Schizophrenia

1. Schizophrenia Lyudmyla T. Snovyda

2. Schizophrenia - • from the Greek roots schizein ( "to split") and phren, phren- ("mind"), is a psychiatric diagnosis that describes a mental illness characterized by impairments in the perception or expression of reality, most commonly manifesting as auditory hallucinations, paranoid or bizarre delusions or disorganized speech and thinking in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood.Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia exists.

3. Schizophrenia - Descriptions of schizophrenia-like symptoms date back to circa 2000 BC in the Book of Hearts—part of the ancient Egyptian Ebers Papyrus. However, study of the ancient Greek and Roman literature shows that although the general population probably had an awareness of psychotic disorders, there was no recorded condition that would meet the modern criteria for schizophrenia.Symptoms resembling schizophrenia were, however, reported in Arabic medical and psychological literature during the Middle Ages. In The Canon of Medicine, for example, Avicenna described a condition somewhat resembling schizophrenia which he called Junun Mufrit (severe madness), which he distinguished from other forms of madness (Junun) such as mania, rabies and manic depressive psychosis.

4. Schizophrenia - • Although a broad concept of madness has existed for thousands of years, schizophrenia was only classified as a distinct mental disorder by Emil Kraepelin in 1893. He was the first to make a distinction in the psychotic disorders between what he called dementia praecox (early dementia—a term first used by psychiatrist Benedict Morel [1809–1873]) and manic depression. Kraepelin believed that dementia praecox was primarily a disease of the brain, and particularly a form of dementia, distinguished from other forms of dementia, such as Alzheimer's disease, which typically occur later in life. • Bleuler described the main symptoms as 4 A's: flattened Affect, Autism, impaired Association of ideas and Ambivalence. Bleuler realized that the illness was not a dementia as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead.

5. Schneiderian classification • The psychiatrist Kurt Schneider (1887–1967) listed the forms of psychotic symptoms that he thought distinguished schizophrenia from other psychotic disorders. These are called first-rank symptoms or Schneider's first-rank symptoms, and they include: • delusions of being controlled by an external force; • the belief that thoughts are being inserted into or withdrawn from one's conscious mind; • the belief that one's thoughts are being broadcast to other people; • and hearing hallucinatory voices that comment on one's thoughts or actions or that have a conversation with other hallucinated voices.

6. Positive and negative symptoms • Schizophrenia is often described in terms of positive (or productive) and negative (or deficit) symptoms. • Positive symptoms include: • delusions, • auditory hallucinations, • and thought disorder, and are typically regarded as manifestations of psychosis.

7. Positive and negative symptoms • Negative symptoms are so-named because they are considered to be the loss or absence of normal traits or abilities, and include features such: • as flat or blunted affect and emotion, • poverty of speech (alogia), • anhedonia, • and lack of motivation (avolition). Despite the appearance of blunted affect, recent studies indicate that there is often a normal or even heightened level of emotionality in Schizophrenia especially in response to stressful or negative events.

8. Positive and negative symptoms • A third symptom grouping, the disorganization syndrome, is commonly described, and includes chaotic speech, thought, and behaviour. There is evidence for a number of other symptom classifications.

9. Dissociation or splitting of psychic processes at schizophrenia could be on 3 levels : • I level - splitting between personality and surrounding; • II level - splitting between 2 psychic spheres; • III level - splitting of psychic processes in sphere of psyche.

10. Subtypes, forms: • Historically, schizophrenia in the West was classified into simple, catatonic, hebephrenic (now known as disorganized), and paranoid. The DSM contains five sub-classifications of schizophrenia: • paranoid type: where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent (DSM code 295.3/ICD code F20.0)

11. Subtypes, forms: • disorganized type: named 'hebephrenic schizophrenia' in the ICD. Where thought disorder and flat affect are present together (DSM code 295.1/ICD code F20.1) • catatonic type: prominent psychomotor disturbances are evident. Symptoms can include catatonic stupor and waxy flexibility (DSM code 295.2/ICD code F20.2) • undifferentiated type: psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met (DSM code 295.9/ICD code F20.3) • residual type: where positive symptoms are present at a low intensity only (DSM code 295.6/ICD code F20.5)

12. Subtypes, forms: • The ICD-10 recognises a further two subtypes: • post-schizophrenic depression: a depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present (ICD code F20.4) • simple schizophrenia: insidious but progressive development of prominent negative symptoms with no history of psychotic episodes (ICD code F20.6)

13. Epidemiology: • Schizophrenia occurs equally in males and females although typically appears earlier in men with the peak ages of onset being 20–28 years for males and 26–32 years for females. Much rarer are instances of childhood-onset and late- (middle age) or very-late-onset (old age) schizophrenia. Schizophrenia is known to be a major cause of disability. In a 1999 study of 14 countries, active psychosis was ranked the third-most-disabling condition, after quadriplegia and dementia and before paraplegia and blindness.

