Lecture Lecture №№88Schizophrenia. Etiology and

pathogenesis. Clinical pictures and types of motion schizophrenia. Nuclear forms of schizophrenia. Differential diagnosis. Treatment

and rehabilitation. Lecturer Savka Svitlana DmitryvnaLecturer Savka Svitlana Dmitryvna

Schizophrenia Schizophrenia are characterized in general by fundamental are characterized in general by fundamental

and characteristic distortions of thinking and and characteristic distortions of thinking and perception, and affects that are inappropriate or perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual blunted. Clear consciousness and intellectual capacity are usually maintained although capacity are usually maintained although certain cognitive deficits may evolve in the certain cognitive deficits may evolve in the course of time. The most important course of time. The most important psychopathological phenomena include thought psychopathological phenomena include thought echo; thought insertion or withdrawal; thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and broadcasting; delusional perception and delusions of control; influence or passivity; delusions of control; influence or passivity; hallucinatory voices commenting or discussing hallucinatory voices commenting or discussing the patient in the third person; thought disorders the patient in the third person; thought disorders and negative symptoms. and negative symptoms.

SuggestedSuggested factors in the factors in the etiology of schizophreniaetiology of schizophrenia

I.I.PredisposingPredisposing (genetic, social (genetic, social circumstances). circumstances).

II. II. PrecipitatingPrecipitating (trigger) - acute life (trigger) - acute life stress.stress.

III. III. Maintaining Maintaining (chronic life stress,(chronic life stress, ffamily emotional reactions).amily emotional reactions).

GENETICS. Evidence for inheritance.Evidence for inheritance. Schizophrenia is more Schizophrenia is more

common in the families of schizophrenic patients than common in the families of schizophrenic patients than in the general population (where the lifetime risk is a in the general population (where the lifetime risk is a little less than 1%). Thus among the siblings of little less than 1%). Thus among the siblings of schizophrenics the risk is about 14%; among the schizophrenics the risk is about 14%; among the children of one schizophrenic parent it is about 13%, children of one schizophrenic parent it is about 13%, and among the children of two schizophrenic parents it and among the children of two schizophrenic parents it is about 37%. Twin stu dies indicate that a major part is about 37%. Twin stu dies indicate that a major part of this familial loading is likely to be due to genetic of this familial loading is likely to be due to genetic rather than to environmental factors. The strik ing rather than to environmental factors. The strik ing finding is that among monozygotic twins the finding is that among monozygotic twins the concordance rate (the frequency of schizophrenia in concordance rate (the frequency of schizophrenia in the sibling of the affected twin) is consistently higher the sibling of the affected twin) is consistently higher (about 50%) than among dizygotic twins (about 17%). (about 50%) than among dizygotic twins (about 17%).

Two main mechanisms have been suggested:Two main mechanisms have been suggested:1.Disordered brain biochemistry1.Disordered brain biochemistry has been has been

suggested for three reasons; first, many genetic suggested for three reasons; first, many genetic disorders are caused by this mechanism; disorders are caused by this mechanism; second, the response of some schizophrenic second, the response of some schizophrenic symptoms to antipsychotic drugs suggests that symptoms to antipsychotic drugs suggests that they have a biochemical basis; third, the abuse they have a biochemical basis; third, the abuse of amphetamine, a drug which increases of amphetamine, a drug which increases dopamine functions, can induce a disorder like dopamine functions, can induce a disorder like schizophrenia. A disorder of dopamine schizophrenia. A disorder of dopamine transmission has been suggested, mainly transmission has been suggested, mainly because effective antipsychotic drugs reduce because effective antipsychotic drugs reduce dopaminergic func tion in the brain. Despite dopaminergic func tion in the brain. Despite extensive research, there is still no convincing extensive research, there is still no convincing evidence that disordered activity of evidence that disordered activity of dopaminergic systems is the cause of dopaminergic systems is the cause of schizophreniaschizophrenia..

