Schizophrenia

Definition
• Thought disorder that impairs judgement, behavior & ability to interpret reality which symptoms
present for at least 6 months

Epidemiology Risk factor

• Incidence: 1% History of schizophrenia in:
• Suicide risk: 10% • Monozygotic twin: 50%
• Gender: M > F • Parents: 15%
• Age group: 15 – 35 y/o • Siblings: 10%
• None: 1%

Causes

Genetic • Family history of schizophrenia (Most important)

• 40% Monozygotic twin
• 10% Dizygotic twin
Neurochemistry •  Dopamine  Activate Positive symptoms of psychosis
•  Serotonin  Block dopamine release   Dopamine   Negative
symptoms & Cognitive symptoms
Neuroendocrine • Abnormal Growth hormone, Prolactin, Cortisol, ACTH
Antenatal/ • Obstetric complication – PROM, Preterm labor, Low birth weight
Perinatal • Prenatal viral exposure – influenza, measles, rubella
Biological • Head injury – paranoid schizophrenia
• Epilepsy & temporal lobe disease – Most common causes
• Cannabis abuse
Psychological • Stressful life events

Clinical features

History MSE
• Hallucination – Most common: Auditory • Saccadic eye movements
• Delusions – Most common: Bizarre • Hypervigilance -  anxiety
• Disorganized speech • Disheveled appearance
• Disorganized behavior • Flattened affect
• Catatonic behavior • Intact memory & orientation
• Negative symptoms • Ideas of reference
• Social & occupational dysfunction • Lack insight into their disease

Most common Schizophrenia features

Auditory hallucination • 3rd person auditory hallucination

• Thought echo (own thought spoken out loud)
• Voice commenting & commanding on patient
Thought disorder Thought alienation
• Thought insertion
• Thought withdrawal
 • Thought broadcasting
Delusion of perception • Perceived normal object, then there is sudden
intense delusional insight into object meaning for
patient
• Ex: Traffic light is green, therefore I am king
Other features • Poor insight
• Neologism
• Catatonia
• Negative symptoms – blunting affect,
anhedonia (inability to feel pleasure), alogia
(poverty of speech), avolition (poor motivation)

DSM-5 Criteria

Criteria About
A Have at least 2 of following symptoms, must at least have one of these (1), (2), (3)
1. Delusions
2. Hallucination
3. Disorganized speech – Ex frequent derailment, incoherence
4. Disorganized behavior
5. Negative symptoms
B Decrease level of function
C At least for 6 months of continuous symptoms of criteria A
D Must rule out
• Schizoaffective disorder
• Depressive or bipolar disorder with mood symptoms
E Must rule out other causes
• Drug abuse or medication

Investigation

Brain Imaging Result

CT scan • Lateral & 3rd ventricular enlargement
•  Cortical volume – a/w presence of negative symptoms, neuropsychiatric
impairment,  neurological sign, poor premorbid adjustment
MRI •  Cerebral vertical
PET scan • Hypoactivity of frontal lobe
(Not usually done) • Hyperactivity of basal ganglia

“Dear friends, the reason why we need to identify positive & negative symptoms predominance is to
determine type of treatment”

Positive symptoms (Psychotic symptoms) Negative symptoms

Symptoms • Delusions – false belief that strongly believe by patient that Mnemonic: 5A
make patient not to change his mind, even if there is • Affect (Flat) –
evidence against it Inappropriate response
» Control • Anhedonia
 » Reference • Alogia – poverty of
• Hallucinations – sensation that not there speech
» Auditory (Most common) • Avolition – 
• Disorganized speech – Word salad Motivation to do
• Disorganized behavior – Bizarre, non-purpose behavior something
» Ex wearing a sweat shirt under a hot sun • poor Attention
• Catatonic behavior – Movement & posture
» Reluctant to move
1st line • Atypical anti-psychotic drug – because less S/E • Atypical anti-psychotic
treatment • Typical anti-psychotic drug: Haloperidol drug: Risperidone

Must rule out common Comorbidity

• Substance related disorder
• Anxiety disorder
• Medical comorbidity – Obese, DM, Metabolic syndrome, CVD, Lung disease

Subtypes of Schizophrenia

Subtypes About Criteria

Paranoid • Highest functioning • Have at least 1 delusion or frequent auditory hallucination
• Onset at Old age • No predominance of disorganized speech, behavior or
inappropriate affect
Disorganized • Poor functioning • Disorganized speech
• Early onset • Disorganized behavior
• Flat affect
Catatonic • Rare At least 2 of following
• Motor immobility
• Excessive purposeless motor activity
• Extreme negativism
• Peculiar voluntary movement
• Echolalia (repeat words) or Echopraxia (mimic behavior)
Undifferentiated • Characteristic of > 1 subtype or none
Residual • Persistent negative symptoms (flattened affect or social withdrawal) with only minimal
positive symptoms (hallucinations or delusions)

Differential diagnosis
• Substance induced – ecstasy, ketamine, phencyclidine, LSD (LSD – almost similar symptoms of
schizophrenia)
• Epilepsy
• Other psychotic disorder – Schizoaffective disorder, Brief reactive psychosis, delusional disorder
• Mood disorder
• Medical – HIV, corticosteroid, tumor
• Personality disorder

Treatment
Phase Condition & Treatment
Acute Condition Treatment
treatment Suicide risk, Aggressive • Hospitalization
Aggressive Rapid tranquilizer (Anti-psychotic)
• Oral: Lorazepam, Olanzapine or Risperidone
• IM: Haloperidol, Lorazepam
 Acute Psychotic symptoms • Start with oral anti-psychotic (low dose)
• Monitor effectiveness & side effect for 2 months
Initial Condition Treatment
treatment Newly diagnose schizophrenia Oral antipsychotic – Olanzapine
• Monitor effectiveness for 1 month  If no
adequate response or intolerable side effect
 Change to another Anti-psychotic
No respond to medication, • ECT
Life threatening symptoms – catatonia,
severe depression
Stabilization Condition Treatment
phase Psychotherapy • Psychoeducation – on schizophrenia
• Cognitive behavioral therapy
• Problem solving therapy
Relapse of psychotic symptoms d/t • Long acting depot (IM Fluanxol, Clopixol)
non-compliance to medication
Post-psychotic depression • Anti-depressant
Maintenance Condition Treatment
phase Condition improve • Control condition with lowest effective dose of anti-psychotic
• Not up to 1/2 effective dose during acute phase
Drug side effect • Monitor & manage side effect
• If intolerable, change to another medication
• If use atypical drug, must regularly monitor metabolic side
effect (BMI, Blood glucose, Blood pressure, Lipid profile)
Acute relapse • Oral anti-psychotic drug

Features of schizophrenia that suggest

Poor prognosis (Not respond to treatment) Good prognosis

• Poor premorbid functioning (most important) • Good premorbid functioning (most important)
• Family history of schizophrenia • Family history of mood disorder
• Early onset • Late onset
• Negative symptoms • Positive symptoms
• No triggering factor • Has triggering factor
• Poor support system • Good support system
• Marital status : Single, divorced or widowed • Marital status : Married

Prognosis
• 1/3 improve
• 1/3 remain the same
• 1/3 worsen