Transcript Paranoid type

SCHIZOPHRENIA
INTRODUCTION:- Schizophrenia was called a type of mental
deterioration beginning early in life. In 1860 the Belgian psychiatrist
Benedict Moral described the case of a 13 year old child who had
formely been the most brilliant pupil in his school, who gradually lost
interest in his studies and he talked frequently of killing his father. He
used the term ‘Demence precoce’ (mental deterioration at an early
age) to describe the condition and to distinguish it from the old age.
ORIGIN:- In the latin form it is called ‘Dementia Praecox’. It was
subsequently adopted in the late 19th century by the ‘German’
psychiatrist ‘EMIL KRAEPELIN’. He refers to a group conditions that
all seemed to have the feature of mental deterioration beginning early
in life. In 1991 a Swiss psychiatrist ‘Eugen Bleuler’ used
Schizophrenia because he thought the condition was characterized
primarily by:
1. Disorganization of thought processes.
2. Lack of coherence between thought and emotion.
3. An inward orientation away from reality.
PREVALENCE AND ONSET:1. Global prevalence rates for schizophrenics are difficult to pin down
because of variation in the criteria in defining cases over time and place.
2. Some believe that it occurs at an approximately constant rate in most
if not all societies.
3. Lifetime prevalence is estimated at 0.7 percent among persons not
currently institutionalized. (Kessler et al., 1994)
4. Allen 1997- Schizophrenia appears both rarer and of less severe
quality in traditional, smaller scale societies than it is in modern, well
developed ones.
5. During any given year almost 1 percent of adult U.S. citizens, over 2
million persons meet diagnostic criteria for schizophrenia.
6. Initial onset occurs between the ages of 15 and 45 and median age is
mid 20s. Prevalence rate is same for men and women early to mid 20
for male and late 20s for females.
7. Because of its complexity, high rate of incidence, tendency to recur or
become chronic, it is considered the most serious and baffling disorder.
CLINICAL PICTURE OR SYMPTOMS OF SCHIZOPHRENIA:The symptoms of schizophrenia have been divided into 2 categories:
1. Positive syndrome:- Positive syndrome are those in which something
has been added to a normal behaviour and experience, style.
2. Negative syndrome:- Negative syndrome refer to an absence or
deficit of behaviour normally present in a person.
Although most person or patients exhibit both positive and negative
signs during the course of their disorder.
Positive sub syndrome
Negative sub syndrome
Hallucinations
Emotional flattening
Delusions
Poverty of speech
Derailment of association
Asociality
Bizarre behaviour
Apathy
Minimal Cognitive impairment
Significant Cognitive impairment
Sudden onset
Insidious onset
Variable course
Chronic course
Type I
Type II
Good response to drugs
Uncertain response to drugs
Limbic system abnormalities
Frontal lobe abnormalities
Normal brain ventricles
Enlarged brain ventricles
Dolphus and Colleagues(1996)
suggested that there are atleast four discriminable patterns of
schizophrenia signs:Positive
Negative
Disorganized
Mixed
 Disturbance of Associative Linking:1. It is also known as ‘thought disorder’. This symptom is most
important in schizophrenic patients.
2. The schizophrenic patient are not able to communicate properly
though. They follow semantic rules and syntactic or how to form
sentence rules but they are not able to make sense.
3. This symptom is not due to low intelligence, low education and
cultural deprivation.
4. This symptom is also known by the names ‘cognitive slippage’,
‘derailment’ or ‘lossening of associations’ or ‘incoherence’.
5. The patient uses words in combination that sounds communicative
but the listener is not able to understand.
6. This symptom is readily recognized by the clinical psychologist.
Disturbance of Thought Content:All types of delusions are included in this symptom.
1. One of the delusion can be that one’s thoughts and feelings are being
controlled by external agents.
2. The private thoughts are being broadcasted to everyone.
3. Thoughts are being inserted in to one’s brain by alien forces.
4. Some mysterious agency has robbed one of one’s thoughts.
5. Some T.V. program have some intended personal meaning often
termed as an “ idea of reference”.
Disruption of Perception:1. The patient is unable to sort out and process the large amount of
sensory information.
2.Everything seems out of control such as thoughts and images, objects
are brighter, thoughts are racing in the head, noises are louder, things
are vivid and they come like a flood from the broken dam.
3. Approximately 50% of the patients experience this break down during
the onset of the disorder.
4. Most of the patients also experience dramatic perceptual
phenomenon that is hallucination, most of the auditory hallucination,
though they suffer from visual and olfactory hallucination. The most
common hallucination is a kind of running commentary which is going
on about a person’s behaviour and thoughts.
