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SCIZOPHRENIA

• The most severe mental illness, characterized by disturbances in thought, affect, & perception.

• Personality is disintegrated & pt.'s functioning deteriorates in all fields.

• Pt. becomes burden to his family and society.

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Etiology:

1- Genetic Factor:• It is evident that there is a genetic

predisposition to this disorder.

• Children of schizophrenic parents are more liable to develop schizophrenia

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• The following table shows the relative risk for relatives or a schizophrenic patient:

• General population 1%• One schizophrenic parent 12% • Two Schizophrenic parents 40%• One sibling with schizophrenia 8%• Dizygotic twin with schizophrenia 12% • Monozygotic twin with schizophrenia 47%

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2- Biologic Factors:*Dopamine theory: • The dopamine theory states that there is

hyperactivity of the dopamine systems in the brains of schizophrenics.

• Dopamine blocking agents are effective in treating schizophrenic symptoms.

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3- Psychosocial Factors:*Psychoanalytic theory: • There is a defect in ego organization, which

affects the interpretation of reality. The child is unable to separate and progress beyond the complete dependence on mother.

• The schizophrenic never attains object constancy (object permanence), he is unable to achieve self-object differentiation. Freud stated that schizophrenia is a regression to primary narcissism in which ego is disintegrated

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*The most acceptable theory is that schizophrenia results from an interaction of different biological and psychosocial factors, but the exact cause is not known.

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CLINICAL FEATURES OF SCHIZOPHRENIA: • It is important to remember that: -No single symptom that diagnoses schizophrenia, most symptoms can be found in other disorders.

• Symptoms in single pt. change from time to time.

• It is important to consider pt.’s intellectual abilities & cultural background before describing what he says or does as symptom of schizophrenia.

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*PRE MORBID PRESONALITY: • Pt.'s personality before onset of schizophrenia is

often strange & pt. is obedient & quiet. • As an adolescent, pt. avoids competition in sports

and other activities, prefers to sit alone to watch TV or has daydreaming.

• It is difficult to know the time of onset of schizophrenia because symptoms develop slowly over a long time.

• Prodromal stage is characterized by peculiar behavior, abnormal affect & bizarre ideas, with strange perceptual experiences.

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MENTAL STATUS EXAMINATIONAPPEARANCE AND BEHAVIOR: • Pt.'s behavior may be very strange; he may be

talkative and hyperactive or mute and very quiet.• Catatonic excitement is used to describe a state of

intense disorganized hyperactivity. • In catatonic stupor pt. seems completely lifeless &

may show signs of negativism, muteness and automatic obedience.

• Pt. is withdrawn & shows lack of self-care & hygiene.

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MOOD AND AFFECT: • Affect is abnormal. It may show: 1. Restricted affective response: Pt. shows very little affect, his face may show little change when talking about different topics. Blunting and flat of affect means absence of any affective response in the facial expression, tone of voice or movements.2. Inappropriate affect: Pt.'s affective response is not going with his experience. 3. Ambivalence: Pt. shows contradicting affects to the same experience, like feeling love and hate to the same person at the same time.

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PERCEPTION: 1. Hallucinations: • Auditory hallucinations are the most common

perceptual disturbance in schizophrenia. • Usually they are voices that talk to pt. or comment on

his actions or thoughts.• Visual hallucinations may occur in schizophrenia, but

should alert to possibility of organic cause. • Tactile and other somatic hallucinations occur rarely,

they require investigation for possible organic cause. 2. Illusions: • Illusions also occur in schizophrenia.

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THOUGHT DISTURBANCE: *Delusions: • In persecutory delusions: Beliefs that others are trying

to harm him or kill him, he may think that his family is putting poison in his food and refuse to eat with them.

• Delusions of reference: Beliefs that others talk about pt. (TV news about him or hearing his name in radio).

• Grandiose delusions: Beliefs of great abilities or wealth. Pt. may think that he is a president or a prophet.

