SCHIZOPHRENIASCHIZOPHRENIA

Mr. Sathish Rajamani M.Sc (N),Mr. Sathish Rajamani M.Sc (N),

Lecturer,Lecturer,

BKIN – Daudhar.BKIN – Daudhar.

DefinitionDefinition The schizophrenic disorders are characterized in The schizophrenic disorders are characterized in

general by fundamental and characteristic general by fundamental and characteristic distortions of thinking and perception, and affectsdistortions of thinking and perception, and affects that are inappropriate or blunted. Clear that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually consciousness and intellectual capacity are usually maintained although certain cognitive deficits may maintained although certain cognitive deficits may evolve in the course of time. evolve in the course of time.

The most important psychopathological phenomena The most important psychopathological phenomena includeinclude• thought echothought echo• thought insertion or withdrawalthought insertion or withdrawal• thought broadcastingthought broadcasting• delusional perception and delusions of controldelusional perception and delusions of control• influence or passivityinfluence or passivity• hallucinatory voices commenting or discussing the patient in hallucinatory voices commenting or discussing the patient in

the third personthe third person• thought disorders and negative symptoms.thought disorders and negative symptoms.

SchizophreniaSchizophrenia

Schizophrenia occurs with regular Schizophrenia occurs with regular frequency nearly everywhere in the world frequency nearly everywhere in the world in 1 % of population and begins mainly in in 1 % of population and begins mainly in young age (mostly around 16 to 25 years).young age (mostly around 16 to 25 years).

Schizophrenia is defined by Schizophrenia is defined by • a group of characteristic positive and negative a group of characteristic positive and negative

symptomssymptoms• deterioration in social, occupational, or deterioration in social, occupational, or

interpersonal relationshipsinterpersonal relationships• continuous signs of the disturbance for at least continuous signs of the disturbance for at least

6 months6 months

HistoryHistory Emil KraepelinEmil Kraepelin: This illness develops relatively : This illness develops relatively

early in life, and its course is likely deteriorating early in life, and its course is likely deteriorating and chronic; deterioration reminded dementia and chronic; deterioration reminded dementia („Dementia praecox“(„Dementia praecox“), but was not followed by any ), but was not followed by any organic changes of the brain, detectable at that organic changes of the brain, detectable at that time.time.

Eugen BleulerEugen Bleuler: He renamed Kraepelin’s dementia : He renamed Kraepelin’s dementia praecox as praecox as schizophreniaschizophrenia (1911); he recognized (1911); he recognized the cognitive impairment in this illness, which he the cognitive impairment in this illness, which he named as a „splittingnamed as a „splitting““ of mind. of mind.

Kurt SchneiderKurt Schneider: He emphasized the role of : He emphasized the role of psychotic symptoms, as hallucinations, delusions psychotic symptoms, as hallucinations, delusions and gave them the privilege of and gave them the privilege of „the first rank „the first rank symptoms”symptoms” even in the concept of the diagnosis of even in the concept of the diagnosis of schizophrenia. schizophrenia.

4 A (Bleuler)4 A (Bleuler) Bleuler maintained, that for the diagnosis of Bleuler maintained, that for the diagnosis of

schizophrenia are most important the following four schizophrenia are most important the following four fundamental symptoms:fundamental symptoms:

• affective bluntingaffective blunting• disturbance of associationdisturbance of association (fragmented thinking) (fragmented thinking)• autismautism• ambivalenceambivalence (fragmented emotional response) (fragmented emotional response)

These groups of symptoms, are called „four A’ s” These groups of symptoms, are called „four A’ s” and Bleuler thought, that they are „primary” for and Bleuler thought, that they are „primary” for this diagnosis.this diagnosis.

The other known symptoms, hallucinations, The other known symptoms, hallucinations, delusions, which are appearing in schizophrenia delusions, which are appearing in schizophrenia very often also, he used to call as a “secondary very often also, he used to call as a “secondary symptoms”, because they could be seen in any symptoms”, because they could be seen in any other psychotic disease, which are caused by quite other psychotic disease, which are caused by quite different factors — from intoxication to infection or different factors — from intoxication to infection or other disease entities.other disease entities.