14. Causes: Data from a PET study suggests that the less the frontal lobes are activated (red) during a working memory task, the greater the increase in abnormal dopamine activity in the striatum (green), thought to be related to the neurocognitive deficits in schizophrenia.

15. Genetic: • Estimates of the heritability of schizophrenia tend to vary owing to the difficulty of separating the effects of genetics and the environment although twin studies have suggested a high level of heritability. It is likely that schizophrenia is a condition of complex inheritance, with several genes possibly interacting to generate risk for schizophrenia or the separate components that can co-occur leading to a diagnosis. Recent work has suggested that genes that raise the risk for developing schizophrenia are non-specific, and may also raise the risk of developing other psychotic disorders such as bipolar disorder.

16. Substance use: • The relationship between schizophrenia and drug use is complex, meaning that a clear causal connection between drug use and schizophrenia has been difficult to distinguish. There is strong evidence that using certain drugs can trigger either the onset or relapse of schizophrenia in some people. It may also be the case, however, that people with schizophrenia use drugs to overcome negative feelings associated with both the commonly prescribed antipsychotic medication and the condition itself, where negative emotion, paranoia and anhedonia are all considered to be core features.

17. Substance use: • Amphetamines trigger the release of dopamine and excessive dopamine function is believed to be responsible for many symptoms of schizophrenia (known as the dopamine hypothesis of schizophrenia), amphetamines may worsen schizophrenia symptoms. Schizophrenia can be triggered by heavy use of hallucinogenic or stimulant drugs. One study suggests that cannabis use can contribute to psychosis, though the researchers suspected cannabis use was only a small component in a broad range of factors that can cause psychosis.

18. Neural: • Functional magnetic resonance imaging and other brain imaging technologies allow for the study of differences in brain activity among people diagnosed with schizophrenia.

19. Signs and symptoms of paranoid schizophrenia • Delusions of persecution — Belief that others, often a vague “they,” are out to get him or her. These persecutory delusions often involve bizarre ideas and plots (e.g. “Martians are trying to poison me with radioactive particles delivered through my tap water”). • Delusions of reference — A neutral environmental event is believed to have a special and personal meaning. For example, a person with schizophrenia might believe a billboard or a person on TV is sending a message meant specifically for them.

20. Signs and symptoms of paranoid schizophrenia • Delusions of grandeur — Belief that one is a famous or important figure, such as Jesus Christ or Napolean. Alternately, delusions of grandeur may involve the belief that one has unusual powers that no one else has (e.g. the ability to fly). • Delusions of control — Belief that one’s thoughts or actions are being controlled by outside, alien forces. Common delusions of control include thought broadcasting (“My private thoughts are being transmitted to others”), thought insertion (“Someone is planting thoughts in my head”), and thought withdrawal (“The CIA is robbing me of my thoughts.”).

21. Signs and symptoms of paranoid schizophrenia • Hallucinations are sounds or other sensations experienced as real when they exist only in the person's mind. While hallucinations can involve any of the five senses, auditory hallucinations (e.g. hearing voices or some other sound) are most common in schizophrenia. Visual hallucinations are also relatively common. Research suggests that auditory hallucinations occur when people misinterpret their own inner self-talk as coming from an outside source. • Schizophrenic hallucinations are usually meaningful to the person experiencing them. Many times, the voices are those of someone they know. Most commonly, the voices are critical, vulgar, or abusive. Hallucinations also tend to be worse when the person is alone.

22. Signs and symptoms of paranoid schizophrenia • 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.").

23. Signs and symptoms of disorganized schizophrenia • Disorganized schizophrenia generally appears at an earlier age than other types of schizophrenia. Its onset is gradual, rather than abrupt, with the person gradually retreating into his or her fantasies. The distinguishing characteristics of this subtype are disorganized speech, disorganized behavior, and blunted or inappropriate emotions. People with disorganized schizophrenia also have trouble taking care of themselves, and may be unable to perform simple tasks such as bathing or feeding themselves. • The symptoms of disorganized schizophrenia include: • Impaired communication skills • Incomprehensible or illogical speech • Emotional indifference

24. Signs and symptoms of disorganized schizophrenia • Inappropriate reactions (e.g. laughing at a funeral) • Infantile behavior (baby talk, giggling) • Peculiar facial expressions and mannerisms • People with disorganized schizophrenia sometimes suffer from hallucinations and delusions, but unlike the paranoid subtype, their fantasies aren’t consistent or organized.

