lSchizophernia

· more florid and dramatic in presentation

· very similar with BPD - high engery, similar negative symptoms
· culturally imbibed psychosis - without medication - mantain and rehabilitation
(symtomps do not show back, rehabilitated with schizo)

History:

John Haslam first person to give an account of Sczhi - 1908 - observation of madness
and melanchony (what it is like, sudden onset, florid symptoms, progress into blinted
inhibited symptoms) adn Pinel - 1801/1809 - brought schiz under the term psychosis
or insanity. Benedict Morel - named schzi under dementia (loss of mind) praecox
(earlier in age). Kraeplin - identify difference between bipolar disorder and sczhi
(BPD - waning phases and schzi - florid symtoms and later subdued) - difference
esssential to ensure that there is right treatment issued for the patients - integrate
and bring similar form of treatment. Luigi Bleuler 1908 - coied the term schizo (mind)
and phernia (mind) - splits in mind - the associated thoughts are disrupted -
associativeness is lost, delusions is also seen inspite of evidence in front of the eyes -
no connection - unable to assimilate to form coherent perception - unable to
integrate the receiving stimuli to form an unified perception

Prevelance:

highest in men, 20s to 30s. women: late 30s. another in 50s

DSM: Schneirder

1. Hallucination: Happens with the senses - Nothing to perceive but still the person
experiences something that is similar to their perception - hear/feel/see without any
sensory source. Shared Psychosis - no stimuli but there is a perceptive experience of
something occuring with the five senses and the body position (special condition -
major ones in the five senses) - auditory are most common, visual hallucinations are
second, olfactory very rare (substance: visual and somatic)
2. Delusions: exaggerated - stringly held belief systems that we have despite any sort
of contradictory evidence. culturally inappropriate - challenge with evidence and
 testing of the "knowlegde" - they cannot produce any evidence, even when
contradictory evidence is provided, they do not accept what is trying to be proved.
paranoia. persecution, grandiosity (grand ideas of themseleves, their abilities ( i can
do aything i want to), identity (high position) and role in society). Erotomania is a
common delusion (not in schzi) - delusion disorders come under the schzi personality
disorder.
vs conviction: culturally non-accepted (cultural appropriation), resistant to any
evidence that is present -. unabel to assimilate any information presented
3. Thought Interuption
4. Pas Control

Symptoms (not indicate good or bad - in consideration with reality):

1. Positive: (present above the reality - extra) Hallucinations (perceive extra

components that involves perceivig something that is not there - first degree (talking
to you), second degree (talking about you), third degree (two or three talkig about
you) - nice or bad things talking, get the infomration about the gender, the content
and the tone of the voice of the hallucination- speech production was active during
hallucination, misperceiving own self talk to you as someone else talking to you - this
is for auditory hallucinations, not yet reserahc on olfactory etc. ) and delusions
(addition of extra layers of the story in the reality - add layers to what is already
there)

2. Negative: (present under the line of reality - not at par) not take care of
themselves (smelly, dressing is wierd) and disorganised behaviour
(improper/uncomfortable standing position & hand movements) (not able to confine
to the normal reality)
Allogia (lack of human speech, sense of understanding the conversation must
continue is lacking in social conversations - flow of conversations is missing, answer
everything in one word - poverty of speech), Antidonia (lack of pleasure- no
motivation to seek pleasure and no experinece of pleasure - unable to experience
any sense of happiness- socially withdraw, not able to do leisurable activities, similar
to depression but with insight (insight is lacking, contradictory ideas is lacking)),
Avolision (lack of motivation to do anything, no motivation to make others
 understadn what they are tryig to say), Affect (emotional expression and experience,
how emotion comes out, it is restricted or blunt, gestures & facial expressions are
restricted or blunt - anger and hostility is present not others)
Disorganised Behaviour - thought, Speech, Behaviour and Affect (disorganised
between what they are saying and expressing - Hallucinations) - Formal Thought
disorder (the way in which the thought is formed is messed up (like my life) - random
or wrong associations (gaps in the associations, the associations are very loose) ->
disorganised speech is resulted from this) - tangentiality (take off on one point and
never return back to the conversation), Thought Block - thought will stop mid-way -
open their mount stop, pause, close their mouth and lean back) - Circumstanciality
(tell a lot of stories and unnecessary things and come back to the point - extra stuff -
substance abuse disorder recovery after interventions )
Catargonia - 12 things in catargonia (from textbook) - disorganised behaviour, a
diagnosis in itself. Very slow thought processing. very agitated and restless (shaking
your legs, more bizarre than fidgeting), very hostile - stereotypic movements
(repetitive movements, constant stares, hostile looks, banging their heads in the
wall, fists on desk - very violent - very florid and rare to see in the early stages).
Gestures not inline with what they are talking. mannerisms (like kids with autism)
psychotic level - regressive level. uprovoacated aggression or hostility - violence.
Takes time to build rapport.

