Schizophrenia

SCHIZOPHRENIA

Dr. Prasanna Prabhakar Khatawkar

M.B.B.S., D.P.M., F.A.G.E., D.N.B. (Psychiatry)

Consultant Psychiatrist

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HISTORY

• Emil Kraepelin : Manic Depressive Psychosis Vs. Dementia Praecox.

• Eugen Bleuler : Schizophrenia (1911)

(Splitting of mind).

4 ‘As’- Abnormal Association.

Autism

Abnormal Affect

Ambivalence

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HISTORY ( cont’d )

• Thomas Szasz : Anti-Psychiatry. “Schizophrenia is myth enabling the society to handle deviant behaviors”.

• Non-disease Models : The societal reaction theory “ A sane reaction to insane world”

• Kurt Schneider (1959) : First rank symptoms.

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EPIDEMIOLGY

• Affects approximately 0.85 % of world’s population.

• Incidence : 15-20 per one lack population

• Prevalence : 0.5-1.0 %

• Lifetime risk : 0.9 %

• Median age of onset : Males –28 years.

Females – 32 years.

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• Increased incidence in-

- Lower socioeconomic class.

- In patients with H/O perinatal

injuries.

- Left handed individuals.

- In individuals with winter

births

EPIDEMIOLGY ( cont’d )

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AETIOLOGY

• Genetic Theories

• Biochemical Theories.

• Family Theories.

• Social Theories.

• Psychological Theories.

• Neurological Structural abnormalities.

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GENETIC THEORIES

• Clustering seen in Families :• Relationship with Pt. :

Parents

Siblings

Child of schizophrenic

Child of two schizophrenics

• Prevalence

5 %

10 %

14 %

46 %

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GENETIC STUDIES

• Twin studies - MZ : DZ Ratio 42% : 9%

• Adoption studies also prove the genetic basis of the illness.

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BIOCHEMICAL STUDIES

• Dopamine over activity seen in Mesolimbic pathway.

• Serotonin hyperactivity and hypo-activity , both have been discussed.

• Lack of evidence to support involvement of other neurotransmitter systems.

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FAMILY THEORIES

• Double – bind theory (Bateson et al.) –

Parents convey two or more conflicting

messages.

• Marital skew and schism (Lidz et al.) –

Skew - Overprotective, intrusive parents.

Schism – Hostility between parents.

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• Life events and Expressed emotions (Vaughn and Leff ) –

Hostility

Over involvement

Critical comments

Excessive warmth in emotions.

Spending > 35 hours in high EE environment

FAMILY THEORIES ( cont’d )

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PSYCHOLOGICAL THEORIES

• Over-inclusive thought process (Cameron )- Normal boundaries of concepts cannot be maintained.

• Concrete thinking (Goldstein) – Inability to think in abstract terms.

• Defective filter (Broadbent) – Inability to filter out unnecessary sensory input.

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• Cognitive and linguistic deficits – Information processing in controlled, conscious tasks is impaired.

PSYCHOLOGICAL THEORIES (cont’d)

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NEUROLOGICAL STRUCTURAL

ABNORMALITIES• Increased ventricular size.

• Increased periventricular fibrillary gliosis (on postmortem).

• Associated various ‘soft’ signs ie. Dysgraphaesthesia, gait abnormalities, clumsiness etc. )

• Impaired dominant lobe functions.

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NEUROLOGICAL STRUCTURAL

ABNORMALITIES ( cont’d )• Abnormal smooth eye pursuit tracking

patterns.

• Non-specific abnormalities on EEG and evoked potentials.

• Non-specific biochemical changes in CSF suggestive of viral infection and immunological abnormalities.

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DIAGNOSIS (ICD-10)

• A. Thought alienation phenomenon.

• B. Delusion of control, passivity, delusional

perception.

• C. First and third person auditory

hallucinations.

• D. Bizarre delusions.

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• E. Hallucinations in other modalities.• F. Thought block.• G. Catatonic symptoms.• H. Negative symptoms – apathy,paucity of speech, blunting of affect, incongruity of

emotional response, social withdrawal etc.• I. Personality deterioration.

DIAGNOSIS (ICD-10) – (cont’d )

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TYPES OF SCHIZOPHRENIA

• Paranoid Schizophrenia

• Hebephrenic Schizophrenia

• Catatonic Schizophrenia

• Undifferentiated Schizophrenia

• Residual Schizophrenia

• Simple Schizophrenia

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HALLUCINATION

• Definition : Hallucination is a false perception in

absence of adequate stimulation ,which is not a sensory distortion or misinterpretation but which occurs at the same time like as a real perception.

It should be substantial,occurring in objective space, clearly delineated, constant and independent of will.

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DELUSION

• Definition :

False belief based on incorrect inferences of external reality that is firmly held despite objective and obvious contradictory evidence or proof and despite the fact that other members of community do not share the belief.

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FORMAL THOUGHT DISORDERS

• Derailment

• Tangentiality

• Incoherence

• Loss of goal

• Metonyms

• Neologisms

• Flight of ideas

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• Circumstantiality

• Persevaration

• Thought block

FORMAL THOUGHT DISORDERS (cont’d )

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MANAGEMENT

• Somatic treatment methods :

- Pharmacological methods.

- MECT

• Non-pharmacological treatment methods.

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PHARMACOLOGICAL TREATMENT

• Antipsychotics

• Classification :

• Phenothiazines –

Aliphatic side chain – eg. Chlorpromazine

Piperazines – eg. Trifluoperazine

Piperadines – eg. Thioridazine

• Thioxanthenes - eg.Thiothixene

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• Dibenzoxapine - eg. Loxapine

• Dihydroindole - eg. Molindone

• Butrophenones – eg. Haloperidol

• Diphenylbutylpiperadine - eg. Pimozide

• Dibenzodiazepine - eg. Clozapine

• Dibenzothiazapine - eg. Quetiapine

• Benzisoxazole - eg. Risperidone

PHARMACOLOGICAL TREATMENT (cont’d )

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• Thienobenzodiazepine - eg. Olanzapine• Benzisothiazolyl Piperazine - eg. Ziprasidone• Benzamides - eg. Sulpiride• Others – eg. Clopenthixole, Sertindole Zotepine• DSS - eg. Aripierazole

PHARMACOLOGICAL TREATMENT (cont’d )

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MODIFIED ELECTROCONVULSIVE THERAPY

• MECT• ‘Modified’ means given under general

anesthesia• Used in schizophrenia for acute agitation,

catatonic symptoms, presence of some associated affective symptoms.

• Not important on management of chronic cases.

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NON-PHARMACOLOGICAL TREATMENTS

• Psychological treatments

• Social treatments

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PSYCHOLOGICAL TREATMENT

• Social Skills Training

• Supportive therapy

• Counseling

• Token economy

• Cognitive – Behavioural Therapy

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PROGNOSIS

• 5 years prognosis ( with treatment )

55 % - Chronic course

45 % - Acute, improving course

49 % - Self- supporting

11 % - Chronically hospitalized

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THANK YOU

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