• Passivity delusions: Beliefs of being influenced by others (others can read his thoughts or a computer is directing his actions).

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*Lack of ego boundary: • Pt. does not have a clear sense of where his

body and internal hallucination from external perceptions.

• His control over his thought process may show thought insertion or thought withdrawal; pt. feels that others can put thoughts into his head (or take), or read his thoughts.

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*Loose associations: • Pt.’s speech is not coherent. • Pt. moves from one subject to another with little or no

relation between the two. *Flight of ideas: • Rapid & continuous flow of ideas, with playing on

words, and constant shifting from one idea to another.

*Neologism: • A new language that can not be understood by others.

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*Thought blocking: • Sudden stop in process of thinking experienced by

pt. as if thoughts withdrawn from his head.• Pt. may stop talking and does not return to

subject.

*Abstract thinking: • Is abnormal; pt. cannot think in abstract terms. • Difficult for him to interpret proverb, or find

similarities between objects.

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IMPULSE CONTROL: • Pt. may have poor control over his actions.• He may be aggressive or intrusive. • Some pt.'s may commit homicide (killing others)

driven by their delusions. Others may commit suicide.

ORLENTATION:• Usually pt. is oriented to place, time & person.

This may be difficult to assess because of poor cooperation from pt.

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MOMERY: • Usually normal, but can be distorted by

delusional thinking (pt. remembers clearly that he was dispelled from school, but may attribute that to the teachers being against him).

JUDGMENT AND INSIGHT: • Pts. have little or no insight into their condition.

Judgment is best assessed by observing pt. in interview or from external sources.

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Course & prognosis of schizophrenia:-Onset is either acute over a few days or gradual over a few months. Precipitating factors: may be present e.g. entering college, marriage, traumatic life event. Course: There is a deterioration over 5 years with frequent remissions and exacerbation. Pt. does not return to his level of functioning in remissions.Prognosis: About 20-30 % of pts. may recover a normal life, 40-60 % remain significantly impaired.

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Types of Schizophrenia:1-Paranoid schizophrenia-Results in less neurological and cognitive impairment and a better prognosis for pt. -In active phase: pt. is extremely ill & symptoms may constitute a danger to self or others. -Delusions: persecutory or grandiose and have a coherent theme. -Persecutory delusions may generate anxiety, suspiciousness, anger, & violent behavior.

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-Auditory hallucinations are common and related to the delusionary theme. -Interaction with others: rigid, intense & controlled. -To diagnose paranoid schizophrenia it must have delusion and hallucinations. -Other diagnostic criteria: disorganized behaviors. -Delusions & hallucinations must be present for significant portion of time, over period of 1 month. -Paranoid schizophrenia usually has a sudden onset, sometimes triggered by severe stresses.

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Prognosis-The course is varied but tends to be more hopeful than courses of other subtypes (pt.'s ego is stronger than other types).

-It is the most responsive schizophrenia to proper treatment and the most likely to qualify for course of a single episode in full remission.

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2-Disorganized Schizophrenia-Formerly known as hebephrenic schizophrenia.

-Silly & childish affect with severe personality disintegration.

-Speech is disorganized and may include word salad.

-Communication includes both real and imaginary words in no logical or incoherent speech & clanging (rhyming).

-Behavior is odd: grimacing, grunting, sniffing, posturing, rocking, stereotyped behaviors and uninhibited sex behaviors such as masturbating in public.

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-Socially, the client is withdrawn and inept.

-Many cognitive & psychomotor defects: concrete thinking, poor interpretation & use of language, inability to abstract, prelogical thought that is associated with “pleasure principle” characteristic of Id portion of personality, & poor coordination.

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-Poor personal grooming: often unable to complete activities of daily living without constant structural reminders, because behavior is aimless and without goal. -Development seems to have been impaired and held to about the age of seven or eight.

Prognosis-Poor, stemming from early pre-morbid history of impaired adjustment that continues after active phase of disorder. -Pt. may or may not have hallucinating or delusion but if they exist, they are disorganized and fragmented.

