Schizophrenia
At the end of the lecture you should be able to
• Define the disorder
• Describe its prevalence
• Narrate first rank, Bleuler’s 4 A’s &
positive/negative symptoms
• Make ICD-10 diagnosis of the illness
• Summarise genetic, biochemical, and
organic etiological factors
• Describe good/bad prognostic
features
• Outline main types of schizophrenia
• Develop a differential
diagnosis: identify historical &
clinical features indicating
general medical, affective, and
other causes
• Summarise treatments
including pharmacological &
psychosocial interventions
• List features distinguishing
delusional disorder,
schizophreniform,
schizoaffective, & brief reactive
psychosis from each other and
from schizophrenia
 Psychoses

Schizophrenia

Brief psychotic
Schizoaffective
episode Psychoses

Delusional disorders
 Schizophrenia
A syndrome in which disturbances of thoughts, feelings, perceptions,
and cognition result in abnormal behaviour
 Epidemiology
Rate Co morbidity
• Lifetime prevalence 1.0% • Medical illnesses 80%
• Point prevalence 0.4% • Cigarette smoking 75%
• Incidence 0.02% • Substance abuse 50%
Age Financial cost
• Males 15-35 • 50% seek treatment
• Females 25-45 • Exceeded $ 65 billion in US
1991
Gender
• Equally common Social class
• Equal in all social classes
Fertility • Up to 10% in deprived areas
• Reduced due to downward drift
• Migration not risk factor
Violence
• Risk 5 times higher
 Etiology

Genetic

Neuro
developmental Physical
Schizophrenia

Biochemical Psychological
 Etiology
Genetic
Substance abuse
• MZ = DZ concordance 50% = 15% • Cannabis increases risk by 2.4-fold
• Premorbid personality 25% • Risk increases in more frequent users
Solitary & suspicious
Emotionally cold Psychosocial
Biochemical • Defective filter
Dopamine Amphetamine psychosis
• Expressed emotions (relapse)
•
Critical comments
Action of typical AP’s
Over involvement
Hostility
• Serotonin LSD psychosis
Action of atypical AP’
Neuro-developmental
• Increased VBR Hippocampus
Physical (CNS)
Para hippocampus
• Genetic Huntington’s chorea Amygdale
Wilson’s disease • Cerebral asymmetry
• Brain Infections Syphilis & HIV
• Head trauma 1. Maternal influenza 2nd trimester
• Brain tumors
2. Winter births 8% higher
3. Birth complications
• Epilepsy
 Schizophrenia
Etiology (summary)
• Neuro-developmental disorder
• Genetically determined or produced in developing brain
• Architecture of temporal lobes & their connections with frontal lobes
abnormal; normal migration of neurons disturbed
• Neurons smaller with less neuropil
• Reduced expression of synaptophysin mRNA
• Absence of gliosis
• Changes manifest in first degree relatives before onset
• Performance IQ lower than verbal
• Subtle intellectual and social disabilities before illness
First rank symptoms
Thoughts
• Insertion
• Withdrawal
• Broadcasting
Auditory hallucinations
• Third person
• Commentary
• Thought echo
Made acts
• Perceptions
• Thoughts
• Feelings
• sensations
Delusional perception
Bleuler’s Four A’s
• Autism: withdrawal into fantasy
• Association loss: between
thoughts or other faculties;
difficulty to give straight answer,
irrelevant answers, concreteness,
over inclusiveness, thought block,
neologisms
• Affect loss: ability to feel or
inappropriateness
• Ambivalence: caught up
between two opposing wishes or
impulses
 Symptoms
Positive Negative
• Delusions
• Affect (blunting)
• Hallucinations
• Alogia
• Thought disorder

