SCHIZOPHRENIA

Dr.Deddy Soestiantoro Sp.KJ M.Kes

 THE HISTORY OF SCHIZOPHRENIA

1860 : Morel -------------Demence precoce

1870 : Hecker------------Hebephrenia
1874 : Kahlbaum--------Katatonia
1896 : Kraepelin---------Dementia praecoc
1906 : Adolf Meyer----Adaptation reaction
1911 : Eugen Bleurer---Schizophrenia
 EPIDEMIOLOGY:
Around 0,3 % population , 60 % mental hospital
in-patients

ETIOLOGY:
I. -Heredoconstitutional factor:
the possibility of schizophrenia:
-one parent (+) , children 7-16 % (+)
-all parent (+) , children 40 %
-monozygotic twin ----85,8 %
-dizygotic twin -------14 %
II. -Psychogenic factor
III. -Exogenic factor
SYMPTOMATOLOGY

-Attention and initiative markedly decrease

-Lazy, lack of self care
-Psychical contact limited,monosyllable, poker face
-Flat affect , emotion difficult to feel, no empaty
-Concentration decrease, discriminative insight disturbed,
but no dementia

-Thought process: association disorders--incoherence,often

with delusion and hallucination. Dereistic thinking, neologisme,
hemmung & sperrung.Sometimes there are depersonalization &
derealization.

-Behavioural symptoms: abulia or hypobulia and also often

impulsivity.
 Usually there's pre-schizophrenic periode around
2 years, e.g
-emotional withdrawl, appearing faraway , apathy,
feeling unwelcome, lack of social contacts,
begining lack of nuance feeling, and finally
went to poor emotional life & dysharmonious
so it finally become unfelt and inapropriate.

The symptoms above are similar with the residual type

which there's remission with sequelle.
THE MAIN CLINICAL FEATURES

-a certain psychotic characteristic during the

active phase,
-multiple specific psychological symptoms,
-deterioration,
-onset before 45 years,
-minimal 3-6 months (PPDGJ-II),
-not because of affective /organic mental
disorders
PRODORMAL OR RESIDUAL SYMPTOMS

-isolation,social impairment, bizzare behavior,lack of self care,

flat affect,blunted or inapropriate, unusual ideas or magical
thought,unusual perception e.g ilusion.

During the phase of the illness minimal there's one of the

following symtoms:
-bizzare delusion,controlled,broadcast/insertion/withdrawl,with
-somatic,megalomania,nihilistic delusions,
-delusion of persecution or jealousy with hallucination,
-auditoric hallucination-comment or dialogue
-auditoric hallucination not related to depression or euphoria
-incoherence
SUBTYPES OF SCHIZOPHRENIA

It's better to look the longitudinal history of the illness.

The classical subtypes of schizophrenia are:

-hebephrenia, catatonia and paranoid type (Kraepelin),
-simplex/simple type ( Bleurer).
Simple type
-slowly beginning, hallucination not frequent/rare,
-limited thought, inability to absstract thought,
-association disorders rare,
-bizzare behavior ass. with emotion,attention & activity.
Hebephrenic type
-rapid disintegration, very disturbed association, a lot of
incoherence, neologisme.
-bizzare delusions, frequent cheerfull hallucinations,
-severe regression, frequent mannerism, deep autism.
Catatonic type
-frequently as stupor or furor catatonic ,
-catalepsy symptoms or flexibilitas cerea.
Paranoid type
-predominant delusions with hallucinations

Schizophreiform disorder
-premorbid tends to normal,
-acute, during 2 weeks untill 6 months
-hazy conciousness,oneroid, double book-keeping
symptom

Schizoaffective type,
-dominant affective symptoms,

Laten type
-unclear symptoms, hide/silent

Residual type
-remission with residual symptoms
DIAGNOSIS

1.Eugen Bleurer: 4 As
Primary symptoms:-association disorders,
-affect disorders,
-autism,
-ambivalence.
Secondary symptoms:-delusions,hallucinations etc.

