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SCHIZOPHRENIA

SCHIZOPHRENIA
Definition: It refers to group of mental illness characterized by specific psychological symptoms leading to disorganization of personality of an individual. The symptoms interfere with patients thinking, emotions and behavior in a characteristic way.

DEFINITION_2

It is defined as a functional psychosis characterized by disturbances in thinking, emotions, volition and perception. Finally leads to personality deterioration.

HISTORY

Previously (1896) Emil Kraeplin termed as dementia praecox( dementia of puberty). Eugen bleuler, first termed the name schizophrenia (1911).

Schizophrenia derived from Greek words schizo means split and Phren means mind.

EPIDEMIOLOGY

Prevalent in all the cultures 4-5 per 1000 population suffer with schizophrenia Most of the cases are in 15-30 years of age group More common in low socio-economic classes Prevalence is common in women compare to men. Life time risk to develop the illness is about 1%.

ETIOLOGY
Idiopathic Genetic factors: if one parent is affected with schizophrenia, a 12% rate is demonstrated in the children. If both are affected the rate of occurrence will be more upto 35-39%. Research is focused on genes on chromosomes 6,13,18 & 22 are related to the development of schizophrenia. Hebephrenic and catatonic subtypes of have greater genetic vulnerability.

ETIOLOGY Cont..

Biochemical and structural brain factors: dopamine hypothesis suggests that schizophrenia is caused by functional hyperactivity of dopamine. Amphetamine and cocaine which release dopamine at central synapses induce schizophrenia like symptoms in normal people. Anti-psychotic medications act by blocking dopamine receptors and reducing the dopamine over activity Dopamine receptors of D-2 type are dense in the brains of schizophrenia (postmortem studies)

Nor epinephrine hypothesis: increased nor epinephrine is associated with increased dopamine activity. GABA hypothesis: it is decreased leading to increase dopamine activity. Serotonin hypothesis: excess causesexcitement and perceptual disturbances, deficiency causes retardation and stupor as seen in catatonia.

ETIOLOGY cont

Structural anomalies of brain: brains of patients with schizophrenia are lighter and smaller. Non-progressive cortical atrophy is seen in 1035% of patients, particularly in the frontal and temporal lobes of the left side. The lateral and third ventricles are enlarged in about half of the patients. Cerebral atrophy and resultant ventricular dilatation are attributed to the viral infection.

ETIOLOGY cont

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Family as a cause of schizophrenia: broken homes, unstable parents and eccentric child raring practices were seen in many cases. Two anomalous family situations leading to the onset of illness have been described: Deviant role relation ship Disordered communication.

ETIOLOGY cont
Lack of warm, nurturing relationship in early years of life contributes to the lack of self identity, reality misconception and relation ship withdrawal. Migration and life changes: rates of schizophrenia are high among migrants which could be attributed to the effects of the new environment and life changes.

ETIOLOGY cont

Psycho-social stresses and social changes: it will precipitate illness in susceptible individual.

Classification of schizophrenia
F20.0 F20.1 F20.2 F20.3 F20.4 F20.5 F20.6 F20.8 F20.9 Paranoid schizophrenia Hebephrenic schizophrenia Catatonic schizophrenia Undifferentiated schizophrenia Post schizophrenic depression Residual schizophrenia simple schizophrenia others schizophrenia unspecified schizophrenia

Paranoid schizophrenia

Paranoid schizophrenia: Commonest type Core symptoms are paranoid delusions Thought disorders of the formal type are usually absent Affect is preserved and is neither shallow nor inappropriate Hallucinations are common with paranoid themes. it has good prognosis if treated early.

Hebephrenic schizophrenia: Early onset occurring around at or around puberty which is insidious but may be acute. It may progress rapidly leading to personality deterioration and negative symptoms. Thought is disorganized, speech incoherent and rambling. Mood is shallow and inappropriate with occasional euphoria- marked silly giggling, smiling and laughter. Hallucinations may be present.

Recovery never occurs and it has worst prognosis among all sub types.