Emotional Dysfunction:1. Inappropriate emotion and affect is the common function in the
schizophrenic patient.
2. They are not able to experience joy and pleasure. (Anhedonia)
3. They may show emotional shallowness and blunting and some of
them totally emotionless.
4. Though they are able to recognize what is happening intellectually but
they are not able to express as for as feelings are concerned.
5. In acute phase, the emotion clashes with the situation. For e.g. the
person may laugh on hearing the death of parent.
Confused sense of self:1. They are confused about their identity.
2. They may adopt a new identity. For e.g. considering themselves
Jesus Christ or the Virgin Mary.
3. They are confused about the aspect of their body, their gender and
about the boundary separating self from the world.
4. They may suffer from ‘cosmic’ and ‘oceanic’ feeling.
5. They may consider themselves tied up with universal power such as
God, Devil etc.
6. The feelings appear to be related to external controlled delusions.
Disrupted Volition:1. Goal directed activity is disturbed.
2. The impairment is there in day today functioning such as work, social
relation, self care.
3. The person is not able to perform the standard performance which he
used to master.
4. They show disregard about personal safety, health and hygiene.
5. This symptom can be due to impairment in the functioning of central
region of cerebral cortex.
Retreat to an Inner World:1. Relation to external world is almost loosened.
2. Withdrawal from reality is there.
3. No active participation in the environment.
4. The person develops his own illogical and fantastic ideas.
5. They interact with the persons of their own creation, it seems to be
self directed dramas.
Disturbed Motor Behaviour:1. Peculiar movement are observed in schizophrenias.
2. This symptom is more in catatonic schizophrenia.
3. The disturbed motor behavior can range from hyperactivity to marked
decrease in motor activity and movement.
4. They show rigid posture, mutism, ritualistic, mannerism and bizarre
expression.
Subtypes of Schizophrenia:According to DSM IV TR 2000 and DSM IV. Five types are given:
1. Undifferentiated type
2. Paranoid type
3. Catatonic type
4. Disorganized type
5. Residual type
Undifferentiated type:1. Undifferentiated type of schizophrenia is something of a wastebasket
category.
2. The basic criteria of this type of schizophrenia patient includes-
delusions, hallucinations, disordered thoughts and bizarre behaviour.
3. Most of this picture is seen in patients who are in the process of
breaking down and becoming schizophrenic.
4. People in the acute, early phases of a schizophrenic breakdown
frequently exhibit undifferentiated symptoms as do those who are in
transitional phase from one to another of the standard subtypes.
5. In some few instances, treatment efforts are unsuccessful and the
mixed symptoms of the early undifferentiated disorder slide into a more
chronic phase typically developing both the more specific symptoms of
other subtypes as well as increasingly severe negative symptoms.
Catatonic Type:1. The central feature of schizophrenia, catatonic type is related to
motor signs.
2. In this type the patient seem in the form of excited of stuporous
condition.
3. In the withdrawal reaction there is a sudden loss of all animation and
a tendency to remain motionless for hours or even days in a single
position.
4. According to DSM IV TR 2000 this disorder can be characterized from
following points* Motor immobility
* Excessive Motor activity
* Extreme negativism/mutism
* Peculiarities of voluntary movement
* Echolalia or echo- praxia imitate the actions of others or obey
commands)
5. Most of the psychologist study this schizophrenia under two stages* Stupor state
* Excited state
6. The clinical picture may undergo an abrupt change, with excitement
coming on suddenly, where in an individual may talk or shout
incoherently, pace rapidly and engage in uninhibited, impulsive and
frenzied behaviour.
7. In this state, an individual may be dangerous. Sometimes it is difficult
to distinguish them from manic patients. They openly may indulge in
sexual activities, attempt self mutilation or even suicide or impulsively
attack or try to kill others.
8. The facial expression is typically vacant, and their skin appears waxy.
9. Threats and painful stimuli have no effect and they may have to be
dressed and washed by nursing personnel.
Disorganized type:1. It usually occurs at an earlier age than most other types of
schizophrenia.
2. It represents a more severe disintegration of the personality.
3. An affected person has a history of oddness over scrupulousness
about trivial things and preoccupation with obscure religious and
philosophical issues.
4. While schoolmates are enjoying normal play and social activities, the
patient gradually becomes more seclusive and more pre occupied by
fantasies.
5. As the disorder progresses the person becomes emotionally
indifferent and infantile.
6. There are many common symptoms such as a silly smile and
inappropriate shallow laughter after little or no provocation.
7. Speech becomes incoherent and may include considerable baby talk,
childish giggling, a repetitious use of similar sounding words and
derailing of associative thoughts.
