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Batch: B2 4th Year


creed or community. Overview Schizophrenia is the most prevalent psychosis.S. Psychotic symptoms persist for months or years. Psychotherapy and behavioral therapy are inconsistently effective in the treatment of schizophrenia. a common type of psychosis. axonal outgrowth. memory deficits. affecting some 2 million Americans. flat or depressed affect. but their long-term use is associated with serious side effects. According to the neurodevelopmental hypothesis. Neuroleptic drugs shorten episodes of acute psychosis. now considered a group or spectrum of disorders rather than a single entity. characterized by abnormalities in perception. and impairment of occupational functioning. social withdrawal. when it triggers abnormalities of neuronal proliferation. content of thought. Neurophysiologic studies have shown generalized limbic lobe and prefrontal cortical abnormalities. and reduce the risk of relapse. in which individual psychic components or functions split off and become autonomous. Early symptoms include shortened attention span. The lifetime incidence risk is about 1%. of which $46 billion reflects lost productivity of patients and their caregivers. a brain lesion is present or acquired early in life but does not fully manifest itself until late adolescence or early adulthood.According to Stedman’s Medical Dictionary schizophrenia is synonymous with and replacing dementia praecox. and risperidone are more effective in improving cognitive function and less likely to induce extrapyramidal side effects. and with similar symptoms and course. temporal cortex. synaptic regression. glutamate. cell migration. Genetic studies suggest that susceptibility to schizophrenia is inherited as a complex of variations affecting several genes. of the rich or the poor. or myelination. and even with intensive psychotherapy and drug treatment about 25% require custodial or institutional care. in which 2 or more relatively complete personalities dominate by turns the psychic life of an individual. The annual cost of the disease to the U. cingulate cortex. and +-aminobutyric acid (GABA) as transmitters or modulators. limit the need for institutional care. The “split” personality of schizophrenia. Virtually all patients display impoverished thought content. cell survival. It is found in all . abnormal smallness of the thalamus. and changes in signal intensity in adjacent white matter. Persons with schizophrenia frequently stop taking their medicine. olanzipine. Newer agents such as clozapine. and it is estimated that at any given time only one-half of them are receiving medical treatment or supervision. and thought processes (hallucinations and delusions) and by extensive withdrawal of interest from other people and the outside world. Brain imaging inconsistently demonstrates structural or physiologic abnormalities in the prefrontal cortex. particularly tardive dyskinesia. with excessive focusing on one's own mental life. is popularly but erroneously identified with multiple personality. and abulia. Cognitive malfunctions are typically accompanied by reduced energy level. Epidemiology Schizophrenia occurs all over the world. and diminished ability to make decisions. The amelioration or exacerbation of schizophrenia by certain pharmacologic agents seems to indicate that it represents a malfunction of neuronal systems using dopamine. and hippocampal formation. serotonin. and there is a lifelong risk of relapse. Although some persons with schizophrenia become assassins or mass murderers. It is not a disease of any particular caste. anhedonia. economy is estimated at $65 billion. quetiapine. about 10% commit suicide. the vast majority pose no threat to society. Most patients become ill before age 40. Onset is typically gradual. with distinction sometimes made between process schizophrenia and reactive schizophrenia. without an obvious precipitating cause.

