Schizophrenia

PhotoCredit: Mindblog.dericbownds.net

Important Terms

• Schizophrenia
• psychotic mental disorder characterized by profound disturbances in thinking, feeling and behaviour
• one of the most studied, but remains one of the least understood of all the psychopathological disorders
• diagnosis is based on the presence of a set of signs and symptoms
• if patient is diagnosed with schizophrenia and is symptomatic then he is in a psychotic state; if there are no delusions/halllucinations then he is in remission.

• Psychosis
• loss of reality testing and impairment of mental functioning
• severe impairment or social and personal functioning
• severe ego regression
• cannot distinguish between reality and fantasy
• inference is not similar to other normal people
• the worst and most common of all psychotic disorders

• Psychotics
• can hear voices which is not there
• can see things out of space
• have “gifts” that normal people don’t have. Gifts which you don’t want to have
• Example of Psychotic Thinking
• Nonpsychotic – Policeman is standing there because he just has to stand somewhere
• Psychotic – Policeman is standing there. It has something to do with me.

• Delusions
• Includes:

1. thought withdrawal
2. thought insertion
3. thought broadcasting
4. made impulses
5. made volitional acts
6. somatic passivity
• “Schneiderian symptoms”

• Hallucinations
• Includes:
1. Voices speaking thoughts out loud
2. Voices arguing
3. Voices commenting on the subject’s actions

• Negative Symptoms
• Includes:
1. Affective flattening
2. Alogia
3. Avolition – apathy
4. Anhedonia – asociality
5. Attentional deficits

History of Schizophrenia

• Emil Kraepilin
• dementia precox
• one who first described this illness
• dementia comes early
• Euen Bleuler and Four As

Diagnostic Criteria (DSM IV-TR)

• Characteristic symptoms (at least 2 of the following for at least 1 month prominence within 6 months):
• delusions
1. perceive something different from the others
2. persists even if a strong evidence is presented
3. should not be congruent with age, level of intelligence and educational attainment
4. most importantly – it’s not shared by others
• hallucinations
1. perceptual disturbance
2. perceiving something when there is nothing
3. most common – auditory
4. if no auditory hallucinations – not schizo (Investigate)
• disorganized speech
1. loose association
2. worst = wood salad – saying random words without meaning e.g taking random words from newspaper and forming it into sentence
3. Tangeniality e.g where do you live? Answer: Living is nothing but a sacrifice
4. Circumstantiality – able to answer but you have to beat around the bush in order to get the answer
• grossly disorganized or catatonic behaviour
1. e.g. taking fecal material and using it as swab in the face
2. e.g. not changing of clothes for many days
3. e.g. taking off clothes in public
• negative symptoms
1. symptoms that normal people have, schizo may not have
2. Anydonia – inability to have pleasure
3. e.g. inability to take a bath
4. e.g. inability to socialize

•  Special symptoms (only 1 for at least 6 months to diagnose):
• bizarre delusions
• e.g. patient thinks of small people living in his testicles resulting to unequal hanging of his testicles
• running commentary
• voice commening on everything that you do
• voices conversing
• special type of hallucination
• voices talk with each other, patient eves drop, patient is usually the topic of the conversation

• social/occupational dysfunction
• six months duration of symptoms
• exclusion of mood and schizoaffective disorder
• exclusion of substance abuse and general medical condition
• relationship to Pervasive Developmental Disorder

Subtypes

• Paranoid subtype
• delusions and prominent hallucinations
• one commonly seen
• easiest to diagnose
• respond well to treatment
• Disorganized Subtype
• disorganized speech
• disorganized behaviour
• flat or inappropriate affect
• Catatonic Subtype
• assume a position and would not move
• waxy flexibility
• rare
• responds well to treatment
• good prognosis
• Echolalia – patient repeats what you say
• Echopraxia – patient follows your movment
• motoric immobility
• excessive motor activity
• peculiarities of voluntary movement - posturing, stereotyped movements, prominent mannerisms, prominent grimacing
• echolalia or echopraxia
• Undifferentiated subtype
• does not meet the criteria for the other subtypes
• Residual Subtype
• attenuated form of the disorder