Course of IllnessCourse of Illness

Course of schizophrenia:Course of schizophrenia:• continuous without temporary improvementcontinuous without temporary improvement• episodic with progressive or stable deficitepisodic with progressive or stable deficit• episodic with complete or incomplete episodic with complete or incomplete

remission remission

Typical stages of schizophrenia:Typical stages of schizophrenia:• prodromal phaseprodromal phase• active phaseactive phase• residual phaseresidual phase

Clinical PictureClinical Picture Diagnostic manuals: Diagnostic manuals:

• lCD-10lCD-10 („International Classification of Disease“, WHO) („International Classification of Disease“, WHO)• DSM-IVDSM-IV („Diagnostic and Statistical Manual“, APA) („Diagnostic and Statistical Manual“, APA)

Clinical picture of schizophrenia is according to lCD-Clinical picture of schizophrenia is according to lCD-10, defined from the point of view of the presence 10, defined from the point of view of the presence and expression of primary and/or secondary and expression of primary and/or secondary symptoms (at present covered by the terms symptoms (at present covered by the terms negative and positive symptoms)negative and positive symptoms)::• tthe he negative symptomsnegative symptoms are represented by cognitive are represented by cognitive

disorders, having its origin probably in the disorders of disorders, having its origin probably in the disorders of associations of thoughts, combined with emotional blunting associations of thoughts, combined with emotional blunting and small or missing production of hallucinations and and small or missing production of hallucinations and delusionsdelusions

• tthe he positive positive symptomsymptom are characterized by the presence of are characterized by the presence of hallucinations and delusionshallucinations and delusions

Positive and Negative SymptomsPositive and Negative Symptoms

NegativeNegative PositivePositive

AlogiaAlogia HallucinationsHallucinations

Affective flatteningAffective flattening DelusionsDelusions

Avolition-apathyAvolition-apathy Bizarre behaviourBizarre behaviour

Anhedonia-asocialityAnhedonia-asociality Positive formal Positive formal thought disorderthought disorder

Attentional Attentional impairmentimpairment

The Criteria of DiagnosisThe Criteria of DiagnosisFor the For the diagnosis of schizophreniadiagnosis of schizophrenia is necessary is necessary presence of one very clear symptom presence of one very clear symptom - - from point a) to d)from point a) to d) or the presence of the symptoms from at least two groups or the presence of the symptoms from at least two groups - -

from point e) to h)from point e) to h)for one month or more:for one month or more:

a)a) the hearing of own thoughts, the feelings of thought the hearing of own thoughts, the feelings of thought withdrawal, thought insertion, or thought broadcastingwithdrawal, thought insertion, or thought broadcasting

b)b) the delusions of control, outside manipulation and influence, the delusions of control, outside manipulation and influence, or the feelings of passivity, which are connected with the or the feelings of passivity, which are connected with the movements of the body or extremities, specific thoughts, movements of the body or extremities, specific thoughts, acting or feelings, delusional perceptionacting or feelings, delusional perception

c)c) hallucinated voices, which are commenting permanently the hallucinated voices, which are commenting permanently the behavior of the patient or they talk about him between behavior of the patient or they talk about him between themselves, or the other types of hallucinatory voices, themselves, or the other types of hallucinatory voices, coming from different parts of bodycoming from different parts of body

d)d) permanent delusions of different kind, which are permanent delusions of different kind, which are inappropriate and unacceptable in given cultureinappropriate and unacceptable in given culture

The Criteria of DiagnosisThe Criteria of Diagnosise)e) the lasting hallucination of every formthe lasting hallucination of every formf)f) blocks or intrusion of thoughts into the flow of blocks or intrusion of thoughts into the flow of

thinking and resulting incoherence and thinking and resulting incoherence and irrelevance of speach, or neologismsirrelevance of speach, or neologisms

g)g) catatonic behaviorcatatonic behaviorh)h) „„the negative symptoms”, for instance the the negative symptoms”, for instance the

expressed apathy, poor speech, blunting and expressed apathy, poor speech, blunting and inappropriatness of emotional reactionsinappropriatness of emotional reactions

i)i) expressed and conspicuous qualitative changes expressed and conspicuous qualitative changes in patient’s behavior, the loss of interests, in patient’s behavior, the loss of interests, hobbies, aimlesness, inactivity, the loss of hobbies, aimlesness, inactivity, the loss of relations to others and social withdrawalrelations to others and social withdrawal

