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Schizophrenia

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Title: Schizophrenia


1
Schizophrenia
  • Lyudmyla T. Snovyda

2
Schizophrenia -
  • from the Greek roots schizein ( "to split") and
    phren, phren- ("mind"), is a psychiatric
    diagnosis that describes a mental illness
    characterized by impairments in the perception or
    expression of reality, most commonly manifesting
    as auditory hallucinations, paranoid or bizarre
    delusions or disorganized speech and thinking in
    the context of significant social or occupational
    dysfunction. Onset of symptoms typically occurs
    in young adulthood.Diagnosis is based on the
    patient's self-reported experiences and observed
    behavior. No laboratory test for schizophrenia
    exists.

3
Schizophrenia -
Descriptions of schizophrenia-like symptoms date
back to circa 2000 BC in the Book of Heartspart
of the ancient Egyptian Ebers Papyrus. However,
study of the ancient Greek and Roman literature
shows that although the general population
probably had an awareness of psychotic
disorders, there was no recorded condition that
would meet the modern criteria for
schizophrenia.Symptoms resembling schizophrenia
were, however, reported in Arabic medical and
psychological literature during the Middle Ages.
In The Canon of Medicine, for example, Avicenna
described a condition somewhat resembling
schizophrenia which he called Junun Mufrit
(severe madness), which he distinguished from
other forms of madness (Junun) such as mania,
rabies and manic depressive psychosis.
4
Schizophrenia -
  • Although a broad concept of madness has existed
    for thousands of years, schizophrenia was only
    classified as a distinct mental disorder by Emil
    Kraepelin in 1893. He was the first to make a
    distinction in the psychotic disorders between
    what he called dementia praecox (early dementiaa
    term first used by psychiatrist Benedict Morel
    18091873) and manic depression. Kraepelin
    believed that dementia praecox was primarily a
    disease of the brain, and particularly a form of
    dementia, distinguished from other forms of
    dementia, such as Alzheimer's disease,
    which typically occur later in life.
  • Bleuler described the main symptoms as 4 A's
    flattened Affect, Autism, impaired Association of
    ideas and Ambivalence. Bleuler realized that the
    illness was not a dementia as some of his
    patients improved rather than deteriorated and
    hence proposed the term schizophrenia instead.

5
Schneiderian classification
  • The psychiatrist Kurt Schneider (18871967)
    listed the forms of psychotic symptoms that he
    thought distinguished schizophrenia from other
    psychotic disorders. These are called first-rank
    symptoms or Schneider's first-rank symptoms, and
    they include
  • delusions of being controlled by an external
    force
  • the belief that thoughts are being inserted into
    or withdrawn from one's conscious mind
  • the belief that one's thoughts are being
    broadcast to other people
  • and hearing hallucinatory voices that comment on
    one's thoughts or actions or that have a
    conversation with other hallucinated voices.

6
Positive and negative symptoms
  • Schizophrenia is often described in terms of
    positive (or productive) and negative (or
    deficit) symptoms.
  • Positive symptoms include
  • delusions,
  • auditory hallucinations,
  • and thought disorder, and are typically regarded
    as manifestations of psychosis.

7
Positive and negative symptoms
  • Negative symptoms are so-named because they are
    considered to be the loss or absence of normal
    traits or abilities, and include features such
  • as flat or blunted affect and emotion,
  • poverty of speech (alogia),
  • anhedonia,
  • and lack of motivation (avolition). Despite the
    appearance of blunted affect, recent studies
    indicate that there is often a normal or even
    heightened level of emotionality in Schizophrenia
    especially in response to stressful or negative
    events.

8
Positive and negative symptoms
  • A third symptom grouping, the disorganization
    syndrome, is commonly described, and includes
    chaotic speech, thought, and behaviour. There is
    evidence for a number of other symptom
    classifications.

9
  • Dissociation or splitting of psychic processes at
    schizophrenia could be on 3 levels
  • I level - splitting between personality and
    surrounding
  • II level - splitting between 2 psychic spheres
  • III level - splitting of psychic processes in
    sphere of psyche.

