INTRODUCTION

SCHIZOPHRENIA

INTRODUCTION

Schizophreniais amental disorderoften characterized by abnormal social behavior and failure to recognize what isreal. Schizophrenia is discussed as if it is a single disease, it probably comprises a group of disorders with heterogeneous etiologies, and it includes patients whose clinical presentation, treatment response, and courses of illness vary. Sign and symptoms are variable and include changes in perception, emotion, cognition, Thinking and behavior.

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The expression of these manifestation varies across patient and overtime, but the affect of the illness is always severe and is usually long lasting.The disorder usually begins before age 25 years, persist throughout life, and affects persons of social classes.Both patients and there family often suffer poor care and social ostracism because of widespread ignorance about the disorder.Schizophrenia is one of the most common the serious mental disorders, but its essential nature remains to be clarified: thus, it is some time referred to as a sign of syndrome, as a group of schizophrenias, or as in the fifth edition of the diagnostic and statistical manual of mental disorders (DSM-5), the schizophrenia spectrum. The diagnosis of schizophrenia is based entirely on the psychiatric history and mental status examination. There is no laboratory test for schizophrenia.

HISTORICAL PERSPECTIVEThe origin of the term SCHIZOPHRENIA has been derived from the Greek word Skhizein meaning to split,and phren meaning mind.Emil Kraeplin(1896) differentiated the major psychiatric illnesses into two clinical types: dementia praecox and manic depressive illness.He recognised the characteristics features of dementia praecox as delusions, hallucinations, disturbances of affect and motor disturbances.Eugen Bleuler(1911) recognised the following six:Schizophrenia did not always have a poor prognosis as described by Kraeplin.Schizophrenia consisted of a group of disorders rather than being a distinct entity. Therefore, he used the term a group of schizophreniasThe characteristics/fundamental symptoms and also accessory/secondary symptoms of schizophrenia( Delusions, hallucinations and negativism ).

Fundamental Symptoms:AMBIVALENCE: marked inability to decide.AUTISM: withdrawal into self.AFFECT DISTURBANCES: inappropriate affect.ASSOCIATION DISTURBANCES: loosening of associations; thought disorders.Kurt Schneider(1959) described symptoms which helped in making a clinical diagnosis of schizophrenia called as Schneiders first rank symptoms of schizophrenia(FRS or SFRS). Also, the second rank symptoms of schizophrenia such as other forms of hallucinations, perplexity and affect disturbances.

DIAGNOSTIC CRITERIA

DIAGNOSTIC CRITERIAA. Two (or more) of the following, each present for a significant portion of time during a 1 -month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions.2. Hallucinations.3. Disorganized speech (e.g., frequent derailment or incoherence).4. Grossly disorganized or catatonic behavior.5. Negative symptoms (i.e., diminished emotional expression or avolition).

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either

1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for minority of the total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

SPECIFICATIONS

The following course specifiers are only to be used after a 1 year duration of the disorder if they are not in contradiction to the diagnostic course criteria.First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.First episode, currently in partial remission: Partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled. First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse). Multiple episodes, currently in partial remissionMultiple episodes, currently in full remission Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with sub threshold symptom periods being very brief relative to the overall course.Unspecified

SYMPTOMS OF SCHIZOPHRENIA

Positive symptoms are those that most individuals do not normally experience but are present in people with schizophrenia. They can include delusions, disordered thoughts and speech, and tactile, auditory, visual, olfactory andgustatory hallucinations, typically regarded as manifestations of Schizophrenia.Positive (things that start to happen)Negative (things that stop happening)Cognitive (related to processing information)

Hallucinations : They might hear, see, smell, or feel things no one else does. Most often they'll hear voices inside their heads. These might tell them what to do, warn them of danger, or say mean things to them. The voices might talk to each other.Delusions :It is a distortion of reality. These are beliefs that seem strange to most people and are easy to prove wrong. The person affected might think someone is trying to control their brains through their TVs or that the FBI is out to get them. They might believe they're someone else, like a famous actor or the president, or that they have superpowers.Disorganized thoughts and speech :People with schizophrenia can have a hard time organizing their thoughts. They might not be able to follow along when you talk to them. Instead, it might seem like they're zoning out or distracted. When they talk, their words can come out all jumbled and not make sense. They can also have trouble concentrating. For example, they might lose track of what's going on in a TV show as they're watching.Disorganized movements : Someone with the condition can seem jumpy. Sometimes they'll make the same movements over and over again. But sometimes they might be perfectly still for hours at a stretch, which is called being catatonic. Contrary to popular belief, people with the disease usually aren't violent.

