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SCHIZOPHRENIA
BYEMMANUEL GODWIN5th year Medical StudentCollege of MedicineUniversity of Nigeria , Enugu Campus
OUTLINE
DEFINITION TYPES CLINICAL FEATURES DIAGNOSTIC CRITERIA(ICD-10 AND DSM –
IV) EINDICES OF PROGNOSIS TREATMENTS PIDEMIOLOGY
DEFINITION
Schizophrenia is a mental disorder characterized by a breakdown of thought process and by deficit of typical emotional responses.
It originates from the greek word skhzein(to split) and phrein(mind)
It doesn’t simply imply split personality as seen in dissociative identity disorder, but it implies splitting of mental functions.
History of schizophrenia
The term schizophrenia was coined by a swiss psychiatrist EUGEN BLEUER
He maintained that the 4 A’s lie at the core of the disorder and are the fundamental aspects of the disorders
Bleuer maintained that the 4A’s are the main core of the disorder while manifest first rank symptoms of schizophrenia are peripheral and not important
Four A’s
Disturbances of association(loosening of association)
Changes in emotional reactivity( flattening of affect)
Withdrawal from reality into the internal world of fantasy(Autism)
Fluctuation between two opposing ideas(ambivalence)
TYPES
Paranoid-types schizophrenia Disorganized-type schizophrenia Catatonia-type schizophrenia Undifferentiated-type schizophrenia Residual-type schizophrenia Simple-type schizophrenia
Paranoid-type schizophrenia
This is the most common form of schizophrenia where the individual has delusions that a person or group of persons are plotting against them. Major symptons include Persecutory Delusion,Auditory hallucination,delusions of false grandeur,Anxietyand Anger
Disorganized-type schizophrenia
In this type of schizophrenia behaviour is disturbed/abnormal and has no purpose, there is formal thought disorder which precipitates as disorganized behaviour and speech.
It is also called hebephrenia with respect to the greek goddess of youth HEBE due to its onset at puberty
UNLIKE paraniod schizophrenia delusions and hallucinations are not prominent features
Disorganized-type schizophreniacontd
Common symptoms include Active behavior but in an aimless manner ,inappropriate emotional response, inappropriate facial responses, inappropriate laughter , anhedonia and avolition are also present ,they may also have delusions and hallucinations
Catatonia-type schizophrenia
This is a form of schizophrenia where a person loses touch with reality,it is a state of neurogenic motor immobility and behavourial disorder manifested by stupor. In this type, behaviours at extreme opposites are manifested.For example, the person might be in a coma-like state unable to speak or move or the person might talk or move in a hyperactive way
It is a chronic disorder
Catatonia-type schizophreniacontd.
Common symptoms include paucity of movement or hyperactivity,stereotyped or repetitive movement and waxy flexibility
Undifferentiated-type schizophrenia
This is a form of schizophrenia that is a jack of all forms but master of none.
