Schizophrenia

SCHIZOPHRENIA

HISTORICAL OVERVIEW
Emil Kraeplin:- He classified mental illness as
a) Manic depressive illness
b) Dementia Praecox :- emphasise the distinct
cognitive decline (dementia) & early onset of disorder
(praecox)

Eugene Bleueler coined the term schizophrenia

that is a Greek word derived from Greek word
Schizo means splitting and phrenia means
mind, which indicates splitting of mind. Bleuler
made a distinction between fundamental and
accessory symptoms of schizophrenia

The fundamental symptoms of bleuler was also

designated as 4 As
1. Disturbance of Association
2. Affective Disturbance
3. Autism
4. Ambivalence

Kurt Schneider tried to make diagnosis more reliable by

identifying group of symptoms characteristics of
schizophrenia, but rare in disorder
Schneider First Rank symptoms
1. Audible Thoughts
2. Voice Arguing
3. Voice Commenting
4. Thought Alienation Phenomena
5. Somatic Passivity Phenomena

DEFINITION
Schizophrenia is a group of mental
disorders that is characterised by
disturbances in thinking, mood and
affect with a disorganized personality

EPIDEMIOLOGY
1. Schizophrenia affects around 0.30.7%
of people at some point in their life.
2. It occurs 1.4times more frequently in
males than females and typically
appears earlier in men. The peak ages
of onset are 25 years for males and 27
years for females.

COURSE OF
SCHIZOPHRENIA

THE 1/4TH , 1/4TH , Rule

Enormous individual variability
1. About 1/4th of those who experience episode
of schizophrenia recover completely
2. Another 1/4th experience recurrent episodes,
but often with only minimal impairment of
functioning
3. The other schizophrenics become chronic
mental illness and the ability to function in
society
may be severely impaired

SCHIZOPHRENIA F20
F20
F20.0
F20.1
F20.2
F20.3
F20.4
F20.5
F20.6
F20.8
F20.9

Schizophrenia
Paranoid schizophrenia
Hebephrenic schizophrenia
Catatonic schizophrenia
Undifferentiated schizophrenia
Post-schizophrenic depression
Residual schizophrenia
Simple schizophrenia
Other schizophrenia
Schizophrenia, unspecified

TYPES
1. Paranoid type: The word paranoid means delusional.
Paranoid schizophrenia is the most common type of
schizophrenia. Delusions or auditory hallucinations
are present, but thought disorder, disorganized
behavior, or affective flattening are not. Delusions are
persecutory and/or grandiose, but in addition to
these, other themes such as jealousy, religiosity, or
somatizationmay also be present.
2. Disorganized type: Namedhebephrenic
schizophreniain the ICD. It has an early and insidious
onset and is often associated with poor pre-morbid
personality. Where thought disorder and flat affect are
present together and extreme social impairment is
present.
3. Catatonic type: Catatonic schizophrenia is
characterized by marked disturbance of motor
behaviour. This may take the form of catatonic
stupor, catatonic excitement and catatonia

The ICD-10 defines two additional

subtypes:[76]
1. Post-schizophrenic depression: A
depressive episode arising in the
aftermath of a schizophrenic illness
where some low-level schizophrenic
symptoms may still be present. (ICD
code F20.4)
2. Simple schizophrenia: Insidious and
progressive development of
prominent negative symptoms with
no history of psychotic episodes.

CAUSES

1.

Genetic Factors :- The greatest risk for developing

schizophrenia is having afirst-degree relativewith the disease
(risk is 6.5%); more than 40% ofmonozygotic twinsof those with
schizophrenia are also affected.If one parent is affected the risk
is about 13% and if both are affected the risk is nearly 50%.

2.

Environmental factors associated with the development of

schizophrenia include the living environment, drug use and
prenatal stressors. Childhood trauma, death of a parent, and
being bullied or abused increase the risk of psychosis.Living in
an urban environment during childhood or as an adult has
consistently been found to increase the risk of schizophrenia by a
factor of two, even after taking into accountdrug use,
ethnic group, and size ofsocial group.Other factors that play an
important role includesocial isolationand immigration related to
social adversity, racial discrimination, family dysfunction,
unemployment, and poor housing conditions

3. Substance use :- About half of those

with schizophrenia use drugs or alcohol
excessively. Amphetamine, cocaine, and to
a lesser extent alcohol, can result in
psychosis that presents very similarly to
schizophrenia Cannabis can be a
contributory factor in schizophrenia, but
cannot cause it alone;its use is neither
necessary nor sufficient for development
of any form of psychosis. Early exposure of
the developing brain to cannabis increases
the risk of schizophrenia.
4. Developmental factors :- Factors such
as hypoxia and infection, or stress and
malnutrition in the mother duringfetal

CLINICAL PICTURE

Thought & Speech Disorders

1.
2.
3.
4.
5.
6.