25. Signs and symptoms of catatonic schizophrenia • The hallmark of catanoic schizophrenia is a disturbance in movement: either a decrease in motor activity, reflecting a stuporous state, or an increase in motor activity, reflecting an excited state. • Stuporous motor signs — The stuporous state reflects a dramatic reduction in activity. The person often ceases all voluntary movement and speech, and may be extremely resistant to any change in his or her position, even to the point of holding an awkward, uncomfortable position for hours. • Excited motor signs — Sometimes, people with catatonic schizophrenia pass suddenly from a state of stupor to a state of extreme excitement. During this frenzied episode, they may shout, talk rapidly, pace back and forth, or act out in violence—either toward themselves or others. • People with catatonic schizophrenia can be highly suggestible. They may automatically obey commands, imitate the actions of others, or mimic what others say.

26. Prognosis: • Numerous international studies have demonstrated favorable long-term outcomes for around half of those diagnosed with schizophrenia, with substantial variation between individuals and regions. One retrospective study found that about a third of people made a full recovery, about a third showed improvement but not a full recovery, and a third remained ill.

27. Prognosis: • The World Health Organization conducted two long-term follow-up studies involving more than 2,000 people suffering from schizophrenia in different countries. These studies found patients have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (USA, UK, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia), despite the fact antipsychotic drugs are typically not widely available in poorer countries, raising questions about the effectiveness of such drug-based treatments.

28. Treatment: • Some Typical antipsychotics: • Tablets Trade Name Normal Daily Dose (mg) Max. Daily Dose (mg) • Chlorpromazine Largactil 75-300 1000 • Haloperidol Haldol 3-15 30 • Pimozide Orap 4-20 20 • Trifluoperazine Stelazine 5-20 • Sulpiride Dolmatil 200-800 2400 • Depot Injections (may be given 2-4 weekly) Trade Name Normal 2 weekly dose Max. 2 weekly dose • Haloperidol Haldol 50 • Flupenthixol decanoate Depixol 40 • Fluphenazine decanoate Modecate 12.5-100 • Pipothiazine palmitate Piportil 50 • Zuclopenthixol decanoate Clopixol 200.

29. Treatment: • Some Atypical antipsychotics: • Tablets Trade Name Normal daily dose (mg) Max. daily dose (mg) • Amisulpiride Solian 50 - 800 1200 • Aripiprazole Abilify 10-30 • Clozapine Clozaril 200-450 900 • Olanzapine Zyprexa 10-20 20 • Quetiapine Seroquel 300-450 750 • Risperidone Risperdal 4-6 16 • Sertindole Serdolect 12-20 24 • Zotepine Zoleptil 75-200 300 • Depot Injections Trade Name Normal 2 weekly dose Max. 2 weekly dose • Risperidone Risperdal Consta 25 50

30. Psychological Treatments: • Cognitive Behavioural Therapy (CBT) • Counselling and supportive psychotherapy • Family work • Cognitive remediation

31. Cultural references: • The book and film A Beautiful Mind chronicled the life of John Forbes Nash, a Nobel-Prize-winning mathematician who was diagnosed with schizophrenia. The Marathi film Devrai (Featuring Atul Kulkarni) is a presentation of a patient with schizophrenia. The film, set in the Konkan region of Maharashtra in Western India, shows the behavior, mentality, and struggle of the patient as well as his loved-ones. It also portrays the treatment of this mental illness using medication, dedication and plenty of patience by the close relatives of the patient. Other factual books have been written by relatives on family members; Australian journalist Anne Deveson told the story of her son's battle with schizophrenia in Tell me I'm Here, later made into a movie.

32. Cultural references: • In Bulgakov's Master and Margarita the poet Ivan Bezdomnyj is institutionalized and diagnosed with schizophrenia after witnessing the devil (Woland) predict Berlioz's death. The book The Eden Express by Mark Vonnegut recounts his struggle into schizophrenia and his journey back to sanity.

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