2.Kurt Schneider:
First rank symptoms:
-halucinations;audible thought, dialogue,commentary
-somatic passivity experience,
-thought process:
-interruption/thought withdrawl,thought broadcast,
-delusional peceptions,
-changing desire-
3.PPDGJ (according to ICD & DSM )
In PPDGJ III schizophrenia is in Group II
Hierarchi of Mental Illness Block Diagnosis
( F20-F29 ) where more completely ass.with
schizotypal disorder , acute & transient
psychotic disorders which can be followed
by schizophrenic symptoms and also
schizophrenic-like type ,and post
schizophrenic depression.
DIFFERENTIAL DIAGNOSIS
-Mental organic disorders
-Other functional psychosis
-Hysteria/Dissociative dsisorders
-Beliefs, tradition, religious
TREATMENTS / MANAGEMENT THERAPY OF SCHIZOPHRENIA

I.Hospitalization

II.Somatic treatments/biological therapies

-pharmacotherapy:
usually using major tranquillizers (antipsychotic/neuroleptic drugs),
first choice is the classic typical antipsychotic and if no progress use
the newer generation of drugs it's the atypical antipsychotic drugs
-other drugs : lithium,anticonvulsants,benzodiazepines
-other biological therapies
-ECT as the last choice if there's no progress in drugs therapy

III.Psychosocial therapies
-Social skills training
-Family-oriented therapies
- Case management
-Assertive community treatment(ACT)
-Group therapy
-Cognitive behavioral therapy
-Individual psychotherapy
-Vocational therapy
PROGNOSIS-I
-40% remission-social recovery,60% deteriorated.
-Less than one year 30% full remission,30% social recovery &
30% will be long stay in mental hospital

-Bad prognosis:
flat affect, lack of initiative,depersonalization & derealization,
bad premorbid personality,gradual symptoms too high perso
nal aspiration,signs of hypochondriasis,persistent hallucination,
recovery more than one year, deep regression.

-Good prognosis:
acute,clear affective ..elements, clear anxiety or emotional
signs, cyclothymic premorbid personality, self-accused hallucination,
longer interval of remission.

-Robin & Guze :

Good :good premorbid personality,clear precitating factor,negative
family hystory or affective elements,clouding conciousness, acute
onset, no flatness of affect, paranoid symptoms.
PROGNOSIS-II (Kaplan & Sadock’s)
To evaluate the prognosis it's better to look up the longitudinal history of illness
begins with the family hystory and at last how about the support system.

Features weighting towards good to poor pronosis in schizophrenia

-Good prognosis
-Family history of mood disorders
-Good premorbid social,sexual & work hystories
-Late onset
-Married
-Acute onset
-Obvious precipitating factors
-Mood disorder symptoms (especially depressive disorders)
-Positive symptoms
-Good support systems
-Poor prognosis
-Family history of schizoprenia
-History of perinatal trauma
-Young onset
-Poor premorbid social,sexual & works histories
-Single,divorced or widowed
-Insidious onset
-No precipitating factors
-Neurological signs & symptoms
-Withdrawn,autistic behavior
-Negative symptoms
-No remmission in 3 years
-Many relapses
-History of assaultiveness
-Poor support systems
F 20. SCHIZOPHRENIA----PPDGJ III / ICD-10
*Schizophrenia and schizotypal --starting almost
similar.

*In schizophrenia:
-distortion of thought & perception
-hallucination & perception changes,
---confusion,elliptical & unclear thought,
-motility--interrupted & interpolation,
-thought insertion,
-inappropriate & blunted affect,
---shallow,capricious,incongruous,
-ambivalency & desire -disorders (volition ):
-inertia,negativism,stupor catatonia,
- the course of illness:
-acute onset or gradual-silent,
-later becomes broader variation,
-not always chronic or become worse
DIGNOSTIC GUIDELINES

Minimal one month at- least one of the following symptoms:

a.thought echo/insertion/withdrawl/broadcast,
b.delusion of control/influence-passivity,
c.comment/dialogue/discussion hallucinations or from the
organs of the body,
d.bizzare delusion
or at least two of the following symptoms:
e.persistent hallucination/delusion/overvalued ideas,
f.interrupted motility thought/insertion-incoherence/neologisme
g.catatonic behavior:excitement,posturing,mutism,negativism
flexibilitas cerea,stupor.
h.negative symptoms :apathy, paucity speech,blunting/
incongruity emotional response,resulting in social withdrawl/
lowering social performance and all of these causing:
i.a significant and consistent change in the overall quality of
some aspect of personal behavior manifest as loss of interest,
aimlessness,idleness,a self absorbed attitude and social
withdrawl
Retrospective:
-prodormal phase/non psychotic:
-loss of interest in works,social activities and personal
appearance and hygiene together with generalized anxiety
and mild depression and preoccupation,before the psychotic
symptoms for some weeks/month

Pattern of course:
-continuosly,
-episodic with progressive deterioration,
-episodic with stable deficit,
-episodic remittent,
-with incomplete remission or
-complete remission.
-other,
-periode of observation less then one year.