10
Subtypes, forms
  • Historically, schizophrenia in the West was
    classified into simple, catatonic, hebephrenic
    (now known as disorganized), and paranoid. The
    DSM contains five sub-classifications of
    schizophrenia
  • paranoid type where delusions and hallucinations
    are present but thought disorder, disorganized
    behavior, and affective flattening are absent
    (DSM code 295.3/ICD code F20.0)

11
Subtypes, forms
  • disorganized type named 'hebephrenic
    schizophrenia' in the ICD. Where thought disorder
    and flat affect are present together (DSM code
    295.1/ICD code F20.1)
  • catatonic type prominent psychomotor
    disturbances are evident. Symptoms can include
    catatonic stupor and waxy flexibility (DSM code
    295.2/ICD code F20.2)
  • undifferentiated type psychotic symptoms are
    present but the criteria for paranoid,
    disorganized, or catatonic types have not been
    met (DSM code 295.9/ICD code F20.3)
  • residual type where positive symptoms are
    present at a low intensity only (DSM code
    295.6/ICD code F20.5)

12
Subtypes, forms
  • The ICD-10 recognises a further two subtypes
  • 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)
  • simple schizophrenia insidious but progressive
    development of prominent negative symptoms with
    no history of psychotic episodes (ICD code F20.6)

13
Epidemiology
  • Schizophrenia occurs equally in males and females
    although typically appears earlier in men with
    the peak ages of onset being 2028 years for
    males and 2632 years for females. Much rarer are
    instances of childhood-onset and late- (middle
    age) or very-late-onset (old age) schizophrenia.
    Schizophrenia is known to be a major cause of
    disability. In a 1999 study of 14 countries,
    active psychosis was ranked the
    third-most-disabling condition, after
    quadriplegia and dementia and before paraplegia
    and blindness.

14
Causes
Data from a PET study suggests that the less the
frontal lobes are activated (red) during a
working memory task, the greater the increase in
abnormal dopamine activity in the striatum
(green), thought to be related to the
neurocognitive deficits in schizophrenia.
15
Genetic
  • Estimates of the heritability of schizophrenia
    tend to vary owing to the difficulty of
    separating the effects of genetics and the
    environment although twin studies have suggested
    a high level of heritability. It is likely that
    schizophrenia is a condition of complex
    inheritance, with several genes possibly
    interacting to generate risk for schizophrenia or
    the separate components that can co-occur leading
    to a diagnosis. Recent work has suggested that
    genes that raise the risk for developing
    schizophrenia are non-specific, and may also
    raise the risk of developing other psychotic
    disorders such as bipolar disorder.

16
Substance use
  • The relationship between schizophrenia and drug
    use is complex, meaning that a clear causal
    connection between drug use and schizophrenia has
    been difficult to distinguish. There is strong
    evidence that using certain drugs can trigger
    either the onset or relapse of schizophrenia in
    some people. It may also be the case, however,
    that people with schizophrenia use drugs to
    overcome negative feelings associated with both
    the commonly prescribed antipsychotic medication
    and the condition itself, where negative emotion,
    paranoia and anhedonia are all considered to be
    core features.

17
Substance use
  • Amphetamines trigger the release of dopamine and
    excessive dopamine function is believed to be
    responsible for many symptoms of schizophrenia
    (known as the dopamine hypothesis of
    schizophrenia), amphetamines may worsen
    schizophrenia symptoms. Schizophrenia can be
    triggered by heavy use of hallucinogenic or
    stimulant drugs. One study suggests that cannabis
    use can contribute to psychosis, though the
    researchers suspected cannabis use was only a
    small component in a broad range of factors that
    can cause psychosis.

18
Neural
  • Functional magnetic resonance imaging and other
    brain imaging technologies allow for the study of
    differences in brain activity among people
    diagnosed with schizophrenia.

