Schizophrenia

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Schizophrenia

• Lyudmyla T. Snovyda

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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 self-reported experiences and observed
  behavior. No laboratory test for schizophrenia
  exists.

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Schizophrenia -
Descriptions of schizophrenia-like symptoms date
back to circa 2000 BC in the Book of Heartspart
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.
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Schizophrenia -

• 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 dementiaa
  term first used by psychiatrist Benedict Morel
  18091873) 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.

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Schneiderian classification

• The psychiatrist Kurt Schneider (18871967)
  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.

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Positive and negative symptoms

• 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.

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Positive and negative symptoms

• 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.

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Positive and negative symptoms

• 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.

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Subtypes, forms

• 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)

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Subtypes, forms

• 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)

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Subtypes, forms

• 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)

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Epidemiology

• Schizophrenia occurs equally in males and females
  although typically appears earlier in men with
  the peak ages of onset being 2028 years for
  males and 2632 years for females. Much rarer are
  instances of childhood-onset and late- (middle
  age) or very-late-onset (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.

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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.
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Genetic

• 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.

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Substance use

• 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.

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Substance use

• 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.

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Neural

• Functional magnetic resonance imaging and other
  brain imaging technologies allow for the study of
  differences in brain activity among people
  diagnosed with schizophrenia.

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Signs and symptoms of paranoid schizophrenia

• 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.

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Signs and symptoms of paranoid schizophrenia

• 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 ones 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.).

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Signs and symptoms of paranoid schizophrenia

• 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.

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Signs and symptoms of paranoid schizophrenia

• 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 includeLoose 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.").

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Signs and symptoms of disorganized schizophrenia

• 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

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Signs and symptoms of disorganized schizophrenia

• 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
  arent consistent or organized.

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Signs and symptoms of catatonic schizophrenia

• 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
  violenceeither toward themselves or others.
• People with catatonic schizophrenia can be highly
  suggestible. They may automatically obey
  commands, imitate the actions of others, or mimic
  what others say.

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Prognosis

• 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.

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Prognosis

• The World Health Organization conducted two
  long-term 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.

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Treatment

• 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
• Trifluoperazine Stelazine 5-20
• 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.

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Treatment

• 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

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Psychological Treatments

• Cognitive Behavioural Therapy (CBT)
• Counselling and supportive psychotherapy
• Family work
• Cognitive remediation

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Cultural references

• 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.

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Cultural references

• 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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