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3-Catatonic schizophrenia: -Has intense psychomotor disturbance. This could be stupor (psychomotor retardation) or excitement (psychomotor excitation).

-Manifestations of psychomotor disturbance include posturing immobility, catalepsy (wax flexibility), mutism, and negativism.

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-There may be autonomic obedience on one hand, & excessive & purposeless movement on other hand, and symptoms include:

-Echopraxia (imitating the movement of others), Echolaila (repeating what was said by another), grimacing, and stereotyped movement.

-Often there is rapid alteration between these extremes.

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-The onset of catatonic schizophrenia often occurs with dramatic suddenness.

-Catatonic stupor may be preceded by an earlier withdraw carried to the extremes.

-It reflects pt.'s reduced neurological ability to filter out stimuli.

-No significant difference of age & sex.

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-When excitement: Needs close watch to prevent harm to self and others. -When stuporous state: Disorder can be life-threatening because pt. approaches a vegetative condition, will not eat & in danger of malnutrition or even starvation. -Other complications: pressure sores from lack of mobility or strange posturing, constipation, or even severe pneumonia in older pts.

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-Delusions often persist throughout withdrawn state. Example: Pt. may believe that he has to hold his hand out flat in front of him because forces of good and evil are warring on the palm of his hand & he will upset the balance of good and evil if he moves his hand. -Pt. seems not to be attending to environment around him, when he later returns to a normal state of consciousness he will remember in detail what has occurred.

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Prognosis:Varies, depending on the age of onset, which is often in the early 20s to 30s.

-It tends to begin with an acute episode.

-If pt. has developed a good support system, before illness he will probably recover from acute phase & have partial or complete remission.

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4-Undifferentiated schizophrenia-It doesn’t clearly meet the criteria necessary for a diagnoses in other types of schizophrenia, has some aspects of each type. -Psychotic manifestations are extreme: fragmented delusions, vague hallucinations, bizarre & disorganized behavior, disorientation & incoherence.-Affect: inappropriate rather than flat & catatonic symptoms are not present.

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-Onset can be acute, with excited behaviors such as aggressive hitting or biting or pt. may have behavior that no longer fit a special type (mixture).

-Usually the pre-dromal symptoms have developed over a period of years.

-Growth and development milestones may have been delayed.

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-Thought processes are fragmented and have a high fantasy.

-Pt. has few or no friends, & family relationships are strained because of odd & restless behaviors .

-Dress and grooming are careless, & pt. seems bored with life.

-Sleep patterns are disturbed by nightmares and early morning awakening.

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Prognosis -Generally poor.

-The course is usually chronic one.

-There are periods of exacerbation and remission.

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5- Residual Schizophrenia-If an individual had at least one acute episode of schizophrenia and is now free of prominent positive symptoms but has some negative symptoms, he is diagnosed as suffering from residual schizophrenia.-In some clients, this pattern may persist for years, with or without exacerbation.-In others, it seems to taper down to a complete remission.

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Diagnostic criteria: -Absence of prominent delusions, hallucinations, disorganized speech, & disorganized or catatonic behavior. -Continuing evidence of presence of negative symptoms or attenuated positive symptoms.-Positive symptoms: Delusions, hallucinations, Bizarre dress & behavior, thought disorganization, aggression, agitated behavior, pressured speech, suicidal ideation. -Negatives symptoms: Flat or inappropriate affect, poor eye contact, Anhedonia attitude, withdrawal, poor grooming and hygiene, lack of expressive gestures, apathy, inattentiveness.

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Prognosis:-Varied and unpredictable.

-Depends largely on pre-morbid history & adequacy of support systems.

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MANAGEMENT OF SCHIZOPHRENLA 1. Hospitalization: -Indicated in acute stage of disorder. -Pt. may be aggressive or self-destructive. -Pt. may have to be restrained. 2. Medications: -Neuroleptics: -Also called anti-psychotic or major tranquilizers.-Used to treat psychotic symptoms.-Dose is determined by pt.'s response & presence of side effects.-They do not treat schizophrenia, but symptoms.