Criteria of time for residual schizophenia minimal 1 year and for

schizotypal disorder 2 years, if the psychotic phase not yet 1
month, the preliminary diagnosis is Acute Schizophrenic-like
Disorder.
Subtypes of schizophrenia

F 20.0 Paranoid schizophrenia

The general criteria for a diagnosis of schizopheni must be satisfied.In addition,
hallucinations and/or delusions must be prominent,and disturbances of affect,
volition and speech,and catatonic symptoms must be relatively inconspicious.
Delusions can be of almost any kind but delusions of control,influence,or passivity,
and persecutory belief of various kinds are the most characteristic.,

F20.1 Hebephrenic schizophrenia

A form of schizopohrenia in which affective changes are prominent,delusions and
hallucinatons fleeting and fragmentary,behaviour irresponsible and unpredictable,
and mannerisms common.The mood is shallow and inappropriate and often
accompanied by giggling or self-satisfied,self-absorbed smiling,or by a lofty
manner, grimaces, mannerisms,pranks,hypochondriacal complaints,and reiterated
phrases. Thought is disorganized and speech rambling and incoherent.There's a
tendency to remain solitary, and behaviour seems empty of purpose and feeling.
Usually starts between the age of 15 and 25 years and gendss to have a poor
prognosis because of the rapid development of negative symptoms,particularly
flattening of affect and loss of volition.
F20.2 Catatonic schizophrenia
Prominent psychomotor disturbances are essential and dominant features and may
alternate between extremes such as hyprkinesis ands stupor,or automatic obedience
and negativism.Constraineds attitude and postures maybe maintained for long
periods. Episodes of violent excitement maybe a striking feature of the condition.

F 20.3 Undifferentiated schizophrenia

Condition meeting the general dignostic criteria for schizophrenia,but not conforming
to any of the above subtypes,or exhibiting the features of more than one of them
without a clear of predominance of a particular set of diagnostic characteristic.

F 20.5 Residual schizophrenia

A chronic stage in the development of a schizophrenic disorders in which there has
been a clear progression from an early stage comprising one or more episodes of
exacerbation to a later stage.

F 20.6 Simple schizophrenia

Slowly progressive develpment of the characteristic negative symptoms of residual
Schizophrenia without any history of hallucinations,delusions or other manifestations
of earlier psychotic episode,and with significant changes in personal behaviour,
manifest as a marked loss of interesr,idleness,and social withdrawal.
F 25 Schizoaffective disorders
These are episodic disorders in which both affective and schizophrenic symptoms are
prominent within the same episode of illness,preferably simultanously,but at least
within a few days of each other.

F 25.0 Schizoaffective disorder,manic type

There must be a prominent elevation of mood,or a less obvious elevation of mood
combined with increased irritability or excitement.Within the same episode,at least one
and preferably two typically schizophrenic symptoms should be clearly present.

F 25.1 schizoaffective disorder,depressive type.

A disorder in which schizophrenic and depressive symptoms are both prominent in the
same episodes of ilness.Depression of mood is usually accompanied by several
characteristic depressive symptomsor behavioural abnormalities such as retardation ,
insomnia, lost of energy, appetite or weight reduction of normal interests,impairment
of concentration guilt,feelings of hopelessness,and suicidal thoughts.At the same time
or within the same episode,other more typically schizophrenic symptoms are present.
This subtype usually less florid and alarming than manic type,but they tends to last
longer and the prognosis is less favourable.Although the majority of patients recover
completely,some eventually develop a schizophrenic defect.

F 25.2 Schizoaffective disorder,mixed type

Disorders in which symptoms of schizophrenia coexist with those of a mixed bipolar
affective disorder.
DELUSIONAL ( PARANOID )
DISORDERS
 PARANOID DISORDERS
A group of severe mental diorders with the main symptoms
is a variety of delusions, often systematic with or without
hallucinations.
The psychotic symptoms often very clear & sometimes
only delusions which is dominant.

Since Hippocrates,paranoia means "sanity",used again by

Vogel, and more confirmed by Kahlbaum (1863).

Kraepelin: introduce the term paraphrenia and there're 4

type: systematic,expansive,confabulative and fantastic.

