SCHIZOPHRENIA

BYEMMANUEL GODWIN5th year Medical StudentCollege of MedicineUniversity of Nigeria , Enugu Campus

OUTLINE

DEFINITION TYPES CLINICAL FEATURES DIAGNOSTIC CRITERIA(ICD-10 AND DSM –

IV) EINDICES OF PROGNOSIS TREATMENTS PIDEMIOLOGY

DEFINITION

Schizophrenia is a mental disorder characterized by a breakdown of thought process and by deficit of typical emotional responses.

It originates from the greek word skhzein(to split) and phrein(mind)

It doesn’t simply imply split personality as seen in dissociative identity disorder, but it implies splitting of mental functions.

History of schizophrenia

The term schizophrenia was coined by a swiss psychiatrist EUGEN BLEUER

He maintained that the 4 A’s lie at the core of the disorder and are the fundamental aspects of the disorders

Bleuer maintained that the 4A’s are the main core of the disorder while manifest first rank symptoms of schizophrenia are peripheral and not important

Four A’s

Disturbances of association(loosening of association)

Changes in emotional reactivity( flattening of affect)

Withdrawal from reality into the internal world of fantasy(Autism)

Fluctuation between two opposing ideas(ambivalence)

TYPES

Paranoid-types schizophrenia Disorganized-type schizophrenia Catatonia-type schizophrenia Undifferentiated-type schizophrenia Residual-type schizophrenia Simple-type schizophrenia

Paranoid-type schizophrenia

This is the most common form of schizophrenia where the individual has delusions that a person or group of persons are plotting against them. Major symptons include Persecutory Delusion,Auditory hallucination,delusions of false grandeur,Anxietyand Anger

Disorganized-type schizophrenia

In this type of schizophrenia behaviour is disturbed/abnormal and has no purpose, there is formal thought disorder which precipitates as disorganized behaviour and speech.

It is also called hebephrenia with respect to the greek goddess of youth HEBE due to its onset at puberty

UNLIKE paraniod schizophrenia delusions and hallucinations are not prominent features

Disorganized-type schizophreniacontd

Common symptoms include Active behavior but in an aimless manner ,inappropriate emotional response, inappropriate facial responses, inappropriate laughter , anhedonia and avolition are also present ,they may also have delusions and hallucinations

Catatonia-type schizophrenia

This is a form of schizophrenia where a person loses touch with reality,it is a state of neurogenic motor immobility and behavourial disorder manifested by stupor. In this type, behaviours at extreme opposites are manifested.For example, the person might be in a coma-like state unable to speak or move or the person might talk or move in a hyperactive way

It is a chronic disorder

Catatonia-type schizophreniacontd.

Common symptoms include paucity of movement or hyperactivity,stereotyped or repetitive movement and waxy flexibility

Undifferentiated-type schizophrenia

This is a form of schizophrenia that is a jack of all forms but master of none.

The person has symptoms as seen in the above forms but not enough to pinpoint it as one of them

Example, the person has a bit of psychomotor(catatonia) and a bit of delusion and hallucinations(paranoid)

Residual-type schizophrenia

This is specifically used for patients that have had one or more episodes of schizophrenia but do not presently have strong positive symptoms like hallucination or delusions. They may have negative symptoms like withdrawal or mild positive symptoms which indicate that the disorder is not yet resolved

It’s usually found in the transition between an acute episode and resolution of the disease

Simple-type schizophrenia

It usually begins in childhood It usually consists of symptoms like

absence of will Reduced thinking and flattening of

affect There is a gradual deterioration of

functioning and reduced socialization It is rarely diagnosed and it’s a

schizophrenia without psychosis

Diagnosis of schizophrenia are usually made clinically based on the patient's behaviours and patients narrative experiences

General Symptoms include Hallucinations Delusions Impairment in social cognition Psychomotor disorders

CLINICAL FEATURES OF SCHIZOPHRENIA CONTD

The symptoms are classified into The Schnederian Classification The Positive, Negative and

