PSYCHIATRY II

SCHIZOPHRENIA
Clinical syndrome w/ profoundly disruptive
psychopathology that involves cognition,
emotion, perception & behavior
Begins before age 25, persist throughout
their life & affects persons of all classes
AFFLICTS ABOUT 1% OF THE
POPULATION USUALLY
BEGINS
BEFORE AGE 25

DIAGNOSIS IS BASED ENTIRELY

ON
PYCHIATRIC HISTORY &
MENTAL
STATUS
EXAMINATION

THERE IS NO LABORATORY TEST

SCHIZOPHRENIA HAS HETEROGENOUS CAUSES
PATIENT SHOWS DIFFERENT CLINICAL
PRESENTATIONS, TREATMENT RESPONSES &
COURSES OF THE ILLNESS
HISTORY
BENEDICT MOREL (1809 1873) French
Demence Precoce deteriorated patient whose
illness began in adolescence
EMIL KRAEPELIN (1856 - 1926) translated it
into
DEMENTIA PRECOX
DEMENTIA distinct change in cognition &
PRECOX - early onset of the disorder
- patient have long term deteriorating course with
symptoms of hallucinations & delusions
EUGEN BLEULER (1857 1939)
SCHIZOPHRENIA
- presence of schisms between thoughts,
emotions, & behavior in patients w/ the disorder
- Primary symptoms (4 As)
Associational Disturbances (looseness)
Affective Disturbances
Autism, Ambivalence
- Secondary symptoms
Hallucinations, Delusions
Ernst Kretschmer (1888-1826), common
among ASTHENIC, ATHLETIC or DYSPLASTIC
body types rather than pyknic
Kurt Schneider (1887-1967) introduce first
& second rank symptoms for the disorder
First Rank
Audible thoughts, delusional perceptions, thought
withdrawal/broadcasting, voices arguing, voices
commenting, somatic passivity
Second Rank
Other disorder of perceptions, sudden delusional
ideas, perplexity
, depressive & euphoric
mood changes, feelings of emotional
impoverishment
Adolf Meyer (1866-1950) founder of
Psychobiology, saw schizophrenia as reaction
to life stresses

Schizophrenia found in all societies &

geographical areas worldwide
Lifetime prevalence is 1 %, about 1 person
in 100 will develop it during their lifetime
NIMH lifetime prevalence (0.6-1.9%)
Annual Incidence 0.5 to 5 per 10,000 w/
incidence higher in persons born in urban
areas of industrialized nations
Equally prevalent in men & women
Earlier onset in men than in women
Peak onset: Men
- 10 to 25 years
Women - 25 to 35 years

ONSET:
Before 10 or after 60 extremely rare
OUTCOME
- Better for female than male
- Men likely impaired by negative symptoms
LATE ONSET SCHIZOPHRENIA
Onsets occurs after age 45

Some studies shows that frequency

increased following exposure to Influenza
which occurs during winter & second
trimester of pregnancy
Northern Hemisphere (USA) - born January
to April
Southern H. born July to September
First degree biological relatives have 10
times greater risk for the disease than the
general populations
Several studies shown that 80% patients
have significant concurrent medical
illnesses & 50 % may be undiagnosed
Schizophrenia patient belongs to the low
socio-economic group
DOWNWARD DRIFT THEORY
affected persons move into or fail to rise
out of the low socio-economic group due
to the illness
SOCIAL CAUSATION HYPOTHESIS
proposes that stresses experienced by the
low socio-economic groups contribute to
the development of the disorder
ETIOLOGY
STRESS DIATHESIS MODEL
( for biological, psychological &
environmental factors)
-a person may have a specific
vulnerability (diathesis) that when acted
on by stressful influence, allows the
symptoms to develop
NEUROBIOLOGY
DOPAMINE HYPOTHESIS
- schizophrenia results from too
much dopaminergic activity
Other neurotransmitters involved:
Serotonin
Norepinephrine
GABA
Neuropathology
Limbic system, basal ganglia
cerebellum, frontal lobe
Eye Movement Dysfunction (present in 50 t0
85% of patient)
inability to follow moving visual target
accurately disorder of smooth visual pursuit
& disinhibition of saccadic eye movement
Psychosocial Factors
Freud: early fixations & ego defects which
resulted to poor object relations
Mahler: never achieves object constancy,
characterize by a sense of secure identity &
which results to from close attachment to the
mother during infancy.
DIAGNOSIS
DSM IV CRITERIA
A)2 or more of the following must be
present for a period of 1 month delusions,
hallucinations, disorganized speech, grossly
disorganized behavior, negative symptoms
(alogia, avolition)
B) Social/occupational dysfunction

