Schizophrenia

1. Schizophrenia Dr.SantoshJha TMU

2. Schizophrenia is a clinical syndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior ►Psychotic ► Chronic ► Starts early ► Disabling ► Burdening ► Threatening ► Stigmatizing ► Service-consuming

3. Emil Kraepelin in 1896- • Dementia precox • Manic Depressive Psychosis • hallucinations and delusions

4. Eugene Bleuler in 1911-schizophrenia Fundamental symptoms: 4As • Ambivalence-inability to decide for or against • Autism- withdrawal into self • Affect disturbance- inappropriate affect • Association disturbance-loosening of associations,thought disorder

6. Epidemiology • 24 million people world wide suffer from schizophrenia • 1 ~ 100 will develop schizophrenia • Equally prevalent in men and women • Ages of onset are 10 to 25 years for men and 25 to 35 years for women

7. □ Non-twin sibling = 8 % □ Dizygotic twin = 12 % □ One parent affected = 12 % □ Two parents affected = 40 % □ Monozygotic twin = 47 % □ Male : Female Ratio = 1 : 1

8. On set of disease A. Perplexity B. Isolation C. Anxiety and Terror.

9. Aetiology ► Genetic predisposition ► Stress-Diathesis Model ► Dopamine Hypothesis ► Neuropathology ► Psychoneuroimmunology ► Psychoneuroendocrinology.

10. C/F Severe disturbances occur in • Language and communication, • Content of thought, • Perception, • Affect, • Sense of self, • Volition, • Relationship to the external world, and • Motor behavior

11. Language and communication • If things turn by rotation of agriculture or levels in regards and timed to everything: I am referring to a previous document when I made some remarks that were facts also tested and there is another that concerns my daughter she has a lobed bottom right ear, her name being Mary Lou…. Much of abstraction has been left unsaid and undone in this product/milk syrup, and others due to economics, differentials, subsidies, bankruptcy, tools, buildings, bonds, national stocks, foundation craps, weather trades, government in levels of breakages, and fuses in electronics to all formerly “stated” not necessarily factuated.

12. A psychiatric nurse describes her own thought disturbances as follows • Not knowing that I was ill, I made no attempt to understand what was happening, but felt that there was some overwhelming significance in all of this, produced either by God or Satan…. The walk of a stranger on the street could be a “sign” to me which I must interpret. Every face in the windows of a passing streetcar would be engraved on my mind, all of them concentrating on me and trying to pass me some sort of message

13. Two patients have described how they feel: • I have experienced this process chiefly as a condition in which the integrating mental picture in my personality was taken away and smashed to bits, leaving me like agitated hamburger, distributed evenly throughout the universe. • I am like a zombie living behind a glass wall. I can see all that goes on in the world, but I can't touch it. I can't reach it. I can't be in contact with it. I am outside. They are inside, and when I get inside, they aren't there. There is nothing there, absolutely nothing.

14. DSM-IV-TR Criteria A. Two (or more) of the following during a 1-month period: (1) delusions (2) hallucinations (3) disorganized speech (e.g., frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior (5) negative symptoms, i.e., affective fl attening, alogia,or avolition B. Social/occupational dysfunction: interpersonal relations, or self-care C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms i.e., active-phase symptoms) and prodromal or residual symptoms.

15. Contd… D. Schizoaffective and mood disorder exclusion : Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either • (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms; or • (2) if mood episodes have occurred during active phase symptoms, their total duration has been brief relative to the duration of the active and residual periods E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. F. Relationship to a pervasive developmental disorder: If there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

16. Positive and Negative Symptoms

17. F20-F29 Schizophrenia, Schizotypal and Delusional Disorders F20 Schizophrenia F20.0 Paranoid schizophrenia F20.1 Hebephrenic schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.4 Post-schizophrenic depression F20.5 Residual schizophrenia F20.6 Simple schizophrenia F20.8 Other schizophrenia F20.9 Schizophrenia, unspecified

18. F20-F29 Schizophrenia, Schizotypal and Delusional Disorders F21 Schizotypal disorder F22 Persistent delusional disorders F22.0 Delusional disorder F22.8 Other persistent delusional disorders F22.9 Persistent delusional disorder, unspecified F23 Acute and transient psychotic disorders F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia F23.2 Acute schizophrenia-like psychotic disorder F23.3 Other acute predominantly delusional psychotic disorders F23.8 Other acute and transient psychotic disorders F23.9 Acute and transient psychotic disorder, unspecified