HALLUCINATIONSTYPES OF HALLUCINATIONS :AUDITORY : Hearing voices : The client may sense that the sounds are coming from inside or outside their mind. They might hear the voices talking to each other or feel like they're telling them to do something.

VISUAL : Seeing things : They might see insects crawling on their hand or on the face of someone they know.

OLFACTORY : Smell things that aren't there :The client may think an odor is coming from something around them, or that it's coming from their own body.

GUSTATORY : False sense of taste :They may feel that something they eat or drink has an odd taste.

TACTILE : Feel things that don't exist : It might seem to them that theyre being tickled even when no one else is around, or they may have a sense that insects are crawling on or under their skin. They might feel a blast of hot air on their face that isn't real.

DELUSIONSTYPES OF DELUSIONS :Delusion of Persecution : The most common type of delusion associated with schizophrenia involves persecutory delusions. The schizophrenic believes that he/she is being followed or is under surveillance, or that he/she is being made fun of, tricked, or treated very unfairly by others. When schizophrenics experience this type of delusion, they may feel very frightened orparanoid. As a result, they will often do things to protect themselves from the persecutor.

Delusions of Reference : This is when the person believes, for example, that things written in a newspaper or stated in a newscast, passages found in a book, or the words in a song are about him/her.

Delusions of Grandeur : These delusions involve the belief that he/she has exceptional power, talent or worth, or is someonefamous. He/she may believe he/she is God or some other type of deity.

Delusions of Erotomania : This type of delusion involves the belief that a particular person, usually a celebrity or someone especially important ( of a higher status), is romantically or sexually involved with or in love with him/her.

Delusion of Somatomania : This involves the belief that he/she has a medical condition or other physical problem or flaw.

Delusion of Jealousy : A delusional belief that ones spouse or lover is unfaithful, based on erroneous inferences from innocent events imagined to be evidence.

Delusion of Infidelity : A belief or suspicion that ones spouse or lover may be disloyal or cheating on the client.

DISORGANIZED SPEECH : Fragmented thinking is characteristic of schizophrenia. Externally, it can be observed in the way a person speaks. People with schizophrenia tend to have trouble concentrating and maintaining a train of thought. They may respond to queries with an unrelated answer, start sentences with one topic and end somewhere completely different, speak incoherently, or say illogical things. Common signs of disorganized speech in schizophrenia include:Loose associations Rapidly shifting from topic to topic, with no connection between one thought and the next.Neologisms Made-up words or phrases that only have meaning to the patient.Perseveration Repetition of words and statements; saying the same thing over and over.Clang Meaningless use of rhyming words (I said the bread and read the shed and fed Ned at the head").

DISORGANIZED BEHAVIOUR : Schizophrenia disrupts goal-directed activity, causing impairments in a persons ability to take care of him or herself, work, and interact with others. Disorganized behavior appears as:A decline in overall daily functioningUnpredictable or inappropriate emotional responsesBehaviors that appear bizarre and have no purposeLack of inhibition and impulse control

NEGATIVE SYMPTOMSNegative Symptoms of schizophrenia represent the absence or diminution of normal intellectual function and expression.They are disruptions to normal emotions and behaviours and are also known as negative deficits.

The negative symptoms are:

AFFECTThe external expression of emotion attached to ideas and mental representation of objects.Schizophrenics have flat(lack of expression),blunt(severe reduction in intensity),or inappropriate(incongruent with situation) affect.

ALOGIAIt is characterised by poverty of speech,a reduction in the amount of speech,speech content,blocking or late replies.

ANHEDONIA It is the inability to feel pleasure in normally pleasurable activities. Schizophrenics experience no pleasure in their daily life or even otherwise.AVOLITION It is the loss of motivation.Deficits in the initiation and maintenance of goal-directed behaviours like work, study, sport, personal hygiene and daily tasks, especially when requiring an effort (cognitive or physical) and significant organisation. Also deficits in desire to undertake such activities.ASOCIALITY It is the diminished interest in, motivation for, and appreciation of social interactions with others, like family and friends. Also, loss of interest in intimate (sexual) relationships independent of any somatic problems.