F20-F29 F20-F29 Schizophrenia, Schizotypal Schizophrenia, Schizotypal and Delusional Disorders and Delusional Disorders

F20 F20 SchizophreniaSchizophrenia F20.0 F20.0 Paranoid schizophrenia Paranoid schizophrenia F20.1 Hebephrenic schizophrenia F20.1 Hebephrenic schizophrenia F20.2 Catatonic schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.3 Undifferentiated schizophrenia F20.4 Post-schizophrenic depression F20.4 Post-schizophrenic depression F20.5 Residual schizophrenia F20.5 Residual schizophrenia F20.6 Simple schizophrenia F20.6 Simple schizophrenia F20.8 Other schizophrenia F20.8 Other schizophrenia F20.9 Schizophrenia, unspecified F20.9 Schizophrenia, unspecified

F20.0 Paranoid Schizophrenia F20.0 Paranoid Schizophrenia

Paranoid schizophreniaParanoid schizophrenia is characterized is characterized mainly by delusions of persecution, mainly by delusions of persecution, feelings of passive or active control, feelings of passive or active control, feelings of intrusion, and often by feelings of intrusion, and often by megalomanic tendencies also. The megalomanic tendencies also. The delusions are not usually systemized too delusions are not usually systemized too much, without tight logical connections much, without tight logical connections and are often combined with and are often combined with hallucinations of different senses, mostly hallucinations of different senses, mostly with hearing voices. with hearing voices.

Disturbances of affect, volition and Disturbances of affect, volition and speech, and catatonic symptoms, are speech, and catatonic symptoms, are either absent or relatively inconspicuous. either absent or relatively inconspicuous.

F20.1 Hebephrenic SchizophreniaF20.1 Hebephrenic Schizophrenia Hebephrenic schizophreniaHebephrenic schizophrenia is characterized by is characterized by

disorganized thinking with blunted and disorganized thinking with blunted and inappropriate emotions. It begins mostly in inappropriate emotions. It begins mostly in adolescent age, the behavior is often bizarre. There adolescent age, the behavior is often bizarre. There could appear mannerisms, grimacing, inappropriate could appear mannerisms, grimacing, inappropriate laugh and joking, pseudophilosophical brooding and laugh and joking, pseudophilosophical brooding and sudden impulsive reactions without external sudden impulsive reactions without external stimulation. There is a tendency to social isolation.stimulation. There is a tendency to social isolation.

Usually the prognosis is poor because of the rapid Usually the prognosis is poor because of the rapid development of "negative" symptoms, particularly development of "negative" symptoms, particularly flattening of affect and loss of volition. Hebephrenia flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents should normally be diagnosed only in adolescents or young adultsor young adults..

Denoted also as Denoted also as disorganized schizophreniadisorganized schizophrenia

F20.2 Catatonic SchizophreniaF20.2 Catatonic Schizophrenia Catatonic schizophreniaCatatonic schizophrenia is characterized is characterized

mainly by motoric activity, which might be mainly by motoric activity, which might be strongly increased (hypekinesis) or strongly increased (hypekinesis) or decreased (stupor), or automatic obedience decreased (stupor), or automatic obedience and negativism. and negativism.

We recognize two forms:We recognize two forms:• productive formproductive form — which shows catatonic — which shows catatonic

excitement, extreme and often aggressive excitement, extreme and often aggressive activity. activity. TreatmentTreatment by neuroleptics or by by neuroleptics or by electroconvulsive therapy.electroconvulsive therapy.

• stuporose formstuporose form — characterized by general — characterized by general inhibition of patient’s behavior or at least by inhibition of patient’s behavior or at least by retardation and slowness, followed often by retardation and slowness, followed often by mutism, negativism, fexibilitas cerea or by mutism, negativism, fexibilitas cerea or by stupor. The consciousness is not absent. stupor. The consciousness is not absent.

F20.3 Undifferentiated F20.3 Undifferentiated SchizophreniaSchizophrenia

Psychotic conditions meeting the general Psychotic conditions meeting the general diagnostic criteria for schizophrenia but diagnostic criteria for schizophrenia but not conforming to any of the subtypes in not conforming to any of the subtypes in F20.0-F20.2, or exhibiting the features of F20.0-F20.2, or exhibiting the features of more than one of them without a clear more than one of them without a clear predominance of a particular set of predominance of a particular set of diagnostic characteristics.diagnostic characteristics.

