Schizophrenia

At the end of the lecture you should be able to
• Define the disorder
• Describe its prevalence
• Narrate first rank, Bleuler’s 4 A’s &
positive/negative symptoms
• Make ICD-10 diagnosis of the illness
• Summarise genetic, biochemical, and
organic etiological factors
• Describe good/bad prognostic
features
• Outline main types of schizophrenia


Develop a differential
diagnosis: identify historical &
clinical features indicating
general medical, affective, and
other causes
Summarise treatments
including pharmacological &
psychosocial interventions
List features distinguishing
delusional disorder,
schizophreniform,
schizoaffective, & brief reactive
psychosis from each other and
from schizophrenia

Psychoses
Schizophrenia

Brief psychotic
episode

Psychoses

Delusional disorders

Schizoaffective

Schizophrenia
A syndrome in which disturbances of thoughts, feelings, perceptions,
and cognition result in abnormal behaviour

Epidemiology
Rate

Co morbidity





Lifetime prevalence 1.0%
Point prevalence
0.4%
Incidence
0.02%

Age

Males
Females

15-35
25-45

Equally common

Fertility

Reduced

Violence

80%
75%
50%

Financial cost

Gender

Medical illnesses
Cigarette smoking
Substance abuse

Risk 5 times higher


50% seek treatment
Exceeded $ 65 billion in US
1991

Social class


Equal in all social classes
Up to 10% in deprived areas
due to downward drift
Migration not risk factor

Etiology
Genetic

Neuro
developmental

Physical

Schizophrenia

Biochemical

Psychological

Etiology
Genetic
• MZ = DZ concordance 50% = 15%
• Premorbid personality 25%
Solitary & suspicious
Emotionally cold

Biochemical

Dopamine

Serotonin

Physical (CNS)
• Genetic



Brain Infections
Head trauma
Brain tumors
Epilepsy

Amphetamine psychosis
Action of typical AP’s

Substance abuse

Cannabis increases risk by 2.4-fold
Risk increases in more frequent users

Psychosocial

Defective filter
Expressed emotions (relapse)
Critical comments
Over involvement
Hostility

LSD psychosis
Action of atypical AP’

Neuro-developmental

Increased VBR

Huntington’s chorea
Wilson’s disease
Syphilis & HIV

Cerebral asymmetry

1.
2.
3.

Maternal influenza
Winter births
Birth complications

Hippocampus
Para hippocampus
Amygdale
2nd trimester
8% higher

Schizophrenia
Etiology (summary)
• Neuro-developmental disorder
• Genetically determined or produced in developing brain
• Architecture of temporal lobes & their connections with frontal lobes
abnormal; normal migration of neurons disturbed
• Neurons smaller with less neuropil
• Reduced expression of synaptophysin mRNA
• Absence of gliosis
• Changes manifest in first degree relatives before onset
• Performance IQ lower than verbal
• Subtle intellectual and social disabilities before illness

First rank symptoms
Thoughts


Insertion
Withdrawal
Broadcasting

Auditory hallucinations


Third person
Commentary
Thought echo

Made acts



Perceptions
Thoughts
Feelings
sensations

Delusional perception

Bleuler’s Four A’s
• Autism: withdrawal into fantasy
• Association loss: between
thoughts or other faculties;
difficulty to give straight answer,
irrelevant answers, concreteness,
over inclusiveness, thought block,
neologisms

• Affect loss:

ability to feel or
inappropriateness

• Ambivalence:

caught up
between two opposing wishes or
impulses

Symptoms
Positive
• Delusions

Negative
• Affect (blunting)

• Hallucinations

• Alogia
• Thought disorder
• Affect (inappropriate)

