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SCHIZOPHRENIA

Schizophrenia is a clinical syndrome of variable,


but profoundly disruptive, psychopathology that
involves cognition, emotion, perception and other
aspects of behavior (Kaplan, 2007)
Characterized by disturbances in:
Affect
Thought
Emotion
Mood
Behavior
Changes in personality, deterioration in function and

intelligence, poor judgment and insight

The diagnosis is based entirely on the psychiatric


history and mental status examination (MSE)

Epidemiology

15-20 per 100,000 per year


Lifetime risk: 0.9-1%
Male and female are equally affected but have
different presentations. Male earlier onset than
female
Median age of onset: Male- 28 years, female-32
years
Commonly detected in late adolescence and early
adulthood but it can occur during adulthood or later.
If later age look into possibility of underlying
organic cause
Increased prevalence among lower social class

Aetiology

Exact cause unknown


Associated with biological and social
factors
Research in finding out relations
between these multiple factors and
gene mutation

1. BIOLOGICAL FACTORS
Genetic

Strong genetic predisposition (familial aggregation)


1. 50% concordance rate among monozygotic twins
2. 40% risk of inheritance if both parents have
schizophrenia
3. 12% risk if one first-degree relative is affected.

Biochemica 1. Dopamine hypothesis/theory too much dopamine


causes schizophrenia
l

2. Partly related to prefrontal cortical (negative


symptoms) and mesolimbic pathways (positive
symptoms)
3. Other neurotransmitters abnormalities
. Elevated serotonin
. Elevated norepinephrine
. Decreased gamma-aminobutyric acid (GABA)- loss
of GABAergic neurons in the hippocampus might
indirectly activate dopaminergic and noradrenergic
pathways.

1. BIOLOGICAL FACTORS
Neuropathology

Multiple developmental abnormalities


Ventricular and sulcus enlargements with
cerebellar atrophy
Brain atrophy
Increase in CSF in ventricles
Decrease in thalamus size
Hypofrontality (decreased in cerebral blood
flow) associated with prominent negative
symptoms

Pre & Perinatal


Complication

Injuries
Infections

Substance Use

1. High prevalence among schizophrenics


2. Can be a comorbidity
3. Difficult to ascertain relationship to be a
cause or consequence of schizophrenia
4. Many studies suggest certain drugs do trigger
onset or relapse

2. PSYCHOSOCIAL FACTOR
Social
Theory

Social selection or social drift theory


Downward drift hypothesis: affected individual
drifts down the social ladder to a lower
socioeconomic status where social demands are
less stressful
Social causation or social breeder theory
Poverty is the cause of schizophrenia
Opposite of social selection

Pathologic
al Family
Relationsh
ip

1.
2.
3.
.

Lidz: Marital Schism and Skew


Double bind theory by Gregory Bateson
High Expressed Emotion (High EE)
Expressed emotion: measure of family environment
that is based on how relatives of patient
spontaneously talk about the patient
. High EE: Hostility, over-involvement, overprotection,
overcritical and over-criticism by parents
. High EE at home can worsen prognosis
. Tests: Camberwell Family Interview and Five Minutes
Speech Sample

Lidz and associates (1957)

Marital schism: disharmonious situation, in which each parent,


preoccupied with his or her own problems, fails to create a
satisfactory role in the family that is compatible with and
reciprocal to the other spouses role. Each parent tends to
undermine the worth of the other, especially to children, and they
seem to compete for loyalty, affection, sympathy and support of
the children. Threats of separation or divorce are common; it is
usual in such families for the father to become ostracized, a
virtual nonentity if he remains in the home

Marital skew: researchers observed in families of


schizophrenic offspring, where the continuity of
marriage is not threatened, but mutually destructive
patterns nevertheless exist. The serious psychological
disturbance of one parent (such as psychosis) usually
dominates this type of home. The other parent, who is
often dependent and weak, accepts the situation, and
goes as far to imply to the children that the home
situation is normal. Such a denial of what they are
actually living through may lead to further denials and
distortions of reality by children