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A-Chlorpromazine (Largactil): -Drug of choice in acute stage.-Has a sedative effect in addition to anti-psychotic effect. -Present in oral form, IM & IV preparation. -Acts by blocking dopamine receptors. -Side effects: extra pyramidal movement, hypotension & anti-cholinergic effects. -Dose: 50-1200 mg daily.

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B-Haloperidol (Haldol): -Potent blocker of dopamine receptors.

-Produces more extra pyramidal & less sedation.

-Can be used in acute stage, but mainly for maintenance in chronic stage.

-Dose: 2-100 mg. daily.

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Side effects of neuroleptics:A-Acute dystonia: -Involuntary muscle contraction particularly of jaw & neck or external ocular muscles. -Treated by IV Anticholinergic drug e.g. benztropine.

B-Parkinsonian syndrome: -Includes: tremor, rigidity & bradykinesia. C-Akathesia: -Subjective sense of restlessness. -Pt. keeps moving here & there.-Treated by benzodiazepines.

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D-Tardive dyskinesia: -A disorder that involves involuntary movements, especially of lower face. -Symptoms include: Facial grimacing, finger movement, jaw swinging, repetitive chewing, & tongue thrusting.-The worst side effects of neuroleptics. -Occurs after prolonged use of neuroleptics. -It is resistant to treatment.

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3. Electroconvulsive therapy (ECT): -Less effective than neuroleptics.-Indicated in catatonic pts. or pts. who can not take meds.

4. Psychosocial treatment: -Behavioral, occupational & group therapy may be used according to needs & functional status of pt. - Supportive psychotherapy is employed & depends on establishing a relationship with pt. to make a Rx alliance.-Very difficult in regressed, aggressive or suspicious pts.-Therapist must be flexible and take into account pt.'s fear of intimacy & close relationships.

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5. Community care: -Services are provided to pt. & his family on local basis.

-Service is provided by a team of professionals working in community centers that are near pt.'s home, & pt. does not have to be hospitalized.

-Family is involved in management plan and care for pt.

-Other services can be approached to provide medical, rehabilitation, &recreational needs.

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OTHER PSYCHOTIC DISORDER

1. Brief psychotic disorder-Psychotic symptoms with acute onset for few hour & not exceeding one month , then person is back to his normal vocational & social performance.

-Usually symptoms appear after stressful events.

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Diagnosis-Presence of one or more of the following: Delusions, hallucinations, disorganized behavior, speech disturbance.

-Period of disorder is not less than 1 day and not more than 1 month then pt. will be back as normal as before.

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Prognosis-Disorder occurs in adolescence or early adulthood with acute onset of psychotic symptoms after few hours of stressful events.-Psychotic symptoms disappear in less than 1 month.-Psychotic symptoms may be followed by symptoms of depression or lack of self-confidence.

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Treatment-Admission may be needed if symptoms are severe or for confirmed diagnoses.

-Drug therapy & psychotherapy to help pt. to get rid of immature defense mechanisms & to increase his self-esteem & self-concept.

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2. Schizophreniform Disorder -More common in adolescence and early adulthood.

-Similar to Schizophrenia in symptoms but differs in period (not more than 6 months), then pt. recovers & will be back to same vocational & social performance.

-Any pt. has symptoms of Schizophrenia & not reach 6 month period, primarily diagnosed as (Schizophreniform disorder) & when exceeds 6 months will be diagnosed as Schizophrenia.

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Prognosis- Mostly, onset is acute & these psychotic symptoms cause disturbance in vocational & social performance, because prognosis is improvement always.

-During onset, there is danger on pt. from suicide during acute symptoms or depression following psychotic symptom.

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Treatment-Admission maybe needed especially for completion of diagnostic process or performing some Rx, or to protect pt. from himself.

