Schizophrenia

M.S Sara Dawod

Introduction

• Emil Kraepelin (1856-1926) was the first present the concept dementia praecox as an early term for schizophrenia (early onset and dementia).

• Eugen bleuler (1857-1939): proposed schizophrenia from greek words schizen: (to split), and phren: (mind).

Introduction

• It is characterized by disturbances in thought, emotion, and behavior.

• It is not “split personality” nor one of “multiple personalities”.

• Has two broad categories of symptoms:• Positive symptoms: reflect excess or distortion

of normal function (criteria A: 1-4).• Negative symptoms: reflect diminution or loss

of normal function.

Diagnostic criteria

A. Characteristics symptoms: two or more of the following, each present for a significant portion of time during 1 month period:1. Delusion2.Hallucination3.Disorganized speech4. Grossly disorganized or catatonic behavior5. Negative symptoms: affective flattening, alogia or avolition.

Diagnostic criteria B. Social/Occupational dysfunction: work, interpersonal relation, self care, academic or occupational achievement.C. Duration: disturbance persist for at least 6 months which should include one month of symptoms of criterion A and may include residual (after active phase) or prodromal periods (before active phase) including:Mild positive symptoms (unusual or odds beliefs, sense the presence of unseen person or force, speech is understandable but vague, abstract, collect odd or worthless objects) and negative symptoms.

Positive symptoms

• Delusion• Hallucination• Disorganized speech• Disorganized behaviors• Catatonic

Delusion • Delusion beliefs involve misinterpretation of perception

and experiences and the person will hold firmly to the belief regardless of evidence to the contrary include:

• Persecutory: more common, spied, followed.• Referential: certain passage from ooks, story, song are

directed at him/her.• Somatic: false belief is that the body is somehow diseased,

abnormal, or changed. An example: a person who believes that his or her body is infested with parasites.

• Religious.• Grandiose: an individual exaggerates his or her sense of

self-importance.

Delusion

• Erotomania: a delusion in which one believes that another person, usually someone of higher status, is in love with him or her.

• Delusional jealousy: a person with this delusion falsely believes that his or her spouse or lover is having an affair. This delusion stems from pathological jealousy and the person often gathers ”evidence” and confronts the spouse about the nonexistent affair.

Types of delusion

• Bizarre delusion: are not understandable and do not derive from ordinary life experiences or culture: loss of control over body and mind: e.g. stranger has removed his internal organs or replace them.

• Non bizarre delusion: e.g. pt’s beliefs she/he under surveillance by police.

Hallucination • Hallucination: distortion in perception without

external stimuli.• Auditory: most common, hearing one or more of

voices (familiar or unfamiliar).• Olfactory: false perception of odor or smell (smell

decaying fish, dead bodies, or burning rubber).• Tactile: a false perception or sensation of

touch(something is crawling under or on the skin).• Gustatory: a false perception of taste (persistent taste

of metal).

Illusion

• An illusion is seeing, hearing, tasting, feeling, or smelling something that is there, but perceiving it or interpreting it incorrectly.

Disorganized speech • It should be severe to affect communication and

become less severe in residual or prodromal period.• Loss of association: slip of the track from one topic to

another.• Tangentially: answers to questions may be not directly

related or completely unrelated.• Incoherence or word salad: nonsense, patients speech

cannot be understand.• Disorganized behavior: dressing unusual (wearing

multiple coats, inappropriate sexual behavior, unpredictable or triggered agitation (shouting).

Catatonic motor behaviors

• Catatonic stupor: decreased reactivity to environment, make little or no eye contact with others and may be mute and rigid.

• Catatonic rigidity: rigid posture and resist effort to be moved.

• Catatonic negativism: active resistant to instructions or attempt to be moved.

• Catatonic posturing: inappropriate or bizarre posture.

Catatonic motor behavior

• Catatonic excitement: purposeless and un stimulated excessive motor activity.

Diagnostic criteria • Negative symptoms are common in prodromal

and residual period and the first sign to warn the family that something wrong happen (withdraw, loss interest in activity, less talkative, spend most of their time in bed, poor hygiene).

• negative symptoms are non specific and can occur due to others factors such as depression, side effect of medication.

Negative symptoms • Affective flattening: restriction in the range and

intensity of emotion: face appears unresponsive with poor eye contact.

• Alogia: poor productivity of thought and speech.

• Avolition: initiation of goal directed behavior and activities: sit for long time and little interest to share in social activity.

Schizophreniageneral information

• Onset occurs between late teen and mid 30s (it can occurs after 45 and more in women, married, better outcome).

• Men:18-25 years, women 25-mid 30s• Women have better prognosis than men• Higher incidence in men than women• The majority (60-70%) do not marry• Has poor insight about their illness• Life expectancy is shorter than general population (suicide

10%)• Comorbidity is high with substance (nicotine: smoking 80-

90%), anxiety, OCD, panic disorders.

Subtypes of schizophrenia

• Paranoid type• Disorganized type• Catatonic type• Undifferentiated type• Residual type• Schizophreniform disorder• Schizoaffective disorder

Paranoid type

• Preoccupation with one or more delusions (persecutory or grandiose) or frequent auditory hallucination.