Double bind theory

Both parents communicate two or


more conflicting messages at the
same time, leaving the child in a
confused state
Emotionally distressing and person
cannot confront the inherent
dilemma, resulting inability to resolve
it or opt out of the situation

Clinical Features
Three dimensions:
1. Negative symptoms: psychomotor
poverty- social withdrawal, poverty of
speech (alogia), restricted affect, decreased
in spontaneity in talk and movement
(avolition)
2. Positive symptoms: reality distortionhallucinations, delusions
3. Disorganized thought, speech, and behavior

Symptoms Ranking
To differentiate schizophrenia from other forms of psychosis,
Kurt Schneider listed the psychotic symptoms that are
particularly characteristic of schizophrenia.
Schneiders First Rank Symptoms (FRS):
1. Hearing thought spoken aloud/ First person hallucination
2. Third person hallucination
3. Hallucination of running commentary
4. Somatic passivity
5. Delusional perception
6. Possession of thought- thought withdrawal, insertion,
broadcast
7. Made action- Action/complex behavior of being control

Symptoms of schizophrenia usually present in


three phases:

1.

2.
3.

Prodromal: decline in functioning that precedes


the 1st psychotic episode. Patient may become
socially withdrawn & irritable with anxiety
symptoms. May have bizarre physical
complaints and newfound interest in philosophy
and bizarre ideas. Inappropriate behaviors.
Active/ acute/ psychotic: the three dimensions
of syndromes
Residual: occurs between episode of active
phase, marked by flat affect, social withdrawal
and negative symptoms. Patients can continue
to have hallucinations even after treatment.

Diagnosis Based on DSM V


A. Two or more of the following, each present
for a significant portion of time during 1
month period (or less if successfully treated).
At least one of these must be (1), (2) or
(3):
1. Delusions
2. Hallucinations
3. Disorganized speech (eg frequent derailment
or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (eg diminished
emotional expression or avolition)

B. Social/occupational dysfunction
C. Duration: Continuous sign of illness for at
least 6 months, including 1 month active
phase
D. Exclude schizoaffective and mood
disorders
E. Exclude substance /general medical
condition
F. If history of autism or communication
disorder of childhood onset is present,
additional diagnosis of schizophrenia is
made only if prominent delusions or
hallucinations and other required
symptoms present for at least 1 month

After 1 Year Duration

Specify if
First episode, currently in acute episode
First episode, currently in partial remission
First episode, currently in full remission
Multiple episodes, currently in acute episode
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous
Unspecified
With catatonia

Factors That Precipitates Relapse

Defaulted medication
Adverse life events
Substance abuse
Living with high EE family

Subtypes of Schizophrenia

Paranoid type: highest functioning type,


older age of onset. Must meet the following
criteria:
1. Preoccupation with one or more delusions of

frequent auditory hallucinations.


2. No predominance of disorganized speech,
disorganized or catatonic behavior or
inappropriate affect.

Disorganized type: poor functioning type,


early onset. Must meet the criteria:
1. Disorganized speech
2. Disorganized behavior
3. Flat or inappropriate affect

Catatonic type: Rare. Must meet at least 2 of


the following criteria:
1. Motor immobility
2. Excessive purposeless motor activity
3. Extreme negativism or mutism
4. Peculiar voluntary movements or posturing
5. Echolalia or echopraxia

Undifferentiated type: Characteristic of more


than 1 subtype or none of the subtypes.
Residual type: Prominent negative symptoms
(flattened affect or social withdrawal) with
only minimal evidence of positive symptoms
(hallucinations or delusions).

Prognosis

Usually chronic and debilitating


50% remain significantly impaired after
diagnosis
20-30% function fairly well in society with
medication.
Associated with worse
prognosis

1.
2.
3.
4.
5.
6.
7.
8.

