Is for the direction of general health practice

1. Dr. PAL KIER,MD

2. Schizophrenia (sch)
Lecture outline:
1. Defination
2. Etiology
3. Epidemiology
4. Clinical features:
Prodromal phase
Residual phase
Acute phase
5. Subtypes:
A. Paranoid D. Undifferentiate
B. Disorganized E. Residual
C. Catatonic
6. Course & prognosis
7. Diagnosis
8. Differential diagnosis
9.Treatment
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3. Schizophrenia (sch)
Def. schizophrenia is a major chronic psychiatric disorder
with varied presentations, which primarily affects
thought, perception, mood & behavior.
The term schizophrenia coined by Euegene Blueler
He calls schizophrenia (=split mind) from the Greek words,
schizein , meaning to “split” & phren , meaning “mind”.
The term “split mind” is *intended to suggest that certain
psychological functions, such as thought, language, and
emotion, which are joined together in normal people, are
somehow split apart or disconnected in schizophrenia.
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4. Etiology -unknown
Most common factors that may contribute to schizophrenia :
A. Genetic factor
B. Environmental factor
C. Neurobiological factor
D. Neourodevelopmental factor
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a. Genetic factor
The likelihood of the person having
schizophrenia is correlated with
closeness of family relationship.
Prevalence of sch in specific population in percent (%)
1.General population 1
2.Nontwin sibling of a sch patient 8
3.Child with one parent with sch 12
4.Child of two parent with sch 40
5.Dizygootic twin of a sch patient 12
6.Monozygotic twin of a sch patient 47

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B. Environmental factor
1. Birth injury & perinatal complications
2. Birth seasonality
C. Neurobiological factor
The dopamine hypothesis :
Hyperactivity in the dopamine system
based on the observation :
- efficacy of antipsychotic drugs
- the exacerbation of symptoms
of sch by stimulant drugs

7. D. Neuro-developmental Factors
Defective formation of neuronal structures in the
limbic & frontal lobe.
Factors that may cause developmental defect are :
genetics, infections,, trauma, maternal starvation
during pregnancy, Rhesus factor incompatibility.
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Epidemiology
 The lifetime prevalence of sch is about 1%.
 Equally prevalent in men & women
 Peak ages onset of are 10-25 years for men & 25-35
years for women.
 Outcome for female schizophrenia patients is better
than that of male schizophrenia patients
 Onset occurs after age 45, characterized as late-onset
schizophrenia

9. Clinical features of Schizophrenia
 3.Active phase
 Manifested by :
 A. Positive symptoms
 B. Negative symptoms
 A. positive symptoms:
 I . Delusions
 II . Hallucinations
 III . Disorganized speech
 IV . Grossly disorganized behavior or catatonic motor behavior
 B. Negative symptoms
 I . Affective fattening
 II. Alogia
 III. Avolition /Apathy
 VI. Anhedonia /Asociality
 V. Inattentiveness 9