She told her mother that when she was ten. perhaps because of increased risk of substance abuse in West. Its prevalence rate is just below 1%. When she was in the tenth standard. which meant he had put his sperms into her body. However there is said to be a greater incidence in men than women. with help from her husband and in-laws! Case 4 Neetu was a carefree. loving. in fact. she attributed it to Krishna writing his name on the table. so there was no question of any physical relationship with her husband. and incidence and life time prevalence are roughly equal worldwide. She had realised this truth only now. She cannot explain the origin of her belief nor why anyone should substitute her children. suddenly became a very religious person. her personality gradually began to change. This could also be due to social drift. One terrible day. fifteen year old. She believed that Krishna slept with her. believed a Khan—a movie star—was out to kill him. Case 2 Samir. her father had exchanged his daal bowl for hers. Only the fortunate few get one episode and then recover partially or fully. taken cold and only once a day. or possibly by her husband). a pavement seller. moody. The majority of sufferers—men or women of any age group—continue to get episodes of illness. Case 3 Roshni believed her sons are not really her own but were planted on her during her delivery (possibly by the doctor. doing academically well in her private school. she started keeping herself as far away as possible from her father. Even more worrying to her parents. This does not prevent her from looking after her children fairly competently. the “truth” came out. silent and withdrawn at home. and then disappearing with the glass. in her twenties. because affected persons often leave home and migrate to urban areas. . When the glass top of a table placed near her cracked in winter. She became restless and inattentive in class. and in urban areas. Some Case Histories Case 1 Shakuntala. Shakuntala gradually stopped eating altogether and lay in bed. The course of Schizophrenia has been documented to be more severe in developed countries and the outcome better in developing and more rural societies. sociable. while delusional disorders account for a fractional percentage of the general population. a minority never recovers from the first episode. while disorders related to it (“Schizophrenia spectrum” disorders) are approximately 5%. the whole country was against him because he knew secrets against powerful people. and increased risk for suicidal and assaulting behaviour (10% of patients commit suicide). It usually begins in adolescence just when the person is learning to be independent and to deal with the world. and brought her for treatment.societies and geographical areas. calling Shri Krishna her child and refusing to eat any food except what she herself offered as prasad. It was only when Shakuntala stopped bathing or changing her clothes and began to mutter to herself that the family knew that something was wrong.

He consults psychiatrists intermittently. sweepers and maids were after her.This outlandish statement alarmed her mother and a psychiatrist was consulted. In addition to medication. These ghosts also took away her thoughts. He began to feel that whenever he spoke to someone. Finally her daughter fell ill as early as 18 years of age. which closed her ears to all outside sound. and “gave” her strange tastes and smells. The scars of schizophrenia will always remain on Neetu’s psyche and she will never really be socially comfortable. favoured her and directed her to do different things via the TV. when she was 22. after her husband’s death when she was 51. His speech became so disorganised even abusive. someone was following her and was convinced all fruit sellers. She cooks for her family once in a while. and spent all his time praying to try and drive away the evil spirits troubling him. These spirits control his body. decades after the first onset. This went on for years. He became very religious. She felt fearful. she became reclusive and isolated. He prescribed antipsychotic drugs. she began to feel that many people were speaking inside her. A famous movie star—xxx Khan though. is doing poorly at his job and finds it difficult to meet daily requirements of life. Finally. hardly speaking to anyone at home. Their sister Parvati was luckier. at the age of 24. She fell ill relatively late. But Neetu is now friendlier with her father. rehabilitation and psychotherapy were also begun. and sometimes would cry without reason too. Then later on. he involuntarily switches on to a totally different topic and his brain is totally empty. Apart from the dramatic symptoms outlined above. accepting that her delusions about him were not real. which unfortunately did not suit Neetu. her parents heard of a new antipsychotic drug and consulted another psychiatrist. As a result he has become a total recluse. Neetu and Roshni are all suffering from schizophrenia. She refused to take medicines. Samir. he often complains of numerous bodily symptoms. She became a recluse. often not even bathing for days together. commenting on her. she would not allow her children to go out at all. and is now thinking of joining Open School to complete her 12th. his own brain would be uncovered and the other person could immediately understand what he was going to talk about. His brother Suresh Chand fell ill at age 38. Case 5 In a family. He felt he could no longer control his emotions. mind and his thoughts even today. . As a result. Five years before her illness began. He complains that whenever he speaks. No illness (except schizophrenia) has ever been diagnosed. Shakuntala. She now often laughed without reason. They threatened her. She felt some ghosts were using her body and spoiling her. and warned her that if she allowed anyone in her family to go out of the house the voices would kill them. She had to be withdrawn from school both because of her odd behaviour and also because of her repeated failures. the disease may affect many members. The first to fall ill was Laxmi Chand. Here is an example. They pollute his thoughts. and her behaviour became more and more queer. Now. they had many other symptoms and disabilities. and put obstructions in his way. He isolated himself from his relatives because he believed that they had set evil spirits onto him. that the listener could not understand it. and heard shrill voices.