This subgroup represents also the former This subgroup represents also the former diagnosis of diagnosis of atypical schizophreniaatypical schizophrenia..

F20.4 Postschizophrenic F20.4 Postschizophrenic DepressionDepression

A depressive episode, which may be A depressive episode, which may be prolonged, arising in the aftermath of a prolonged, arising in the aftermath of a schizophrenic illness. Some schizophrenic schizophrenic illness. Some schizophrenic symptoms, either symptoms, either „„positivepositive““ or or „„negativenegative““, , must still be present but they no longer must still be present but they no longer dominate the clinical picture. dominate the clinical picture.

These depressive states are associated These depressive states are associated with an increased risk of suicide. with an increased risk of suicide.

F20.5 Residual SchizophreniaF20.5 Residual Schizophrenia AA chronic stage in the development of chronic stage in the development of

schizophrenia with clear succession from schizophrenia with clear succession from the initial stage with one or more episodes the initial stage with one or more episodes characterized by general criteria of characterized by general criteria of schizophrenia to the late stage with long-schizophrenia to the late stage with long-lasting negative symptoms and lasting negative symptoms and deterioration (not necessarily irreversible).deterioration (not necessarily irreversible).

F20.6 Simple SchizophreniaF20.6 Simple Schizophrenia

Simple schizophrenia is characterized by Simple schizophrenia is characterized by early and slowly developing initial stage early and slowly developing initial stage with growing social isolation, withdrawal, with growing social isolation, withdrawal, small activity, passivity, avolition and small activity, passivity, avolition and dependence on the others.dependence on the others.

The patients are indifferent, without any The patients are indifferent, without any initiative and volition. There is not initiative and volition. There is not expressed the presence of hallucinations expressed the presence of hallucinations and delusions.and delusions.

Genetics of SchizophreniaGenetics of Schizophrenia

Many psychiatric disorders are Many psychiatric disorders are multifactorial (caused by the interaction of multifactorial (caused by the interaction of external and genetic factors) and from the external and genetic factors) and from the genetic point of view very often genetic point of view very often polygenically determined.polygenically determined.

Relative risk for schizophrenia is around:Relative risk for schizophrenia is around:• 1% for normal population1% for normal population• 5.6% for parents5.6% for parents• 10.1% for siblings10.1% for siblings• 12.8% for children12.8% for children

Etiology of SchizophreniaEtiology of Schizophrenia

The etiology and pathogenesis of The etiology and pathogenesis of schizophrenia is not knownschizophrenia is not known

It is accepted, that schizophrenia is It is accepted, that schizophrenia is „the group of schizophrenias“ which „the group of schizophrenias“ which origin is multifactorial:origin is multifactorial:• internal factors – genetic, inborn, internal factors – genetic, inborn,

biochemicalbiochemical• external factors – trauma, infection of external factors – trauma, infection of

CNS, stressCNS, stress

Etiology of Schizophrenia - Etiology of Schizophrenia - Dopamine HypothesisDopamine Hypothesis

The most influential and plausible are the The most influential and plausible are the hypotheses, based on the supposed disorder of hypotheses, based on the supposed disorder of neurotransmission in the brain, derived mainly fromneurotransmission in the brain, derived mainly from1.1. the effects of antipsychotic drugs that have in common the the effects of antipsychotic drugs that have in common the

ability to inhibit the dopaminergic system by blocking ability to inhibit the dopaminergic system by blocking action of dopamine in the brainaction of dopamine in the brain

2.2. dopamine-releasing drugs (amphetamine, mescaline, dopamine-releasing drugs (amphetamine, mescaline, diethyl amide of lysergic acid - LSD) that can induce state diethyl amide of lysergic acid - LSD) that can induce state closely resembling paranoid schizophreniaclosely resembling paranoid schizophrenia

Classical dopamine hypothesis of schizophreniaClassical dopamine hypothesis of schizophrenia: : Psychotic symptoms are related to dopaminergic Psychotic symptoms are related to dopaminergic hyperactivity in the brain. Hyperactivity of hyperactivity in the brain. Hyperactivity of dopaminergic systems during schizophrenia is result dopaminergic systems during schizophrenia is result of increased sensitivity and density of dopamine D2 of increased sensitivity and density of dopamine D2 receptors in the different parts of the brain.receptors in the different parts of the brain.