Autistic Thinking
Thought Blocking
Neologism
Poverty of Speech
Delusions
Loosening of Association

Disorders of Perception
7. Hallucinations Auditory & Visua
Disorders of Affect
8. Apathy
9. Emotional Blunting
10.Anhedonia

Disorders of Motor Behaviour

1. Increase or decrease in psychomotor activity
2. Mannersims
3. Stereotypes
4. Decreased self-care and poor grooming
Other Features
5. Impaired Social Relations
6. Loss of ego boundaries
7. Loss of insight
8. Poor judgement
9. No disturbance of consciousness, orientation,
attention and memory.

POSITIVE SYMPTOMS
Those that appear to reflect an excess
or distortion of normal functions.
Positive symptoms are those that have
a positive reaction from some
treatment. In other words, positive
symptoms respond to treatment.
Hallucinations. Distortions or
exaggerations of perception in any of
the senses.

NEGATIVE SYMPTOMS
Those that appear to reflect a diminution
or loss of normal functions.

POSITIVE SYMPTOMS

NEGATIVE SYMPTOMS

Hallucinations

Alogia

Delusions

Avolition

Bizzare Behaviour

Flattening of Affect
Anhedonia
Attentional Impairment

SCHIZOPHRENIA
TREATMENT
Therapeutic Goals
1. Minimise Symptoms
2. Minimise Side-Effects
3. Prevent Relapse
4. Maximise Function
5. Recovery
Types of Treatment
1. Biological Treatment
A) Pharmacotherapy
B) ECT
C) Deep Brain Stimulation
2. Psychological /Psychotherapeutic Treatment

TYPES OF DRUG
TREATEMENT
1. AntiPsychotics
a) First Generation Antipsychotics
b) Second Generation Antipsychotics
c) Third Generation Antipsychotics
2. Adjunctive Medications
a) Lithium Carbonate
b) Anti-Depressants
c) Anti-Convulsants
d) Benzodiazepines
3. Other Medications
a) Anti-Parkinsons
b) Beta- Blockers

IPS GUIDELINE
RECOMMENDATIONS
Therapy include 3 phases
1. Acute Phase:- ( Goal- Symptom Reduction,
Improvement of Functioning)
2. Post-Acute Phase or Continuation Phase:- (GoalConsolidation of remission, Relapse Prevention). It
usually lasts 6 months
3. Stable Phase or Maintenance Phase:- (Improving or
maintaining functioning or prevention of recurrence)
Choice of Drug depends upon
1. Side-Effect Profile
2. Response Pattern
3. Patient preferences and Cost
4. Preferred Route of Administration

DURATION OF TREATMENT
It should be individualised. The suggested
guidelines are:1. First Episode Patients:- 1-2 yrs of
maintenance
2. Patient with several episode or
exacerbation :- >/ 5 yrs of maintenance
3. Patient with h/o aggression or suicide :Indefinite Period even life long

ECT
Schizophrenia itself is not a
primary indication for ECT.
The indications for ECT in schizophrenia
are :1. Catatonic Stupor
2. Uncontrolled Catatonic Excitement
3. Acute Exacerbations not controlled
with drug
4. Severe side-effects with drugs in
presence of untreated or resistant
schizophrenia
5. Risk of suicide, homicide or physical
assault

PSYCHOLOGICAL THERAPIES
1. Group Therapy
2. Behaviour Therapy
3. Family Therapy
4. Social Skill Training
5.Rehabilitation

CASE SCENARIO
Mr. Ali aged 26 yr male, admitted in psychiatric ward on
18-1-15 is a diagnosed case of paranoid schizophrenia
since 5 yrs. On asking, client often gives delusional
description about self and others.
On conversation client verbalises that You have to rule
the world, because you cannot trust anyone. He always
maintain a in-secured position saying that people are
planning to kill him.
Clients relative complained that he often gets irritated
on asking him to brush or bath. Also verbalised that client
gives odd description of self and others
On examination, general appearance of client was found
to be unkempt, inadequate hygiene with evidence of body
odour and dirty , delusional thinking and derealisation
was identified.

Draw a concept map care plan for Ali.