lasting each time for less than six months. but may again become placid. as they grow older. monozygotic and dizygotic. Symptoms Onset of illness may be sudden even catastrophic. • Good premorbid social and occupational performance • Absence of blunted or flat affect • If the combined duration of symptomatology exceeds 6 months. The most researched among these are Dopamine. Some people. are fortunate to experience a gradual decline in symptoms.becomes closer.Brief Psychotic Disorder • ICD-10: psychotic conditions with onset within 2 weeks and full remission within 1 to 3 months • DSM-IV TR: sudden onset of psychotic symptoms lasts 1 day or more but less than 1 month. wax and wane. The illness is marked by a variety of symptoms. however. Remission is full • With/without marked stressors • Emotional turmoil and confusion: good prognosis • Negative symptoms: poor prognostic features • Confusion or perplexity at the onset. Sudden onset sufferers generally have a better prognosis. In most people the disease runs a long and continuous course.“proband” . rhesus (Rh) factor incompatibility may all end into the schizophrenia phenotype. Only last for a brief period. As an added complication. influenza epidemics or maternal starvation. to the critical role that the environment plays in modulating genetic susceptibility in mental disorders. This may be due. and appear again after some time. do not share the disorder). various combinations of genes may all lead to the same disorder. This ambiguity could be due to environmental influences or interactions with other genes. catecholamines and Gamma Amino Butyric Acid (GABA). which use two types of twin pairs for exploring the role of inheritance that is. The disease may erupt and become severe. risk of schizophrenia increases. A given susceptibility gene may or may not result in the disorder. The most prominent features are: disordered thinking . then schizophrenia should be considered. About 25 per cent people with schizophrenia become symptom-free in their later lives. disappear. Thus schizophrenia may be due to failure of the normal development of the brain or a disease process that alters a normally developed brain leading to multiple possible outcome types. This risk increases from 1% in the general population to nearly 50% where both parents are schizophrenic or in pairs of monozygotic twins. one or more specific gene/s has not been unambiguously identified so far. The illness may then stop recurring. These studies have shown that as relationship to the identified patient . cognitive dysfunction and disturbances in affect. This is called schizophreniform disorder. The neurotransmitter hypothesis of schizophrenia postulates either increased or disturbed production or transmission of various neurotransmitters in the brain. Etiology Schizophrenia has a very strong hereditary component. or insidious and gradual. Alternately genetic susceptibility or “mistakes” in neurodevelopment during intrauterine life may also increase susceptibility to this disorder. But even monozygotic twins are not always concordant (i.e. In some people the symptoms may come and go only once. Environmental factors such as gestational and birth complications. subtle neurological manifestations. in part. Also.. despite strong evidence for genetic susceptibility. Whether these disturbances are the cause or effect of the disease are still matters of debate. Familial risk has been documented through twin studies. The severity of symptoms and the functioning of a person may.

Hallucinations (hearing threatening or unfriendly voices.which becomes incoherent. impulsive actions and utterances. and hallucinations. This lack of insight worsens their suffering because they do not understand the fact that medication is a necessity for them. Bizarre delusions is another common feature. incongruity of emotion. symptoms of almost all other mental illnesses in one form or other. or that his thoughts are being said aloud or broadcast on radio or TV). Paranoid thoughts (the beliefs that one is surrounded by hostile forces which keep a close watch and secretly intervene to harm). often of unfriendly kind. disjointed. Sufferers may also perform strange movements. that other people can read his thoughts. where a person begins to hear voices. at some time or other) Difficulties in money management Severe distrust or suspiciousness Compromised learning ability Poor memory Physical violence Risk of harming self Poor grooming and hygiene . Symptoms of Schizophrenia “Core” symptoms Disorderly thinking Incongruity of emotion Impulsive actions and utterances Bizarre delusions (with little or no appreciation of why the ideas are not acceptable to the people around). or rambling speech Abnormal posturing or movement Difficulty in coping with home and work related responsibilities Associated symptoms Unexplained physical tiredness Poor concentration Sleeping problems Appetite problems Diminished sexual interest Overly dependent behaviour (In short. that other people put thoughts into his mind or withdraw them and make them public in some way. Passivity feelings (the person is convinced that his actions are controlled by an alien power). where none exist). disjointed and rambling. Incoherent bizarre behaviour Incoherent. or sees objects that do not exist. Thought insertion and thought broadcasting (the person feels that his thoughts are not his own. Most people with schizophrenia do not recognise that their mental functioning is disturbed or that they need help.

