1. SCHIZOPHRENIA SCHIZOPHRENIA Dr Nadira Khamker Senior Consultant
Department Psychiatry
Weskoppies Hospital
University of Pretoria , Faculty of Health & Science

3. SCHIZOPHRENIA
Schizophrenia is a psychiatric disorder with unknown aetiology. It is characterized by psychotic symptoms which incapacitate the patient’s level of functioning. It is a chronic condition with a prodromal, acute and residual phase, or remission.

4. Psychosis ?
ill-defined,generic term Lack of insight is a core feature Delusions and hallucinations are often present

5. History of schizophrenia
Emil Kraepelin ( ) Eugen Bleuler ( ) “Dementia precox” Bleuler coined the term “schizophrenia”

6. Epidemiology
0,5-1% of population Genetic predisposition Women=men Women : mean age of 1st episode is 26,8 years Men : mean age of 1st episode is 21,4 years

7. upto 50% may be undiagnosed common in schizophrenia,
Epidemiology contd
Genetic factors- 10x ↑ risk in persons with 1st degree relatives for developing the disease.
Medical illnesses- c
comorbid conditions ,
upto 50% may be undiagnosed
Substance abuse-
common in schizophrenia,
association between cannabis and schizophrenia
Infection and Birth Season

9. Aetiology
Unknown Diathesis-vulnerability Eco-genetic factors Dopaminergic hypothesis

11. CLINICAL FEATURES POSITIVE SYMPTOMS POSITIVE SYMPTOMS
NEGATIVE SYMPTOMS
COGNITIVE SYMPTOMS
AGGRESSIVE SYMPTOMS
AFFECTIVE SYMTOMS

12. Symptom clusters
Reality distortion Psychomotor poverty Disorganisation Cognitive domain

13. POSITIVE SYMPTOMS NEGATIVE SYMPTOMS COGNITIVE SYMPTOMS
REALITY DISTORTION
PSYCHMOTOR POVERTY
DISORGANISATION
DELUSIONS
LACK OF AFFECTIVE RESPONSIVENESS
INAPPROPRIATE AFFECT
HALLUCINATIONS
LOSS OF DRIVE OR VOLITION
INCOHERENT SPEECH
POVERTY OF SPEECH AND MOVEMENT
DISORGANISED BEHAVIOUR
SOCIAL WITHDRAWAL

14. Reality distortion
Hallucinations Delusions

15. Hallucination : definition
False sensory perception not associated with real external stimuli; there may or may not be a delusional interpretation of the hallucinatory experience. Auditory, visual, olfactory, tactile and somatic hallucinations.

16. Hallucinations in Schizophrenia
Ask the patient if he / she is hearing voices, other people can’t hear and ask in detail about the quality, frequency, intensity and reaction towards these voices

17. Delusions : definition
False, fixed belief, based on incorrect inference about external reality, not consistent with patient’s intelligence and cultural background; cannot be corrected by reasoning. Somatic, paranoid ( persecutory and of reference), erotomania, of control / poverty/self-accusation

18. Delusions
Overvalued idea is NOT a delusion but an unreasonable, sustained false belief maintained less firmly than a delusion. Bizarre delusion is absurd and implausible Nihilistic delusion is the false feeling that self, others or the world is nonexistent or coming to an end

19. Delusions
Delusions of poverty :they believe they are bereft or will be deprived from all property Somatic delusions: involving body (brain is rotting) Persecutory delusions: being harassed, cheated, or percecuted Delusion of grandeur: exaggerated concept of power or intelligence

20. Delusions
Delusions of reference: the behaviours of others refers to them, people are talking about him / her. Delusions of self-accusation: feelings of remorse and guilt. Delusions of control: their thoughts, will or feelings are controlled by external forces

21. Delusions of control (bizarre)
Thought withdrawal Thought insertion Thought broadcasting Thought control

22. Form of thought disturbances
Neologism : new words by combining syllabes Word salad: inhorent mixture of words Perseveration: persisting response to previous stimulus Verbigaration:meaningless repetition of words Echolalia: repeating of words Blocking: abrupt interruption in train of thinking

23. Thought content in schizophrenia
Delusions Preoccupation Ideas of reference and influence phobias Poverty of content Obsessions and compulsions Suicidal or homicidal ideas

24. Psychomotor poverty
Lack of affective responsiveness Loss of drive or volition Poverty of speech and movement Social withdrawal

25. Negative symptoms(5As)
Affective blunting / flat affect Alogia –relative absence in amount/ content of speech Avolition-inability to initiate and persist in activities Anhedonia-loss of enjoyment for activities Attention impaired

26. Disorganisation
Inappropriate affect Disorganised behaviour

27. Grossly disorganized or catatonic behavior
Aggressive,violent outbursts Bizarre clothing appearance Inappropriate social / sexual behavior Catatonic behavior ,ranging from extreme excitement to stupor