Etiology of Schizophrenia - Etiology of Schizophrenia - Neurodevelopmental ModelNeurodevelopmental Model

Neurodevelopmental modelNeurodevelopmental model supposes in supposes in schizophrenia the presence of “silent lesion” in schizophrenia the presence of “silent lesion” in the brain, mostly in the parts, important for the the brain, mostly in the parts, important for the development of integration (frontal, parietal and development of integration (frontal, parietal and temporal), which is caused by different factors temporal), which is caused by different factors (genetic, inborn, infection, trauma...) during very (genetic, inborn, infection, trauma...) during very early development of the brain in prenatal or early early development of the brain in prenatal or early postnatal period of life. postnatal period of life.

It does not interfere too much with the basic brain It does not interfere too much with the basic brain functioning in early years, but expresses itself in functioning in early years, but expresses itself in the time, when the subject is stressed by the time, when the subject is stressed by demands of growing needs for integration, during demands of growing needs for integration, during formative years in adolescence and young formative years in adolescence and young adulthood.adulthood.

Treatment of SchizophreniaTreatment of Schizophrenia The acute psychotic schizophrenic patients will The acute psychotic schizophrenic patients will

respond usually to antipsychotic medication.respond usually to antipsychotic medication. According to current consensus we use in the first According to current consensus we use in the first

line therapy the newer atypical antipsychotics, line therapy the newer atypical antipsychotics, because their use is not complicated by appearance because their use is not complicated by appearance of extrapyramidal side-effects, or these are much of extrapyramidal side-effects, or these are much lower than with classical antipsychotics.lower than with classical antipsychotics.

conventional antipsychotics(classical neuroleptics)

chlorpromazine, chlorprotixene, clopenthixole, levopromazine, periciazine, thioridazine

droperidole, flupentixol, fluphenazine, fluspirilene, haloperidol, melperone, oxyprothepine, penfluridol, perphenazine, pimozide, prochlorperazine, trifluoperazine

atypical antipsychotics

amisulpiride, clozapine, olanzapine, quetiapine, risperidone, sertindole, sulpiride

"It's extremely rare for patients with "It's extremely rare for patients with schizophrenia to be offered ECT,“.schizophrenia to be offered ECT,“.

Most people are given ECT every two Most people are given ECT every two to five days for a total of 6 to 12 to five days for a total of 6 to 12 sessions. After the sessions are sessions. After the sessions are complete, a course of medication can complete, a course of medication can help maintain remission of help maintain remission of symptoms.symptoms.

ECTECT

Psychotherapy is not the treatment Psychotherapy is not the treatment of choice for someone with of choice for someone with schizophrenia. Used as an adjunct to schizophrenia. Used as an adjunct to a good medication plan, however, a good medication plan, however, psychotherapy can help maintain the psychotherapy can help maintain the individual on their medication, learn individual on their medication, learn needed social skills, and support the needed social skills, and support the person's weekly goals and activities person's weekly goals and activities in their community.in their community.

PSYCHOLOGICAL PSYCHOLOGICAL THERAPIESTHERAPIES

This may include advice, This may include advice, reassurance, education, modeling, reassurance, education, modeling, limit setting, and reality testing with limit setting, and reality testing with the therapist. Encouragement in the therapist. Encouragement in setting small goals and reaching setting small goals and reaching them can often be helpful.them can often be helpful.

PSYCHO SOCIAL THERAPIESPSYCHO SOCIAL THERAPIES

  This supportive group therapy can This supportive group therapy can be especially helpful in decreasing be especially helpful in decreasing social isolation and increasing reality social isolation and increasing reality testing.testing.

Group therapy focuses on real-life Group therapy focuses on real-life plans, problems, and relationships; plans, problems, and relationships; on social and work roles and on social and work roles and interaction;interaction;

GROUP THERAPYGROUP THERAPY

  This therapy encourages the family This therapy encourages the family to convene a family meeting to convene a family meeting whenever an issue arises,whenever an issue arises,

FAMILY THERAPYFAMILY THERAPY