Clinical Presentation
- Positive
Delusion
Hallucination
- Negative
As - Allogia, Antidonia, Affect, avlosion
Disorganised Behaviour
Thought
Speech
Behaviour
Affect

Categories
1. Paranoia schizo - most common and most researched:
 Delusions of reference, Delusions of persequsion, Delusion of special mission
(delusion of grandiosity), Delusion of jealousy, delusion of indefility
Hallucinations: threatening, delusions degrading oneself - directly. command
hallucinations, command, commentary, interactive. - smell, taste visual is rare - in
line with paranoid nature.
Less negative symptoms - incongruence in what they are saying and feeling -
affect is disorganised - unporvocated anger, unprovocated laughter and crying.
absconding mindset - leave home for long periods of time to be found by
others in a tattered/ruin state - they would lack the insight of the missing period -
dissociative episode - getaway/hide
2. Hebephrenic
Self-absorbed - no interactino with outer world
laugting and child-like behaviours
auditory hallucinations
shift rapidly to an aggressive hostile mode
active mannerisms
tendency to repeat what is said to them
no active delusions , yes to active hallucinations - not very consistent, no As
(no lack of anything), yes to disorganised behaviour
3. Catatonia
cannot identify any hallucinations and delusions
All As - Allogia, Antidoia, Avolision
Mutism - absolutely no speech -active - refuse to speak, incoherent thoughts -
knows language but do not communicate - form of catadonia with predominant
mutism
all negative symptoms
Cataplexy - uncomfortable body position
Antiplexy - resistant to movement, not at all flexible
opposite to what you tell them - negativism
mannerism - agitation
grimacing - smile a lot
echolalia - repeat what you say
echopracia - repeat what they see
4. Undifferentiated
Pakka schizo - not fall in any of the above category
5. Residual
whatever is left of the schizo - proper schzi disgnosis one year back and they
 are left with the negative symptoms - residue of the initial disorder
paranoid or hebephrenic epsiodes - predominant
predominant negative sym. - tired, no conversation, constant catatonic sym,
do everything slowly
hard to differentiate from dementia (ensure that there are ay background of
schizo)
general reduction in speech patterns

Terms of a clinical setup - specturm

Functional --- (a lot of disorders - listed below in the order from the functional end to the
schizophernia) --- Schizophernia
1. Schizotypal
Cluster A - odd and eccentric behaviour, can live with normal people, wierd,
find little difficult to become normal/fully functional - close to functional part,
eccentiric ideology
2. Delusional DIsorder
similar to schizo. not have full blown hallucination, fully functional except
delusions, no Disorganised beha., very strong delusions, very resistant to
proof, all hallucinations in line with delusions, almost to normal person, no
negative symptoms, very clear delusions, good judgement, good cognitive
practical answers - except for delusions. Types
a. presecutory delusions: someone is after me
b. erotomania: believing that someone is in love with one
c. jealous: of spouse, infedility, sus, earlier infedility
d. somatic: believe very strong that their body part is not there (rare) "It
isn't there but working due to special power", sensations above the skin
(hallucinations), based on the sensation, they come to a conclusion
from the sensation (differs from the hallucination), involves bodily
sensations.
e. nilhistic delusion: something related to death, decay and not being
alive. Claim they are dead
f. unspecified
g. Grandiose: bring idea of self in terms of identity, role and others),
Onset: later than schizo, 35-40 for women - later onset, more prevanlent in
women than men. anyone has 1-2% chance of developing schizo from
delusional disorder
Proper schizo - only duration differs - all psychotic
 3. Brief Psychotic Disorder
Very brief episode of psychotic disorder, 24 hours to 1 month, all normal
symtoms of schizo, onset: acute - develop rapidly, within a month, symtopms
developed just over sometime - not disgnosis of schizo
4. Schizophreniform
symptoms present for 1 month and 6 months, all symptoms of schizophernia
but only for that time, within this duration, there is one month of active schizo
symtomps
5. Schizophernia
symptoms present for 6 months to 1 year, all symptoms of schizophernia but
only for that time, within this duration, there is one month of active schizo
symtomps
Schizo-affective disorder:
- episode of schizo -> one more episode of schizo -> normal -> depression or mania -
> schizo -> depression or mania
- sepearte schizo and affective (mood related) disorders in separate times (separate
episodes of each) [DSM-5] but ICD (Indian Psychiatric Settings) states that the schizo
and affective problems must be together
- Between schizopherniform and schizophernia on the spectrum of disorders.
Each of these can have the types based on the schizo types