COGNITIVE SYMPTOMS Cognitive symptoms are subtle and are often detected only when neuropsychological tests are performed.Cognitive impairments often interfere with the patient's ability to lead a normal life and earn a living. They can cause great emotional distress. They include the following:Poor executive functioning (the ability to absorb and interpret information and make decisions based on this information)Trouble focusing or paying attention (difficulty in sustaining attention)Problems with working memory (the ability to keep recently learned information in mind and use it right away)

OTHER EARLY SYMPTOMSSocial withdrawalHostility or suspiciousnessDeterioration of personal hygieneFlat, expressionless gazeInability to cry or express joyInappropriate laughter or cryingDepressionOversleeping or insomniaOdd or irrational statementsForgetful; unable to concentrateExtreme reaction to criticismStrange use of words or way of speaking

TYPES OF SCHIZOPHRENIA

The following Subtypes of Schizophrenia have been described based predominantly on Clinical presentation.

*These Subtypes are no longer recognised by the 5th Revision of the Diagnostic Statistical Manual (DSM 5) but they are listed in the 10th Revision of the International Statistical Classification of diseases and Related Health Problems (ICD 10).

We have included the above in our Presentation because we believe them to be of clinical significance to describe the phenomenology of schizophrenia.

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Schizophrenia F20Paranoid Schizophrenia F20.0Hebephrenic or Disorganised schizophrenia F20.1Catatonic Schizophrenia F20.2Undifferentiated schizophrenia F20.3Post Schizophrenic depression F20.4Residual Schizophrenia F20.5Simple Schizophrenia F20.6Other Schizophrenia F20.8 INCLUDES: 1. CENESTHOPATHIC Schizophrenia2. SCHIZOPHRENIFORM DISORDER NOSSchizophrenia, Unspecified F20.9*according to ICD 10 classificatory system.

COURSE AND PROGNOSIS

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COURSEPremorbid patterns of symptoms may be first evidence of illness.Characteristic symptoms may begin in adolescence which develop in prodomal symptoms in few days or months.Some drastic changes such as relatives death, going to college, substance abuse may precipitate the symptoms to last for years.After first episode a patient gradually recovers and may function relatively normally.Patients usually relapse however pattern of illness in first 5 years after diagnosis indicates patient course.Further deterioration in patients baseline functioning follows each relapse of the psychosis.Sometimes clinical observable post-psychotic depression follows the episode.Positive symptoms tends to decrease and negative symptoms increase with passage of time.

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PROGNOSISAfter knowing the disorder :only 10-20% of patient can be described as having a good outcome more than 50% of patients can be described as having a poor outcomepoor outcome includes repeated hospitalization exacerbation of symptoms episodes of major mood disorders and suicide attemptsremission rate ranges 10-60%estimate of 20-30% of all schizophrenia patients continue to experience normal lives estimate 40-60% remain significantly impaired by their disorder for entire lifepatients with schizophrenia are much more disturbed than patients having mood disorder

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ETIOLOGY

GENETIC PREDISPOSITION:Schizophrenia occur at an increased rate among the biological relatives of patients with schizophrenia. If one parent has the disorder there are 46% chances that the offspring might have them.If both the parents are suffering from the disorder there are 52% chances of the offspring might suffer from.In the case of monozygotic twins who have identical genetic endowment, there is an approximately 50% concordance rate of schizophrenia.

BIOCHEMICAL FACTORS DOPAMINE HYPOTHESIS : schizophrenia results from too much dopaminergic activity. The theory evolved from two observations. First, the efficacy and the potency of many antisocial drugs are correlated with their ability to act as inhibitors of the dopamine type 2 (D2) receptor. Secondly, Drugs that increase dopamine activity e.g., cocaine and amphetamine, are psychotomimetic. Excessive dopamine release in patients with schizophrenia has been linked to the severity of positive psychotic symptoms. NOREPHINEPHRINE : Anhedonia the impaired capacity for emotional gratification and the decreased ability to experience pleasure has long been noted to be a prominent feature of schizophrenia.

BRAIN METABOLISM : studies using resonance spectroscopy, a technique that concentration of specific molecules in the brain, found that patients with schizophrenia had lower levels of phosphomonoester and inorganic phosphate and higher levels of phosphodiester than a control group.

EYE MOVEMENT DYSFUNCTION : the inability to follow a moving visual target accurately is the defining basis for the disorders of smooth visual pursuit and disinhibition of saccadic eye movement seen in patients with schizophrenia. Various studies have reported abnormal eye movements in 50- 85% of patients with schizophrenia compared with about 25% in psychiatric patients without schizophrenia and fewer than 10% in nonpsychiatrically ill control participants.