Cognitive Classification

The Schnederian Classification

The german psychiatrist in the 20th century Kurt Schneider listed the following symptoms known as the FIRST RANK SYMPTOMS and they include

Hearing thoughts spoken aloud Third person auditory hallucination Hallucination in the form of commentary Somatic hallucination Thought withdrawal or insertion Thought broadcasting Delusional perception Feelings or actions experienced as made or influenced by

external agent of force

The Positive, Negative and Cognitive Classification

Positive symptoms refers to an excess or distortion of normal functions and refer to symptoms that are not found in an otherwise normal person. These symptoms respond well to medications and they include

DELUSIONS HALLUCINATIONS THOUGHT AND SPEECH DISORDER DISORGANIZED BEHAVIOUR

The Positive, Negative and Cognitive Classification

Negative symptoms refers to a reduced or absent characteristic normal function

They often appear several years before first acute episode

They often lead to relationship problems with family and friends

They generally respond less to medication and they include

LOSS OF INTEREST IN EVERYDAY ACTIVITY LACK OF EMOTION REDUCED ABILITY TO CARRY OUT

ACTIVITIES NEGLECT OF PERSONAL HYGIENE SOCIAL WITHDRAWAL LOSS OF MOTIVATION

The Positive, Negative and Cognitive Classification

Cognitive symptoms involve problems with thought processes, they carry the most disability as the patient has reduced ability to perform daily routine task and they include

Memory problems Difficulty in paying attention Problems with interpreting information

DIAGNOSIS

The diagnosis of schizophrenia is made on clinical grounds with investigations done principally to rule out organic brain disease. However, a reasonable diagnosis must be in line with either or the two criteria below.

ICD10 criteria DSM iv TR criteria.   NB: in practice, agreement between the two

systems is high.

ICD10 CRITERIA

This system uses the self-reported experiences of the person and reported abnormalities in behavior, followed by clinical assessment by a mental health professional. The ICD-10 put more emphasis on schneiderian first rank symptoms of acute schizophrenia which include.

Auditory hallucinations-second/third person type, thought echoes

Broadcasting, insertion/withdrawal of thoughts Controlled feeling, impulses or acts (passivity

phenomenon) Delusional perception

DSM iv TR CRITERIA

  According to the DSM iv TR, to be diagnosed with

schizophrenia, three of the following criteria must be met. characteristic symptoms:- two or more of the following, each

present for most of the time during one month period (or loss, if symptoms remitted with treatment).

Delusions Hallucinations Disorganized speech which is a manifestation of formal

thought disorder. Grossly disorganized behaviors Negative symptoms Blunted affect

Alogia (lack or decline in speech) Avolition (lack or decline in motivation) Social or occupational dysfunction:- For a significant

portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self care, are markedly below the level achieved prior to onset.

Significant duration:- continuous signs of the disturbance persist at least six months. This six months period must include at least one month of symptoms (unless, if symptoms remitted with treatment) if signs of disturbance are present for more than a month but less than six months, the diagnosis of schizophreniforn disorder is applied

EPIDEMIOLOGY

The prevalence of schizophrenia is similar world wide at about 1% of the population and the disorder is more common in men. The children of one affected parent have approximately a 10% risk of developing the illness, but this rise to about 50% in identical twins. The usual age of onset is the mid-twenties.

INDICES OF PROGNOSIS

About ¼ of those with acute schizophrenic episode have a good outcome, 1/3 develop chronic schizophrenia and remainder recover after each episode but suffer relapses , most will not work or live independently. Prophylactic treatment with antipsychotic drugs reduces the rate of relapse in the first 2 years after episode of schizophrenia from 70% to 40%. Schizophrenia is associated with suicide, 1 in 10 patients take their own lives.

TREATMENTPharmacotherapy

Psychotherapy

Psychosocial

PHARMACOTHERAPY Anti psychotic medications are a must use to help

control both positive and negative symptoms Older or newer anti psychotics may suffice in this case,

as they all share (as a mechanism of action) the capacity to antagonize postsynaptic dopamine receptors in the brain.

