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1. Disorganization of thought processes.

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1 1. Disorganization of thought processes.
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.

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 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.

4 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

5 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.

6 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.

7 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.

8 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.

9 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.

10 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.

11 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.

12 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.

13 7. In this state, an individual may be dangerous
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.

14 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 15. The prognosis is generally poor if a person develops disorganized schizophrenia.
Paranoid type:- Formerly about one half of all schizophrenic first admissions to hospitals were diagnosed as schizophrenia paranoid type. In recent years, however the prevalence of the paranoid type has shown a substantial decrease. Paranoid type schizophrenic persons show histories of increasing suspiciousness and of severe difficulties in interpersonal relationships. The symptoms picture is dominated by absurd, illogical and often changing delusion. Delusion are the most frequent and may involve a wide range of bizarre ideas and plots.

16 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.

17 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 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.

18 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 respect 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.

19 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.

20 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.

21 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

22 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.

23 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.

24 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.

25 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)

26 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.

27 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.

28 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)

29 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

30 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.

31 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).


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