28. Cognitive domain
Impaired attention and concentration Impaired memory and learning Impaired executive functioning ( e.g. abstract thinking, problem solving)

29. Disorganized speech Disturbance in form of thought:
Circumstantiality ( delays in reaching answer)
Irrelevant answer
Derailment (deviates from train of thought)
Tangentially( never gets back to desired goal)
Loosening of associations(shift in unrelated manner)
Incoherence(thoughts not understandable)

30. SCHIZOPHRENIA: SYMPTOLOGY DSM IV CRITERIA A:
TWO OR MORE OF THE FOLLOWING:
Delusions
Hallucinations
Disorganized speech
Grossly disorganized behavior
Negative symptoms
Present for at least one month

31. CRITERIA A
If the delusion is bizarre, only one of the A Criteria is required. For example if you believe the microchip in your front tooth controls world’s events A voice keeping up a running commentary on the person’s behavior or thoughts or….. Two or more voices conversing with each other.

32. DIAGNOSIS
B. Social and occupational dysfunction C Duration D Exclusion criteria E Substance abuse

33. Schizophrenia sub types
Paranoid Catatonic Residual Undifferentiated Disorganized

34. CLINICAL FEATURES
No symptom or sign is definitive for schizophrenia Careful history important as symptoms change with time Premorbid symptoms and signs appear before the prodromal phase Patients may have shcizoid or schizotypal personalities May be quiet, passive and introverted children Few friends, solitary activities May present with somatic complaints Family and friends may notice changes in social, occupational, personal activities May then present with peculiar behaviour, abnormal affect, unusual speech, bizarre ideas, perceptual disturbances

35. MENTAL STATE EXAMINATION
GENERAL APPEARANCE AND BEHAVIOUR
May be unkempt, poor self-care
Psychomotor activity
SPEECH
Monotonous, poverty of speech
Disorganised speech
MOOD AND AFFECT
Reduced emotional responsiveness
Inappropriate emtions
PERCEPTUAL DISTURBANCES
Hallucinations
THOUGHT FORM DISTURBANCES
Loosening of associations
Tangentiality
THOUGHT CONTENT DISTURBANCE
Delusions
IMPULSIVENESS,VIOLENCE,SUICIDE, HOMICIDE
SENSORIUM AND COGNITION
Memory,
JUDGEMENT AND INSIGHT

36. Good prognosis in schizophrenia
Obvious precipitating factors Acute onset Good premorbid history / later onset Mood symptoms or family history of moodsx Married and / or good support system Positive symptoms

37. Longitudinal course
Symptoms start in adolescence Prodromal symptoms may last for 1 year Exacerbations and remissions Baseline functioning deteriorates Positive symptoms less severe with age but negative symptoms may increase in severity

39. Chronic illness Premorbid symptoms Relapsing and remitting course Deterioration in functioning over time

40. Course and prognosis
10-20% suffer one episode and remain symptom free 60% follow a course of relapses and remissions, of which half achieve full remission and half partial remission.

41. Indications for referral
Frequent relapses Resistance to treatment Co-morbid conditions Lack of sufficient support / resources at primary level

42. Psychoeducation
It is a biological disease of the brain The precise etiology is unknown Genetic vulnerability Environmental factors Long-term treatment Rehabilitation necessary

43. Psychological interventions
Cognitive behavioural therapy Psychoeducation Family therapy Social skills training

44. Social interventions
Halfway houses / step down facilities Supervised group houses Unsupervised houses Day centres Supported employment Disability grants

45. Other Psychotic Disorders
Psychotic disorders due to GMC Substance-induced psychotic disorders Shared psychotic disorder Psychotic disorder not otherwise specified Delusional disorder Schizophreniform disorder Schizoaffective disorder Brief Psychotic Disorder

46. Compared with schizophrenia
Sx <1month = brief psychotic disorder
…………………………..
>1<6months=
Schizophreniform
>6months=
schizophrenia

47. Delusional disorder
Nonbizarre delusions No marked impairment in functioning Types include: erotomania, grandiose, jealous, persecutory,somatic and mixed

48. Schizoaffective disorder
Substantial period of illness also mood symptoms Bipolar type versus depressive type Better prognosis than schizophrenia

49. Differential diagnosis of PSYCHOTIC symptoms
Substance-related disorders Epilepsy- TLE Cerebral tumours / trauma AIDS, Neurosyphilis,herpes encephalitis Porphyria SLE, Wilson’s disease, B12 deficiency

50. Conclusion
Psychotic disorders cause extreme distress and diability over periods of time
Disorder is treatable and relapses can be limited
Primary health care worker has an important role to play