Title: Schizophrenia
1Schizophrenia
2Schizophrenia -
- 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.
3Schizophrenia -
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.
4Schizophrenia -
- 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.
5Schneiderian 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.
6Positive 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.
7Positive 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.
8Positive 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.
10Subtypes, 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)
11Subtypes, 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)
12Subtypes, 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)
13Epidemiology
- 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.
14Causes
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.
15Genetic
- 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.
16Substance 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.
17Substance 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.
18Neural
- Functional magnetic resonance imaging and other
brain imaging technologies allow for the study of
differences in brain activity among people
diagnosed with schizophrenia.
19Signs 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.
20Signs 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.).
21Signs 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.
22Signs 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.").
23Signs 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
24Signs 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.
25Signs 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.
26Prognosis
- 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.
27Prognosis
- 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.
28Treatment
- 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.
29Treatment
- 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
30Psychological Treatments
- Cognitive Behavioural Therapy (CBT)
- Counselling and supportive psychotherapy
- Family work
- Cognitive remediation
31Cultural 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.
32Cultural 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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