PSYCHOSOCIAL AND PSYCHOANALYTIC THEORIES If schizophrenia is a disease of the brain, it is likely to parallel disease of other organs whose courses are affected by psychosocial and biological factors affecting schizophrenia. LEARNING THEORIES : according to learning theories, children who later have schizophrenia learn irrational reactions and ways of thinking by imitating parents who have their own significant emotional problems. SCHIMS AND SKEWED FAMILIES : Theodore Lidz described two abnormal patterns of family behaviour. In one family type, with a prominent schism between the parents, one parent is overly close to the child of the opposite gender. In the other family type, a skewed relationship between a child and one parent involves a power struggle between the parents and the resulting dominance of one parent.

These dynamics stress the tenuous adaptive capacity of the person with schizophrenia.EXPRESSED EMOTION : Parents or other caregivers may behave with overt criticism, hostility, and overinvolvement toward the person with schizophrenia. Many studies have indicated that families with high levels of expressed emotion, the relapse rate for schizophrenia is high. The assessment of expressed emotion involves analyzing both what is said and the manner in which it is said.

EPIDEMIOLOGY

According to the World (Mental) Health Report 2001, about 24 million people worldwide suffer from schizophrenia. The point prevalence of schizophrenia is about 0.5% - 1%.Schizophrenia is prevalent across racial, sociocultural and national boundaries, with a few exceptions in the prevalence rates in some isolated communities.The incidence of schizophrenia is believed to be 0.5 per 1000.The onset of Schizophrenia occurs usually later in women and often runs a relatively more benign course, as compared to men.

CO-MORBIDITY

Rates of co-morbidity with Substance Related Disorders are high in Schizophrenia (50% have been reported to abuse tobacco and smoke cigarettes regularly)Co-morbidity with Anxiety disorders is increasingly recognised.Rates of Obsessive Compulsive Disorder and Panic Disorder are highly elevated in individuals with Schizophrenia compared with the general population.Schizotypal or Paranoid Personality Disorder (PPD) may sometimes precede the onset of Schizophrenia.Life expectancy is reduced because of the associated medical conditions, e.g.: Weight gain, Diabetes, Metabolic syndromes and Cardiovascular and Pulmonary diseases.Poor engagement in health maintenance behaviours, (e.g.: Exercise) increases the risk of chronic disease.

DIFFERENTIAL DIAGNOSIS

PSYCHOSIS

Mood disordersSchizophrenia spectrum disordersorganic mental disorders

SubstanceinducedDeliriumDementiaAmnestic d/o

Functionaldisorders

Schizophrenia and Bipolar DisorderSchizophrenia and bipolar disorder are often misdiagnosed as one another, and this is not so surprising when we consider how much the two disorders have in common. For example:Schizophrenia and bipolar disorder share medications. Five of the current atypical antipsychotics originally approved to treat schizophrenia are now also approved as treatment for acute mania. Two of them are even approved as maintenance treatments for bipolar disorder. The fact that these two diseases are helped by some of the same pharmacological treatments indicates that they may have similar pathophysiology causing the symptoms.The positive symptoms of schizophrenia can look like the symptoms in about 50% of manic episodes, especially those with psychotic features. (These can include delusions of grandeur, hallucinations, disorganized speech, paranoia, etc.)The negative symptoms of schizophrenia can closely resemble the symptoms of a depressive episode(these include apathy, extreme emotional withdrawal, lack of affect, low energy,social isolation, etc.)The two disorders share abnormalities in some of the same neurotransmitter systems. For example, both depressive episode symptoms and the negative symptoms of schizophrenia are at least partially mediated by serotonin. Likewise, the positive symptoms of schizophrenia and the symptoms of mania are mediated in some way by excesses of dopamine signaling. The atypical antipsychotics approved for both these disorders work on both the serotonin and the dopamine systems.

Cues to Determine he Initial Diagnosis of Schizophrenia and Bipolar DisorderBipolar DisorderSchizophreniaPremorbid BehaviourSocial WithdrawnHistory of Depression?Yes No Onset Rapid Insidious Family HistoryGenerally Affective DisordersSchizophrenia

OnsetSymptomsCourse DurationSchizophreniaUsually insidiousManyChronic>6 monthsDelusional disorderVaries (usually insidious)Delusions onlyChronic>1 mo.Brief psychotic disorderSuddenVariesLimited