Somatic type–Delusional parasitosis. Hallucinations must occur in clear consciousness. and display a blank facial expression. feel. monotonous voice. smell. their speech may become incoherent or nonsensical. their persistence and bizarreness eventually can only be explained on the basis of illness. laugh suddenly without explanation. he may maintain a rigid. Delusions may be of grandeur. and thought processes are fragmented or disorganized. He may also have . Social withdrawal Several “negative” symptoms may occur—the most characteristic being social withdrawal— avoiding others. However. it is important to look at its characteristic symptoms: Delusions Delusions are false ideas or beliefs that may sometimes be believed for short periods of time. or may engage in constant. power or persecution. are especially common: including two or more voices conversing with each other. or may display clearly inappropriate sexual behaviour such as masturbate in public (extremely rare in our population). they may show “poverty” of speech (either less words or less ideas conveyed through words). A patient complained of mobile jammers closing up his insides so that he could not pass stool! Another believed that strangers from space had passed some kind of rays into his brain because of which his brain stopped working. hear. Jealousy. Bizarre behaviour A person with schizophrenia may appear disheveled. Grandiose. decreased emotional expressiveness. Body odour (Bromosis). Delusional disorder: Presence of non-bizarre delusions lasting for more than 1 month without prominent hallucinations. wear multiple shirts. and may see. or taste things that are not really there. coats. They may jump from topic to topic or string together loosely associated phrases. Auditory hallucinations. may walk backward. bizarre pose for hours. In severe cases muteness—no speech at all—may intervene. In rare cases. Disorganised thinking and speech Since speech is the mirror of thought. She/He may also believe that others are controlling his thoughts or that his own thoughts are being broadcast to the world so that other people can hear them. random or repetitive movements. or slow speech. scarves and gloves or use inappropriate make up). oddly dressed (for example. They may also combine words and phrases in meaningless way or make up new words. Erotomanic/Amorous. They may suddenly stop talking in the middle of a conversation. make strange faces. such as hearing voices when no one else is around. or voices that command the person to do something. and talking in a low. avoid eye contact with others. Persecutory. Hallucinations People with schizophrenia may also experience hallucinations (false sensory perceptions). may talk to himself. voices that continually comment on the person’s thoughts or behaviour.To develop a clearer understanding of the illness. or even extremely bizarre. In addition. Dysmorphic delusions. may shout or swear without provocation.