8. The patient may invent new words.
9. Speech becomes wholly incomprehensible.
10. Hallucinations, particularly auditory ones, are common.
11. In occasional cases, individual become hostile and aggressive.
12. They may exhibit peculiar mannerism and other bizzare forms of
behaviour.
13. These behaviour may take the form of odd facial grimaces, talking
and gesturing to themselves, sudden inexplicable laughter and weeping.
14. In some cases an abnormal interest in urine and feces which they
may smear on walls and even on themselves.
15. The prognosis is generally poor if a person develops disorganized
schizophrenia.
 Paranoid type:-
1. Formerly about one half of all schizophrenic first admissions to
hospitals were diagnosed as schizophrenia paranoid type.
2. In recent years, however the prevalence of the paranoid type has
shown a substantial decrease.
3. Paranoid type schizophrenic persons show histories of increasing
suspiciousness and of severe difficulties in interpersonal
relationships.
4. The symptoms picture is dominated by absurd, illogical and often
changing delusion.
5. Delusion are the most frequent and may involve a wide range of
bizarre ideas and plots.
6. An individual’s thinking and behaviour become centered on the
themes of persecution, grandeur.
7. In chronic cases, there is usually less disorganization of the
behaviour than in other types of schizophrenia and less extreme
withdrawal from social interaction.
8. Paranoid schizophrenia patients can sometimes be dangerous if they
are convinced that people are persecuting them.
9. Paranoid patients tend to be higher on adaptive coping and cognitive
integrative skills.
10. Paranoid patients are far from easy to deal with because of weaving
of delusions and hallucinations into a paranoid construction.
11. They show less bizarre behaviour and less extreme withdrawal from
the outside world than the other types of schizophrenia and less likely to
be confined in protective environment.
 Residual type:Mild indications of schizophrenia shown by individuals in remission
following a schizophrenia episode. They show some signs of their
past disorder such as odd beliefs, flat affect and eccentric behaviour.
CASUAL FACTORS IN SCHIZOPHRENIA
There are three factors which influence the schizophrenic patients:
* Biological factors
* Psychosocial factors
*Socio-cultural factors
1. Biological factors:- Paul E. Meehl (1962), “Schizophrenia, while its
content is learnt is fundamentally a neurological disease of genetic
origin”.
Research relating to biological factors implicated on
genetics and on various biochemical, neurophysiologic and
neuroanatomical process.
 Genetic influences:- Many psychologist have proved from their
studies that heredity factors play an important role in the development of
schizophrenia. Some experimenters have studied the level of
schizophrenia in the individuals which are grown by schizophrenic
parents. It has been seen that in comparison to non-schizophrenic
parents children, the chance of schizophrenia is found more in
schizophrenic parents’ children (Reider, 1973). The chance of
schizophrenia is more in the children of those whose both parents are
suffered from schizophrenia rather than whose only one parent suffers
(Kringlen, 1978). The evidence includes a strong correlation between
closeness of blood relationship, chances will be more to become
schizophrenic. As the genetic research itself teaches us individual
environments have a powerful effect in determining outcomes with respec
to schizophrenia. It is clear from all the studies that for the schizophrenia,
predisposition is transmitted genetically. But the conclusion of this study
can not be used to solve the problem of heredity vs environment because
schizophrenic patients not only receive defective genes from their parents
but also receive defective mal adaptive environment which foster
schizophrenia.
 Twin studies:- It is known that identical twins MZs have same
genetic endowment due to splitting in single fertilized ovum. In USA it is
found that in the 175 sets of twins. MZs has high concordance rate for
schizophrenia in comparison to DZs (Kallmam, 1946). Gottesman et al
1987 found after the deep study on genetic factors that the concordance
rate for MZs is 44.30% and for DZs it is 12.08%. Now here question
arise if genetic transmission is whole explanation for schizophrenia then
why has MZs twins did not have concordance rate to be 100%. Here we
have to accept the significance of environment too. (Torrey et al 1994)
 Adoption studies:- Many of the psychologists studied such children
who were separated in their very early age from their schizophrenic
parents also develop the traits similar to schizophrenic later on in their
life and they tend to develop many other mental problems such as they
are more likely to become mentally retarded neurotic and psychopathic.
Some times this is also because they have poorly functioning adoptive
parents.
 Bio Chemical Factors:- In schizophrenia one of the important
chemical imbalance found to be is ‘dopamine’. It is believed that
schizophrenia is the product of an excess of dopamine activity at certain
synaptic sites. It has also been found that dopamine blocking drugs
have been proved useful in the treatment of schizophrenia. The latest
researches emphasize that it is not dopamine but there are many other
bio chemical processes which are involved in the disorder called
schizophrenia but we are not sure of them till now.
