Schizophrenia Explained In Details
What is Schizophrenia ?
As per fourth edition of Diagnostic & Statistical Manual of Mental Disorders (DSM-IV) schizophrenia is described as “a disturbance that lasts for at least 6 months and includes at least a month of active - phase symptoms (that is, two (or more) of the following.
: delusions
: hallucinations
: disorganized speech
: grossly disorganized and catatonic behavior,
: negative symptoms “
History of schizophrenia :
* Dr. Emile Kraeplin was the first person (German Physician) to identify a ‘discrete mental illness’ which is different from other mental illnesses. To this illness he is called ‘dementia praecox’.
‘Dementia’ is a disease of the brain and ‘Praecox’ for early onset age.
He believed that ‘this is a brain disorder (like dementia), but which starts at early age group (unlike Alzhiemer’s Dementia)
He was the first person to differentiate this ‘mental illness’ from manic depressive psychosis (1887)
Eugen Bieuler (1911) coined the term ‘Schizophrenia’ as the ‘dementia praecox’ was misleading (it was not like dementia and also was starting at late age also).
Schizo - Split
Phrene - mind.
This is to describe fragmented thinking of people with disorder.
It is different from split personality / multiple personality disorder.
Bleuler was the first person to describe positive & negative symptoms of schizophrenia.
Both Bleuler & kraepelin subdivided schizophrenia into categories depending on symptoms & prognosis.
How common is Schizophrenia?
Incidence & Epidemiology :-
At any one time, about 7 in 1,000 adults have schizophrenia.
( BMS 2007 335 : 91-95 )
The chance of getting schizophrenia at some point in your life is about 1 in 100
((Mueser KT schizophrenia 2004 : 363 : 2063)
Roughly three men get schizophrenia for every two women who get it. (Bhugra D. The global prevalence of schizophrenia. PLOS medicine. 2005; 2-151)
Schiz tends to affect people for the first time as young adults . The average age for first getting symptoms is 25. However men tend to be affected at a younger age than women. ( Aleman A. Khan RS, Salten JP, Sex differences is the risk of schizophrenia Evidence from meta-analysis, Archives of general psychiatry : 2003; 60:565-571)
More incidence in urban populations as compared to rural population .
As per one study done at Chandigarh in 1993, the annual incidence rates obtained were 4.4 and 3.8 per 10,000, for rural and urban areas , respectively.
(Ref : Indian J Psychiatry 1993 JAN-MAR; 35(i), 11 -17 PMCID-PMC 2972559)
Prevalence is much higher than incidence due to better care and medical management availability.
What are Causes of schizophrenia ?
1837. DR.W.A.F. BROWN : (Best known English Psychiatrist).
“Insanity, then, is inordinate or irregular or impaired action of the mind, of the instincts, sentiments, intellectual, or perceptive powers, depending upon and produced by an organic change in brain.”
1837: DR. AMARIAH BRIGHAM: (One of the founders of American psychiatry)
“Insanity is now considered a physical disorder, a disease of the brain.”
Since 1980’s due to development in imaging techniques; evidence has become overwhelming that schizophrenia & manic-depressive disorder are diseases of brain ,just as multiple sclerosis parkinson's disease, etc. are diseases of the brain .
Who can get Schizophrenia ?
How and why does schizophrenia develop?
- Experts now agree that (Schizophrenia develops as a result of interplay between biological predisposition and environment a person is exposed to.)
Brain development disruption is now known to be the result of genetic predisposition and environmental stressors early in development, leading to subtle alterations in the brain that make a person susceptible to developing schizophrenia.
Even though genetic predisposition is a strong component, it can not turn on the disorder, unless and until, the environment / external stressors which can turn on the disorder are present.
Dr. Iro Giick “New schizophrenia treatments”
Stanford university : schizophrenia & Bipolar Education Day July 2005.
Genetic Predisposition
Early environmental insults
Later environmental insults
Psychosis
*Set of relatively well established risk factors for schizophrenia :-
winter
Place & time birth
urban.
Influenza
Respiratory
Infection Rubella
Polio virus
CNS
Prenatal
Famine
Bereavement
Flood
Unwantedness
Maternal depression
Rh.incompatibility
- Hypoxia
Obstetric - CNS Damage
- Low birth weight
- Pre-eclampsia
- Family history
( source : public library of science, 2005).
* Psychological theories about the family:-
Double bind : the parents convey two or more conflicting &
incompatible messages at same time.
Marietas skew & schizm : (LIdz et. al 1957)
Skew : over protective, intrusive dominant, mother and
evercompliant, submissive father.
