SCHIZOPHRENIA

-Gopika P Nair

T.Y.B.A

INTRODUCTION: The hallmark of schizophrenia is a significant

loss of contact with reality, referred to as psychosis.

It encompasses several differing types of relatively severe mental disorder..

As the APA(1997) has put it, "It is likely that schizophrenia is the final common pathway for a group of disorders with a variety of etiologies, courses, and outcomes.”

Typical schizophrenic- detached from reality, lost adequate mental integration & communication with the surrounding environment.

ORIGIN OF THE SCHIZOPHRENIA CONCEPT:

Benedict Morel: Used the term ‘dementia precoce’(mental deterioration at an early age)to describe the condition and to distinguish it from the dementing disorders of the old age.

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

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

Epidemiology :

As prevalent as epilepsy. Life time risk – 1% People whose fathers were older- 2-3 times more

risk Avg onset – 25 years for men and 29 for women. Majority of cases- late adolescence &early

adulthood. Males develop a more severe form of the disorder. Point prevalence- 0.2 – 2 % Lifetime prevalence- 0.% Incidence rate of new cases of schizo. In the U.S -

0.2% per year.

1 Out of 100

Worldwide

3% of Divorced

or Separated

2.5 Million Currently

in U.S.

2% of Singles

1% of Married

CLINICAL PICTURE D.S.M 4 CRITERIA: 2 or more of these symptoms present for a

significant portion of time during a 1 month period-1) Hallucinations2) Delusions3) Disorganized speech4) Catatonic behavior5) Negative symptoms Dysfunction in work, interpersonal relations or self

care. Signs of disturbance for atleast 6 months sith

atleast 1 month of symptoms listed above,

Major Divisions of Symptoms:

Positive syndrome schizophrenia: emotional turmoil, motor agitation, delusions, hallucination, minimal cognitive impairment, sudden onset etc.

Negative syndrome schizophrenia: apathy, emotional flattening, asociality, poverty of speech, insidious onset, chronic course.

Type I- positive + (good response to drugs, limbic system abnormalities, normal brain ventricles)

Type II- negative+(uncertain response to drugs, frontal lobe abnormalities, enlarged brain ventricles)

Some imp. Symptoms:

Delusions: A delusion is a false belief Some common schizophrenic delusions include:

Being cheated Being harassed Being poisoned Being spied upon Being plotted against

Most delusions are very grandiose and involve the patient at the center of some large plot or scheme

Hallucinations: A hallucination is a nonexistent stimulus that is

perceived as real The most common schizophrenic hallucination is

hearing voices, however the patient may also have visual hallucinations where they see a person or object that does not exist

Hallucinated voices often interact with the patient: By commenting on their behavior By ordering them to do things By warning of impending dangers By talking to other voices about the patient

Disturbance of associative linking: cognitive slippage , derailment, loosening or incoherence, word salad.

Disturbance of thought content Disruption of perception Emotional dysfunction: anhedonia(emotional

shallowness) Confused sense of self Disrupted volition- goal directed activity is

disrupted. Retreat to an inner world Disturbed motor behavior.

Subtypes Undifferentiated :a) Waste basket categoryb) Mixed symptom picturec) Most patients remain undifferentiated for

a long periodd) Not an early or slow insidious onsete) Sudden breakdown.f) Recurrent episodes- common.

Catatonic :a) Pronounced motor signs b) Echopraxia (imitate others) c) Echolalia (mimic phrases)d) Highly suggestible.e) No attention to bowel or bladder control,

may droolf) Facial expression- vacantg) Sudden transformation from extreme

stupor to great excitement.

Disorganized:a) Occurs at an earlier stageb) More severe disintegration of personality.c) Uncommon.d) DSM III- called “hebephrenic” schizophreniae) History of oddnessf) Gradually becomes more seclusive & more

preoccupied with fantasiesg) Emotionally indifferent, infantile, silly smile,

inappropriate laughterh) Incoherent speechi) Neologism (invent new words)j) Hallucinations – particularly auditory k) Delusionsl) Hostile & aggressivem) Obscene behavior, absence of shamen) Poor prognosis

Paranoid: a) History of increasing suspiciousnessb) Severe difficulty in interpersonal

relationshipsc) Absurd , illogical & changing delusionsd) Persecutory delusionse) Themes of grandeurf) Higher lever of adaptive coping & cognitive

integrative skillsg) Less bizarre behaviorh) Less extreme withdrawal from the outside

world.

Other subtypes

Residual type Schizoaffective disorder- schizophrenia+

mood disorders Schizophreniform disorder

Causal factors:1)Biological

2)Psychosocial3)Socio-Cultural

Biological View

Genetic Factors

Biochemical Abnormalities

Abnormal Brain Structure

Neurophysiogical

Neurodevelopmental

Genetic aspects:

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

b) Tend to run in families.c) 1st degree relative-10%d) 2nd degree relative- 3%Twin studies:e) Higher concordance rate among MZ

twins than the DZ twinsf) More discordant pairs than

concordant pairs.g) 50% gene sharing- lifetime risk of 6%Adoption studies:h) Overcomes a true separation of

hereditary from environmental influences.

