SCHIZOPHRENIA

Mr. Aaron S. Gogate-Basic Bsc(N)

INTRODUCTION

A Greek word splited as:

SKCHIZO-To Divide

PHREN-Mind

Termed by kraplein in 1896 as ‘Demensia Precox’

In 1908 Eugene bleuler coined it as Schizophrenia

DEFINITIONIt is a psychotic condition characterized by a disturbance in thinking, emotions, volitions and faculties in the presence of clear consciousness, which usually leads to social withdrawal

It is a type of functional psychosis characterized mainly by disturbance in thinking and associated disturbances in psychomotor activity, affect, perception and behavior.

ETIOLOGY

1) IDOPATHIC

2) HEREDITARY:-

-Incidence high in univolvar twins

-Transmission through one or more

autosomal recessive genes

3) PERSONALITY-SCHIZOID

4) CHILD DEVELOPMENT AND PARENT CHILD RELATIONSHIP

5) AGE-Peak in between 15-30 and also some after30 yrs

6) SEX-Equal in both sexes

7) SOCIAL ISOLATION-Predisposed unstable personal relationship

8) INTELLIGENCE

9) OVERCROWDING SLUMS

10) PRECIPITATION-Stress, regarding ineffective disease, pregnancy, family problem, etc.

11) ENDOCRINE-Excess of dopamine dependent neuronal activity in brain

12) ASSOCIATED WITH OTHER DISEASES-More common in temporal lobe epilepsy

BLEULER’S FOUR A’S

Affective disturbances: inability to show appropriate emotional responses, blunted or flattened affect

Autistic thinking: preoccupation with the self, with little concern for external reality

Ambivalence: opposing emotions e.g.: love and hatred

Associative looseness: inability to think logically

CLINICAL MANIFESTATIONSa) Autistic thinking-important feature

b) Considers two things identical

c) Disturbed thinking, emotions and behavior.

d) Patient appears absurd and bizarre

e) Social withdrawal from religion, philosophy, science, sex, and power

g) Absence of links between ideas, crowding and poverty of ideas, flight of ideas

h) Word are linked without meaning(word salad)

DISTURBANCES OF EMOTION:-

a. Emotional blunting or shallowness of affect

b. Inappropriate affect-patient laughs when he is expected to cry and cries when he is expected to laughs

c. Hypersentiveness or insensitiveness of feelings

d. Ambivalence-experience of 2 opposite of feelings

DISTURBANCES OF BEHAVIOR:-

a) Irrelevant and inappropriate behavior

b) Awkward actions

c) Rowdy, violent, assaultive(a person has a physical or verbal violence), agitation

d) Suicidal and homicidal tendencies

e) Criminal and sexual over activity, pervasive

DISTURBANCES OF WILL AND VOLITION:-

a) Reduction of drive and desire to carry out routine work

b) Avoiding mixing in family and friends(aloof)

c) Reduced efficiency and activity

d) Feeling of passivity(mind and thoughts controlled by outside force

DISTURBANCES OF PERCEPTION:-

a) Hallucination –auditory and visual are common, others are very rare.

b) Hallucinations are either structured(human or animal voice) or unstructured(vague voices)

DISTURBANCES OF MOTIVITY:-

a) In catatonic, increased psychomotor activity, stupor, negativism, stereotype, mutism, verbegeration(repeating the same words)

b) Waxy flexibility

DISTURBANCES OF ATTENTION:-

a) Excessive day dreaming and fantasy

b) Muttering

c) Spells of laughter and crying without reason

d) Childish behavior

e) Patient passes urine and stool in his clothes and plays with has own excreta

f) Absent mindedness

g) Makes lot of mistakes in work

PSYCHOPATHOLOGY

THE ILLNESS OF AS A PHENOMENON OF REGRESSION

E.G- Reversal to infantile and childhood patterns of psychological living a state of organization where reality does not exist. Thus the patient attempt to resolve his psychological conflicts by denying the harsh and painful reality world and living in a fantasy would full of pleasures

TYPES OF SCHIZOPRENIAA. PARANOID SCHIZOPHRENIA:- Early onset ‘Paranoia’ means ‘delusional’ It occurs between 25-30 yrs Seen more in males than females Delusion of suspiciousness, persecution and

grandeur Disorganization of speech and thought Hallucinatory voices of threatening or

commanding, also voices of whistling and laughs

Affect is usually of hostility, anger or suspiciousness

Negative symptoms like flat affect, poverty of speech and poor activity

Prognosis is good

B. HEBEPHRENIC SCHIZOPHRENIA:- Early and insidious onset Occurs between the age of 20-25 yrs Thinking disturbances Regression Childish behavior Inappropriate affect Somatic delusion Unpredictable, giggling and silliness Irrelevant Poverty of ideas Prognosis is poor

