1. Schizophrenia
By mbbsppt.com

2. As per ICD-10 Schizophrenia is a disorder characterized by fundamental distortions of thinking & perception and disturbances of affect.
Schizophrenia is the most serious mental disorder presenting in psychiatric clinics.
Schizophrenia is the most common reason for admission psychiatric inpatient facilities.

3. Schizophrenia myths
Split personality: Mistaken as split or dual personality because the word schizophrenia comes from Greek words that means "split mind." Here the split is referring to a split from reality – not a dual or multiple personality.

4. Schizophrenia myths Caused by bad parenting or child hood trauma.
Caused by Sprits & Evil.
Is a life long, untreatable illness.
People with schizophrenia have sub-normal intelligence.

5. History of Schizophrenia
Morel : Used the term “Demence Precoce” (for deteriorated patients whose illness began in adolescence).
Kraeplin : Translated Morel’s Demence Precoce to “Dementia Precox”(disturbance in cognitive process with early age onset & having a long term deteriorating course).

6. History of Schizophrenia
Eugen Bleuler : Coined the term ‘Schizophrenia’(presence of schisms between thought, emotion & behavior (Blueler stressed that Schizophrenia need not have a deteriorating course).

7. Bleuler’s Four A’s
loosening of Association-Ideas shift from one subject to another in unrelated way.
Blunting of Affect-Severe reduction in the body language.
Ambivalence-Coexistence of two opposing impulses at the same time in same persons mind.
Autistic thinking.

8. Schneider’s First rank symptoms
Kurt Schneider: Formulated First Rank Symptoms of Schizophrenia.
A group of symptoms described by Schneider, for making a diagnosis of Schizophrenia. These symptoms includes the following:
A) Hallucinations:
Audible thoughts.
Hearing voices arguing.
Hearing voices commenting on the subject’s behavior.

9. B) Changes in thought process:
Thought insertion- The experience that the subject thought belong to others who have intruded their thoughts upon the subject.
Thought withdrawal-Thought are being withdrawn from patient’s mind by some other person.
Thought broadcasting- The subject’s private thoughts are known to others.

10. C) Other external impositions:
Made Impulses- The subject is being forced to do things that he or she does not want to do.
Made Volition- The subject is being forced to want things that he or she does not really want.
Made Feel- The subject is being made to feel the emotions or sensations (often sexual) that are not his or her own.

11. Epidemiology People irrespective of cultures, races & social classes.
1% world’s population is affected by schizophrenia.
Gender & Age: Equally prevalent in men & women , can affect at any age but onset is slightly earlier in male.

12. Other factors in Schizophrenia
Suicide risk in Schizophrenia:
About 50% of all schizophrenic patients attempt suicide at least once during their lifetime.
15% of schizophrenic may die because of completed suicide.
Substance use in Schizophrenia:
Cigarette Smoking- 3/4th of all schizophrenic patients smoke cigarette.
Alcohol : 30 to 50%, Cannabis: 15 to 25% , Cocaine : 5 to 10%

13. Etiology
Neurobiological theory
Genetics theory
Psychosocial theory

14. Neurobiological theory
Major Neurotransmitters involved are:
Dopamine.
Serotonin.

15. Dopamine Hypothesis:
Hyperactivity of dopominergic system leads to symptoms of this disorder.
This theory evolved because of two observations:
All most all psychotropic drugs effective in schizophrenia have been demonstrated to have the ability to block dopamine activity.
Substances that increase dopaminergic activity can lead to the production of psychotic symptoms similar to those seen in schizophrenia

16. Role of Serotonin in schizophrenia:
Observation that many newer & atypical antipsychotics exert their beneficial effects in schizophrenia because of their potent ability to antagonize 5-HT2 receptors of serotonin has led to speculation that serotonin is implicated in the etiology of schizophrenia.

17. Genetics Theory
Studies suggest that is a genetic component of inheritance of Schizophrenia :
General Population – 1%
Non twin sibling of Schizophrenia patient- 8%
Child with one parent with Schizophrenia-12%
Dizygotic twin of Schizophrenia patient-12%
Child of two parents with Schzophrenia-40%
Monozygotic twin of Schizophrenia patient-47%

18. Psychosocial theory
Stress-Diathesis Model: Vulnerability to the illness increases with stressful influence.
Harry Sullivan: Caused due to isolation.
Socio cultural theory: Though prevalence is uniform across cultures but studies show that it is more common in lower socio economic status.