• Affect (inappropriate)
• Avolition

• Attention • Anhedonia
 Mental Status Examination
Acute Chronic
A & B: poor rapport, self neglect,
w
A & B: ithdrawn, fearful, abnormal movements
noisy Affect: blunting, inappropriate
Affect: perplexity, inappropriate Thought: poverty, derailment,
delusions±
Thought: vagueness, delusions Perceptions: hallucinations±
Perceptions: Hallucinations Orientation: age disorientation
Orientation: normal A & C: impaired
Memory: normal
A & C: impaired
Insight: impaired
Memory: intact
Insight: impaired
Diagnostic criteria
ICD 10
Symptoms
• First rank symptom
or
• Bizarre delusion
or (2) of the following:
• Persistent hallucinations
accompanied by delusions
• Thought disorder
• Catatonic behaviour
• Negative symptoms
Duration one month
Organicity absent
 Types
(Divisions arbitrary)

Paranoid Catatonic
• Delusions & hallucinations • Muscle tone
• Personality intact abnormalities
• Prognosis better • Inhibited / excited states
Hebephrenic • Posturing
• Primitive behaviour Simple
• Shallow inappropriate • Increasing eccentricity
affect
• Progressive deterioration
• Thought disorder
• Worst prognosis
 Differential diagnosis
Syndromes Assessment
Substance abuse History
Amphetamine & cocaine: hallucinations and delusions with CNS
overactivity Premorbid personality: antisocial, schizoid
Alcohol hallucinosis: auditory hallucinations with clear consciousness Physical symptoms suggestive of organic disease or
Alcohol withdrawal substance abuse
Anticholinergics MSE
CNS disease Overactivity, flight of ideas, goal directed speech, elation,
Tumors, stroke, brain trauma fleeting grandiose delusions
Temporal lobe epilepsy Visual & tactile hallucinations
Endocrine disease Illusions
Thyroid & adrenals Cognitive function tests
Metabolic disorders Physical Examination
Porphyria, B12 deficiency, Wilson's disease Focal signs
Infective Investigations
Syphilis, HIV
Toxicological screening
Toxic Electroencephalogram
Heavy metal poisoning CT scan
Bipolar affective disorder Confirm diagnosis
Collateral information
Family history
Course of illness
 Management
(A.Physical)
Typical AP’s Atypical AP’s
Oral Clozapine 50-900 mg/D
• Chlorpromazine 100-1800 mg/D • 30% resistant cases respond
• Haloperidol 3-60 mg/D • Sedation 90%
Depots • Agranulocytosis 0.8%
• Flupenthixol 40mg/2weeks • Seizures 3%
Side effects Risperidone 2-6 mg/D
• Sedation 70%, • EPS 20%
• Anticholinergic 50% • Agitation 20%
• EPS 60% (Dystonia 30%,
Parkinsonism 40%, Akathisia Role of ECT
40%),
• Catatonic
• Neuroleptic malignant syndrome
0.2% • Aggressive/homicidal/suicidal
• TD 4% each year • Twice/week up to 6-12
 Management
Select one drug Review medication
 side effects every 6 months
 behaviour of the patient
considering
 previous response
• response
6 weeks minimal trial • side effects
• EE
15-25% non-responsive • stressors
Continue medications for one
year
 Management
B. Psychosocial C. Rehabilitation
• Family intervention
• Stepwise stimulation
(Psycho education)
• Reduce EE • Occupational therapy
(Reduces relapse from 50% to • Day care
21% in 2 years)
• Community homes
• Self-care/social skills
• Residential care
training
• Assertive training
 Course and prognosis
A:15% resolve completely
B: 30% recovery incomplete, minimal residual damage
C: 30% defect state, increases with each relapse
D:15% progressive downhill course
E: 40% attempt while 10% commit suicide; mortality twice as higher

Good prognosis Bad prognosis

• Sudden onset • Insidious onset
• Good premorbid • Abnormal premorbid
adjustment personality
• Late onset
• Early onset
• Female & married
• Male & married
• Perplexity
• F/H affective disorder
• Blunting & apathy
• Supportive family • F/H schizophrenia
• Developing countries • High EE family
• Developed countries