The person has symptoms as seen in the above forms but not enough to pinpoint it as one of them
Example, the person has a bit of psychomotor(catatonia) and a bit of delusion and hallucinations(paranoid)
Residual-type schizophrenia
This is specifically used for patients that have had one or more episodes of schizophrenia but do not presently have strong positive symptoms like hallucination or delusions. They may have negative symptoms like withdrawal or mild positive symptoms which indicate that the disorder is not yet resolved
It’s usually found in the transition between an acute episode and resolution of the disease
Simple-type schizophrenia
It usually begins in childhood It usually consists of symptoms like
absence of will Reduced thinking and flattening of
affect There is a gradual deterioration of
functioning and reduced socialization It is rarely diagnosed and it’s a
schizophrenia without psychosis
Diagnosis of schizophrenia are usually made clinically based on the patient's behaviours and patients narrative experiences
General Symptoms include Hallucinations Delusions Impairment in social cognition Psychomotor disorders
CLINICAL FEATURES OF SCHIZOPHRENIA CONTD
The symptoms are classified into The Schnederian Classification The Positive, Negative and
Cognitive Classification
The Schnederian Classification
The german psychiatrist in the 20th century Kurt Schneider listed the following symptoms known as the FIRST RANK SYMPTOMS and they include
Hearing thoughts spoken aloud Third person auditory hallucination Hallucination in the form of commentary Somatic hallucination Thought withdrawal or insertion Thought broadcasting Delusional perception Feelings or actions experienced as made or influenced by
external agent of force
The Positive, Negative and Cognitive Classification
Positive symptoms refers to an excess or distortion of normal functions and refer to symptoms that are not found in an otherwise normal person. These symptoms respond well to medications and they include
DELUSIONS HALLUCINATIONS THOUGHT AND SPEECH DISORDER DISORGANIZED BEHAVIOUR
The Positive, Negative and Cognitive Classification
Negative symptoms refers to a reduced or absent characteristic normal function
They often appear several years before first acute episode
They often lead to relationship problems with family and friends
They generally respond less to medication and they include
LOSS OF INTEREST IN EVERYDAY ACTIVITY LACK OF EMOTION REDUCED ABILITY TO CARRY OUT
ACTIVITIES NEGLECT OF PERSONAL HYGIENE SOCIAL WITHDRAWAL LOSS OF MOTIVATION
The Positive, Negative and Cognitive Classification
Cognitive symptoms involve problems with thought processes, they carry the most disability as the patient has reduced ability to perform daily routine task and they include
Memory problems Difficulty in paying attention Problems with interpreting information
DIAGNOSIS
The diagnosis of schizophrenia is made on clinical grounds with investigations done principally to rule out organic brain disease. However, a reasonable diagnosis must be in line with either or the two criteria below.
ICD10 criteria DSM iv TR criteria. NB: in practice, agreement between the two
systems is high.
ICD10 CRITERIA
This system uses the self-reported experiences of the person and reported abnormalities in behavior, followed by clinical assessment by a mental health professional. The ICD-10 put more emphasis on schneiderian first rank symptoms of acute schizophrenia which include.
Auditory hallucinations-second/third person type, thought echoes
Broadcasting, insertion/withdrawal of thoughts Controlled feeling, impulses or acts (passivity
phenomenon) Delusional perception
DSM iv TR CRITERIA
According to the DSM iv TR, to be diagnosed with
schizophrenia, three of the following criteria must be met. characteristic symptoms:- two or more of the following, each
present for most of the time during one month period (or loss, if symptoms remitted with treatment).
Delusions Hallucinations Disorganized speech which is a manifestation of formal
thought disorder. Grossly disorganized behaviors Negative symptoms Blunted affect
Alogia (lack or decline in speech) Avolition (lack or decline in motivation) Social or occupational dysfunction:- For a significant
portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self care, are markedly below the level achieved prior to onset.
Significant duration:- continuous signs of the disturbance persist at least six months. This six months period must include at least one month of symptoms (unless, if symptoms remitted with treatment) if signs of disturbance are present for more than a month but less than six months, the diagnosis of schizophreniforn disorder is applied
EPIDEMIOLOGY
The prevalence of schizophrenia is similar world wide at about 1% of the population and the disorder is more common in men. The children of one affected parent have approximately a 10% risk of developing the illness, but this rise to about 50% in identical twins. The usual age of onset is the mid-twenties.
INDICES OF PROGNOSIS
About ¼ of those with acute schizophrenic episode have a good outcome, 1/3 develop chronic schizophrenia and remainder recover after each episode but suffer relapses , most will not work or live independently. Prophylactic treatment with antipsychotic drugs reduces the rate of relapse in the first 2 years after episode of schizophrenia from 70% to 40%. Schizophrenia is associated with suicide, 1 in 10 patients take their own lives.
TREATMENTPharmacotherapy
Psychotherapy
Psychosocial
PHARMACOTHERAPY Anti psychotic medications are a must use to help
control both positive and negative symptoms Older or newer anti psychotics may suffice in this case,
as they all share (as a mechanism of action) the capacity to antagonize postsynaptic dopamine receptors in the brain.