19. F20-F29 Schizophrenia, Schizotypal and Delusional Disorders F24 Induced delusional disorder F25 Schizoaffective disorders F25.0 Schizoaffective disorder, manic type F25.1 Schizoaffective disorder, depressive type F25.2 Schizoaffective disorder, mixed type F25.8 Other schizoaffective disorders F25.9 Schizoaffective disorder, unspecified F28 Other nonorganic psychotic disorders F29 Unspecified nonorganic psychosis

20. F20.0 Paranoid Schizophrenia • Paranoid schizophrenia is characterized mainly by delusions of persecution, feelings of passive or active control, feelings of intrusion, and often by megalomanic tendencies also. The delusions are not usually systemized too much, without tight logical connections and are often combined with hallucinations of different senses, mostly with hearing voices. • Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous.

22. F20.1 Hebephrenic Schizophrenia • Hebephrenic schizophrenia is characterized by disorganized thinking with blunted and inappropriate emotions. It begins mostly in adolescent age, the behavior is often bizarre. There could appear mannerisms, grimacing, inappropriate laugh and joking, pseudophilosophical brooding and sudden impulsive reactions without external stimulation. There is a tendency to social isolation. • Usually the prognosis is poor because of the rapid development of "negative" symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults. • Denoted also as disorganized schizophrenia

23. pseudophilosophical brooding

24. F20.2 Catatonic Schizophrenia • Catatonic schizophrenia is characterized mainly by motoric activity, which might be strongly increased (hyperkinesis) or decreased (stupor), or automatic obedience and negativism. • We recognize two forms: • productive form — which shows catatonic excitement, extreme and often aggressive activity. Treatment by neuroleptics or by electroconvulsive therapy. • stuporose form — characterized by general inhibition of patient’s behavior or at least by retardation and slowness, followed often by mutism, negativism, fexibilitas cerea or by stupor. The consciousness is not absent.

25. motoric activity~hyperkinesis or stupor or automatic obedience and negativism.

26. schizophrenic patient stands in a catatonic position

27. F20.3 Undifferentiated Schizophrenia • Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes in F20.0-F20.2, or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics. • This subgroup represents also the former diagnosis of atypical schizophrenia.

28. F20.4 Post schizophrenic Depression • A depressive episode, which may be prolonged, arising in the aftermath of a schizophrenic illness. Some schizophrenic symptoms, either „positive“ or „negative“, must still be present but they no longer dominate the clinical picture. • These depressive states are associated with an increased risk of suicide.

29. F20.5 Residual Schizophrenia • A chronic stage in the development of schizophrenia with clear succession from the initial stage with one or more episodes characterized by general criteria of schizophrenia to the late stage with long-lasting negative symptoms and deterioration (not necessarily irreversible).

30. F20.6 Simple Schizophrenia • Simple schizophrenia is characterized by early and slowly developing initial stage with growing social isolation, withdrawal, small activity, passivity, avolition and dependence on the others. • The patients are indifferent, without any initiative and volition. There is not expressed the presence of hallucinations and delusions.

31. F21 Schizotypal disorder • This disorder is characterized by eccentric behavior and by deviations of thinking and affectivity, which are similar to that occurring in schizophrenia, but without psychotic features and expressed symptoms of schizophrenia of any type.

32. F22 Persistent Delusional Disorders • Includes a variety of disorders in which long-standing delusions constitute the only, or the most conspicuous, clinical characteristic and which cannot be classified as organic, schizophrenic or affective. • Their origin is probably heterogeneous, but it seems, that there is some relation to schizophrenia.

33. F22.0 Delusional Disorder • A disorder characterized by the development of one delusion or of the group of similar related delusions, which are persisting unusually long, very often for the whole life. • Other psychopathological symptoms — hallucinations, intrusion of thoughts etc. are not present and are excluding this diagnosis. • It begins usually in the middle age.

34. F23 Acute and Transient Psychotic Disorders • The criteria should be the following features: • acute beginning (to two weeks) • presence of typical symptoms (quickly changing “polymorphic symptoms”) • presence of typical schizophrenic symptoms. • Complete recovery usually occurs within a few months, often within a few weeks or even days. • The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks.