Early onset
Poor social support
Negative symptoms
Family history
Gradual onset
Male
Many relapses
Poor premorbid functioning
(social functioning)

Associated with better


prognosis:

1.
2.
3.
4.
5.
6.
7.
8.

Later onset
Good social support
Positive symptoms
Mood symptoms
Acute onset
Female
Few relapses
Good premorbid functioning

Management

Mainstay treatment: antipsychotic


agents to block post synaptic dopamine
receptor
Acute phase for aggressive behavior:
antipsychotics: haloperidol and midazalom 4-6

hours/day

Augmentation
anxiolytics (benzodiazepine), mood stabilizers

(anticonvulsants, lithium) or antidepressants

Maintenance therapy: long term

1. Pharmacology
Typical neuroleptic/ antipsychotic

E.g.: haloperidol, chlorpromazine, triluoperazine,


perphenazine, sulpiride

Atypical neuroleptic

E.g.: resperidone, olanzapine, quatiapine,


clozapine, aripiprazole

Depot preparation

E.g.: fluphenazine decanoate, fluphentixol


decanoate, resperidone depot

Important Side Effect and Sequelae of Antipsychotic


Drugs
Extrapyramidal symptoms (especially high
potency traditional antipsychotics e.g haloperidol
and trifluoperazine):

1.

dystonia (spasm) of face,neck and tongue


parkinsonism (resting tremor,rigidity,bradykinesia)
akathisia (feeling of restlessness)
treatment: antiparkinsonian agents
(benztropine,amantadine) benzodiazepines

Anticholinergic symptoms (especially low potency


traditional neuroleptic and atypical neuroleptic e.g
chlorpromazine and thioridazine ):

2.

dry mouth, constipation, blurred vision


treatment :as per symptoms (eye drops, stool softeners,
etc)

Tardive dyskinesia (high potency


antipsychotics) :

3.

Neuroleptic malignant syndrome (high potency


antipsychotics):

4.

5.

darting or writhing movements of face, tongue and head


Treatment: discontinue offending agent and substitute atypical
neuroleptic. Benzodiazepines ,beta blockers and cholinomimetics
may be used short term. The movements often persist despite
withdrawal of the offending drug

Confusion, high fever, elevated blood pressure, tachycardia,


sweating and greatly elevated creatine phosphokinase (CPK) levels
can be life threatening

Weight gain, sedation, orthostatic hypotension, ECG


changes, hyperprolactinemia, hematologic effects,
ophthalmologic conditions, dermatologic conditions,
hyperlipidemia and glucose intolerance

2. Psychosocial Treatment
/Psychiatric Rehabilitation
Behaviour therapy
Family therapy
Group therapy
Vocational rehabilitation/ occupational
therapy
Social skill training
Psychoeducation/ health education
Cognitive remedial therapy (CRT)
Crisis support /management
Assertive community management
(ACT)

3. Others

ECT: helpful in catatonic state, acute


state with poor drug response
Supportive
Compliance therapy
Cognitive behaviour therapy (CBT)

Brief psychotic disorder

Sudden onset of psychotic


symptoms, which lasts 1 day or more
but less than 1 month.
Prognosis:
50-80% recovery rate
20-50% may eventually be diagnosed
with schizophrenia or mood disorder.

DSM V diagnosis

A. Presence of one or more of following


symptoms. At least one of these must be
(1), (2) or (3)
1. delusions
2. hallucinations
3. disorganized speech
4. grossly disorganized or catatonic behavior

B. Duration of at least 1 day but less


than a month with eventual full return to
premorbid level of functioning

C. Exclude major depressive or


bipolar disorder with psychotic
features or another psychotic
disorder like schizophrenia or
catatonia. Also exclude substance
abuse or medical condition

Specify if
With marked stressors
The symptoms occur in response to events
Without marked stressors
The symptoms does not occur in response to
events.
With postpartum onset
Onset is during pregnancy or within 4 weeks
postpartum.
With catatonia