Terminology
1. Active Phase: all symptoms are fully present / fuly blown, aka acute - symptoms
have just started and unhandled, no therapy here, only psychopharmacology -
psychiatry.
2. Prodromal Phase: before active, symptoms are building up, sus, few sleepless
nights, starting to have ideas. still functioning, they are showing mild symptoms, hold
on social conversations.
3. Residual Phase: with or without treatment, after active, some of the symptoms,
most of them being negative, they are left with it, the florid symptoms are gone, not
fullly functional
4. Remittance Phase: The period where they are fully functional - normal people, still
medication, no symptoms.
5. Relapse Phase: if the symptoms continues after the remittance, there is relapse.
Prodromal -> active -> residual -> Remittance -> relapse
If remittance is not given, active adn residual are repeated
active
 - psychiatry not therapy
- medications throughout the life
- medication compliance
- helping the family / members close to the individual: not personal, they are
to be psychoeducated about the illness and the effects. - strong feelings of the
caregivers are needed for the support they need. - caregiver counselling and
support
prodromal
- prevention
- adolescence, women in 30s or after menopause
- stress management, basic CBT, life skill management, life style management,
social skills training
- to ensure that they are not into active - fully blown life.
remittance
- ensure that there is medication to ensure lack of relapse
- psychoeducation for themselves and families for ennsuring that the
medication is continued.
- relapse plan: how to cope out with the relapse of the symtoms.
residual
- stress, lifeskill, lifestyle management
- relapse plan: how to cope out with the relapse of the symtoms.
- community based rehab - get them back into community, rehabilitated with
community, social skills, jobs (employed and settled)
Relpase
- Whole cycle starts again
Prodromal to active development - how the symptoms beings to develop - look into the
relapse plan
1. Abrupt onset - all happens between 24-48 hours, not do anything at that point of
time
2. Acute - 1 week
3. Insidious - 1 week to 1 month, a lot that can be done.
- when did what develop? what came first? how long did it happen? what did your
caregivers do?