19
Signs and symptoms of paranoid schizophrenia
  • Delusions of persecution Belief that others,
    often a vague they, are out to get him or her.
    These persecutory delusions often involve bizarre
    ideas and plots (e.g. Martians are trying to
    poison me with radioactive particles delivered
    through my tap water).
  • Delusions of reference A neutral environmental
    event is believed to have a special and personal
    meaning. For example, a person with schizophrenia
    might believe a billboard or a person on TV is
    sending a message meant specifically for them.

20
Signs and symptoms of paranoid schizophrenia
  • Delusions of grandeur Belief that one is a
    famous or important figure, such as Jesus Christ
    or Napolean. Alternately, delusions of grandeur
    may involve the belief that one has unusual
    powers that no one else has (e.g. the ability to
    fly).
  • Delusions of control Belief that ones thoughts
    or actions are being controlled by outside, alien
    forces. Common delusions of control include
    thought broadcasting (My private thoughts are
    being transmitted to others), thought insertion
    (Someone is planting thoughts in my head), and
    thought withdrawal (The CIA is robbing me of my
    thoughts.).

21
Signs and symptoms of paranoid schizophrenia
  • Hallucinations are sounds or other sensations
    experienced as real when they exist only in the
    person's mind. While hallucinations can involve
    any of the five senses, auditory hallucinations
    (e.g. hearing voices or some other sound) are
    most common in schizophrenia. Visual
    hallucinations are also relatively common.
    Research suggests that auditory hallucinations
    occur when people misinterpret their own inner
    self-talk as coming from an outside source.
  • Schizophrenic hallucinations are usually
    meaningful to the person experiencing them. Many
    times, the voices are those of someone they know.
    Most commonly, the voices are critical, vulgar,
    or abusive. Hallucinations also tend to be worse
    when the person is alone.

22
Signs and symptoms of paranoid schizophrenia
  • Disorganized speech
  • Fragmented thinking is characteristic of
    schizophrenia. Externally, it can be observed in
    the way a person speaks. People with
    schizophrenia tend to have trouble concentrating
    and maintaining a train of thought. They may
    respond to queries with an unrelated answer,
    start sentences with one topic and end somewhere
    completely different, speak incoherently, or say
    illogical things.
  • Common signs of disorganized speech in
    schizophrenia includeLoose associations
    Rapidly shifting from topic to topic, with no
    connection between one thought and the
    next.Neologisms Made-up words or phrases that
    only have meaning to the patient.Perseveration
    Repetition of words and statements saying the
    same thing over and over.Clang Meaningless use
    of rhyming words (I said the bread and read the
    shed and fed Ned at the head.").

23
Signs and symptoms of disorganized schizophrenia
  • Disorganized schizophrenia generally appears at
    an earlier age than other types of schizophrenia.
    Its onset is gradual, rather than abrupt, with
    the person gradually retreating into his or her
    fantasies. The distinguishing characteristics of
    this subtype are disorganized speech,
    disorganized behavior, and blunted or
    inappropriate emotions. People with disorganized
    schizophrenia also have trouble taking care of
    themselves, and may be unable to perform simple
    tasks such as bathing or feeding themselves.
  • The symptoms of disorganized schizophrenia
    include
  • Impaired communication skills
  • Incomprehensible or illogical speech
  • Emotional indifference

24
Signs and symptoms of disorganized schizophrenia
  • Inappropriate reactions (e.g. laughing at a
    funeral)
  • Infantile behavior (baby talk, giggling)
  • Peculiar facial expressions and mannerisms
  • People with disorganized schizophrenia sometimes
    suffer from hallucinations and delusions, but
    unlike the paranoid subtype, their fantasies
    arent consistent or organized.

25
Signs and symptoms of catatonic schizophrenia
  • The hallmark of catanoic schizophrenia is a
    disturbance in movement either a decrease in
    motor activity, reflecting a stuporous state, or
    an increase in motor activity, reflecting an
    excited state.
  • Stuporous motor signs The stuporous state
    reflects a dramatic reduction in activity. The
    person often ceases all voluntary movement and
    speech, and may be extremely resistant to any
    change in his or her position, even to the point
    of holding an awkward, uncomfortable position for
    hours.
  • Excited motor signs Sometimes, people with
    catatonic schizophrenia pass suddenly from a
    state of stupor to a state of extreme excitement.
    During this frenzied episode, they may shout,
    talk rapidly, pace back and forth, or act out in
    violenceeither toward themselves or others.
  • People with catatonic schizophrenia can be highly
    suggestible. They may automatically obey
    commands, imitate the actions of others, or mimic
    what others say.