Differential Diagnoses

• Other Psychiatric Conditions
• Brief Psychotic Disorder
• Schizophreniform Disorder
• Schizoaffective Disorder
• Delusional Disorder
• Mood Disorder
• Personality Disorder
• Other Medical Conditions
• Substance-Induced Psychosis

Epidemiology

• Lifetime prevalence 1-1.5% of the general population
• Equal prevalence between the sexes
• Earlier onset for men

Structures Involved

• No specific regional brain abnormalities or nerve cell lesions have been identified
• The damage seems to be in the way the regions are connected to one another
• MRI studies have demonstrated decreased volume in the frontal and temporal lobes, hippocampus, thalamus and the cerebellum

Etiology

• Stress-Diathesis Model

1. Poor parenting has been discounted
2. If diathesis is strong, then little stress is needed for patient to be symptomatic

• Neurodevelopmental Abnormalities

1. Increased ectopic grey areas (failure of migration)
2. Bigger cavum

• Neurochemistry
• Dopamine hypothesis - most important Neurotransmitter
• e.g. Amphetamine (Meth, Shabu) - people who get intoxicated with shabu have symptoms similar to Schizophrenia
• Most medicines effective in the treatment is blocking dopamine -other neurotransmitters, including serotonin, glutamate and GABA
• Genetic Factors
• Outweighs environmental Factors
• Heterogeneous
• Psychosocial Factors

• Economic Factors
• Psychoanalytic theories
• Family dynamics
• Premorbid Personality
• Ask parents how the person is before the Schizophrenia
• Cluster A
• Schizotypal
1. tendency to isolate
2. problems with association
3. weird though processes
• stays home all the time
• good in spelling
• not good in math
• not interested in sports
• reading books in philosophy
• not cherished having dates
• no girlfriend/boyfriend
• does not like petting
• overly concerned over masturbation

Workup

• There are no medical tests to diagnose schizophrenia. A psychiatrist should examine the patient to make the diagnosis
• Brain scans (such as CT or MRI) and blood tests may help to rule out other disorders that have similar symptoms to schizophrenia.

Treatment

• During an episode of schizophrenia, you may need to stay in the hospital for safety reasons.
• MEDICATIONS
• Antipsychotic medications are the most effective treatment for schizophrenia - change balance of chemicals in the brain and help control symptoms
• Common side effects from antipsychotics may include:

1. Sleepiness (sedation)
2. Dizziness
3. Weight gain
4. Increased chance of diabetes and high cholesterol
5. Feelings of restlessness or "jitters"
6. Slowed movements
7. Tremor
• Long-term use of antipsychotics may increase risk for tardive dyskinesia (repeated movements that cannot be controlled, especially around the mouth)
• Clozapine is the most effective medication for reducing schizophrenia symptoms, but it also cause more side effects than other antipsychotics.

SUPPORT PROGRAMS AND THERAPIES

• Supportive therapy - helpful for many people
• Behavioral techniques - used to improve social and work functioning
• Family members of persons with schizophrenia should be educated about the disease and offered support. Programs that emphasize outreach and community support services can help people who lack family and social support.

It is important that the person with schizophrenia learns how to:

• Take medications correctly and how to manage side effects
• Notice the early signs of a relapse and what to do if symptoms return
• Cope with symptoms that occur even while taking medication. A therapist can help.
• Manage money
• Use public transportation

Complications

Increased risk for:

• Developing a problem with alcohol or drugs: This is called a substance abuse problem. Using alcohol or other drugs increases the chances your symptoms will return.
• Physical illness: People with schizophrenia may become physically sick, because of an inactive lifestyle and side effects from medication. A physical illness may not be detected because of poor access to medical care and difficulties talking to health care providers.
• Suicide