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Schizophrenia.

Presented by Dr MORAH .N Psychiatry dept NAUTH

Outline.

Introduction. Epidemiology. Etiology/ pathophysiology. Clinical presentation Diagnosis. Types of schizophrenia

Treatment
Complications / differential diagnosis.

prognosis
Conclusion.

Introduction.

In 1908 eugene blueler was the first man to coin the word schizophrenia from greek, 'skhizen' (split) and 'phren' (mind) meaning split personality.

Introduction cont
Blueler characterized schizophrenia as having 4 basic symptoms, ie the 4 'A's
Flattened affect, Autism,

Impaired association,
Ambivalence.

Introduction cont

Currently there is no generally accepted definition for schizophrenia but its know to be xterized by the ff;

psychosis(loss of contact with reality)

hallucination(false perception)

delusion(false belief)

Disorganized speech & behavior Flattened affect

Introduction cont
Cognitive deficit
Occupational & social dysfunction.

Epidermiology.

Schizophrenia has been found to have an even world wide distribution.


Age of onset is usually btw the age of 15-45 yrs. Average age of onset is 18yr in and 25yrs in , with a : of 1:1 Incidence of 0.16 0.54 per 1000 population.

Prevalence of 1.4 4.6 per 1000 population

Etiology.
Although the specific cause is unknown, its has been shown to have some biological basis, evidenced by alteration in the brain structure.
Enlargement of the ventricles

se size of the anterior hippocampus


Changes in neurotransmitters (dopamin & glutamate)

Etiology.

A combination of genetic and environmental factor play a role in the development of schiz,
Genetic factors

People with a family history of schizophrenia who suffer from transient psychosis has a 2040% chances of being diagnosed one year later.

Genetics cont

People with 1st degree relatives having schizo have 10% chance of developing the disease as against 1% in the general population.
People with both parents having schizophrenia have 40% chances of developing the disease. Monozygotic twins have a concordance of about 50% as against 10% in dizygotic twins.

Environmental
Some of the environmental factors found common among px with schizo are:

Maternal exposure to famine & influenza while pregnant. Low birth weight

Rh incompatibility in 2nd pregnancy


Early use of cannabis Becoming unemployed or impoverished. Breaking off a romantic relationship.

Pathophysiology.

There are several hypothesis about neurochemical mechanism underlying schizophrenia. DOPAMINE
Over activity of dopamine at the D2 receptor is proposed due to the effect of anti dopamine drug (anti-psychotics) at ameliorating antipsychotic symptoms. In contrast reduced activity on D1 receptor manifest as deficit in working memory.

Pathophysiology cont..
GLUTAMATE

Reduced level of glutamate is proposed based on psychotic & cognitive symptoms generated in humans exposed to ketamine or phencyclidine which are non competitive antagonist at the glutamate receptor.

MUTATIONS

Mutation in various gene has been implicated in schizophrenia eg are DISC1, ERBB4, NRG1.

Pathophysiology cont

These mutations has also been noticed in other neuropsychiatric conditions, & some of these gene has been found to be beneficial for development. It must be emphasized that there are only working models and a true pathophysiology remains to be established.

Clinical presentation.
Schneilder's symptoms of first rank.

Hearing thoughts spoken aloud.


Third person hallucination.

Hallucination in the form of a commentary


Somatic hallucination. Thought withdrawal & insertion Thought broadcasting Delusional perception

Feelings or actions experienced as made or influenced by external agent.

Clinical presentation
Currently could be grouped Into; positive , negative, disorganized and cognitive.

POSITIVE 1 = delusion (persecutory, reference, thought insertion or withdrawal)

2= hallucination ( auditory, visual, olfactory, gustatory or tactile)

Clinical presentation
NEGATIVE (leads to poor motivation & diminished sense)

1= blunted affect 2= poverty of speech (alogia)

3=Inability to experience pleasure (anhedonia)


4=lack of interest in relationship (asociality) 5=lack of motivation (avolition)

Clinical presentation.
DISORGANIZED/ BIZZARRE BEHAVIORS.

1= child like silliness 2= agitation 3= inappropriate appearance 4= hygiene and conduct.

4= catatonia (making rigid postures)

Clinical presentation cont


COGNITIVE.; these patients have impairment in
1= attention

2= processing speed 3= working memory 4=abstract thinking

5= problem solving.
Symptoms of schizophrenia typically impair the ability to function & often markedly interfere with work, social relations & self care.