Catatonic schizophrenia: Motor and volition disturbances are most prominent features. This may take the form of catatonic excitement and stupor. In excitement, increase psychomotor activity, [stereotyped and purposeless over activity and impulsive behavior is seen] Increase in speech production Alternatively in stupor all motor activity is reduced in the form of mutism and stupor. Posturing, negativism, echolalia and echopraxia are common.

Catatonic stupor

Simple schizophrenia: Slow and progressive withdrawal from social and work situations. Has insidious onset presence of negative symptoms, vague hypochondriacal features wandering tendency, self absorbed idleness and aimless activity, except for lack of drives, initiative and shallow emotions patient does not exhibit any psychotic features. .

Residual schizophrenia: chronic stage with incomplete remission and residual symptoms as lack of drive, under activity, shallow affect and regressed behavior. Undifferentiated schizophrenia: when several psychotic symptoms are present and differentiation to any clinical group is not possible

Undifferentiated schizophrenia

CLINICAL MANIFESTATIONS
POSITIVE SYMPTOMS: Delusions Hallucinations Bizarre behavior Aggression Agitation Suspiciousness Excitement Grandiosity

NEGATIVE SYMPTOMS: Apathy, Anhedonia, Asociality, A volition, Alogia Attention deficits, Social withdrawal Diminished emotional response Blunted affect/ flat effect Stereotyped thinking Artificial gestures Lack of spontaneity

Bleulers 4 As
primary\essential Association defect Affect (blunt\flat) Autism(thinking which is dominated by fantasies) Ambivalence( simultaneous occurrence of contradictory feelings, wishes, attitudes or ideas) Secondary\accessory Delusions Hallucination

Kurt schneider first rank symptoms

Audible thoughts or thought echo Voices commenting on him in the third person or voices heard Voices arguing Passivity feeling Thought withdrawal or insertion Thought broad casting Delusional perception Other perceptual, motor and affective symptoms are called second rank symptoms.

Disturbances of thinking
Stream: incoherence or absence of link between ideas, crowding of ideas, thought block, thought withdrawal, flight of ideas etc.. Content: irrelevant and meaning less ideas, pseudo religious, neologism, delusions.

Disorders of speech: Poverty of speech Poverty of ideation Ehcolalia Circumstantiality , Tangentiality Perseveration Verbigeration Neologism, word salad Mutism

Emotional blunting, unexplainable depression, elation, giggling. Mood incongruous that is inappropriate to thoughts and current situations.

Disturbances of emotions

Disturbances of perceptions:
Hallucination are important perceptual disturbance. Auditory hallucination are the commonest. Visual, tactile, olfactory, gustatory are also seen.

Disturbances of behavior
Irrelevant and inappropriate behavior. Increase / decrease in psychomotor activity. Mannerisms, grimacing, stereotypes, decreased self care and poor grooming are common. Withdrawal from reality into fantasy, stupor. Suicidal and homicidal tendencies. Criminal and sexual over activity and lack of insight.

Volitional disturbances: Deterioration in will power, drive and ambition. Disturbances of attention: Excessive day dreaming, muttering, spells of laughter and cry without reason, absent mindedness.

Diagnosis
Detailed history Mental status examination Psychiatric testing- projective tests Acc. To ICD-10 req: a) Presence of psychotic symptoms for a period of one month or more b) At least one (if clear cut) or two or more( if not clear cut) of the following symptoms:

Diagnosis cont.
Thought echo, thought insertion or withdrawal/broadcasting Delusional perception Hallucinatory voices Impossible delusions

Symp. at least two of the following: Persistent hallucinations Neologisms/incoherent speech Catatonic symptoms Negative symptoms Personality deterioration

Management
Antipsychotic- clozapine, risperidone, olanzapine, quetiapine and ziprasidone. Neuroleptics- phenothiazines (for blocking of D2 receptors. Sedatives like phenobarbitone sodium are indicated when patient is excited, rowdy and restless. Hypnotics for sleeplessness. Lithium, proponolol, beta blockers and antidepressants.

Management
2) ECT 3) Hospitalization and milieu therapy 4) Group therapy 5) Behaviour therapy 6) Social skilltraining 7) Cognitive therapy 8) Individual psychotherapy 9) Psycho-social rehabilitation 10) Family therapy.