19. Clinical Features & Symptoms
Schizophrenia is characterized by disturbance in:
Disturbance in thought & speech.
Disturbance in perception.
Disturbance in motor behavior.
Disturbance in affect or Negative symptoms.
Relationship to external world.

20. Disturbance of Thought & Speech
Loosening of Association- Flow of thought in which ideas shift from one subject to another in completely unrelated way.
Derailment-sudden deviation in train of thought at times similar to LOA.
Flight of Ideas- Constant shifting from one idea to another, ideas seems to be connected but in less severe form.

21. Disturbance of Thought & Speech
Clang Association- Association of words similar in sound but not in meaning & words have no connection.
Cryptolalia- A private spoken language.
Neologism- New word created by the patient.
Word Salad-Incoherent mixture of words.

22. Disturbance of Thought & Speech
Delusion
False unshakable belief, which can not be corrected by reasoning & are not consistent with patient’s intelligence & cultural background.

23. Disturbance of Thought & Speech
Different types of Delusions are:
Persecutory Delusion.
Delusion of Reference.
Delusion of Control.
Delusion of Jealousy or Infidelity.
Eratomania.
Delusion of Grandiosity.

24. Disturbance of Thought & Speech
Thought of control-other person controlling patient’s thought.
Thought Insertion- The experience that the subject thought belong to others who have intruded their thoughts upon the subject.
Thought withdrawal-thought are being withdrawn from patient’s mind by some other person.

25. Disturbance of Thought & Speech
Thought Broadcasting- The subject’s private thoughts are known to others.
Thought Blocking- Abrupt interruption of train of thought.
Thought echo- hearing one’s own thought being spoken aloud.

26. Disturbance of Perception
Hallucinations:
False sensory perception not associated with real external stimuli.
Auditory-False perception of sound mainly voices. Most common hallucination in psychiatric disorders.
Visual Hallucination- False perception involving sight.

27. Disturbance of Perception
Olfactory hallucination- false perception of smell.
Gustatory Hallucination- False perception of taste.
Somatic Hallucination- false perception of things occurring to the body.

28. Disturbance in Motor Behavior
These can be either decrease or increase in psychomotor activity i.e. from mutism to excitement or aggressiveness.
Mutism- Voiceless without structural abnormality.
Sterotypy- repetitive fixed pattern of physical activity.
Akinesia- lack of physical movements.

29. Disturbance in Motor Behavior
Negativism- motiveless resistance to all attempts to be moved or to all instructions.
Automatic obedience- Automatic following of suggestions i.e. command automatism.
Waxy flexibility- Condition in which a person can be molded into a position that is then maintained.

30. Disturbance in affect and Negative symptoms
Alogia:
Inability to speak because of a mental
disorder.
Poverty of Speech.
Increased response latency.
Affective Flattening:
Unchanged facial expression.
Poor eye contact.

31. Disturbance in affect and Negative symptoms
Avolition-apathy:
Impaired grooming & Hygiene.
Decrease in self care.
Anhedonia:
Loss of pleasure seeking activity.
Few friends / Relationships.
Little sexual & recreational interest.

32. Other Clinical features
Decreased functioning in work & social relations as compared to earlier levels.
Decrease in self care.
Loss of ego boundaries.
Multiple somatic complaints mainly in early stages.
Absence of Insight.
Generally no clinically significant disturbance of consciousness, orientation, memory & intelligence.

33. Diagnosis
DSM IV TR
ICD 10

34. Diagnosis by ICD 10
A) Thought echo, Thought withdrawal, Thought insertion, Thought broadcast.
B) Delusion of control, influence, or passivity; delusional perception.
C) Voices conversing with each other or Voices giving running commentary or other type of voices coming from some part of the body .
D) Persistent delusion (culturally inappropriate)

35. Diagnosis by ICD 10 E) Persistent hallucination in any modality.
F) Break in train of thought.
G) Catatonic behavior.
H) Negative Symptoms.
I) Significant and persistent change in
behavior.

36. Diagnosis by ICD 10
1 clear cut symptom or 2 less clear symptom from A to D. Or
Symptoms from at least 2 groups of E to H.
Should be present for most of the period of 1 month or more.

37. Types of Schizophrenia
Paranoid ( F 20.0 )
Hebephrenic ( F 20.1 )
Catatonic ( F 20.2 )
Undifferentiated ( F 20.3 )
Post Schizophrenic Depression ( F 20.4 )
Residual ( F 20.5 )
Simple ( F 20.6 )

38. Paranoid Schizophrenia
The commonest type.
Characterized by one or more stable Delusion mainly persecutory or grandeur.
Also associated with hallucination mainly auditory.
Aggressive behavior or Suspiciousness.
Intelligence level not affected.