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PSYCHIATRY II
C) Duration: persist at least 6 mons
D) No due to a substance/general medical
condition
SUBTYPES:
1. PARANOID:
preoccupation of with one or more delusions,
frequent auditory hallucinations
2. DISORGANIZED:
disorganized speech & behavior, flat or
inappropriate affect
3. CATATONIC:
motoric inability, waxy flexibility, excessive
purposeless motor activity, extreme
negativism, peculiar voluntary movements,
echolalia, echopraxia
4. UNDIFFRENTIATED TYPE:
criteria A is present but the criteria are not
met for paranoid, catatonic & disorganized
5. RESIDUAL TYPE
absence of prominent symptoms but has
continuing evidence of negative symptoms
(odd beliefs, unusual perceptual experiences)
OTHER SUBTYPES:
Bouffee Delirante (acute delusional psychosis)
Oneiroid
Paraphrenia
Simple Deteriorative Disorder
Early Onset Schizophrenia
Deficit Schizophrenia
CLINICAL SYMPTOMS
No clinical symptoms is pathognomonic
History is essential for diagnosis
Symptoms changes with time
Premorbid signs & symptoms:
- quiet, passive, introverted, few
friends no dates or close friends,
avoid team sports, enjoy solitary
activities avoids social activities
POSTIVE SYMPTOMS: (productive)
Hallucinations & Delusions
NEGATIVE SYMPTOMS: (deficit)
Affective flattening or blunting, poverty of
speech (alogia), lack of motivation, social
withdrawal
MENTAL STATUS EXAMINATION:
Appearance disheveled, agitated, silent,
immobile
MOOD, FEELING & AFFECT - reduced emotional
responsiveness
PERCEPTUAL DISTURBANCES auditory
hallucination
COURSE & PROGNOSIS
Course: has exacerbation & remission with
deterioration of functioning following relapse
Prognosis:
Criteria for good prognosis late onset,
acute onset, married, good support system,
positive symptom, good pre-morbid social, sexual
& work histories

Malingering & Factitious Disorder

Other psychotic Disorder
Mood Disorder
Personality Disorder
TREATMENT
Hospitalization for diagnostic purposes,
stabilization of medications, patients
safety, issues of self-care
Pharmacotherapy
Dopamine receptor antagonist
Serotonin dopamine antagonist
DOPAMINE RECEPTOR ANTAGONIST
(CONVENTIONAL ANTI-PSYCHOTIC
MEDICATIONS)
Example: haloperidol, chlorpromazine
associated with serious side effects
such as:
- Akathesia
- Parkinsonian symtoms
- Tardive dyskinesia
SEROTONIN-DOPAMINE ANTAGONIST
(ATYPICAL ANTI-PSYCHOTIC)
Example: clozapine, respiridone,
olanzapine, quetiapine
effective for broader range of
patients with schizophrenia with
fewer side effects
OTHER DRUGS:
o LITHIUM
o ANTICONVULSANTS
o BENZODIAZEPINES
o ELECTROCONVULSIVE THERAPY
THERAPUETIC PRINCIPLES:
1. Define target symptoms
2. Use medications that work well in
the past with the patient
3. Minimum trial is 4 to 6 weeks of
adequate dosage (avoid increasing
dosage at first two weeks of
treatment)
4. Avoid using more than one drug
unless indicated in treatment
resistant (combination of tegretol can
be use)
5. Patient should be maintained in
lowest possible effective dosage of
medications
PSYCHOSOCIAL THERAPIES
increase social abilities, selfsufficiency, practical skills &
interpersonal communications
Example:
- Social skills training
- Family oriented therapy
- Group & Individual therapy
VOCATIONAL THERAPY
setting & method used to help
patient regain old skills or develop
new ones

DIFFERENTIAL DIAGNOSIS
Secondary Psychotic Disorder

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