Schizm: hostility between parents.
Abnormal family communications.
Many studies have indicated that families with high levels of
expressed emotions (criticism, hostility, over involvement)
The relapse rate of schizophrenia is high.
What are changes in the brain associated with schizophrenia?
(1) Neurotransmitter dopamine levels increase in schizophrenia. Leading to most
of the abnormal behavior in the patient.
(Most of the antipsychotics are dopamine receptor blockers.)
(2) Other neurotransmitter involved in schizophrenia are serotonin,
nor-epinephrine, which are co-related with suicidal behaviour and
frequency of relapse respectively, in schizophrenia.
(3) Decrease in the size of amygdala, the hippocampus, and
Parahippocampal gyrus commonly seen is schizophrenia.
(4) It has been observed that patients with schizophrenia have
enlarged lateral & third ventricles.
(5) EEG of schizophrenia pt’s brain shows abnormal records i/f/o
increased sensitivity, increased theta and delta activity and
possibly more than usual epileptiform activity and possible more
than usual left-sided abnormalities.
Diagnosis :-
Diagnosis of schizophrenia mainly depends on clinical evaluation (details of history, mental status examination) and ruling out organic conditions (by investigating).
DSM-5 Diagnosis: Schizophrenia
1)Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated).
At least one of these must be delusions, hallucinations or disorganized speech:
Delusions
Hallucinations
Disorganized speech (e.g., frequent derailment or incoherence)
Grossly disorganized or catatonic behavior
Negative symptoms (i.e., diminished emotional expression or avolition)
2) Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet the above criteria (i.e., active phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested only by negative symptoms or by two or more symptoms listed above present in an attenuated form.
3) For a significant portion of time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or selfcare is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is a failure to achieve expected level of interpersonal, academic, or occupational functioning).
4) Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out.
5) The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
6) If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated)
Symptoms in schizophrenia :-
Positive Symptoms :-
(MAYO CLINIC.com)
Hallucinations :- (1) Auditory
(2) visual
(3) Ol Factory (Smell)
(4) Gustatory (Taste)
(5) Tactive (touch)
Delusions :- (i) Persecutory, Jealous
(ii) Guilt
(iii) Grandiosity, religious
(iv) Somatic
(v) Ideas of reference
(vi) Being controlled or mind reading
(vii) Thought broadcasting, insertion or withdrawal
Bizarre Behavior :-
(i) clothing, appearances
(ii) social, sexual
(iii) Aggression / Agitation
(iv) Stereotyped behavior.
Positive Formal Thought Disorder :-
(i) Derailment
(ii) Tangentiality / circumstantiality
(iii) Incoherence or clang association
(iv) Illogical speech
SYMPTOMATOLOGY :-
Hallucinations :- (Jasper’s definition)
A False perception which is not a sensory distortion or a misinterpretation, but which occurs at the same time as real perceptions.”
“It is a perception without an object.”
What distinguishes hallucination from true perceptions is that they come from ‘within’, although the subject reacts to them as if they were true perceptions coming from without.
Eg: Auditory hallucinations : Person starts hearing ‘someone giving common to him’ or “running dialogue between two or more voices”
. visual hallucinations :- Person actually starts seeing people, images, objects even though no one is around.
. tactile hallucinations :- small animals crawling over body, sensation of heat, electric shock, sexual sensations, etc without any external stimulus.
Delusions :-
- “A false, unshakable belief that is out of keeping with the patient’s social & cultural background.”
It is a belief which a person holds despite giving contrary evidence.
Sudden development of delusions idea - Autochthonous
Eg: Delusions of persecution :-
Person starts believing that people are talking about him and/spying on him, they are out to kill him.
Delusions of infidelity :- Person starts feeling the spouse is unfaithful to him / her.
Delusions of grandiosity :- Person starts feeling he is king of the Universe, etc.
Ideas of reference :- Feels that people are looking at him, news in the newspapers is directly related to him, etc.
Thought broadcasting :- Starts believing that his thoughts are broadcasted hence people come to know what he is thinking.
Thoughts of being controlled :- Someone is controlling my thoughts and my actions.
(3) Bizarre Behavior :-
Socially inappropriate behavior, disorganized clothing and aggressive behavior is very common in schizophrenia.
(4) Positive formal thought disorder.
Schizophrenia includes disorder of the form of thought in the form of looseness of association, derailment, tangentiality, circumstantiality, word salad and mutism.
What are negative features in schizophrenia ?