-ECT maybe needed especially in catatonic symptoms.

-Psychotherapy is very important in helping them in social & psychological adjustment after experience of psychoses..

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3. Schizoaffective Disorder-Symptoms of schizophrenia are mixed with mood symptoms.

-If depression symptoms are present: schizo-depressive disorder.

-If mania symptoms are present: schizo-manic disorder.

-This diagnosis increases when specialist is not sure of diagnosis.

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Prognosis-Disorder starts in early adulthood & tends to become chronic. Treatment-Admission of pt. to hospital is needed with giving drugs (anti-depression , anti-mania) in addition to psycho & social therapy.

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4. Delusional disorders (paranoia) (paraphrenia) -Disorder in which organized delusions dominate without physical causes & symptoms of mood disorder or schizophrenia are not present.

-Affect is appropriate to contents of delusions and personality of pt. is intact to a great degree & testing reality is nearly normal.

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A- Erotomania: -The delusion that dominates on pt. that he is loved by another one a romantic love to a degree of spiritual integration and the “another one” is a famous one or the boss in the work.

-Usually pt. is female.

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B- Grandiose:-Pt. believes that he is great but unknown or he discovered important discoveries.

-The content of delusion could be religious by which pt. controls group of people & becomes their leader.

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C- Jealousy:-Pt. is convinced that his wife is unfaithful & he is collecting even weak evidence to prove her unfaithfulness & he strengthens his delusion by these evidences.

- Usually he acts abnormally under effect of delusions so he confronts his wife & may jail her at home & prevent her leaving alone or to observe & follow her secretly & usually he beats her.

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D-Persecutory:-The most common type.

-Pt. believes that others are observing him, following him & trying to put poison for him or to prevent him from achieving his goals, etc….

-Usually easy to get angry, aggressive against people.

-May go to court for several complains against his “proposed” enemies.

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E- Somatic type:-Occurs in different ways.

-Most common type that pt. is convinced that a bad odor is coming out from his skin, mouth or having skin contamination or a part of his body is ugly or part of his body is not working (as large intestine).

-Discovered when they go to physician or plastic surgeon to correct part of body that is ugly!, so physician sends him to psychologist or psychiatrist.

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Prognoses:-Usually starts at middle age (25-40). -May become chronic especially persecutory type.-Rarely that prevents the daily performance of pt. -Pt. & his working ability is not affected even when disorder becomes chronic.-Social & marital relationships are usually affected, but in general pts. are normal in appearance, behavior if no relation with their delusions.

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5. Shared psychotic disorder- Occurs to pt. as a result of his strong relations with another one who has originally these psychotic symptoms or prominent delusions.

-Usually this disorder occurs after a period of living together & isolation from people & lack of communication with others.

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Prognosis:-Usually it is chronic and starts in any age.-Percentage of recovery is 10-40%. Treatment:-It is necessary to separate them.-Medication if needed.-Psychotherapy-Connecting pts. with external environment & world around them.

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6. Post-Partum Psychoses-Early symptoms (3rd day of delivery) include: insomnia, instability, feelings of exhaustion, mood swinging & attacks of crying. -Late symptom include: Suspicion, lack of coordinated thinking, preoccupation with thoughts as that she is not married & she is still virgin.

-Delusions are similar to feelings of hate toward her baby and may order her to kill him.

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Prognosis -Pt. may become dangerous on self or baby based on contents of hallucinations & agitation.-Prognosis depends on personality integration & adjustment before setting disorder in addition to family association that support pt. & helps in reaching good prognoses.

-Next delivery usually will be accompanied with another attack.

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Treatment -Usually treatment especially drugs.-Mother will be given chance to communicate with her baby if she wishes that but under observation.-Psychotherapy is important especially after finishing acute stage of psychotic symptoms.-Psychotherapy focuses on inner conflict & helping mother to accept role of motherhood & asking husband & surrounded people to decrease feelings of stress.