, gustatory are Visual, tactile, olfactory, gustatory are also seen.also seen.

Disturbances of behaviorDisturbances of behavior Irrelevant and inappropriate behavior. Irrelevant and inappropriate behavior. Increase / decrease in psychomotor Increase / decrease in psychomotor

activity.activity.Mannerisms, grimacing, stereotypes, Mannerisms, grimacing, stereotypes,

decreased self care and poor grooming are decreased self care and poor grooming are common.common.

Withdrawal from reality into fantasy, Withdrawal from reality into fantasy, stupor.stupor.

Suicidal and homicidal tendencies.Suicidal and homicidal tendencies.Criminal and sexual over activity and lack Criminal and sexual over activity and lack

of insight.of insight.

Volitional disturbances: Deterioration in will power, drive and ambition.

Disturbances of attention: Excessive day dreaming, muttering, spells of laughter and cry without reason, absent mindedness.

DiagnosisDiagnosisDetailed historyDetailed historyMental status examinationMental status examinationPsychiatric testing- projective testsPsychiatric testing- projective testsAcc. To ICD-10 req:Acc. To ICD-10 req:a) Presence of psychotic symptoms for a) Presence of psychotic symptoms for

a period of one month or morea period of one month or moreb) At least one (if clear cut) or two or b) At least one (if clear cut) or two or

more( if not clear cut) of the more( if not clear cut) of the following symptoms: following symptoms:

Diagnosis cont….Diagnosis cont….

Thought echo, Thought echo, thought insertion or thought insertion or withdrawal/broadcastiwithdrawal/broadcastingng

Delusional perceptionDelusional perception Hallucinatory voicesHallucinatory voices Impossible delusionsImpossible delusions

Symp. at least two of Symp. at least two of the following:the following:

Persistent Persistent hallucinationshallucinations

Neologisms/Neologisms/incoherent speechincoherent speech

Catatonic symptomsCatatonic symptoms Negative symptomsNegative symptoms Personality Personality

deteriorationdeterioration

ManagementManagementAntipsychotic- clozapine, risperidone, Antipsychotic- clozapine, risperidone,

olanzapine, quetiapine and olanzapine, quetiapine and ziprasidone.ziprasidone.

Neuroleptics- phenothiazines (for Neuroleptics- phenothiazines (for blocking of D2 receptors.blocking of D2 receptors.

Sedatives like phenobarbitone Sedatives like phenobarbitone sodium are indicated when patient is sodium are indicated when patient is excited, rowdy and restless.excited, rowdy and restless.

Hypnotics for sleeplessness.Hypnotics for sleeplessness.Lithium, proponolol, beta blockers Lithium, proponolol, beta blockers

and antidepressants. and antidepressants.

Management…Management…2) ECT2) ECT3) Hospitalization and milieu therapy3) Hospitalization and milieu therapy4) Group therapy4) Group therapy5) Behaviour therapy5) Behaviour therapy6) Social skilltraining6) Social skilltraining7) Cognitive therapy7) Cognitive therapy8) Individual psychotherapy8) Individual psychotherapy9) Psycho-social rehabilitation9) Psycho-social rehabilitation10) Family therapy.10) Family therapy.