39. Hebephrenic Schizophrenia
The onset is generally early.
Marked regression to primitive, disinhibited and unorganized behavior.
Usually active but aimless, non constructive.
Thought disorder pronounced.
Social behavior are mainly effected.
Inappropriate emotional responses.

40. Catatonic Schizophrenia
Catatonic schizophrenia is characterized mainly by motoric activity, which might be strongly increased (hyperkinesis) or decreased (stupor), or Rigidity or automatic obedience and negativism.

41. Catatonic Schizophrenia
A type of schizophrenia at least two of the following is present:
Motoric immobility as evidenced by stupor.
Excessive motor activity.
Extreme negativism or mutism.
Posturing/stereotyped.
Echolalia or Echopraxia.

42. Undifferentiated Schizophrenia
Patients who are clearly schizophrenic but cannot be easily fitted into one or the another type .

43. Post Schizophrenic Depression
Depressive episode occurring during Schizophrenic illness.
Schizophrenia symptoms are present but not the clinical picture.
Depressive symptoms are not as severe to meet the criteria of severe depressive episode.`

44. Residual Schizophrenia
A chronic stage in the development of Schizophrenia in which there has been a clear progression from early positive symptoms to present negative symptoms.

45. Simple Schizophrenia An uncommon disorder with insidious onset.
Here the patient shows inability to meet the demands of the society.
There is a decline in total function without any hallucination or delusions.

46. Good Prognosis Bad Prognosis
Late onset
Young onset
Obvious precipitating factors
No precipitating factors
Acute onset
Insidious onset
Good premorbid social, sexual, and work histories
Poor premorbid social, sexual, and work histories
Mood disorder symptoms (especially depressive disorders)
Withdrawn, autistic behaviour
Married
Single, divorced, or widowed
Family history of mood disorders
Family history of schizophrenia
Good support systems
Poor support systems
Positive Symptoms
Negative symptoms

47. Management
The treatment of Schizophrenia can be discussed under the following major heading:
Somatic Treatment.
Pharmacological treatment.
Electro-convulsive therapy (ECT).
Miscellaneous treatments.
Psychosocial treatment & rehabilitation.

48. Pharmacological treatment
First drug used for treatment was Reserpine in India by Sen and Bose in 1931(side effects were severe suicidal ideation & depression).
Delay and Deniker formally discovered the antipsychotic in 1952 (chlorpromazine) and the outcome of schizophrenia was significantly improved.

49. Typical antipsychotic drugs (Chlorpromazine, Haloperidol, Flupenthixol, Trifluperazine, Thioridazine , Pimozide etc.)
Atypical antipsychotic (Olanzapine, Clozapine, Quetiapine, Resperidone, Aripiprazole, Ziprasidone, Amisulpiride etc.)

50. Typical Antipsychotics related to high-affinity antagonism of dopamine D2 receptors.
Atypical Antipsychotics have a higher ratio of serotonin type 2 (5-HT2) to D2 dopamine receptor blockades than the typical. They have low blockade potential for D2 that is why the incidence of extra pyramidal side effects is low.

51. Atypical antipsychotics are more commonly used now a days.
These drugs are commonly used in outpatient settings, hospitalization is indicated if there is:
Neglect of food and water intake
Danger to self and others
Poor treatment adherence
Significant neglect of self care
Lack of social support

52. Pharmacological treatment of schizophrenia is divided in two phases:
Treatment of acute psychosis
Stabilization phase and Maintenance phase

53. Treatment of acute psychosis:
The focus is to alleviate the most severe psychotic symptoms, This phase last for 4 to 8 weeks. Symptoms like agitation, frightening delusions, hallucinations suspiciousness are treated.
Stable or maintenance phase:
The illness is in relative remission. The focus is to prevent relapse and helping patient to improve level of functioning.

54. Electroconvulsive therapy:
Not indicated as primary treatment, indicated only when the illness having catatonic symptoms or patient is showing severe side effects on antipsychotics.
Research has shown that a combination of ECT & antipsychotics is better than either of the two alone.

55. Miscellaneous treatment:
Psychosurgery like limbic lobectomy, insulin coma therapy, high multivitamin therapy were previously used for treatment but not used now a days.

56. Psychosocial treatment:
Psychotherapies included variety on methods, the focus is to enable patient to develop social and vocational skills for independent living.
Many therapies like social skill training, family oriented therapy, group therapy, cognitive therapy, individual psychotherapy, vocational therapy etc are used and have shown promising results.