1% for normal populat

ion

Relative risk for

schizophrenia

Biochemical factors:a) Neurotransmitter implicated- dopamineb) Too many dopamine receptors or these

receptors have become supersensitivec) Dopamine blocking drugs are therapeutically

nonspecific for schizophrenia.d) These drugs reduce dopamine levels to

abnormally low levels causing additional problems of severe nature.

e) Brain chemistry of schizophrenia remains imperfectly understood.

Neurophysiological factors:a) Inappropriate autonomic arousalb) Disruptions in normal attentional and

information processing capabilitiesc) Deficient in the ability to track a moving

target visually (SPEM deficit)d) Close relatives share this SPEM deficite) Anomalies are also seen in EEG reactions to

momentary sensory stimulation.f) Reflex hyperactivity & deficit performance in

neuro-psychological testing .g) Behavioral deficits such as poor p[erceptual

motor coordination or anomalies in reaction time performance suggesting neurological impairment.

Neuroanatomical :a) Abnormal enlargement of brain’s ventriclesb) Enlarged sulcic) Deficient size of temporal lobesd) Some of these abnormalities could be due to

long term use of antipsychotic medicationse) Frontal, temporolimbic, basal ganglia are

chiefly involved in integrative functionsf) Hypofrontality

Neurodevelopmental: Schizophrenics are more likely to have been

born in the winter & early spring moths Early motor abnormalities – an extremely

strong predictor of later schizophrenia. Rh incompatibility also seems to be associated

with an increased risk of schizophrenia Maternal influenza in 2nd trimister is associated

with impaired fetal growth, obsterical complications and later developing schizophrenia.

Common factor between stillbirths and schizophrenia.

Psychosocial causal factor: Faulty communication:• Double blind communication• Communication deviance• These amorphous and fragmented communications

may reflect genetic susceptibility to schizophrenia on part of the relative.

Families and role of stress:• Patients who returned home to their families had

higher chances of relapse than who returned to live alone.

• EE is also seen as a predictor of relapse• High EE- environment doubled the chances of relapse

Socio-Cultural factors: Growing up in an urban environment

increases the risk of developing schizophrenia Immigrants have higher risk than the natives

in developing schizophrenia Immigrants with darker skin have a much

higher risk than do immigrants with lighter skin.

Occurs less often in traditional , less well-developed cultures.

Lower the socio-economic status, the higher the prevalence of schizophrenia.

Treatments & Outcomes

Clinical outcome:• 15-25 years after developing

schizophrenia, around 38% patients have a favorable outcome of being recovered.

• Only 16 % recover to the extent that they no longer need treatment.

• For around 12% , long term institutionalization is necessary.

Pharmacological approach: 1st generation antipsychotics:a) Chlorpromazine(Thorazine)b) Also referred to as neurolepticsc) These revolutionized treatment of schizo more

than 50 years ago.d) The earlier the patients receive these medications,

the better they tend to do over the longer term..e) Dopamine antagonists.f) Clinical changes can be seen within the first 24

hours of treatment.g) These 1st generation ones work better for positive

symptoms of schizo.h) Side effects- drowsiness, dry mouth, weight gain.i) Extrapyramidal side effects (EPS)j) Tardive dyskinesia side effects.

2nd generation antipsychotics:a) These appeared in the 1980’s.b) 1st of these is clozapine(clozaril)c) Far fewer EPS symptoms.d) Effective in allevating both +ve & -ve

symptoms.e) Side effects- drowsiness, weight gain,

diabetes.f) Rarely, clozapine causes

agranulocytosis(drop in white blood cells)

Psychosocial approach:Mental health patients have been slow to realize the

limitations of an exclusively pharmacological approach to the treatment of schizophrenia.

Family therapy:• Working with patients and their families• To educate them about schizo• To help them improve their coping & problem

solving skills• To enhance communication skills.Case management:• People who help patients find services they need to

function in the community.• Refers them to people who will provide the needed

service.

Social skills training:• To help patients acquire the skills to function better in

the day to day life.• Employment, relationship, self-care skills .• Skills in managing medications.Cognitive behavioral therapy:• The goal is to decrease the intensity of positive

treatments, reduce relapse & decrease social disability.

• Patients who received cbt showed decreases in hallucination & delusions.

Individual psychotherapy:• Involves a staged, non psychodynamical approach

oriented to the learning of coping skills for managing emotion & stressful events.

Conclusion:

The hope for a reliable cure for schizo has not yet materialized nor can it be discerned anywhere on the horizon. Antipsychotic medications are not a cure. The psychosocial based efforts to compensate for the shortcomings of antipsychotic medication in treating schizo are not really “in place”. However, an effective approach is giving our support and unconditional love to these patients.

Thankyou!