SCHIZOPHRENIA

INTRODUCTION
 Characterized by fundamental and
characteristic distortions of thinking and
perception, and by inappropriate or blunted
affect.
 Clear consciousness and intellectual capacity
is usually maintained, although certain
cognitive deficit may evolve in the course of
time
 Functional psychotic disorder with
multifactorial etiology
 HISTORY
 1852: Benedict Morel: “demence precoce”
 1896: Emil Kraeplin: “dementia praecox”
 1911: Eugen Bleular: “Schizophrenia”
Basic symptoms:
Autism, Ambivalence, affective blunting,
Association
Accessory symptoms:
Hallucination, delusion, catatonic symptoms,
speech disorders
 HISTORY contd…

 1959: Kurt Schneider: “Schneider first rank

symptoms of schizophrenia”
 Current Classification
ICD-10 (WHO) & DSM-IV (APA)
 EPIDEMIOLOGY
 Incidence: 0.05 - 0.25%
 Prevalence: 0.2 - 1%
 Sex: Equal
 Age: 15-25yrs (Could be any age)
 Socio-economic: No difference
 Risk for children of two schizophrenic parents: 50%
 No population or culture has been identified in which
schizophrenia does not occur
 Prognosis is generally better in developing countries
SCHNEIDER’S FIRST RANK SYMPTOMS
A. Hallucinations
1. Hearing thought spoken aloud
2. Third person hallucination
3. Hallucination in the form of commentary
B. Thought Alienation Phenomena
4. Thought withdrawal
5. Thought insertion
6. Thought broadcasting
C. Passivity phenomena
7. “Made” feelings or affect
8. “Made” impulses
9. “Made” volition or actsfeelings or affect
10. Somatic passivity
D. Delusional perception
 Positive symptoms – hallucinations,
delusions, bizarre behaviour, formal thought
disorder, inappropriate affect

 Negative symptoms – affective flattening,

poverty of speech/thought, avolition – apathy,
anhedonia, social withdrawal, inattentiveness
 CLINICAL FEATURES
A) General Behavior
Withdrawal
Overactivity, aggressive, aversive or
destructive
Catatonic stupor
Waxy flexibility
Posturing
Negativism
Automatic obedience
echolalia
Echopraxia
(B) Disorders of thinking
a) Disturbance of thought process
i) Irrelevant speech
ii) Incoherent speech
iii) Loosening of association
iv) Circumstantiality
v) Tangentially
vi) Neologism
vii) Verbigeration
ix) Poverty of thought
x) Thought block
xi) Perseveration
xii) thought being read
xiii) thought control
xiv) Thought withdrawal
b) Disturbance of thought content
Delusion (control, persecution,
reference, grandeur)
(C) Disorders of perception
Hallucination - Auditory, visual, tactile,
gustatory and olfactory

(D) Disorders of Affect

Apathy
Blunting
Incongruity

(E) Attention and Concentration

Attention - difficult to arouse
concentration - generally poor
(F) Impulse control
Usually poor
Behaviors is unpredictable

(G) Orientation and consciousness

Conscious and oriented to time, place and person

(H) Intelligence and memory

Usually not affected

(I) Insight and Judgement

Insight is often poor and can not make proper
Judgement
 CATEGORIES (SUBTYPES)
I. Paranoid:
Delusion & Hallucination
II. Hebephrenic (Disorganized):
Disorganized speech &
Flat and inappropriate affect
III. Catatonic:
Psychomotor disturbance
IV. Undifferentiated:
Meeting general criteria but no specific subtype prominent
V. Post-schizophrenic depression:
Some residual symptoms, but depressive picture
prominent

VI. Residual schizophrenia:

Previous “positive” symptoms
Prominent “negative” symptoms

VII. Simple schizophrenia:

No delusion or hallucination
Insidious development of negative symptoms
without positive symptoms
 ETIOLOGY
I. Genetics

A. Close relatives show much higher risk of schizophrenia

compared to general population.

B. MZ twin have a high concordance rate for schizophrenia

C. The biological parents of a schizophrenic shown higher

prevalence of this disorder then the adopted parents
 Schizophrenia and Genetics
 Sz risk increases with genetic similarity
Lifetime risk
of developing 40
schizophrenia
for relatives of 30
a schizophrenic
20

10

General Siblings Children Fraternal Children Identical

population twin of two twin
schizophrenia
❚ This suggests a biological cause victims
II. Biogenic Amines

Schizophrenia is presently thought to be probably due to increase

of dopamine at the post synaptic receptor. Other neurotransmitters
like serotonin, excitatory amino acids (glutamate and aspartate) are
also presumably involved.

III. Neuropathology

Cranial CT Scan, MRI and post-mortem studies show enlarged

lateral and third ventricles, and mild cortical atrophy
PET - shows hypofrontality and decreased glucose utilization in
dominant temporal lobe.
IV. Psycho Social

A. Socio-economic status

B. Family psychopathology: Inappropriate communication

amongst the family members

C. Stress
Schizophrenia commonly develops during adolescence and or in
post-partum phase and both these periods are of intense
endocrine disturbances as well as psychological stress. It is
possible that some biological or psychological stress may be
associated with the precipitation of the disorders in vulnerable
individual.
 INVESTIGATION
 No diagnostic test
 Screen for drugs of abuse (urine)
 Bloods for CBC, biochemistry, blood glucose,
TFTs, TPHA and VDRL
 EEG
 ECG
 CT and MRI brain
 MANAGEMENT
 a) Management of acute episode

 b) Maintenance treatment

 c) Rehabilitation
 TREATMENT
 May require admission if acutely disturbed or
present a risk to self or others
 Admission may be useful in assessment
 Essential to assess suicide risk as there is a
mortality of about 10% from suicide in SCZ
 May require involuntary detention in some
cases
 Antipsychotic drugs are mainstay of treatment
 Generally atypicals are first-line treatment eg
olanzapine, respiridone, arpiprazole
 May require depot injection
 Side effects of typicals can be stigmatising
 Side effects of atypicals – screen for DM
 Atypicals have fewer extra-pyramidal side
effects and tend to be better for negative
symptoms that typicals
 Initial management may include use of sedative
medication such as lorazepam
 IM medication may be required in a very disturbed,
involuntary patient
 Maintenance treatment – generally maintenance on
one medication
 Compliance may be a significant problem because of
long-term nature of treatment and lack of insight
 Psychosocial treatment
 Education of patient and carers
 Reduction of high expressed emotion – shown to affect

relapse rates
 Cognitive behavioural therapy – controversial

 Rehabilitation
 PROGNOSIS
 22% have one episode and no residual impairment
 35% have recurrent episodes and no residual
impairment
 8% have recurrent episodes and develop significant
non-progressive impairment
 35% have recurrent episodes and develop
significant progressive impairment
 The majority therefore do not recover fully
 Suicide rate is up to 13%
 Little evidence that antipsychotic have altered
the course of illness for most patients
 However, evidence that prolonged psychosis
which is untreated has a bad prognosis
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