Affective flattening
Unchanging facial expressions
Decreased expressive gestures
Poor eye contact
Inappropriate affect
vocal poverty , lack of words
Alogia :-
Poverty of speech
Thought blocking
Increased response latency
3 . Avolition :-
Poor grooming and hygiene
Poor performance at work / school
Physical energies
Anhedonia :-
Decreased recreational interests, activities
Decreased sexual interest / activity
Poor ability for intimacy, closeness
Decreased or absent relationship with friends / poors
Attention
Social in attentiveness
In attentiveness doing tesing
Which other conditions look like Schizophrenia ?
D. D. for schizophrenia in medical illness :-
Substance induced :-
(i) Amphetamine (ii) Hallucinogens (iii) Alcohol (iv) Cocaine
(v) Barbiturate withdrawals (vi) Phencyclidine (vii) Ketamine
(viii) Wernicke - Korsakoff syndrome.
Infections :-
(i) AIDS (iii) Neurosyphilis
(ii) Creutzfeldt - Jakob disease (iv) Herpes encephalitis
Neurologic
What is long term outcome in Schizophrenia ?
Prognosis :-
Reported recovery rates range from 10-60 percent.
20-30 percent of schizophrenia pr s leave somewhat normal life
20-30 percent patients continue to experience moderate symptoms
40-60 % of pts remain significantly impaired by disorder throughout their life.
Treatment :-
Biological therapies
ECT
Psychosocial Treatments :-
(1) CBT
(2) Cognitive Remediation & Rehabilitation
(3) Social skills training
(4) Vocational rehabilitation
(5) Family Therapy
Biological Treatment of schizophrenia
First Acute Psychotic episode : -
Considering intensity of patients aggressive behavior, risk of self or other harm, hallucinations, frank delicious, disorganized thought & behavior pt may need immediate hospitalization and initiation of medications.
When patients are noncompliant parenteral formulations are used .
The mainstay of treatment involves the use of first generation antipsychotics like haloperidol or second generation antipsychotics like olanzapine and risperidone (particularly those for which therapeutic blood level can be quickly attained.) Anticholinergic agents are often indicated for prophylaxis of EPS.
Clinical response rates to both first and second generation antipsychotics are high in a first psychotic episode, up to 75%, in some well designed studies. (Robinson et. al. 2005).
A large percentage of first episode patients respond within the first week of treatment, with response rates reaching a plateau in the subsequent 3 months.
Maintenance treatment in schizophrenia.
With the resolution of an acute psychotic episode, patients with schizophrenia are transitioned to maintenance treatment to optimize prevention of relapse to acute psychosis and to improve psycho-social function and general recovery.
Once diagnosis of schizo is certain, antipsychotic medication should be continued indefinitely, is a manner analogous to the lifelong pharmacological treatment indicated for disorders such as diabetes mellitus and hypertension.
In addition to minimized relapse, sustained treatment with antipsychotics may modify the long term work of this illness. (Tandon 1998)
(i) Full antipsychotic withdrawal in schizophrenic patients are associated with significantly increased rates of relapse, as high as 98% at 2 years in one study. (Gitlin et at 2001)
(ii) The rate of relapse among schizophrenia patients was increased five fold over the rates of those who continued treatment. (Robinson et at 1999)
(iii) Intermittent dosing is probably less efficacious in preventing relapse compared to continuous dosing.
(Robinson et at 2005)
ECTS
ECT is another treatment modality that may continue to have a title in the rapid treatment of acute and subacute states that are refractory to pharmacological intervention, peutiordary catatonia.
(Tharyan & Adams 2005)
ECT treatment has been refined considerably over the years and now is quite safe administered, with minimal short term adverse events and no evidence for long term morbidity associated with its use.
(Rasmussen et al 2002)
Psycho-social treatments for Schizophrenia
Cognitive Behavior Therapy , a type of psychotherapy.
Many Randomized controlled studies have shown that CBT is associated with greater improvement in symptom severity relative to both supportive therapy and treatment as usual.
(Dickerson & Lehman 2006, Turkington et at. 2006)
Cognitive Remediation :-
-: Reference :-
The American Psychiatric Publishing Textbook of psychiatry (fifth edition : 2009)
Stahl’s Essential Psychopharmacology; Stephen M. Stahl (2008)
Fish’s clinical psychopathology; Patricia Casey; Brendan Kelly (2007)
Kaplan & Sadock’s Synopsis of psychiatry ; Harold I. Kaplan M.D., BENJAMIN J. SADOCK, M.D. (1994)
www.mayoclinic.com
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