2.Abnormal brain development. Several strands of evidence suggest that some kind of disorder of brain development could be important in the etiology of schizophrenia, but the ideas are speculative. First “soft signs” (neurological signs which do not point to a local lesion in the brain) have been reported in adults with schizophrenia, suggesting a neurological abnormality of some kind. Second, schizophrenics are more likely than other people to have a history of obstetric complications, and these could have caused brain damage.

Predisposing factors:it has been suggested that adverse living conditions it has been suggested that adverse living conditions contribute to etiology, since rates of schizophrenia are contribute to etiology, since rates of schizophrenia are higher among people living inhigher among people living in areas of social areas of social deprivation. However, this association could arise deprivation. However, this association could arise because people who are developing schizophrenia tend because people who are developing schizophrenia tend to be ineffective socially and therefore move into to be ineffective socially and therefore move into socially deprived residential areas (“social drift”). socially deprived residential areas (“social drift”). Schizophrenia is more frequent among people of low Schizophrenia is more frequent among people of low social class and this association could be explained social class and this association could be explained similarly: either life in a lower social class environment similarly: either life in a lower social class environment is stressful, or people who are developing is stressful, or people who are developing schizophrenia tendschizophrenia tend to move into jobs that are of lower to move into jobs that are of lower social class.social class.

Precipitating (trigger) factorsPrecipitating (trigger) factors- - are stressful events occurring shortly before are stressful events occurring shortly before the onset of the disorder. Maintaining factors the onset of the disorder. Maintaining factors include chronic family stress, particularly include chronic family stress, particularly strongly expressed feelings among family strongly expressed feelings among family members (“high emotional expression”, often members (“high emotional expression”, often referred to as “high EE”). Some schizophrenics referred to as “high EE”). Some schizophrenics are highly aroused (as judged by physiological are highly aroused (as judged by physiological measures). It has beenmeasures). It has been suggested that social suggested that social withdrawal is a protective mechanism to reduce withdrawal is a protective mechanism to reduce arousal, and that strongly expressed feelings arousal, and that strongly expressed feelings within the family provoke relapse by increasing within the family provoke relapse by increasing arousal.arousal.

Epidemiology.Epidemiology. The annual incidence of schizophrenia is

between 0.1 and 0.5 per 1,000 of the population, with the highest rates be ing among young men and women aged between 35 and 39 years. The point prevalence of schizophrenia is between 2.5 and 5.3 per thousand (substantially higher than the incidence because some cases become chronic). The lifetime risk of developing schizophre nia is about 1 in 100 (7.0-9.0 per thousand).

The types of debut of The types of debut of schizophrenia:schizophrenia:

I. Acute beginning of disease: 1. Maniac-like debut. 2. Depressive debut. 3. Delirious debut. 4. Epileptic form debut.

The types of debut of The types of debut of schizophrenia:schizophrenia:

II. Gradually beginning of disease:II. Gradually beginning of disease: 1. Affective willing impoverishing of person. 1. Affective willing impoverishing of person. 2. Anti social debut.2. Anti social debut. 3. Mannered-bizarrerie debut 3. Mannered-bizarrerie debut 4. Psychoasthenic debut.4. Psychoasthenic debut. 5. Neurosthenic (asthenohypochondrical) debut5. Neurosthenic (asthenohypochondrical) debut 6. Hysteric debut6. Hysteric debut 7. Hallucination-delusion debut.7. Hallucination-delusion debut.

Basic form of Basic form of schizophreniaschizophrenia

Paranoid schizophreniaParanoid schizophrenia Hebephrenic schizophreniaHebephrenic schizophrenia Catatonic schizophreniaCatatonic schizophrenia Simple schizophreniaSimple schizophrenia

Paranoid schizophreniaParanoid schizophrenia

Paranoid schizophrenia is dominated by Paranoid schizophrenia is dominated by relatively stable, often paranoid delusions, relatively stable, often paranoid delusions, usually accompanied by hallucinations, usually accompanied by hallucinations, particularly of the auditory variety, and particularly of the auditory variety, and perceptual disturbances. Disturbances of perceptual disturbances. Disturbances of affect, volition and speech, and catatonic affect, volition and speech, and catatonic symptoms, are either absent or relatively symptoms, are either absent or relatively inconspicuous. inconspicuous.