 Neuro Physiological factors:- Imbalance of various neuro
physiological process such as inappropriate automatic arousal is found
to be strongly linked with schizophrenia. Disordered physiology would
disrupt normal attention and information processing capabilities and will
in turn become the under lying factor for cognitive and perceptual
distortion in schizophrenia. Many psychologist have found out that many
of the schizophrenic experience deficit cognitive functioning, attentional
deficits, reflects hyper activity, poor perceptual motor coordination and
this indicates role of neuro physiological factors in schizophrenia.
 Neuro Anatomical factors:- Research on the structural properties of
brain was possible only after the development of computer dependent
technologies such as CAT (Computerized Axial Tomography), PET
(Positron Emission Tomography), MRI (Magnetic Resonance Imaging).
Much evidence now indicates that in the minority of
schizophrenics who are showing chronic and negative symptoms show
abnormal enlargement of the brain ventricles- The hollow areas filled
with cerebral spinal fluid lying deep with in the core. (Pearlson et al
1989, Raz 1993, Stevens 1997). Several other studies show enlarged
fissures( narrow and long crackling and splitting or separation of parts)
in the surface of cerebral cotex are responsible for this disorder.
(Cannon and Marco 1994). Low birth weight and fetal damage from
some unknown agent seem to be responsible for this disorder. Gur and
Pearlson 1993 concluded on the basis of review of neuro imaging
studies in schizophrenia that they are primarily three brain region which
are involved in integrated function and has an important role to play in
the development of this disorder.
* The frontal
* The temporal limbic
* The interior limbic system such as basal ganglia
 Neuro development issues:- Fetuses and new borns having early
insults according to developmental view are at the higher risk for
misconnected circuits during cell reorganization and thus more
vulnerable to develop schizophrenia. Maternal influenza in the
second month of the pregnancy is associated with impaired fetal
growth enhanced obstetrical complication and later developing
schizophrenia. In one of the later studies by ‘Takei’ and colleagues
1997 identifies that the critical period in catching infection is 5 month
of pregnancy. Here, the risk of influenza exposure is critically
associated with enlarged ventricles and sulci among the group of 83
schizophrenia patient as compared to control group.
1. Psycho social factors in Schizophrenia:Damaging Parent-Child and family interaction:- These studies focus on
following factors:
i. Schizophrenogenic parents
ii. Destructive parental interaction
iii. Faulty communication.
i) Some of variables which play an important role in developing
schizophrenia are parents hostility, deliberate rejection or gross
parental inaptitude (absurd,silly). Many professional have blamed
parents for their angry and insensitive behaviour towards their
children one of the indirect cause of schizophrenia. But nothing can
be said conclusively regarding these factors.
Many psychologist have also
reported and studies have shown a high evidences of emotional
conflicts in the family from which schizophrenic person’s emerge.
ii) Destructive Parental interaction:- one of the other factors which
can be responsible for this disorder is the state of severe chronic
discord in which continuation of the marriage is constantly
threatened. Some of the family show that the family members
entered into the ‘collusion’ in which the seriously disturbed behaviour
of one or the other parent was redefined as normal and justified by
rationalization. This particular type of situation also found to be
closely associated with this disorder.
iii) Faulty communication:- Gregory Bateson 1959, 1960 was first to
emphasize the conflicting and confusing nature of communication
among members of families experiencing a schizophrenic outcome. He
used the term ‘double bind’ communication to describe one such
pattern. In this pattern the parent presents to the child ideas, feelings,
demands that are mutually in compatible. For e.g. the mother may be
verbally loving and accepting but emotionally anxious and rejecting or
she may complain about her sons lack of affection but freezes up or
punish him when he approaches her affectionately. In such situations
mother effectively prohibits comment on such behaviour and father is
too ineffective to intervene.
Two another style of thinking and communication in the
family are strongly linked to the thought disorder of schizophrenia they
are amorphous and fragmented. The amorphous pattern is
characterized by the failure in differentiation and fragmented thinking
involves greater differentiation but lowered integration.
iv) The role of excessive life stress and expressed emotions:- A marked
increase in the severity in the life stress has been found during the ten
week period prior to a person’s schizophrenic break down. Problems are
related to difficulties in intimate personal relationship such as break up.
Relapse of schizophrenia is also related with stress and negative
communication called expression emotion (EE). Two component appear
to be critical of EE is emotional over involvement with the patient and
excessive criticism of the patient. EE may be especially intense where
family members have the view that symptoms are under voluntary
control of the patient (Weisman et al 1993)
 Socio Cultural factors:1.Prevelence rates for schizophrenia appear to vary a lot throughout the
world.