Management

Brief hospitalization
Supportive psychotherapy
Course of antipsychotics for
psychosis itself and/or
benzodiazepines for agitation

SCHIZOPHRENIFORM
DISORDER

Two or more of the following , each present for a


significant portion of time during a one month
period .1 or 2 or 3 must be present:
1 delusion
2 hallucination
3 disorganize speech
4 grossly disorganize/ catatonic behavior
5 negative symptoms

Episode last at least one month but less than 6


month
Not attributable to psychological effects of
substance or other medical conditions

Schizoaffective disorder
By wei li ;p

NUMBER 1

An uninterrupted period of illness,


Major mood episode with concurrent
criterion A of schizophrenia.
#The major depressive episode:
Meet the criterion A1 of depressed
Mood
@ sad /high at the same time as crazy
Fulfilling criteria for both

NUMBER 2

Delusion and hallucination for 2 or more


weeks in the absence of major mood
episode (depressive/ manic) during
lifetime duration of illness
@there must be at least 2 weeks (in your
entire life) whereby you are crazy
without being sad /high
*ps: we want make sure you are really
crazy not just crazy because you are
high/sad

NUMBER 3

Symptoms that meet the criteria for major


mood episode are present in the MAJORITY of
the total duration of active and residual
portions of illness
@ You have to be sad/high MOST of the time
while being crazy
Ps: you can be sad/ high after doing crazy
stuff ( regretful etc)
We want to make sure you are really sad
because you are sad not because of your
craziness

NUMBER 4

Disturbance not due to drugs/


substance or medical condition

Juz to make sure your are Naturally


and Primarily crazy AND sad/high ,
without any help from substance/
secondary causes

Criteria A for
Schizophrenia

2 (or more)of the following, each present for a


significant proportion of time during a 1
month period (or less if successfully
treatment) At least one of these must be
(1,2,3)
1 delusions
2 Hallucination
3 Disorganized speech
4 grossly disorganized/ catatonic behaviour
5 negative symptoms(anhedonia, flat affect,
alogia,avolition,poor attention)

Criteria manic episode

A distinctive period of
abnormally and persistently
elevated, expansive or irritable mood
and abnormally and persistently
increased goal directed activity or
energy
lasting a least one week
Most of the day
Nearly everyday

During that period

Inflated self esteem/ grandiuosity


Decreased need for sleep ( after 3 hours)
More talkative than usual/ pressred speech
Flight of ideas/ subjective experiences of racing
thoughts
Distractibilty , as reported/ observed
Increased goal directed activity/ psychomotor
agitation
Excessive involvement in high risk activity
@think a lot, talk a lot, do a lot (dangerous)
because you think you are Sooo great, plus no
need to sleep

Severe enough to impair social/


occupational functioning
to necessitate hospitalization to
prevent self harm/ psychotic features
@ you are screwed up and need to go
to the hospital

Criteria A depression

Five symptoms in 2 week period AND change from


previous functioning
At least one of them is (depressed mood/ loss of
interest@pleasure)
Significant LOW/ (5% of Bdy weight GOW)/ LOA without
diet
Insomnia/ hypersomnia
Psychomotor agitation/retardation
Fatigue/ loss of energy
Worthlessness/ inappropriate guilt
diminished ability to think/ concentrate/
indecisiveness
Recurrent thoughts of death, suicide, ideas, plan

Diagnosed? Please specify


Bipolar type
Depressive type
With catatonia
First episode/ multiple episodes (at least 2)
~ currently in acute episode
~currently in partial remission (partially
fulfilled criteria)
~currently in full remission (no symptoms)
Continuos ( all the time have/ subthreshold
only brief)
unspecified

Catatonia
Clinical picture dominated by 3 or more
1. Stupor
2. Catalepsy like stone no feel
3. Waxy flexibility like wax
4. Mutism
5. Negativism
6. Posturing
7. Mannerism
8. Stereotypy
9. Agitation not by external stimuli
10. Grimacing
11. Echolalia
12. Echopraxia

Psychotic?