Antipsychotics can be categorized into two main groups: the older conventional antipsychotics, which have

also been called first-generation antipsychotics or dopamine receptor antagonists e.g Clorpromazine, piperazine

the newer drugs, which have been called second-generation antipsychotics or serotonin dopamine antagonists (SDAs) e.g Clozapine

PHARMACOTHERAPY contd.

The newer Anti psychotics are however better preferred as a result of their ability to both reduce dopamine levels and stabilize serotonin levels (a neurotransmitter pathology seen in schizophrenia). They also have less extra pyramidal effects

NB: They are called atypical antipsychotics b/c they share the property of weak D2 receptor antagonism and more potent 5-HT2A receptor blockade

Phases of Treatment in Schizophrenia

Treatment of Acute Psychosis: In acute psychosis ,patient presents with most

severe psychotic symptoms Acute schizophrenia is typically associated with

severe agitation, which can result from such symptoms as frightening delusions, hallucinations, or suspiciousness, or from other causes, including stimulant abuse. NB: Patients with akathisia can appear

agitated when they experience a subjective feeling of motor restlessness, so u have to differentiate the two.

This phase usually lasts from 4 to 8 weeks

Treatment of Acute Psychosis contd.

Clinicians have a number of options for managing agitation that results from psychosis.

Antipsychotics and benzodiazepines can result in relatively rapid calming of patients. With highly agitated patients, intramuscular administration of antipsychotics produces a more rapid effect. An advantage of an antipsychotic is that a single intramuscular injection of haloperidol (Haldol), fluphenazine (Prolixin, Permitil), olanzapine (Zyprexa), or ziprasidone (Geodon) will often result in calming without an excess of sedation

Benzodiazepines are also effective for agitation during acute psychosis. Lorazepam (Ativan) has the advantage of reliable absorption when it is administered either orally or intramuscularly. The use of benzodiazepines may also reduce the amount of antipsychotic that is needed to control psychotic patients.

Phases of Treatment in Schizophrenia contd.

Treatment During Stabilization and Maintenance Phase : In the stable or maintenance phase, the illness is in a

relative stage of remission The goals during this phase are to prevent psychotic relapse

and to assist patients in improving their level of functioning During this phase, patients are usually in a relative state of

remission with only minimal psychotic symptoms. Stable patients who are maintained on an antipsychotic

have a much lower relapse rate than patients who have their medications discontinued.

It is generally recommended that multiepisode patients receive maintenance treatment for at least 5 years, and many experts recommend pharmacotherapy on an indefinite basis.

Other Biological Therapies

ECT has been studied in both acute and chronic schizophrenia. Studies in recent-onset patients indicate that ECT is about as effective as antipsychotic medications and more effective than psychotherapy.

Psychotherapy Studies on the effects of individual psychotherapy in

the treatment of schizophrenia have provided data that the therapy is helpful and that the effects are additive to those of pharmacological treatment

The suggested type is SUPPORTIVE PSYCHOTHERAPY with the primary aim of having the patient understand that the therapist is trustworthy and has understanding of the the patient, no matter how bizarre.

It is nothing more than an “ego builder” Making the patients feel that he/she can trust you

about anything and all you will do is to support them and ensure that they take their medications.

Psychosocial Therapies Psychosocial therapies include a variety of

methods to increase social abilities, self-sufficiency, practical skills, and interpersonal communication in schizophrenia patients. The goal is to enable persons who are severely ill to develop social and vocational skills for independent living. Such treatment is carried out at many sites: hospitals, outpatient clinics, mental health centers, day hospitals, and home or social clubs.

Social Skills Training

Social skills training is sometimes referred to as behavioral skills therapy . Along with pharmacological therapy, therapy can be directly supportive and useful to the patient. In addition to the psychotic symptoms seen in patients with schizophrenia, other noticeable symptoms involve the way the person relates to others, including poor eye contact, unusual delays in response, odd facial expressions, lack of spontaneity in social situations, and inaccurate perception or lack of perception of emotions in other people.

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