2.Variation in occurrence of the disorder in the various socio groups and
geographical regions is quiet evident but no biological explanation for
this variation is identified. (Kirch, 1993)
3. Systematic differences in the content and form of schizophrenia
between cultures and even sub cultures have been noticed. For e.g.
among the aborigines of west Malesia, Kinzie and Bolten found the
positive syndrome type more in lower socio-economic group rather
than in the higher socio-economic class. Affected individual often drift
downward on the socio economic ladder because this disorder
prevents them from finding jobs or developing human relationships
that might otherwise provide economic stability. (Gottesman, 1991)
Treatment and outcome
Before the 1950’s the prognosis for schizophrenia was extremely
unfavourable and even hopeless. Only those patients who were
diagnosed schizophrenic and could afford expense of private
hospitalization got some treatment only because they belonged to
wealthy family but otherwise. The therapies were inadequate most of
the times and the patients were simply left to adjust to an institution
and was expected never to leave.
Anti Psychotic Medication:- (Drug therapy)
1. For most schizophrenic patient, the outlook today is not nearly so
bleak as it was before 1950s.
2. Improvement came with dramatic introduction of anti psychotic drugs
which are also known major tranquilizers.
3. With the advent of these drugs patients indeed becomes ‘tranquil’ but
the changes were very abrupt and it was difficult to find the extent of
effect these drug had.
4. These drugs transformed the environment of mental hospitals by
eliminating the threat of wild, dangerous and violent behaviours of
the patients.
5. A schizophrenic person who enters a mental hospital today has an
80-90% chance to being discharged within a matter of weeks or at
most month. Unfortunately the rate of readmission is high and almost
10% patient show resistance to drug.
6. Many patients experience repeated discharges and readmissions
showing revolving door and pattern.
7. The hope of reliable cure for schizophrenia has not materialized nor
can it be seen anywhere on the horizon and we must keep in our
mind that anti psychotic medicine are not a cure for the schizophrenic
because they are not able to develop the social recovery of the
patient.
Psycho social approaches:1. Mental health professional have realized the serious limitation of an
exclusively pharmacological approach to the treatment of
schizophrenia.
2. There are several programs of ‘self help’ for patients who are in the
hospital or who have moved from the hospitals to their real life
situations.
3. Token economy as a ‘social economy’ program has proved helpful in
social learning programs. (Paul and Lentz,1977)
4. Individual psycho therapy by highly experienced therapists and anti
psychotic medication has proved helpful in treating schizophrenia.
(Karon and Vandenbos,1981)
5. Perhaps the most notable indication of a changing view on the
treatment of schizophrenia is the content of recently published
‘American Psychiatric Associations’ (1997) ‘Practice guide line for the
treatment of patients with schizophrenia.’
this document contains comprehensive
recommendation on managing the patients in various phases. It also
recommends the importance of psycho social interventions. It also
mentions those problems that are unresponsive to anti psychotic
drugs. It also states some of the therapies which are to be used in
combination with medication such as:•
Family therapy:- Although this therapy is not new in the treatment of
schizophrenia but there is a renewed emphasis on its importance
and its role related to expressed emotion (EE) factor. Family therapy
would appear to be an excellent
i) Medium for identifying instances of EE and for teaching family
members
ii) How to control and avoid it. (Tarrier and Barrowclough, 1990)
• Individual Psycho Therapy:- One-on-one individual psycho therapy of
schizophrenia has a rich history but had not been given its due
importance. This treatment is very effective in:
i) Enhancing social adjustment.
ii) Social role performance of the discharged patients.
iii) It also helps in learning coping skills for managing emotions and
stressful events. It is similar to cognitive behaviour therapy and it is an
important component in all the treatment package for schizophrenia.
• Social skills training and community treatment:- Training in useful
skills:
i) Is a useful procedure for overcoming embarrassment, ineptitude,
awkwardness and attentional clue lessness displayed in social
situations by many schizophrenics.
ii) This technique also help them in learning how to use different
resources.
iii) Also, how to get their lives organized.
Community based follow up are required in making the patients learn
how to manage their life problems such programs are known as
Assertive Community Treatment (ACT) and Intensive Case
Management (ICM) such programs have to ensure that discharged
patient do not get overlooked and lost in the real life settings. The more
intensive the services, the larger the effect in clinical improvement and
social functioning of the patient. (Brekke et al, 1997).
Finally the need is to coordinate.
Anti psychotic medication with other non medical services. When done
well, the patient benefits substantially (Klerman et al, 1994; Kopelowicz,
1997).