SCHIZOPHRENIAS

A group of common major psychoses with a

complex syndromal presentation, affecting young
adults, showing chronic changes in behavior,
perception, thoughts and emotions, causing a
fundamental disorganization in personality and
deterioration from previous levels of functioning
Epidemiology
It is a universal disease found in all countries
and all times with constant prevalence rates

 Incidence – 15-20/ 100,000/year

 Prevalence – 0.5 – 1%

 Normal risk (life time) – 0.7 – 1.3% (1%)

Exceptions to Universal Epidemiology
 Some communities have high incidence
Northern Sweden, Western Ireland, Catholics in
Canada, Tamils of South India and Sri Lanka

 In Northern Sri Lanka 34.6 / 100,000 / yr*

 Some communities have low incidence

Hutterites, Anabaptist section of United States

*
Somasundaram D.J., Yoganathan S. & Ganeshvaran T.
(1993) Schizophrenia in Northern Sri Lanka, Ceylon
Medical Journal, 38, 131- 135.
Epidemiology ctd..

 Age – 15 -45 years

 Sex – Male : Female 1:1

 Onset is earlier in men

 Aetiology- Multifactorial
Variable Phenotypic Expression
Hereditary
40% of the Pts have a family history
In Jaffna – 63
%
Relationship Likelihood of dev. Sch.
Both parents 46%
One parent 15%
One sibling 10 – 14%
MZ twin 42%
DZ twin 10 – 14%
2nd degree relatives 2 -3 %
Not related 1%
Environmental factors

 Family

 Disorders in relationship and communication

 Emotional family, Double bind messages,
dominant mother
 High Expressed Emotion (EE)
- hostility
- critical
- over involvement
 Viral infection
- In utero influenza like virus
 Birth trauma
- hypoxia, cerebral injuries
 Endocrine Factors
Postpartum psychosis
Later onset in females
 Stress
Psychological – life events, trauma,
migration
Physical – Viral encephalitis, Pyrexia,
anti-malarials, surgery
 Sensory loss / deprivation

 Head injury
 Epilepsy
 Drugs – amphetamines, L dopa, cannabis
 Multisystem CT disorders
 Socio – cultural
low socioeconomic state, urban (homeless,
prostitutes, prisons)

single, unemployed
?cause or ‘drift’
Neurotransmitters in Schizophrenia

 Dopamine Hypothesis
 Dopamine Hyperactivity in Mesolimbic pathways
Hypofunction in Mesocortical pathways
 Glutamate Hypothesis
 NMDA hypofunction
 The role of Serotonin
 Dysfunction in DA release
DA Pathways in Schizophrenia
Neurodevelopmental theory
 Observations
 Neuro imaging
 Neurological soft signs
 Hypofrontality
 Neurocognitive and social cognitive impairments-
poor functional outcome

 Hypothesis
 Pathological changes laid down in early life
 Non progressive damage
 Genetic
predisposition

Neuro developmental abnormalities

Cognitive and social impairment
Env. factors
- In utero infection
- Obst. injury
- Social adversity
- Life stress
Neurological soft signs

Biochemical abnormalities
(DA, 5HT)

SCHIZOPHRENIA
 Symptoms of Schizophrnia
 Positive Symptoms
 Hallucinations
 Delusions
 Passivity
 Negative symptoms
Apathy
 Amotivation / Avolition
 Asocialization
 Disorganization
 Thoughts
 Emotions
The Puzzle of Schizophrenia
Disorganized thoughts
Diagnosis of Schizophrenia
 Schneider's First rank symptoms
 Auditory Hallucinations –3rd person, thought echo,
commenting voices
 Thought - insertion, withdrawal, broadcasting
 Delusional perception

 Passivity

 Somatic hallucinations

 ICD 10

 DSM V
Differential diagnosis
 Medical  Psychiatric
 Epilepsy  Brief/Reactive
 Cerebro vascular psychosis
disorders  Schiz. Affective dis.
 Cerebral neoplasms  Affective disorder
 Head injury  Delusional disorder
 Infections  Dissociative conditions
 Encepalitis, AIDS,  Possession
Systemic infections,  PD
 Substances  OCD
 Amphetamines,

Hallucinogens,
alcohol
Co-morbidity
the simultaneous presence of two chronic diseases or
conditions in a patient: "the comorbidity of anxiety
and depression in Parkinson's disease

 Depression

 OCD

 Anxiety disorders

 Substance abuse
Management
1. Pharmacological management

2. Other physical management

3. Psychological management

4. Rehabilitation

5. Family work

Biopsychosocial approach
Pharmacological management
 Antipsychotics

1. Typical antipsychotics
– Chlorpromazine, Trifluoperazine, Haloperidol,
Droperidol, Pimozide,

2. Atypical antipsychotics
 Olanzapine, Risperidone, Quetieapine,
Amisulpiride, Ziprasidone, Aripiprazole,
Clozapine
 Selection of drugs depends on

 Availability

 Side effect profile

 Symptoms

 Specific contra indications

 Familiarity

 Cost
 Management

 Initial tranquilization

 Control of acute psychotic symptoms

 Resistant Schizophrenia- Clozapine
 Long term maintenance treatment- depot
Mental Asylum
 Psychosocial management
 PsychoEducation

 Supportive psychotherapy

 CBT for resistant hallucinations and delusions-

Cognitive remediation
 Social skills training
 Rehabilitation
 Helps to reintegrate

 Training in
 Self care, ADLs
 Attending skills, Communication skills, Ability to
concentrate…
 Vocational training, working in a supportive environment

 Helps in the management of

 Negative symptoms
 Dealing with resistant symptoms
 Dependency / institutionalized syndrome
Rehabilitation – ctd
 Day care centers / hospitals

 Half way homes / Supported accommodation

 Occupational Therapy

 Vocational training

 Supportive working environments

 Home environment
Occupational Therapy-
Vocational training

Agrotherapy
Family work
 Psycho education
 Learning better coping strategies
 Familiarizing with medications, symptoms,
risk assessments and limit settings
 Dealing with expressed emotions (EE)
 Need for optimal stimulation
 Family groups
 Supportive counselling to the family members
 Study of relapse rate over a period of 9 months

Total group

Low EE High EE

<35 hrs. / wk. >35 hrs./wk.

On drugs Not on drugs

12% 15% On drugs Not on drugs On drugs Not on drugs
15% 42% 53% 92%

EE
 Hostility
 Critical
 Over involvement
Community

 Awareness
 Reducing stigma
 Avoiding provoking behaviours
 Rehabilitation
 Community Care
Early signs of relapse
Outcome
 30% - good recovery with previous level of
functioning
 30% - good recovery with residual
symptoms. able to function socially without
help.
 30% - handicapped by the illness. getting
frequent relapses and exacerbations. need
long term, closely supervised care
 10% - get worse, suicide
 Course
Reactive/ Brief Psychosis

Periodic Schizophrenia

Episodic Schizophrenia

Sluggish/ Deteriorating Schizophrenia

 Prognosis
 Good Prognosis
 Sudden onset
 Late onset
 Ass. with precipitators
 Good premorbid personality
and work record
 No F/H or P/H
 Prominent affective symptoms
 Early Treatment
 Quick response to treatment
 Compliance with medication
 Low EE
 Work, marriage,
 Family support
 Bad Prognosis
 Insidious onset
 Early onset
 No precipitators
 Schizotypal personality,
poor work records
 A positive F/H or P/H
 Negative symptoms
 Delayed Treatment (DUP)
 Poor response to treatment
 Poor drug compliance
 High EE
 Unemployment, social drift
 Lack of family support