Transcript 8 Schizophrenia

Schizophrenia
Lyudmyla T. Snovyda
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 selfreported experiences and observed behavior. No
laboratory test for schizophrenia exists.
Schizophrenia Descriptions of schizophrenia-like symptoms date
back to circa 2000 BC in the Book of Hearts—part 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.
Schizophrenia 
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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 dementia—a term first used by
psychiatrist Benedict Morel [1809–1873]) 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.
Schneiderian classification
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The psychiatrist Kurt Schneider (1887–1967) 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.
Positive and negative symptoms
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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.
Positive and negative symptoms
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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.
Positive and negative symptoms
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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.
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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.
Subtypes, forms:
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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)
Subtypes, forms:
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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)
Subtypes, forms:
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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)
Epidemiology:
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Schizophrenia occurs equally in males and females
although typically appears earlier in men with the
peak ages of onset being 20–28 years for males and
26–32 years for females. Much rarer are instances of
childhood-onset and late- (middle age) or very-lateonset (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.
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.
Genetic:
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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.
Substance use:
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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.
Substance use:
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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.
Neural:
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Functional magnetic resonance imaging
and other brain imaging technologies
allow for the study of differences in
brain activity among people diagnosed
with schizophrenia.
Signs and symptoms of paranoid
schizophrenia
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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.
Signs and symptoms of paranoid
schizophrenia
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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 one’s 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.”).
Signs and symptoms of paranoid
schizophrenia
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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.
Signs and symptoms of paranoid
schizophrenia
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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
include:Loose 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.").
Signs and symptoms of
disorganized schizophrenia
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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
Signs and symptoms of
disorganized schizophrenia
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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 aren’t consistent
or organized.
Signs and symptoms of catatonic
schizophrenia
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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 violence—
either toward themselves or others.
People with catatonic schizophrenia can be highly suggestible.
They may automatically obey commands, imitate the actions of
Prognosis:
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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.
Prognosis:
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The World Health Organization conducted two longterm 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.
Treatment:
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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
TrifluoperazineStelazine5-20
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.
Treatment:
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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
Psychological Treatments:
Cognitive Behavioural Therapy (CBT)
 Counselling and supportive
psychotherapy
 Family work
 Cognitive remediation
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Cultural references:
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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.
Cultural references:
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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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