and planning ahead. depression. Negative symptoms (affective flattening. the worse is the outcome. and careful mental status examination. endocrine. head • EEG and MRI as needed • HIV and syphilis tests when needed. The deficit form of . • Genetic-chromosomal phenocopies: Huntington’s. become overly dependent. tumour. syphilis. Therefore. Renal and Thyroid function tests. Other symptoms People with schizophrenia may face difficulties with memory. may oversleep or find difficulty in sleeping. NSAIDs. aqueduct stenosis. Electrolytes. those caused by head trauma or a brain infection. steroids.difficulty in experiencing pleasure and may not participate in any work or social activities. avolition). alogia. and suicidal thoughts. • Fasting glucose. trauma. Disorganised speech. The onset of schizophrenia among women is said to be bimodal. AIDS. XXX. developing an independent diagnostic test. They commonly suffer from anxiety. is a priority research area for this disease. • ECG and X-ray chest. antihypertensives. deficiency. XYY. it may result in incorrect or harmful treatment. attention span. Course of illness is said to be more benign in females perhaps because Estrogen modifies course or because females show better response to antipsychotic drugs. • Lipid profile. familial basal ganglia calcification and others. • Mood disorders. • Brain injuries or disease: CV episodes. anti-parkinsonian. Wilson’s disease. and several others. chorea. there is poor intermediate and poor long-term course. The more acute the onset and later the age of onset. Onset and Course of Illness Western research describes men as having mostly unimodal onset of positive symptoms with peak incidence from 18 to 25 years of age. with the first peak between 20 and 25 years of age and second peak after 40 years of age. XXY. This lack of volition stops him from initiating and pursuing goal-directed activities. Investigations • Careful history and full physical-neurological examination • Complete Blood Count. Differential diagnosis • Drugs: of abuse. and face problems in money management. The longer the duration of untreated psychosis. Hallucinations. Diagnosis Schizophrenia is diagnosed by its psychopathology—abnormalities in thinking and perception as inferred by the person’s speech and behaviour. Grossly disorganised/catatonic behaviour. abstract thinking. antidepressants. the better is the prognosis. If a misdiagnosis occurs. • Metabolic-systemic diseases: infectious. are essential for diagnosis. autoimmune. Diagnosis of Schizophrenia: Delusions. preferably laboratory based. Where the onset is insidious. Laboratory Test and Differential Diagnosis Individual symptoms of schizophrenia can occur in a diverse number of illnesses–for example. • Liver. Since there are no blood or laboratory tests: a detailed history of mental and physical disorders in the individual and his family. They may experience physical tiredness for no valid reason. suffer a loss of sexual interest.

to diminish anxiety. Aripiprazole • Long Acting Injectables: Fluphenazine. Poor self care. The disease progresses if left untreated. Other modes of administration such as long acting injectable antipsychotics or mouth dissolving oral medication can also be tried. Management and Treatment In the acute stage—lasting usually for 4–8 weeks—the chief aim is to control acute psychotic symptoms. During the subsequent stabilisation phase. The mainstay of treatment in schizophrenia are drugs mainly antipsychotics. Uncooperative patients may need home visits and treatment in the home setting. Risperidone. Egocentric (Western) cultures traditionally are more stressful for men and here they show worse prognosis. or violence towards others. as this drug can cause fatal leucocytopenia. If there is no response. Individual selection is based on history of response to a drug. There is also higher risk of drug abuse. This is not a self-limiting disease. the aim is to consolidate therapeutic gains as risk of relapse increases if treatment is stopped. motor side effects (table below) are seen while newer ones cause different metabolic side effects. Some antipsychotic drugs available in India • Typicals: Chlorpromazine. Most common especially with older antipsychotics. Up to 10% of patients commit suicide and up to one third attempt it at some point of the disease. Among resistant cases Clozapine may be considered under strict monitoring of blood count parameters. Relatives are confused wondering if the person is ill or just pretending. They may also need to be brought to hospital either after preliminary treatment at home or (if dangerous to self or to others) under police escort. as ups and downs may occur in the course of the disease. Non-progression does not mean cure. Flupenthixol. or there are various life stresses. Haloperidol. There is increased risk of self harm or suicide. Lastly during the stable or maintenance phase the patient is in remission. as behaviour may swing from normal to abnormal. especially in the West and especially of nicotine. Clozapine. Trifluoperazine. and side effect profile of the drug. The economic and human costs of this illness are high the world over. induce remission. inactivity and slowness become sources of distress to both sufferers and their families. Flupenthixol. Newer antipsychotics are now the first drugs of choice. Olanzapine. older antipsychotics can be tried. Risperidone. Similar to other classes of drugs antipsychotics show several different types of side effects. Many leave home and are lost and others remain disabled. Ziprasidone. This is because most antipsychotics are broadly similar in efficacy and differ mainly in their side effect profiles. But even in developing countries up to half the sufferers may remain unemployed and dependent. This illness is said to have a better outcome in developing rather than in industrialised countries. Motor side effects of antipsychotic drugs . and the aim is to prevent relapse and improve level of functioning. preference for a particular drug or mode of administration. Haloperidol. Clopenthixol.schizophrenia with mainly negative symptoms is predominantly a male disease. maintain the achieved clinical effect and to prevent relapse. Quetiapine. Some may be totally withdrawn and uncaring of themselves and others. Antipsychotic drugs antagonise postsynaptic dopamine receptors in the brain and are useful to manage acute positive psychotic symptoms. • Atypicals/Newer: Thioridazine.