26
Prognosis
  • Numerous international studies have demonstrated
    favorable long-term outcomes for around half of
    those diagnosed with schizophrenia, with
    substantial variation between individuals and
    regions. One retrospective study found that about
    a third of people made a full recovery, about a
    third showed improvement but not a full recovery,
    and a third remained ill.

27
Prognosis
  • The World Health Organization conducted two
    long-term follow-up studies involving more than
    2,000 people suffering from schizophrenia in
    different countries. These studies found patients
    have much better long-term outcomes in developing
    countries (India, Colombia and Nigeria) than in
    developed countries (USA, UK, Ireland, Denmark,
    Czech Republic, Slovakia, Japan, and Russia),
    despite the fact antipsychotic drugs are
    typically not widely available in poorer
    countries, raising questions about the
    effectiveness of such drug-based treatments.

28
Treatment
  • Some Typical antipsychotics
  • Tablets Trade Name Normal Daily Dose (mg) Max.
    Daily Dose (mg)
  • Chlorpromazine Largactil 75-300
    1000
  • Haloperidol Haldol 3-15
    30
  • Pimozide Orap 4-20
    20
  • Trifluoperazine Stelazine 5-20
  • Sulpiride Dolmatil 200-800
    2400
  • Depot Injections (may be given 2-4 weekly) Trade
    Name Normal 2 weekly dose Max. 2 weekly dose
  • Haloperidol Haldol 50
  • Flupenthixol decanoate Depixol 40
  • Fluphenazine decanoate Modecate 12.5-100
  • Pipothiazine palmitate Piportil 50
  • Zuclopenthixol decanoate Clopixol 200.

29
Treatment
  • Some Atypical antipsychotics
  • Tablets Trade Name Normal daily dose (mg) Max.
    daily dose (mg)
  • Amisulpiride Solian 50 - 800 1200
  • Aripiprazole Abilify 10-30
  • Clozapine Clozaril 200-450 900
  • Olanzapine Zyprexa 10-20 20
  • Quetiapine Seroquel 300-450 750
  • Risperidone Risperdal 4-6 16
  • Sertindole Serdolect 12-20 24
  • Zotepine Zoleptil 75-200 300
  • Depot Injections Trade Name Normal 2 weekly
    dose Max. 2 weekly dose
  • Risperidone Risperdal Consta 25 50

30
Psychological Treatments
  • Cognitive Behavioural Therapy (CBT)
  • Counselling and supportive psychotherapy
  • Family work
  • Cognitive remediation

31
Cultural references
  • The book and film A Beautiful Mind chronicled the
    life of John Forbes Nash, a Nobel-Prize-winning
    mathematician who was diagnosed with
    schizophrenia. The Marathi film Devrai (Featuring
    Atul Kulkarni) is a presentation of a patient
    with schizophrenia. The film, set in the Konkan
    region of Maharashtra in Western India, shows the
    behavior, mentality, and struggle of the patient
    as well as his loved-ones. It also portrays the
    treatment of this mental illness using
    medication, dedication and plenty of patience by
    the close relatives of the patient. Other factual
    books have been written by relatives on family
    members Australian journalist Anne Deveson told
    the story of her son's battle with schizophrenia
    in Tell me I'm Here, later made into a movie.

32
Cultural references
  • In Bulgakov's Master and Margarita the poet Ivan
    Bezdomnyj is institutionalized and diagnosed with
    schizophrenia after witnessing the devil (Woland)
    predict Berlioz's death. The book The Eden
    Express by Mark Vonnegut recounts his struggle
    into schizophrenia and his journey back to
    sanity.

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