Causes - both nature and nature components of the disorders as the temperament of the
indiviudal (inherent) is affected by teh environmental cues (nurture) in the expression of
the disorder
1. Biological:
has a lot of role owing to the psychotic nature of the illness
a. genetic causes
Entire spectrum of the disorder has several genes inherentances that leads to
the development of the disorder and decide the type of schizo that is
developed- anywhere in the spectrum
how likely I am to develop schzi: depends on how close the relative with schizo
is,
if it is a first degree relative, there is basically a higher chance (parents,
siblings); one parent, high; more parents, higher
Family studies, one parent - child, two parent - child, first degree
relative, second degree relative.
Only determine how likely the development is, not how severe or
what type
The second degree relative, has much lesser chance of developing
schizo
Studies - done to find out the amount of genetic influence in the disorder (is
there a high chance of schizo development from gene or modelling (seeing
parents showing symptoms of schizo or thought disorders)
Twin Studies: how much is the disorder present in individuals with same
genetic compositions if one of them have the disoder (mono and
dizygotic twins), most of them develop in the same environment,
undergo same parenting styles, and same type of parenting. If the
identical mono twin has schizo, one has more chance (46%) of
development of schizo. On the other hand with di there is 14% chance.
There is a large genetic component present in schizo.
Look into genes:
Mono have same genes, but dizygotic have difference in the gene
that controls dopamine (pleasure controlling neurotransmitter),
This decreases the chance of schizo and results in the conclusion
that dopamine plays an important role in teh control of
expression of teh disorder.
Adoption Studies
Grew up in a family atmosphere without schizo although
biological faimly has schizo
Still, there is a 10% chance of getting the disorder - strong genetic
relative
 Even if there is second degree schizo, there is 10 times likely to
develop the disorder
Stats
First degree - 10%
Second Degree - 3%
b. Brain Abnormalities
I. Grey matter (dentrites, neurons, etc.- thinking, perception, memory)
1. Prefrontal cortex:
communication, thinking, higher order perception and higher
order thinking. - decisions made in prefrontal cortex after the past
experience and memory to cordinate with the motor systems,
planning between the systems
This starts degrading, when there is a problem with this system,
there is loss of coordination, loss of thoughts, controlling and
coordinating behaviour, disorganised behaviour, unable to
distinguish between thought and belief (delusion), unable to
distinguish the sensations to experience (hallucination)
comes to person's social and cognition.
abnromality in this area - some level of socio emotional
component, unable to understand the expression of emotions in
others, sus (schiztypal disorder)
brain damage in adolscents, to develop the disorder
2. hippocampus:
memory control system (modify, save, retrieve)
Unable to access all the memories through a thought.
Loss of the connection between the memory - consolidation problems -
unable to retrieve cues and assimiliate information in the present
unconscious
abormal shape and size in schizo - irregular shape and size
II white matter (axon - transmission of information)
1. Working memory:
Hold on to the memory and other cues (assimilate) to understand
the problem solving
white matter send cues from memory and sensory organs, white
matters involves in consolidation of the information
decrease in white matter
slower information transmission from memory and other
 sensory organs
decreased connectivity
impact on working memory as there is lesser information
passed on it from the white matter
III. Ventricles
fluid filled chamber that provides nutriets to the brain and takes away
waste from the brain
Closely connected to the limbic system (responsible for primitive
emotions - fear, anger) - amygdala
Enlarged vetricles
emotional processing is affected
poor emotional responses and expression due to increased
pressure on the limbic system
abnormal ventrivle = severe symptoms
IV. Developmental
Birth complications, esp perinatal hypoxia (not enough supply of
oxygen), can result in the schizo.
Gestation - viral infection when the baby in womb (herpes)
even malnutrition (pregnant during world famine in china delivered
more schizo than other children)
spring born babies are more likely in the schizo (as lot of virus are
contracted in the winter preiod)
c. Neurotransmitters
Dopamine
Excessive dopamine reinfornce the first thought and block the rational
thinking
Very less self control on thoughts
drugs that block the reuptake - decrease the positive symtpoms (anta)
drugs that increase the dopamine release - increase the positive
symtoms (agonist)
schizo Had more receptors in some areas of brain than normal people -
more sensitive to dopamine, similar to what happens when people have
higher level of dopamine
None of the negative symptoms went way.
Frontal lobe - dopamine was lesser, depleted, responded less there. -
basal ganglia (emotions, esp pleasure) - very high but thinking area
(frontal lobe) was low
 Lower level of dopa cause negative symptoms and higher level of dopa
atypical antipsychotics - partially agonists - places with high dopa -
reduce and places with low dopa - increase-> reduce both postive and
negative symptoms, reduce all symptoms.
<include drug names>
Serotonin - happiness molecule
when drug that inhibit the reuptake of serotonin, then the symptoms of
schizo come to decreased
It is implicated in the presentation of schizo
no full research
GABA/ Glutamate - excitatory drug (wake and does a lotta work! - connect,
assimilates - linked with all parts of the brain (white matter of the axons))
when neurotransmitter iis not produced or potent enough, the
messages to the brain are not transmittered well enough
inhibit glutamate -> causes positive symtoms
there is a disruption of the glutamate transmission in the brain -
something is blocked
Disruption of linkage or connection of messages to all parts of the brain.
PCP and ketamine that inhibit the glutamate function -> found to show
the positive symptoms
implicated in schizo
Drugs
Agonists:
Drugs that increase the number of messages that pass through
the synapse
Action: release more neurotransmitters or increase the potency
of neurotransmitters or increase receptors
Antagonists:
Decrease the number of messages that pass through the synapse
Action: Decrease the number of neurotransmisters or bind and
block the number of receptor
2. Psycho-Social Theories
Psychological Inluences
1. Stress
Perceived stress is higher
stressful events are higher
Hindsight bias
 greater number of stressfil event (s)(key) before the onset -> shw
the schizo symtoms
precipitating factors: factors that come before the disorder that
increase the chnace of the disorder
stressful events are precipitating factors
Stressful events -> schizo -> avoid -> escape
more likely to percieve stress
Exp: stressful movies to normal and bpolar and schizo people,
most likely to go into an avoidance coping mechanism and both
the parties hsow high stress
avoidance coping
fantasy rich stressful coping mechanism - escapist fantasis
delusions, hallucinations
Prodrom Social Support - move away from the social support and
withdraw- more drifting and reinforces the schizo symptoms
Social Influences
Lower Socio-economic status
Lower socio-economic status increased schizo - Theories
1. Social Drift: When have symptoms of schizo, cannot comprehend and
make logical decisions, hence, it is difficult to holdon a job ->unable to
have a stable financial situation and hodl a familial life -> standard of
living is low -. drift away from the society and stay away. Studies of
fmailies with schizo, siblings with schizo were always in low ses. even
father and son comparison can be seen. Lower SES - lesser chance of
treatment, lesser medication needs, lesser social support.
2. Urban Birth: People in urban areas are more likelly to have schizo
(better access to medical facilities as compared to rural areas, in villages
they are less aware of schizo) Why? There is more stress in the cities -
more complexities. Village: simple lifestyles and basic amenities,
happiness. But in urban, there is so much more pressure. Higher needs,
existential crisis, etc. More complex needs -> more psychotic disorders.
Overcrowding increases the chance of risk during pregnancy like in
urban areas (one of the possible reasons) and increased amount of
stressors in the world around one.
Family Influences
Symptomss -> Medicine -> home -> get back home WHY??
1. Schizophrenogenic mother - 1948
 When the mother is cold and distant (blunt affect, hostile, not talking or
interacting), more likely to have schizo
discarded
patriarchial
no psychological evidence
2. Double Bind communication
Two messages a kid receives from a mother, Two opposing messaging to
the same kid and they are binding agents repeating these points.
Cause the split in schizo - prevalent in families - causes more stressors
and lead to other mental issues
3. Expressed Emotion
People who went back home but those who came back with symptoms
George W Brown - Expressed Emotions
When there is three particular emotions that is expressed by the
family to the person suffering from schizo leads to relapse or make the
symptoms come back
Hostility - indfiiferent from whats gong on, not supporting,
pushing the person away. Increase the trigger to perceive hostility and
get symptoms
Over criticality towards this person
Over involved - "don't do this" - unnecessairly too involved
to remove the independence of the person
All these three things when present lead to schizo
Two things when absent lead to development of schizo
Warmth
Positive Regard
Cognitive Theory
Reduced Mental Sentivity but there is stimulus bombaring - social interaction
is draining - hence it is easier to shut down the brain to control the thoughts
Negative symptoms are defined from this
Cross cultural belief
non-engagement in religion
Demons!
Emotional Overinvolvment differneces in cultures
patient centric view