35. F24 Induced Delusional Disorder • A delusional disorder shared by two or more people with close emotional links. Only one of the people suffers from a genuine psychotic disorder; the delusions are induced in the other(s) and usually disappear when the people are separated. • The psychotic disorder of the dominant member of this dyad is mainly, but not necessarily, of schizophrenic type. The original delusions of dominant member and his partner are usually chronic, either persecutory or megalomanic.

36. F25 Schizoaffective Disorders • Episodic disorders in which both affective and schizophrenic symptoms are prominent (during the same episode of the illness or at least during few days) but which do not justify a diagnosis of either schizophrenia or depressive or manic episodes. • Patients suffering from periodic schizoaffective disorders, especially with manic symptoms, have usually good prognosis with full remissions without any remaining defects.

37. Other subtypes • Pseudoneurotic schizophrenia (Hoch & Polatin—predominant neurotic symptoms last for years & has poor prognosis (pan-anxiety,pan-neurosis,pan-sexuality) • Schizophreniform disorder--< 6 months and good prognosis • Oneiroid schizophrenia • Van Gogh syndrome • Late paraphrenia • Pfropf schizophrenia

38. Etiology of Schizophrenia • The etiology and pathogenesis of schizophrenia is not known • It is accepted, that schizophrenia is „the group of schizophrenias“ which origin is multifactorial: • internal factors – genetic, inborn, biochemical • external factors – trauma, infection of CNS, stress

39. Biological theroies • Genetic hypothesis • Biochemical theories • Brain imaging • Psychological theories • Stress • Family theories • Information processing hypothesis • Psychoanalytical theories • Socio-cultural theories

41. Differential Diagnosis 1. Schizotypal Disorder 2. Acute &Transient Psychotic Disorders 3. Delusional Disorders 4. Schizoaffective Disorder 5. Bipolar Disorder 6. Psychotic Depression 7. Substance-Induced Psychotic Disorders 8. Psychotic Disorders due to OBS or GMC 9. Quasi-Psychotic Presentations in the course of: 1. Mental Retardation 2. Some Personality Disorders 3. Obsessive-Compulsive Disorder 3. Factitious Disorder 4. Malingering?

42. Prognosis Factors associated with good prognosis include:: 1. Sudden Onset / Precipitating Factors 2. Short Episode 3. Minimal Negative Symptoms 4. Paranoid Type 5. Female Gender 6. No Previous Psychiatric History 7. Prominent Affective Symptoms 8. Older Age of Onset 9. Being Married 10. Good Previous Personality 11. Good Work Record 12. Good Psychosexual Adjustment 13. Good Social Relationships . 14. Good Compliance

43. Management . Physical Treatment A. Psychopharmacological: 1. Antipsychotics: Typical Antipsychotics Atypical (2nd Generation). 2. Adjunct Medications B. Electroconvulsive Therapy (ECT). ( (mostly in Catatonic Stuper

44. Management . : Psychological Interventions: . Supportive Therapy Individual Psychotherapy Cognitive Behavioral Therapy Family Therapy Marital Therapy Psychoeducation

45. Management Socio-Occupational Rehabilitation Occupational Therapy Social Skill Training Residential Support Community-Outreach Services Sheltered Employment

46. Drug Treatment of Schizophrenia 1. Typical Antipsychotics: A. Oral: ► Chlorpromazine 100 mg tid ► Haloperidol 5 mg tid B. Aqueous Injections: ► Chlorpromazine 50 mg IM (±Promethazine 50 mg) ► Haloperidol 5 mg IM (±Promethazine 50 mg) C. Depot Injections: ► FluphenazineDecanuate 25 mg IM once per month ► Haloperidol Decanuate 100 mg IM once per month ► FlupenthixolDecanuate 40 mg IM once per month ► ClopenthixolDecanuate 200 mg IM once per month.

47. Drug Treatment of Schizophrenia - 2 Atypical Antipsychotics: A. Oral: ► Risperidone 2-6 mg per day ► Olanzapine 5-10 mg per day ► Clozapine 300-900 mg per day (for resistant cases only) B. long-acting: ► Risperidone 25-50 mg IM every two weeks.

48. 3. Adjunct Medications: Anxiolytics / sedatives Antidepressants Anticholinergics Mood stabilizers