• Avolition

• Attention

• Anhedonia

Mental Status Examination
Acute

Chronic

A & B: poor rapport, self neglect,
A & B: ithdrawn, fearful,
abnormal movements
noisy
Affect: blunting, inappropriate
Affect: perplexity, inappropriate Thought: poverty, derailment,
delusions±
Thought: vagueness, delusions Perceptions: hallucinations±
Orientation: age disorientation
Perceptions: Hallucinations
A & C: impaired
Orientation: normal
Memory: normal
A & C: impaired
Insight: impaired

w

Memory: intact
Insight: impaired

Diagnostic criteria
ICD 10
Symptoms





First rank symptom
or
Bizarre delusion
or (2) of the following:
Persistent hallucinations
accompanied by delusions
Thought disorder
Catatonic behaviour
Negative symptoms

Duration one month
Organicity absent

Types
(Divisions arbitrary)
Paranoid
• Delusions & hallucinations
• Personality intact
• Prognosis better
Hebephrenic
• Primitive behaviour
• Shallow inappropriate
affect
• Thought disorder

Catatonic
• Muscle tone
abnormalities
• Inhibited / excited states
• Posturing
Simple
• Increasing eccentricity
• Progressive deterioration
• Worst prognosis

Differential diagnosis
Assessment

Syndromes
Substance abuse
Amphetamine & cocaine: hallucinations and delusions with CNS
overactivity
Alcohol hallucinosis: auditory hallucinations with clear consciousness
Alcohol withdrawal
Anticholinergics

CNS disease

History
Premorbid personality: antisocial, schizoid
Physical symptoms suggestive of organic disease or
substance abuse

MSE

Thyroid & adrenals

Overactivity, flight of ideas, goal directed speech, elation,
fleeting grandiose delusions
Visual & tactile hallucinations
Illusions
Cognitive function tests

Metabolic disorders

Physical Examination

Tumors, stroke, brain trauma
Temporal lobe epilepsy

Endocrine disease
Porphyria, B12 deficiency, Wilson's disease

Infective
Syphilis, HIV

Toxic
Heavy metal poisoning

Bipolar affective disorder

Focal signs

Investigations
Toxicological screening
Electroencephalogram
CT scan

Confirm diagnosis
Collateral information
Family history
Course of illness

Management
(A.Physical)
Typical AP’s

Atypical AP’s

Oral

Clozapine 50-900 mg/D





Chlorpromazine 100-1800 mg/D
Haloperidol 3-60 mg/D

Depots

Flupenthixol 40mg/2weeks

Side effects




Sedation 70%,
Anticholinergic 50%
EPS 60% (Dystonia 30%,
Parkinsonism 40%, Akathisia
40%),
Neuroleptic malignant syndrome
0.2%
TD 4% each year

30% resistant cases respond
Sedation 90%
Agranulocytosis 0.8%
Seizures 3%

Risperidone 2-6 mg/D

EPS 20%
Agitation 20%

Role of ECT


Catatonic
Aggressive/homicidal/suicidal
Twice/week up to 6-12

Management
Select one drug
 side effects
 behaviour of the patient
 previous response
6 weeks minimal trial
15-25% non-responsive
Continue medications for one
year

Review medication
every 6 months
considering



response
side effects
EE
stressors

Management
B. Psychosocial
• Family intervention
(Psycho education)

• Reduce EE
(Reduces relapse from 50% to
21% in 2 years)

• Self-care/social skills
training
• Assertive training

C. Rehabilitation




Stepwise stimulation
Occupational therapy
Day care
Community homes
Residential care

Course and prognosis
A:15% resolve completely
B: 30% recovery incomplete, minimal residual damage
C: 30% defect state, increases with each relapse
D:15% progressive downhill course
E: 40% attempt while 10% commit suicide; mortality twice as higher








Good prognosis
Sudden onset
Good premorbid
adjustment
Late onset
Female & married
Perplexity
F/H affective disorder
Supportive family
Developing countries








Bad prognosis
Insidious onset
Abnormal premorbid
personality
Early onset
Male & married
Blunting & apathy
F/H schizophrenia
High EE family
Developed countries

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