Treatment
Biological Treatment
1. Institutionalisation
2. Locotomy - Brain surgery - reduced functioning and mellow (invasive, florid symptoms
exists)
3. Insulin Coma Therapy - high dose of insulin, induced coma for a very long time, normal
after "waking"up from coma - high chances of mortality
4. electro convulsive therapy (EcT) - shock treatment - electric charges to the brain to
restart the brain - side effects of memory loss.
5. Antipsychotics
first gen antipsychotics or typical
controlled all the postive symptoms
side effects - extra pyramidal symptoms (EPS)
drowsy, tremors, diahhrea, weight gain
Dopamine control
Drug compliance was very very poor due to high side effects
atypical antipsychotics
Increase and decrease dopamine when needed
partially agonists
Side effects did happen but after some time
Parkinsons medications to reduce the EPS which resembles the parkinsons
symptoms
Psychological treatment
cognitive part
mainly based on the stressors that exist in the nature, basic problem solving and
stressmanagement while increasing drug compliance
to give their diagnosis and ensure that they are taking the drugs regularly
help them understand the symptoms and the imporatnce of use of drugs
metacognition
thiking about how you are thinking
chronic schizo
to curb them of their negative symptoms
reinforcers (tokens, positive reinforcements, rewards, token economy)
Positive symptoms are ignored, the negative symptoms are taken into account
family
psychoeducation to family and drug compliacne help
communicatino
loop in family: highh chnaces of remittance and lesser relapse
social
poor social skill development
gather and educate several schizo patients andteach them social skills- eye contact,
monitoring ocnversations adn improving conversations, mock interviews, senstizing
the people in the job to ensure that they are aware of the schizo, role play
vocational training (social worker, case management work)
social skills using new techniques and role plays
support group
patients and caregivers
assertive community program
in remittance and no symptoms but get them back into a functional social
community,interact and ensure that they are responsible and take up responsibilities
and roles while attenting support groups and other rehabilitation habits.
clubhouse: no supervision
half way homes: resident doctor to check in on them, live in apartment with
supervision