Hebephrenic schizophreniaHebephrenic schizophrenia A form of schizophrenia in which affective A form of schizophrenia in which affective

changes are prominent, delusions and changes are prominent, delusions and hallucinations fleeting and fragmentary, hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and behaviour irresponsible and unpredictable, and mannerisms common. The mood is shallow and mannerisms common. The mood is shallow and inappropriate, thought is disorganized, and inappropriate, thought is disorganized, and speech is incoherent. There is a tendency to speech is incoherent. There is a tendency to social isolation. Usually the prognosis is poor social isolation. Usually the prognosis is poor because of the rapid development of “negative” because of the rapid development of “negative” symptoms, particularly flattening of affect and symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young be diagnosed only in adolescents or young adults. adults.

Catatonic schizophreniaCatatonic schizophrenia Catatonic schizophrenia is dominated by Catatonic schizophrenia is dominated by

prominent psychomotor disturbances that may prominent psychomotor disturbances that may alternate between extremes such as alternate between extremes such as hyperkinesis and stupor, or automatic hyperkinesis and stupor, or automatic obedience and negativism. Constrained obedience and negativism. Constrained attitudes and postures may be maintained for attitudes and postures may be maintained for long periods. Episodes of violent excitement long periods. Episodes of violent excitement may be a striking feature of the condition. The may be a striking feature of the condition. The catatonic phenomena may be combined with a catatonic phenomena may be combined with a dream-like (oneiroid) state with vivid scenic dream-like (oneiroid) state with vivid scenic hallucinations. hallucinations.

Simple schizophreniaSimple schizophrenia A disorder in which there is an insidious A disorder in which there is an insidious

but progressive development of oddities but progressive development of oddities of conduct, inability to meet the demands of conduct, inability to meet the demands of society, and decline in total of society, and decline in total performance. The characteristic negative performance. The characteristic negative features of residual schizophrenia (e.g. features of residual schizophrenia (e.g. blunting of affect and loss of volition) blunting of affect and loss of volition) develop without being preceded by any develop without being preceded by any overt psychotic symptoms. overt psychotic symptoms.

Types of flowing of Types of flowing of schizophrenia:schizophrenia:

I. Chronic flowing – continuous-progredient I. Chronic flowing – continuous-progredient type. It develops during many years and type. It develops during many years and finishes specific dementia.finishes specific dementia.

II. Fits-like progredient type – with acute fits and II. Fits-like progredient type – with acute fits and periods remission. Result in defect of periods remission. Result in defect of personality. personality.

III. Fits-like type (reccurent) - with acute fits III. Fits-like type (reccurent) - with acute fits (flashes, as maniac and depressive phase) and (flashes, as maniac and depressive phase) and periods remission after its. Result in defect of periods remission after its. Result in defect of personality. Defect of personality is personality. Defect of personality is insignificant.insignificant.

IV. Constant (stationary) – flowing of disease is IV. Constant (stationary) – flowing of disease is unchanged during years.unchanged during years.

Types of remission of Types of remission of schizophrenia:schizophrenia:

I. Complete (remission A) – total disappear I. Complete (remission A) – total disappear positive symptoms and preserves insignificant positive symptoms and preserves insignificant negative symptoms.negative symptoms.

II. Incomplete (remission B) – significant II. Incomplete (remission B) – significant lowering positive symptoms and preserves lowering positive symptoms and preserves temperate negative symptoms (work ability is temperate negative symptoms (work ability is limited).limited).

III. Incomplete (remission C) - temperate III. Incomplete (remission C) - temperate lowering positive symptoms, significant defect lowering positive symptoms, significant defect of personality (work ability is total lost).of personality (work ability is total lost).

