2. To Know Schizophrenia is to know Psychiatry The most devastating illness that psychiatrist treat. One of the most challenging disease in medicine 1% of population has schizo. An enormous economic burden ? A major health concern
4. History Emil Kraepelin- original term-dementia praecox-early age, chronic deteriorating course. EugenBleuler- coined the term schizophrenia (split mind) affective blunting, loosening of associations, autism (withdrawal) and ambivalence (coexisting conflicting ideas) - 4 As- earned acceptance in USA Kurt Schneider first rank symptom
5. Psychotic mental disorder of unknown aetiology characterized by disturbances in Thinking (e.g. distortion of reality, delusions and hallucinations) Mood (e.g. ambivalence, inappropriate affect) Behaviour(e.g. Apathetic withdrawal, bizarre activity) at least 6 months Definition
9. Aetiology Uncertain; however there is evidence for several risk factors. Several models which can be grouped into….
10. Aetiology – Bio Genetics Consideration 1st degree & 2nd degree relative Environmental Abnormalities of pregnancy and delivery [2%] Maternal Influenza – 2nd trimester [2%] Fetal Malnutrition [2%] Winter & Low Social Class birth [1.1%]
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12. Social Studies have shown an excess of schizophrenic patients in lower socioeconomic groups and in urbanised areas. This used to be attributed to “social drift” Cannabis abusers [2%]
13. Psychological abnormalities in processing sensory information, in separating “signal from background noise”, or in manipulating abstract information Excess life traumas against controls at first presentation
14. Pathophysiology disorder of dopaminergic function: related to increased dopamine activity in certain neuronal tracts. Other neurotransmitter abnormalities implicated in schizophrenia: elevated serotonin. elevated norepinephrine. decreased gamma- aminobutyric acid (GABA).
15. Schizophrenia Subtypes Classically divided into five subtypes Paranoid[stable, often persecutory delusion/hallucinations only] Hebephrenic[thought/affective changes + -ve symptoms] Undifferentiated [psychosis w/out clear predominance] Catatonic[prominent psychomotor disturbances] Residual [low intensity +vesymtoms]
18. DIAGNOSIS CRITERIA OF SCHIZOPHRENIA The diagnosis of schizophrenia is based entirely on the clinical presentation – history and examination.
19. ICD diagnostic criteria – 1 of the following At least one of the symptoms a-d or two of the symptoms e- i a.Thought echo, insertion, or withdrawal and thought broadcasting b. Delusions of control, influence, or passivity; delusional perception c. Hallucinatory voices-running commentary or other < part of body d. Persistent delusions of other kinds
20. ICD diagnostic criteria – 2of the following e. Persistent hallucinations in any modality occurring everyday for weeks or months f. Breaks or interpolation in the train of thought > incoherenceor irrelevant speech, or neologism g.Catatonicbehavior, such as excitement, posturing, or waxy flexibility, negativism, mutism, stupor h. ‘negative’ symptoms; apathy, paucity of speech, blunting of emotional response A significant and consistent change in behavior > aimless, idle, self-absorbed att
21. DSM-IV diagnostic criteria A. Characteristic symptoms. At least 2 of the following; each for 1- month period: a. delusions b. hallucinations c. disorganized speech d. grossly disorganized or catatonic behavior e. negative symptoms, i.e. avolition, flattening of affect, alogia (poverty of speech) F. Social/occupational dysfunction G. Continuous signs of the disturbance persists for at least six months H. Schizoaffective and mood disorder exclusion I. Substance/medical condition exclusion J. Relationship to pervasive developmental disorder autism+ schiz.<D/H-1 m
23. Kurt Schneider (German psychiatrist) ’s symptoms of first rank Auditory hallucinations: audible thought or thought echo ; referring third person; running commentary. Alienation of thought: thought insertion or withdrawal Diffusion of thought (thought broadcasting) Sensation of feelings, impulses or acts being controlled by external forces Somatic passivity < external agency (e.g. X-rays, hypnosis) Delusional perception
24. Schneider first rank symptoms of schizophrenia Individual symptoms that are highly specific for schizophrenia Occur in about 80% of schizopts, 40% in bipolar mood disorder ( only mania)& 20% in severe major depression
28. Prognosis Recover completely/long term minimal symptoms- 30%(The percentage on the rise) Recurrent illness -poorer prognosis Young patient -high risk of suicide
30. Assessment No confirmatory laboratory studies. Diagnosis made based on psychotic symptoms and functional deterioration. Diagnostic evaluation: aim Establish the presense of psychosis Eliminate other differential diagnosis
31. Component of Evaluation Evaluation of of psychosis Medical evaluation Mental status and siucidality
47. Follow manual on Garispanduan Perkhidmatan Rawatan Susulan PesakitMental di Klinik KesihatanStable phase 36
48. Acute phase From home to hospital Restrain Aid from policemen Safety of care provider, family members and patient is crucial In the hospital Room of seclusion Consider involuntary admission
49. Physical restrain Family education and counselling Emergency medication Antipsychotic Combination: antipsychotic + benzodiazepine Administered parenterally If cooperative, oral administration allowed.
50. Relapse prevention phase Started on routine anripsychotic as early as possible. Maintenance doses of medication established and side effect reviewed. Patient education and reassurance. Building a therapeutic alliance with patient and family Treatment resistance – Clozapine Assertive Community Therapy(ACT)
51. ACT? Combined medication and psychosocial treatments with aggressive delivery and follow-up. Activities: Daily home visit “eyes-on” medication administration Transportation to clinician appointment
52. Stable phase Follow up at primary care clinic. Life long medication Remission for at least 1 year achieve in 70 – 80% of patient taking antipsychotic at full doses Psychosocial support
53. Psychosocial and rehabilitation care Social skill training Employment training Cognitive remediation therapy Psychoeducation Family therapy Don’t forget medical illness too…
JOHN FORBES NASH JR. Born on June 13, 1928, (age 78)Maths professor - Winner of the Nobel Prize in Economics (1994) - Known for –Nash equilibrium -Nash embedding theorem -Algebraic geometry SUFFERING FROM schizophrenia SINCE HE WAS 30 YEARS OLD
Severity – more wore in men sue to more negative symptoms and less able to function in society
Hebephrenic = DisorganisedThe DSM-IV-TR contains five sub-classifications of schizophrenia, although the developers of DSM-5 are recommending they be dropped from the new classificationThe ICD-10 defines two additional 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 and progressive development of prominent negative symptoms with no history of psychotic episodes.