Studies state that 55% of sufferers show moderately good outcomes and 45% have more severe outcomes. respiratory muscles. hyperlipidemias and new onset type II diabetes mellitus. Hence multiple relapses are detrimental to overall outcome. patients may regain some degree of social and occupational competence and become less disruptive and easier to manage. Later on. Nevertheless the majority will continue to experience various symptoms and to have social and cognitive disabilities. Increased risk for cardiovascular disease. Other common side effects (newer antipsychotics) Sedation. Outcome Therapeutic advances over the last four decades have enabled most persons with schizophrenia to live in the community. With each episode. better adjustment in adolescence. Weight gain. supportive psychotherapy has a definite role to play to improve symptoms and enhance quality of life. Each successive episode requires longer returning to a remitted state. spasmodic torticollis. strategies for coping and social skills training. Family Therapy and Vocational Rehabilitation Rather than formal psychotherapy. Psychotherapy should focus on education about illness. considerable amounts of patience and perhaps most importantly the ability to allow the patient to proceed at his own pace would be the best strategy for success. . Role of Psychotherapy. Use of structured but realistic activity schedules and programmes. In several World Health Organisation studies on outcome. Other predictors of good outcome were: being married. During the first 5 to 10 years patients may have multiple exacerbations followed by a Plateau phase where there is underlying deterioration. rigid posture Tongue protrusion. rigidity. It also helps to reduce disinterest and passivity. festinant gait. Reducing rather than increasing. It is essential to continue pharmacological treatment because stopping medication often precipitates relapse. ophisthotonus. limbs. Effective and earlier initiation of pharmacological treatment makes considerable difference in early course and a modest impact on long-term course. This involves setting a target well beneath a patient’s capability in order to enable him to attain it. In general studies clearly demonstrated the effectiveness of social skills training procedures in improving specific behavioural social skills as well as more global measures. patients seem to lose something that they do not recapture. The relationship between social competence and psychiatric disorder has been known for quite some. of female gender. restlessness Abnormal involuntary movements of face. the pressures and expectations that patients impose on themselves and those which others impose on them improves performance. oculogyric Movement. The technique of paradoxical intention may be useful. the most important predictors of good outcome were origin from a developing centre and acuteness of onset.Parkinsonian: Dystonias: crisis Akathisia: Tardive dyskinesia: Tremor. The prophylactic use of antipsychotics reduces relapse rates. bradykinesia. more frequent contacts with friends and no use of street drugs.

Such groups now growing in India too support members. They have played an important role in improving health care conditions for the mentally ill as well as for reducing the stigma associated with mental illness. This is because schizophrenia patients have a low level of job retention both due to the disease process itself as well as due to stigma. provide education. Supported employment programmes. Working with the entire family from time to time helps both patients and careers and helps to prevent negative familial affect (criticism. individual placement programmes that immerse and support patients at the job site are the need of the hour in India. dispel myths about the illness and improve treatment standards. Educational and supportive family interventions have an important effect on relapse prevention. Vocational rehabilitation is the most important aspect of psychological intervention in schizophrenia. over involvement). It also helps to reduce heavy burden of caring for chronically ill.Families are important allies of professionals in the management of schizophrenia. hostility. Family advocacy and mental health consumer movement has been especially active among sufferers and carers of schizophrenia. .

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