10. I. Delusions
Common delusions in schizophrenia :
1. Thought insertion - the belief that thought are being
Implanted in one’s mind by other people or forces.
2. Thought withdrawals - the belief that one’s thoughts
are being removed from one’s mind by other people or
forces.
3. Thought broadcasting-the belief that one’s thought can
be heard by others ,as they were being broadcast into
the air.
4. Thought controls- delusion that one’s thoughts are
being controlled by other people or forces
5. Bizarre delusion: an absurd,implosible,stange false
belief (e.g., invaders from space have implanted
electrodes in the patient's brain)
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11. Other types of delusions in schizophrenia
1. Persecution : false belief that one is being harassed,
cheated, persecuted, mistreated
2. Grandeur : exaggerated conception of one’s importance,
power or identity.
3. Referential : false belief that the behavior of others refers
to oneself.
4. Jealous : false belief that one’s lover is unfaithful.
5. Somatic : the false belief that somehow one’s body is
diseased, abnormal or changed.
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12. II. Hallucination
In case of schizophrenia hallucinations are usually auditory
(e.g., voices accusing,threatening,insulting,or
commanding,two or more voices converse with each other)
Somatic hallucinations: false sensation of things occurring
in or to the body, most often visceral origin (e.g., a burning
sensation in the brain, a pushing sensation in the vessels)
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13. III. Disorganized speech (formal
thought Disoredr )
Common formal thought disorder in sch :
1. Loosening of association: flows of thought in which ideas
shift from one subject to another in a completely unrelated
way .
2. Incoherence: a pattern of speech which is incomprehensive
at times
3. Neologism: new word or phrase created by the patient
4. Irrelevant answer: answer that is not in harmony with
question asked (patient appears to ignore or not attend to
question)
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14. Other formal thought disorder in sch
1. Circumstantiality : indirect speech that is delayed in
reaching the point or its goal idea.
2. Tangentiality : inability to have goal-directed associations
of thought.
3. Derailment : gradual or sudden deviation in train of
thought.
4. Blocking : abrupt interruption in train of thinking before
a thought or idea is finished
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15. IV. Grossly disorganized behavior or
catatonic motor behavior
1. Groslly disorganized behavior
 giggling or laughing without explanation
 untriggered agitation,outburst of anger
 self neglect
 social withdrawal
 unable to comprehend social conventions
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16. 2.Catatonic motor behavior
motoric immobility or stupor
excessive motor activity
Negativism
peculiar or odd voluntary movement
echolalia or echopraxia
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17. V. Negative symptoms
1.affective flattening : absence of emotional expressions
2.Alogia : restriction in the fluency and productivity of
thought & speech
3.Avolition : restriction in the initiation of goal directed
behavior
4.Anehedonia : loss of interest in pleasurable activities
5. Inattentiveness
1.Affective flattening
 unchanging facial expression
 decreased spontaneous movements
 poor eye contact
 paucity of expressive gesture
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18. 2.Alogia
 poverty of speech
 increased latency of response
3.Avolition
 impaired grooming
 lack of persistence at work or school
4.Anhedonia
few recreational interests & activities
impaired ability to feel intimacy & closeness
few relationships with friends & peers
5. Inattentiveness
 Social inattentiveness
 Inattentiveness during mental status test
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19. Course & outcome
Course
Onset
acute
insidious
Course of schizophrenia :
 exacerbation & remission
 deterioration
 positive symptoms to become les sever with time, but
negative symptoms may increase in severity
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Outcome
 Schizophrenia dose not always run deteriorating course &
several factors have been associated with good
prognosis.
20-30% -lead somewhat normal lives
20-30% -experience moderate symptoms
40-60% -functionally impaired their entire life

21. Good prognostic factors of schizophrenia:
1.Acute onset
2.Presence of precipitating factor
3.Absence of family history
4.Prominent affective symptoms
5.Late age of onset
6.Absence of negative symptoms
7.History of good premorbid functioning
8.Good family & social environment
9.Good drug compliance
10.Regular occupational history
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Diagnosis
Diagnostic criteria
A. Characteristic symptoms- two or more of the
following:
delusion
hallucinations
disorganized speech
disorganized or catatonic behavior
negative symptoms
B. Functional impairment
C. Duration of illness : ≥ 6mns
D. Ruled out : schizoaffective disorder, mood
disorder, psychosis due to substance use
or general medical condition

23. Treatment
General principles :
Selection of a specific Antipsychotic, Dosage & Schedule
Selection of antipsychotic
 Efficacy
 side effect profile
 history of prior response to a specific drug
 history of response of a family member to a certain
antipsychotic drug
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24. selecting the dose
age
level of agitation
degree of psychosis
Smoking
medical illness, pregnancy
Schedule
 divided doses
 single doses
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25. Treatment of schizophrenia
pharmacotherapy
1.Short-term Rx (Rx of acute phase or state)
 haloperidol 2-5mg i.m. prn
 diazepam 5-10mg i.m. Prn
2.Early Rx
 haloperidol 2/1.5 -5mg or chlorpromazine 100-200mg
3.Maintenance Rx
 decreased about 20% of early treatment dose
 * fluphenazine deconate (slow release)
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26. 4.Rx of non-responsive
Serotonin-dopamine antagonists (Resperidone, olanzapine
Others
5.ECT
6.Psychotherapy (social skill training, Family therapy)
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27. Questions?
Comments?
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