SCHIZOPHRENIA

SCHIZOPHRENIA

Dr Nadira KhamkerSenior ConsultantDepartment PsychiatryWeskoppies HospitalUniversity of Pretoria , Faculty of Health & Science

SCHIZOPHRENIA

Schizophrenia is a psychiatric disorder with unknown aetiology.

It is characterized by psychotic symptoms which incapacitate the patient’s level of functioning.

It is a chronic condition with a prodromal, acute and residual phase, or remission.

Psychosis ?

ill-defined,generic term

Lack of insight is a core feature

Delusions and hallucinations are often present

History of schizophrenia

Emil Kraepelin ( 1856-1926)

Eugen Bleuler ( 1857-1939)

“Dementia precox”

Bleuler coined the term “schizophrenia”

Epidemiology

0,5-1% of population

Genetic predisposition

Women=men

Women : mean age of 1st episode is 26,8 years

Men : mean age of 1st episode is 21,4 years

Genetic factors- 10x ↑ risk in persons with 1st degree relatives for developing the disease.

Medical illnesses- c

– comorbid conditions ,– upto 50% may be undiagnosed

Substance abuse-

– common in schizophrenia,– association between cannabis and

schizophreniaInfection and Birth Season

Epidemiology contd

Aetiology

Unknown

Diathesis-vulnerability

Eco-genetic factors

Dopaminergic hypothesis

CLINICAL FEATURES

POSITIVE SYMPTOMS NEGATIVE

SYMPTOMS

AFFECTIVE SYMTOMS

AGGRESSIVE SYMPTOMS

COGNITIVE SYMPTOMS

POSITIVE SYMPTOMS

Symptom clusters

Reality distortion

Psychomotor poverty

Disorganisation

Cognitive domain

POSITIVE SYMPTOMS

NEGATIVE SYMPTOMS

COGNITIVE SYMPTOMS

REALITY DISTORTION

PSYCHMOTOR POVERTY

DISORGANISATION

DELUSIONS LACK OF AFFECTIVE RESPONSIVENESS

INAPPROPRIATE AFFECT

HALLUCINATIONS LOSS OF DRIVE OR VOLITION

INCOHERENT SPEECH

POVERTY OF SPEECH AND MOVEMENT

DISORGANISED BEHAVIOUR

SOCIAL WITHDRAWAL

Reality distortion

Hallucinations

Delusions

Hallucination : definition

False sensory perception not associated with real external stimuli; there may or may not be a delusional interpretation of the hallucinatory experience.

Auditory, visual, olfactory, tactile and somatic hallucinations.

Hallucinations in Schizophrenia

Ask the patient if he / she is hearing voices, other people can’t hear and ask in detail about the quality, frequency, intensity and reaction towards these voices

Delusions : definition

False, fixed belief, based on incorrect inference about external reality, not consistent with patient’s intelligence and cultural background; cannot be corrected by reasoning.

Somatic, paranoid ( persecutory and of reference), erotomania, of control / poverty/self-accusation

Delusions

Overvalued idea is NOT a delusion but an unreasonable, sustained false belief maintained less firmly than a delusion.

Bizarre delusion is absurd and implausible

Nihilistic delusion is the false feeling that self, others or the world is nonexistent or coming to an end

Delusions

Delusions of poverty :they believe they are bereft or will be deprived from all property

Somatic delusions: involving body (brain is rotting)Persecutory delusions: being harassed, cheated, or

percecutedDelusion of grandeur: exaggerated concept of power or intelligence

Delusions

Delusions of reference: the behaviours of others refers to them, people are talking about him / her.

Delusions of self-accusation: feelings of remorse and guilt.

Delusions of control: their thoughts, will or feelings are controlled by external forces

Delusions of control (bizarre)

Thought withdrawal

Thought insertion

Thought broadcasting

Thought control

Form of thought disturbances

Neologism : new words by combining syllabes

Word salad: inhorent mixture of words

Perseveration: persisting response to previous stimulus

Verbigaration:meaningless repetition of words

Echolalia: repeating of words

Blocking: abrupt interruption in train of thinking

Thought content in schizophrenia

Delusions

Preoccupation

Ideas of reference and influence

phobias

Poverty of content

Obsessions and compulsions

Suicidal or homicidal ideas

Psychomotor poverty

Lack of affective responsiveness

Loss of drive or volition

Poverty of speech and movement

Social withdrawal

Negative symptoms(5As)

Affective blunting / flat affect

Alogia –relative absence in amount/ content of speech

Avolition-inability to initiate and persist in activities

Anhedonia-loss of enjoyment for activities

Attention impaired

Disorganisation

Inappropriate affect

Disorganised behaviour

Grossly disorganized or catatonic behavior

Aggressive,violent outbursts

Bizarre clothing appearance

Inappropriate social / sexual behavior

Catatonic behavior ,ranging from extreme excitement to stupor

Cognitive domain

Impaired attention and concentration

Impaired memory and learning

Impaired executive functioning ( e.g. abstract thinking, problem solving)