• Non of the following is prominent: disorganized speech, disorganized or catatonic behavior or flat or inappropriate affect

Paranoid type

• Onset tend to be later in life than other types of schizophrenia.

• Show little or no impairment on neuropsychological or other cognitive testing.

Disorganized type

A. All the following are prominent:• Disorganized speech• Disorganized behavior which may lead to

inability to perform daily activity (dressing, meals, showering) e.g. (tie ribbon around his big toe, incontinent)

• Flat or inappropriate affect

Catatonic type • Dominated at least two of the following:• Motoric immobility: catalepsy: waxy inflexible or stupor.• Excessive motor activity (purposeless and not influenced

by external stimuli, may shout and talk).• Extreme negativism (motiveless resistance to all

instructions or maintenance of rigid posture against attempt to be moved. and mutism: inhibition of speech for hours or days.

• Echolalia: repetition of a word or phrase just spoken by other person. Or echopraxia: repetition imitation of the movements of another person. Neologisms: creat new expression: jittersitters.

Undifferentiated type

• A type in which symptoms meet criterion A are present but the criteria are not met for the paranoid, disorganized, or catatonic type.

Residual type

• Absence of prominent delusion, hallucination, disorganized speech, and grossly disorganized or catatonic behavior.

• Continue evidence of disturbance as indicated by the presence of negative symptoms (flat affect, poverty of speech, avolition).

• If hallucination and delusion are present, they are not prominent.

Schizophreniform disorder

• Criteria of schizophrenia are met.• Episodes of disorders last at least 1 month but

less than 6 months.• It differs from brief psychotic disorder which

has duration for one day and less than 1 month.

Schizoaffective disorder

• Uninterrupted period of illness during which there is either major depressive episode (2 weeks), manic episode or mixed episode (1 week) concurrent with symptoms that meet criterion A of schizophrenia.

• During the same period of illness, there have been delusion or hallucination for at least 2 weeks in the absence of prominent mood symptoms.

Possible causes of schizophrenia

• Stress: undesirable and unpleasant external event (loss jobs, illness, poor housing).

• Lower social class: more stressors, poor health, nutrition, inadequate education, criminal behavior.

• family pattern communication (double bind).• heredity (genetics):first degree relative.• Identical twins: monozygot (44.3%) than

dizygotic twins (12.8%).

Possible causes of schizophrenia

• Cultural changes: migration, economic crisis, industrialization, urbanization.

• drugs (alcohol, cannabis, cocaine, amphetamine).

• History of temporal lobe epilepsy.• Initiating factors: leave home to marry, work,

study, have responsibility, live alone, divorce or death of parents, rape..etc

Possible causes of schizophrenia

• Physiology structural changes: ventricular enlargment which leads to cognitive impariment, negative symptoms, and atrophy of frontal lope (cause infection).

• Biochemical: increase dopamine level.• Viral infection in pregnancy or obstetrical

complication.• Neurological abnormalities: perinatal

complication, lags in maturation of brain.

Possible cause of schizophrenia

• The characteristics of parents (anxious, aggressive, rejecting, dominating mothers and inadequate, passive, and indifferent father).

• Characteristics of child (clinging to mothers, shared mothers room until late adolescence, had nightmare, neurotics, fearful and panic when away from home, friendless, lonely, shy, disinterested, dull, destructive, prone to flight).

Treatment

• Insulin coma treatment: 1933 (cause death).

• Convulsive therapy: electroconvulsive therapy (ECT) (anesthesia and muscle relaxant).

• Medication

Medications

• Antipsychotic agents: reduce positive symptoms but negative one.

• Chlorpromazine• Butyrophenones (Haldol)• Thioxanthenes (Navane)

Meditation • Side effect:• Dry mouth, dizziness, blurred vision, restlessness, sexual

dysfunction.• Extrapyramidal side effects: tremors of fingers, drooling,

dystonia (prolonged, repetitive muscle contractions), muscle rigidity, chewing movement, akasthesia (inability to remain instill), arching of back and involuntary muscles movement.

• Neuroleptic malignant syndrome: fatal, severe muscle rigidity accompanied by fever, increase BP and may lapse into a coma.

Tratment

• Atypical antipsychotic drugs: Olanzapine (zyprexz), resperidone (resperidal).

• Side effect: DM, pancreatitis.

Psychological Treatment

• Psychoanalytic therapies: communication pattern and achieve insight into the role the past has played in current problem and it was not successful with pt. it assumes that pt return to early childhood communication and the fragile ego cannot deal with stress so we teach the pt adult communication (eye contact).

• Social skills training: teach skills (e.g medication, daily activity, ordering meals by role playing and modeling).

Psychological Treatment

• Family therapy: hostile, overprotective, hypercritical family leads to relapse and hospitalization so provide education about disease, medication, help family to avoid blaming, improve communication and problem solving skills, instilling hope that things can improve and increase social contact.

Treatment

• Cognitive behavioral therapy.• Case management: multidisplinary team that

provide services in the community ranging from medication, psychotherapy, housing, employment.

• Residential treatment: homes in community and have part time jobs or go to school.

• Group therapy: social skills training, psycho-education, medication, time out groups.