Freud: paraphrenia is identically the same as paranoid

schizophrenia.
EPIDEMIOOGY
Prevalence (USA) 0.025-0.03% ( Schizophrenia 0.1 %
and affective disorders 0.5%).Women twice than men
and usually single and suspected with homosexual
orientation and chronic prejudice.

Age:average 40 years,when the delusions cannot be

tolerated anymore, the agression drive will invite
counter agression from the environment and so
make it easier to develope delusion of persecution,
nihilistic etc.,resulting abandoned by friends, feeling
isolated/unwelcome and inferior, finally become
more paranoid.
 SYMPTOMS
The main symptoms:delusions,logic,sistimatic,complex,sometimes
looks like isolated /apart from the personality,so the personality seems
intact, and disturbed when the delusions being touch.

-Persecuted delusions:feels being hatred- by relatives,want to be

unmistakeable, the misintepretation & misunderstanding resulting in
persecuted delusions.

-Delusion of reference if there's a feeling that someone is talking or

commenting obout him/her

-Litygious type: feeling of being treated unfair,feeling of being right and

superior.

-Exaltase type:delusions of grandeur,megalomania,often appear long

time after persecuted delusions, often feels as God‘s mission

-Erotic type:feeling the celebrities fall in love with him/her.

Often appear as suicidal homocidal action.
ETIOLOGY

-Psychogenic cause: frustated ambition drive

-Freud :homosexual fixation
-sadistic experiences during early childhood
( anal sadistic phase)

-Genuine paranoid rarely seen,usually an extension of

paranoid premorbid personality.
-more often in the form of paranoid reaction,
-the defence mechanism which is used: denial &
projection

-Heriditary / constitutional e.g:

-low threshold for frustation,
-rigid in relationship,
-hypersensitivity etc.
Premorbid usually paranoid personality e.g
blame on others easily,many prejudice,
uneasy to confess wrong,often irritable
easily hurt, angry, egocentric and easily
paranoid/ suspicious.

Prognosis:
Not so good in genuine paranoia with
paranoid personality back ground which
begins gradually or if there's a picture of
schizophrenic symptoms because of rarely
full remission.
In PPDGJ II these disorders includes:
-paranoia
-shared paranoid disorders,
-paraphrenia,
-unspecified paranoid disorders

In PPPDGJ III
-F22 Persistent delusional diorders
-F 23.3 Other acute predominantly delusional
psychotic disorder.
-F 24 Induced delusional disorder
SHARED PARANOID DISORDER (Folie a Deux / Trois)

1877: Laseque & Falret: induced psychosis with symptom

of delusions,in close relatives, the induced person
which is submissive,suggestibel, dependent and
emotionally depends on the first.
The used defence mchanism is identification.
INVOLUTIONAL PARAPHRENIA

Rarely genuine,often mixed wirth melancholia

Premorbid full of defence mechanism projection,
inferior,critical,tends to blame others,jealous,
cannot forgive,suspicious.

Symptoms:-organized persecutory delusion,

annoyed, feeling of hostility.

Prognosis:-worse than involutional melancholia

DELUSIONAL DISORDER IN PPDGJ III/ICD-10
-Having uncertain relation with schizophrenia

-Specifically:persistent single/systematic delusions,

sometimes all life ---long.
-Often delusions of persecutory,hypochondriac,grandiose or
which is related with court,jealousy,abormal body,feels
that the body has bad smell or homosexual.
-Depression symptoms can be found intermittently.
-Maybe there're olfactoric and tactil hallucinatios
-Auditoric hallucination appears temporaly & generally in
old age.
-Usually in midslife age ,except in abnormal body delusion
which often in young age
-Often related with environtmental situation,persecutrory
delusion frequently in minority group.

-Apart from the behavior & attitude related with delusions, the
affect, talking & behaviour still normal.
Other persistent delusional disorder

-Delusional disorder with persistent

hallucination or schizophrenic
symptoms which not enough for
schizophrenic criteria and minimally 3
months duration.

-Includes here: delusional dysmorphobia

& involutional paranoid state.
OTHER NON-ORGANIC PSYCHOSIS

Includes here are depressive type psychosis

or excitation, reactive confusional state,
acute or psychogenic paranoid disorders,
brief reactive psychosis and unspecified
psychosis.

Usually there's a real stressor in

interpersonal relatioship problems or
environmental problems which are very
stressfull and generally last during 2weeks
until 6 months and the prognosis usually
good enough