Give as of schizophrenia
if needed add on some anxiolytic
Primary options
alprazolam: 0.25 mg orally (immediate-release) three times
daily initially, increase gradually according to response,
maximum 4 mg/day
OR
clonazepam: 0.25 mg orally twice daily initially, increase
gradually according to response, maximum 4 mg/day
OR
diazepam: 2-10 mg orally two to four times daily
OR
buspirone: 7.5 mg orally twice daily initially, increase
gradually according to response, maximum 60 mg/day

Antidepressant

Depressed?

Primary options
fluoxetine: 20 mg orally once daily initially, increase
gradually according to response, maximum 80 mg/day
OR
paroxetine: 20 mg orally once daily initially, increase
gradually according to response, maximum 50 mg/day
OR
citalopram: 20 mg orally once daily initially, increase
gradually according to response, maximum 40 mg/day
OR
sertraline: 50 mg orally once daily initially, increase
gradually according to response, maximum 200 mg/day
OR
mirtazapine: 15 mg orally once daily initially, increase
gradually according to response, maximum 45 mg/day

Mood stabiliser

Manic?

Primary options
lithium: 300 mg orally (immediate-release) two to three times
daily initially, increase gradually according to response and
serum drug level, maximum 2400 mg/day
OR
carbamazepine: 200 mg orally (extended-release) twice daily
initially, increase gradually according to response and serum
drug level, maximum 1600 mg/day
OR
valproate semisodium: 250 mg orally three times daily initially,
increase gradually according to response and serum drug
level, maximum 60 mg/kg/day (monitor carefully if dose >45
mg/kg/day)
OR
lamotrigine: dose may depend on what drugs a patient is
currently on; consult specialist for guidance on dose

NON PHARMOCOLOGICAL !!!!


Psychosocial interventions
(community,family, individual)

for treatment to be successful, issues such as tenuous housing,


low income, inadequate work skills, poor social support, and
restricted access to health care need to be overcome.

Assertive community treatment,


supported employment,
skills training,
cognitive behavioural therapy,
cognitive remediation,
token economy interventions,
family-based services are recommended.
Patient education about illness and medication
Monitor for depressive symptoms and risk factors for suicide.

General health maintenance

15- to 20-year reduction in life


expectancy!!!
adverse effects of medications?.
Possible adverse effects include
neurological adverse effects, metabolic
abnormalities (weight gain, blood glucose
levels), hyperprolactinaemia, cardiac
abnormalities, agranulocytosis, postural
hypotension, and anticholinergic adverse
effects.

Difference of mood disorders with


schizo affective?

Schizoaffective fulfills both the


criteria of mood disorders AND
schizophrenia
Mood disorders may have features of
psychosis but psychosis not entirely
fulfill the criteria of schizophrenia

Delusional Disorders

More often in older patients ( after age 40),


immigrants and hearing impaired patients.
Criteria
Non-bizarre, fixed delusions for at least 1 month
Does not meet criteria for schizophrenia
Functioning in life not significantly impaired.

Prognosis
50%-full recovery
20%-reduced symptoms
30%-no change

Types of Delusional
Disorder

Erotomanic type
Delusion revolves around love. (the persons delusion is

that another person is in love with the individual)

Grandiose type
Inflated self worth (the persons delusion is the

conviction of having some great talents)

Somatic type
Physical delusion (the persons delusion involves bodily

functions or sensations)

Persecutory type
Delusion of being persecuted (the persons delusion

involves individuals belief that has been cheated,


poisoned, spied on, conspired against, followed,
drugged in pursuit of long-term goals)

Jealous type
Delusion of unfaithfulness

Mixed type
More than one of the above

Treatment
Pharmacological

Anti-psychotic medication
Non-pharmacological

Psychotherapy
Cognitive therapy
Supportive therapy
Insight-oriented therapy