C. SIMPLE SCHIZOPHRENIA:- Insidious and gradual course Occurs between age of 15-20 yrs More incidence in males Disturbances in affect Disturbances in thinking Delusions and hallucinations are rare Wandering aimlessly Prognosis is poor

D. CATATONIC SCHIZOPHRENIA:- Occurs between age of 20-25 yrs Equal in both sexes Disturbances of thinking, affect and behavior Acute or sub-acute onset Autism Purposeless excitement and destructive

behavior Delusion and hallucinations are common Prognosis is good but reoccurs are common

E. CATATONIC STUPOR:- Absence of speech Maintenance of rigid posture against efforts to

be moved Negativism Bizarre postures for longer period of time Stuporous reaction towards surrounding Ecolalia-mimicking of phrases and words Echopraxia-mimicking of actions observed Waxy flexibility Ambitendency

F. RESIDUAL SCHIZOPHRENIA:- Emotional blunting Eccentric behavior Social withdrawal A type of schizophrenia which has been at

least one episode in the past but without prominent psychotic symptoms at present

G. UNDIFFERENTIATED SCHIZOPHRENIA:- Late schizophrenia occurs after 40 yrs of age Schizoaffective psychosis with symptoms of

depression and mania and also neurosis Prognosis is poor.

H. CHILDHOOD OR JUVENILE SCHIZOPHRENIA:-

Not common but seen between age of 5-10 yrs and 12-14 yrs

Onset is acute or gradual Prognosis is poor

I. SCHIZOAFFECTIVE PSYCHOSIS:- Symptoms of schizophrenia associated with

symptoms of depression and mania

J. PSEUDO-NEUROTIC SCHIZOPHRENIA:- Core of illness is schizophrenia but presenting

symptoms are suggestive of neurotic symptoms like anxiety state, phobic reactions, obsessive compulsive neurosis or hysteria

Treatment such as psychotherapy, abreactive therapy or drug therapy is not satisfactory

Careful psychiatric examination done through repeated interview, reveals the true nature of illness

PROGNOSIS1) Duration of illness:-

Shorter duration carries better prognosis

2) Type of schizophrenia:-

Catatonic and paranoid type carries good prognosis. simple, hebephrenic, juvenile, pseudo-neurotic types do not carry good prognosis.

3) Personality:-

Non schizoid and stable

personality respond better

4) Precipitating factor:-

Presence of precipitating factor carries good prognosis.

5) Age:-

20-30 yrs of age carries better prognosis than other ages.

6) Type of onset:-

Acute onset carries better prognosis than gradual onset.

DIAGNOSISI. PSYCHIATRIC HISTORY

II. A MENTAL STATUS EXAMINATION

III. CLINICAL OBSERVATION

IV. CT SCAN

V. MRI

VI. OFFICIAL DIAGNOSIS IS BASED ON ICD 10 CRITERIA

TREATMENT MODALITIESA. PHARMACOTHERAPY:-

Conventional antipsychotics are now used less frequently, because of their only partial efficacy and adverse effects.

The following are the drugs given to non-compliant patients;

-Chlorpromazine:50- 100mg/day

-Fluphenazine decanoate:20-25mg IM every 1-3 wks

-Haloperidol:5-20mg/day IM

-Trifluoperazine:1-5mg/day IM

Commonly used atypical antipsychotics;

-Clozapine:25-450mg/day PO

-Resperidone:2-10mg/day PO

-Olanzapine:10-20mg/day PO

-Ziprasidone:20-80mg/day PO Other drugs used in schizophrenia are mood

stabilizers, anti depressants, benzodiazepines, etc.

B. ELECTROCONVULSIVE THERAPY(ECT):- Indications are catatonic stupor, catatonic

excitement Severe side effects with drugs Usually 8-10 ECT’s are required to be given About 8-10 convulsions spread over a period

of 4-6 weeks

C. PSYCHOLOGICAL THERAPIES:- Cognitive therapy, group therapy, behavior

therapy, family therapy

D. PSYCHOSURGERY:- Prefrontal leucotomy