IV. Partially (remission D) – lowering of acuity IV. Partially (remission D) – lowering of acuity flowing of disease (patients need in treatment).flowing of disease (patients need in treatment).

Treatment of Treatment of schizophreniaschizophrenia

Antipsychotic drugs.Antipsychotic drugs. Anxiolytics.Anxiolytics. Electro-convulsive therapy.Electro-convulsive therapy. Psychotherapy.Psychotherapy.

ANTIPSYCHOTICSANTIPSYCHOTICS (Neuroleptics, Major (Neuroleptics, Major

Tranquillisers) Tranquillisers) Antipsychotics are used principally Antipsychotics are used principally

in the treatment of psychoses. in the treatment of psychoses. They diminish the agitation, They diminish the agitation, delusions, hallucinations and delusions, hallucinations and thought disorder of these illnesses. thought disorder of these illnesses. The drugs have less effect on the The drugs have less effect on the symptoms of apathy and symptoms of apathy and withdrawal. Treatment response is withdrawal. Treatment response is most dramatic during the first six most dramatic during the first six weeks thereafter it tapers off. weeks thereafter it tapers off.

ANTIPSYCHOTICS – GENERAL ANTIPSYCHOTICS – GENERAL PRECAUTIONSPRECAUTIONS

All antipsychotics are central nervous system All antipsychotics are central nervous system depressants and metabolised in the liver therefore depressants and metabolised in the liver therefore care should be taken when: care should be taken when:

• • prescribing them for persons with respiratory or prescribing them for persons with respiratory or cardiac problems; cardiac problems;

• • using with other central nervous system using with other central nervous system depressants including alcohol; depressants including alcohol;

• • driving a car or as reaction times can be slowed. driving a car or as reaction times can be slowed. • • prescribing for persons with liver problems; prescribing for persons with liver problems; • • prescribing with other drugs metabolised in the prescribing with other drugs metabolised in the

liver. liver. Lower doses are usually required in the elderly. Lower doses are usually required in the elderly. They should be used with caution in children and They should be used with caution in children and

adolescents. adolescents. These drugs should not be prescribed for persons These drugs should not be prescribed for persons

with known hypersensitivity to the drugs. with known hypersensitivity to the drugs.

TYPICAL ANTIPSYCHOTICSTYPICAL ANTIPSYCHOTICS SHORT SHORT ACTING INJECTIBLESACTING INJECTIBLES

GENERIC NAME BRAND NAMEGENERIC NAME BRAND NAME chlorpromazine Largactil chlorpromazine Largactil haloperidol Serenace haloperidol Serenace trifluoperazine Stelazinetrifluoperazine Stelazine LONG ACTING INJECTIBLESLONG ACTING INJECTIBLES GENERIC NAME BRAND NAMEGENERIC NAME BRAND NAME

flupenthixol decanoate Fluanxol flupenthixol decanoate Fluanxol fluphenazine decanoate Modecate fluphenazine decanoate Modecate haloperidol decanoate Haldohaloperidol decanoate Haldo zuclopenthixol decanoate Clopixol Depot zuclopenthixol decanoate Clopixol Depot

ATYPICAL ATYPICAL ANTIPSYCHOTICSANTIPSYCHOTICS

GENERIC NAME BRAND NAME(S)GENERIC NAME BRAND NAME(S) amisulpride Solian amisulpride Solian aripiprazole Abilify aripiprazole Abilify clozapine Clozaril, Clopine clozapine Clozaril, Clopine olanzapine Zyprexa, Zydis (wafers) olanzapine Zyprexa, Zydis (wafers) quetiapine Seroquel quetiapine Seroquel risperidone Risperdal risperidone Risperdal

ANTICHOLINERGICS ANTICHOLINERGICS (Side Effect Drugs, (Side Effect Drugs,

Antiparkinsonians)Antiparkinsonians) These drugs are used principally These drugs are used principally

for the treatment of Parkinson’s for the treatment of Parkinson’s Disease. In this context, they are Disease. In this context, they are used to treat drug-induced used to treat drug-induced parkinsonism and other movement parkinsonism and other movement disorders caused by the disorders caused by the administration of antipsychotic administration of antipsychotic medications. They may be taken medications. They may be taken orally or given by injection as the orally or given by injection as the situation warrants. situation warrants.