Diagnosis and types.


No definitive test for schizophrenia exist. Diagnosis is based on a comprehensive assessment of history, symptoms & signs. Information from from collateral sources.
Although some structural changes may be seen on imaging, these are insufficiently specific to have diagnostic value.

Diagnosis and types cont


According to the diagnostic & statistical manual of mental disorder (DSM-IV), 2 or more characteristic symptom for a significant portion of a month are required for the diagnosis, with a prodromal sign of illness with social, occupational or self care impairment must be evident for a 6 month period.

Diagnosis and types cont


DSM-IV proposed 5 subtypes;


1-paranoid = delusion & hallucination (auditory) 2- disorganized/ heberphrenic = disorganized speech & behavior, with flat affect. 3- catatonia =immobility or excessive motor activity, assumption of bizarre position 4- residual = chronic schizo, for at least 1 yr with persistent, negative symptoms, but no recurrence of positive symptoms 5-undifferentiated = mixed.

Diagnsis and types cont


ICD-10 according to WHO proposed 2 additional subtypes;
1- deficit syndrome = describes a subtype of schizophrenia with early, sever & persistent negative symptoms. 2- simple= xterised by insidious development of odd behavior, social withdrawal and declining performance at work. Since clear symptoms of schizophrenia are absent the diagnosis is difficult to make.

Clinical subtypes.
Crow (1985), described 2 syndromes of schizophrenia based upon a combination of clinical and neurobiological factors .

TYPE 1;

Acute onset, mainly positive symptoms & preserved social functions during remission. Has a good response to anti-psychotic drugs, associated with behavioral of dopamine over activity.

Clinical subtypes cont


TYPE 2;
Has an insidious onset, mainly negative symptom Poor outcome and response to antipsychotic drugs

No evidence of dopamine hyperactivity but with structural brain changes.

Treatment.
GOALS;

Reduce severity of psychotic symptoms . Prevent recurrence of symptomatic episodes & associated deterioration of function. Help patient function at the highest level possible. Treatment could be grouped into pharmacological and non pharmacological.

Pharmacological.

Pharmacology cont.

Pharmacology cont..
Because most of these patients do not have insight about there health condition, non compliance to medication do occur, hence the long acting depot could be used;

Fluphenazine decanoate 12.5-50mg (2-4wk) Fluphenazine enanthate 12.5-50mg (1-2wk) Haloperidol decanoate 25-150mg ( 3-5wk) Resperidone microshpere 25-50mg (2wk)

Pharmacological cont
Antipsychotics are effective in 70% of first episode cases.
After the drug is commenced it takes 6-8wks to achieve full remission, then maintenance is initiated with the lowest dose that prevents symptoms recurrence.

Choice of drug depend on


Side effect

Cost
Past Hx of favorable response to any drug.

Non pharmacological
Psychotherapy.
The goal of psychotherapy is to develop a collaborative relationship btw the patient, family & physician so that the patient can learn to understand and manage the illness, take drugs as prescribed and handle stress more effectively.

Rehabilitation and community support service.

Complications
Suicide occur in about 10% of schizophrenic patients and is most common among the paranoid types because these patients retain the capacity for grief and anguish.
On the average, the illness reduce life expectancy by 10yrs.

Violence out burst.


Depression.

Differential diagnosis.

Bipolar disorder.
Drug induced psychosis Delusional disorder Depression.

Prognosis.
This depends on ;

Type If associated with other mental disorders, eg OCD(poor), personality disorder (good) Adherence to medication. OVER ALL achieve significant & lasting improvement

improve, but have intermittent relapse & deficit

are severely & permanently incapacitated.

Prognostic factors
Good factors

Poor factors
Poor premorbid fxn Early age of onset Insidious onset Disorganized type

Good premorbid fxn Late age of onset Sudden onset Paranoid type.

Women
Minimal cognitive impairment.

Men
Co-morbid substance abuse Repeated relapse.

Prognosis.
JOHN NASH a US mathematician and joint winner of the 1994 nobel prize for economic, suffered from schizophrenia.

His life has been a subject of the 2001academic award film 'a beautiful mind'.

conclusion
The cause of schizophrenia is unknown, but evidence for genetic component is strong. There is no cure for schizophrenia it could only be managed.

Reference.

Oxford book of psychiatry


Merck manual 8th edition. Harrision's principle of medicine 18th edition. Kaplan text book of psychiatry. Wikiepedia

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