Antipsychotics can be categorized into two main groups: the older conventional antipsychotics, which have
also been called first-generation antipsychotics or dopamine receptor antagonists e.g Clorpromazine, piperazine
the newer drugs, which have been called second-generation antipsychotics or serotonin dopamine antagonists (SDAs) e.g Clozapine
PHARMACOTHERAPY contd.
The newer Anti psychotics are however better preferred as a result of their ability to both reduce dopamine levels and stabilize serotonin levels (a neurotransmitter pathology seen in schizophrenia). They also have less extra pyramidal effects
NB: They are called atypical antipsychotics b/c they share the property of weak D2 receptor antagonism and more potent 5-HT2A receptor blockade
Phases of Treatment in Schizophrenia
Treatment of Acute Psychosis: In acute psychosis ,patient presents with most
severe psychotic symptoms Acute schizophrenia is typically associated with
severe agitation, which can result from such symptoms as frightening delusions, hallucinations, or suspiciousness, or from other causes, including stimulant abuse. NB: Patients with akathisia can appear
agitated when they experience a subjective feeling of motor restlessness, so u have to differentiate the two.
This phase usually lasts from 4 to 8 weeks
Treatment of Acute Psychosis contd.
Clinicians have a number of options for managing agitation that results from psychosis.
Antipsychotics and benzodiazepines can result in relatively rapid calming of patients. With highly agitated patients, intramuscular administration of antipsychotics produces a more rapid effect. An advantage of an antipsychotic is that a single intramuscular injection of haloperidol (Haldol), fluphenazine (Prolixin, Permitil), olanzapine (Zyprexa), or ziprasidone (Geodon) will often result in calming without an excess of sedation
Benzodiazepines are also effective for agitation during acute psychosis. Lorazepam (Ativan) has the advantage of reliable absorption when it is administered either orally or intramuscularly. The use of benzodiazepines may also reduce the amount of antipsychotic that is needed to control psychotic patients.
Phases of Treatment in Schizophrenia contd.
Treatment During Stabilization and Maintenance Phase : In the stable or maintenance phase, the illness is in a
relative stage of remission The goals during this phase are to prevent psychotic relapse
and to assist patients in improving their level of functioning During this phase, patients are usually in a relative state of
remission with only minimal psychotic symptoms. Stable patients who are maintained on an antipsychotic
have a much lower relapse rate than patients who have their medications discontinued.
It is generally recommended that multiepisode patients receive maintenance treatment for at least 5 years, and many experts recommend pharmacotherapy on an indefinite basis.
Other Biological Therapies
ECT has been studied in both acute and chronic schizophrenia. Studies in recent-onset patients indicate that ECT is about as effective as antipsychotic medications and more effective than psychotherapy.
Psychotherapy Studies on the effects of individual psychotherapy in
the treatment of schizophrenia have provided data that the therapy is helpful and that the effects are additive to those of pharmacological treatment
The suggested type is SUPPORTIVE PSYCHOTHERAPY with the primary aim of having the patient understand that the therapist is trustworthy and has understanding of the the patient, no matter how bizarre.
It is nothing more than an “ego builder” Making the patients feel that he/she can trust you
about anything and all you will do is to support them and ensure that they take their medications.
Psychosocial Therapies Psychosocial therapies include a variety of
methods to increase social abilities, self-sufficiency, practical skills, and interpersonal communication in schizophrenia patients. The goal is to enable persons who are severely ill to develop social and vocational skills for independent living. Such treatment is carried out at many sites: hospitals, outpatient clinics, mental health centers, day hospitals, and home or social clubs.
Social Skills Training
Social skills training is sometimes referred to as behavioral skills therapy . Along with pharmacological therapy, therapy can be directly supportive and useful to the patient. In addition to the psychotic symptoms seen in patients with schizophrenia, other noticeable symptoms involve the way the person relates to others, including poor eye contact, unusual delays in response, odd facial expressions, lack of spontaneity in social situations, and inaccurate perception or lack of perception of emotions in other people.
Thank You