ANXIOLYTICS ANXIOLYTICS (Antianxiety Drugs)(Antianxiety Drugs)These compounds are effective in relieving These compounds are effective in relieving

the symptoms of anxiety. The main compounds the symptoms of anxiety. The main compounds in this category are the benzodiazepines. in this category are the benzodiazepines.

SIDE EFFECTS SIDE EFFECTS Drowsiness Drowsiness Impairment of concentration and reaction Impairment of concentration and reaction

times times Impairment of some memory functions Impairment of some memory functions Muscle incoordination – especially in the Muscle incoordination – especially in the

elderly which can lead to falls elderly which can lead to falls Muscle weakness Muscle weakness Blurred vision Blurred vision

BENZODIAZEPINES BENZODIAZEPINES GENERIC NAME BRAND NAME(S) GENERIC NAME BRAND NAME(S)

alprazolam Xanax, Kalma alprazolam Xanax, Kalma bromazepam Lexotan bromazepam Lexotan clobazam Frisium clobazam Frisium clonazepam Rivotril, Paxam clonazepam Rivotril, Paxam diazepam Antenex, Ducene, diazepam Antenex, Ducene,

Valium Valium lorazepam Ativan lorazepam Ativan oxazepam Alepam, Murelax, oxazepam Alepam, Murelax,

Serepax Serepax

Electroconvulsive therapy (ECT)Electroconvulsive therapy (ECT)

Electroconvulsive therapyElectroconvulsive therapy, also known as , also known as electroshock, is a well-established, albeit electroshock, is a well-established, albeit controversial, psychiatric treatment in which controversial, psychiatric treatment in which seizures are electrically induced in anesthetized seizures are electrically induced in anesthetized patients for therapeutic effect. Today, ECT is patients for therapeutic effect. Today, ECT is most often used as a treatment for severe most often used as a treatment for severe major depression which has not responded to major depression which has not responded to other treatment,other treatment, and is also used in the and is also used in the treatment of mania (often in bipolartreatment of mania (often in bipolar disorder),disorder), catatonia andcatatonia and schizophrenia.schizophrenia.

PsychotherapyPsychotherapy

PsychoanalyticPsychoanalytic Cognitive behavioral Cognitive behavioral PsychodynamicPsychodynamic ExistentialExistential HumanisticHumanistic TranspersonalTranspersonal HypnotherapyHypnotherapy Gestalt TherapyGestalt Therapy

Social treatment and rehabilitationSocial treatment and rehabilitation Much of the skill in treating schizophrenia is in Much of the skill in treating schizophrenia is in

arranging an environmentarranging an environment that is optimally that is optimally stimulating. With insufficient stimulation negative stimulating. With insufficient stimulation negative symptoms increase; with too much stimulation symptoms increase; with too much stimulation positive symptoms become more pronounced. To positive symptoms become more pronounced. To achieve the desired balance, attention has to be achieve the desired balance, attention has to be given to the patient's accommodation his work, and given to the patient's accommodation his work, and his leisure activities. As explained above, strong his leisure activities. As explained above, strong emotional reactions by relatives are a potent form emotional reactions by relatives are a potent form of stress; therefore an effort should be made to of stress; therefore an effort should be made to reduce such reactions with family counseling. If reduce such reactions with family counseling. If this effort is unsuccessful, the patient may choose this effort is unsuccessful, the patient may choose to live in a hostel, a group home, or lodgings. A to live in a hostel, a group home, or lodgings. A homeless patient may also live in such homeless patient may also live in such accommodation. Similar attention needs to be given accommodation. Similar attention needs to be given to finding suitable work and suitable leisure to finding suitable work and suitable leisure activities for the patient.activities for the patient.