Disorganized speech

Disturbance in form of thought:

Circumstantiality ( delays in reaching answer)

Irrelevant answer

Derailment (deviates from train of thought)

Tangentially( never gets back to desired goal)

Loosening of associations(shift in unrelated manner)

Incoherence(thoughts not understandable)

SCHIZOPHRENIA: SYMPTOLOGY

DSM IV CRITERIA A:

TWO OR MORE OF THE FOLLOWING:DelusionsHallucinationsDisorganized speechGrossly disorganized behaviorNegative symptomsPresent for at least one month

CRITERIA A

If the delusion is bizarre, only one of the A Criteria is required.

For example if you believe the microchip in your front tooth controls world’s events

A voice keeping up a running commentary on the person’s behavior or thoughts or…..

Two or more voices conversing with each other.

B. Social and occupational dysfunction

C Duration

D Exclusion criteria

E Substance abuse

DIAGNOSIS

Schizophrenia sub types

Paranoid

Catatonic

Residual

Undifferentiated

Disorganized

No symptom or sign is definitive for schizophreniaCareful history important as symptoms change with timePremorbid symptoms and signs appear before the prodromal

phasePatients may have shcizoid or schizotypal personalitiesMay be quiet, passive and introverted childrenFew friends, solitary activitiesMay present with somatic complaintsFamily and friends may notice changes in social, occupational,

personal activitiesMay then present with peculiar behaviour, abnormal affect,

unusual speech, bizarre ideas, perceptual disturbances

CLINICAL FEATURES

GENERAL APPEARANCE AND BEHAVIOUR– May be unkempt, poor self-care– Psychomotor activity

SPEECH– Monotonous, poverty of speech– Disorganised speech

MOOD AND AFFECT– Reduced emotional responsiveness– Inappropriate emtions

PERCEPTUAL DISTURBANCES– Hallucinations

THOUGHT FORM DISTURBANCES– Loosening of associations– Tangentiality

THOUGHT CONTENT DISTURBANCEDelusions

IMPULSIVENESS,VIOLENCE,SUICIDE, HOMICIDESENSORIUM AND COGNITION

– Memory,JUDGEMENT AND INSIGHT

MENTAL STATE EXAMINATION

Good prognosis in schizophrenia

Obvious precipitating factorsAcute onsetGood premorbid history / later onsetMood symptoms or family history of moodsxMarried and / or good support systemPositive symptoms

Longitudinal course

Symptoms start in adolescence

Prodromal symptoms may last for 1 year

Exacerbations and remissions

Baseline functioning deteriorates

Positive symptoms less severe with age but negative symptoms may increase in severity

Chronic illness

Premorbid symptoms

Relapsing and remitting course

Deterioration in functioning over time

Course and prognosis

10-20% suffer one episode and remain symptom free

60% follow a course of relapses and remissions, of which half achieve full remission and half partial remission.

Indications for referral

Frequent relapses

Resistance to treatment

Co-morbid conditions

Lack of sufficient support / resources at primary level

Psychoeducation

It is a biological disease of the brain

The precise etiology is unknown

Genetic vulnerability

Environmental factors

Long-term treatment

Rehabilitation necessary

Psychological interventions

Cognitive behavioural therapy

Psychoeducation

Family therapy

Social skills training

Social interventions

Halfway houses / step down facilities

Supervised group houses

Unsupervised houses

Day centres

Supported employment

Disability grants

Other Psychotic Disorders

Psychotic disorders due to GMCSubstance-induced psychotic disordersShared psychotic disorderPsychotic disorder not otherwise specifiedDelusional disorderSchizophreniform disorderSchizoaffective disorder Brief Psychotic Disorder

Compared with schizophrenia

Sx <1month = brief psychotic disorder

…………………………..>1<6months=Schizophreniform

…………………………..>6months=schizophrenia

Delusional disorder

Nonbizarre delusions

No marked impairment in functioning

Types include: erotomania, grandiose, jealous, persecutory,somatic and mixed

Schizoaffective disorder

Substantial period of illness also mood symptoms

Bipolar type versus depressive type

Better prognosis than schizophrenia

Differential diagnosis of PSYCHOTIC symptoms

Substance-related disorders

Epilepsy- TLE

Cerebral tumours / trauma

AIDS, Neurosyphilis,herpes encephalitis

Porphyria

SLE, Wilson’s disease, B12 deficiency

Conclusion

Psychotic disorders cause extreme distress and diability over periods of time

Disorder is treatable and relapses can be limited

Primary health care worker has an important role to play