SCHIZOPHRENIA

INTRODUCTION
• Schizophrenia is a PSYCHOTIC DISORDER
– A severe mental disorder in which thinking and
emotion are so impaired that the individual is seriously
out of contact with reality
• Refers to a group of disorders - there is not one
essential symptom that must be present for a
diagnosis
• Instead, patients experience different
combinations of the main symptoms of
schizophrenia
• 1% of population
• Men = women
MEN WOMEN
 Present earlier at age 20s  Present late at age 30s
 More severe  Less severe
 More likely negative symptoms

• Onset at age 15-45 year old

• With strong family hx of schizophrenia
 TWO CATEGORIES OF SYMPTOMS IN
SCHIZOPHRENIA
NEGATIVE symptoms
• Behavioral deficits that
endure beyond an acute
episode of schizophrenia
• More negative symptoms
are associated with a poorer
prognosis
• Some negative symptoms
might be secondary to
medications and/or
institutionalization
POSITIVE symptoms
• Distortions or excesses of
normal functioning
– delusions,
– hallucinations,
– disorganized speech,
– thought disturbances,
– motor disturbances
• Positive symptoms are
generally more responsive to
treatment than negative
symptoms
 DELUSIONS
• False beliefs that are firmly and consistently held despite disconfirming evidence or
logic
• Individuals with mania or delusional depression may also experience delusions.
• However, the delusions of patients with schizophrenia are often more bizarre
(highly implausible).

• Delusions of Grandeur - Belief that one is a famous or powerful person from the
past or present
• Delusions of Control - Belief that some external force is trying to take control of
one’s thoughts (thought insertion), body, or behavior
• Thought Broadcasting- Belief that one’s thoughts are being broadcast or
transmitted to others
• Thought Withdrawal- Belief that one’s thoughts are being removed from one’s
mind
• Delusions of Reference- Belief that all happenings revolve around oneself, and/or
one is always the center of attention
• Delusions of Persecution- Belief that one is the target of others’ mistreatment, evil
plots, and/or murderous intent
 HALLUCINATIONS
• Sensory experiences in the absence of
any stimulation from the environment
• Vivid, clear, cannot control
• Any sensory modality may be involved
– auditory (hearing);
– visual (seeing);
– olfactory (smelling);
– tactile (feeling);
– gustatory (tasting)
• Auditory hallucinations are most
common
– Hearing own thoughts spoken by another
voice
– Hearing voices that are arguing
– Hearing voices commenting on one’s own
behavior
 THOUGHT DISTURBANCES
(content and process)
CONTENT PROCESS
• Reflect patient’s belief, ideas, • How patient’s express thoughts- logical,
interpretations of her surrounding meaningful, goal directed
o Poverty of thoughts o Loose of association (no
o Delusions connection)
o Suicidal/homicidal o Flights of idea
o Phobias o Tangentiality (never get to point)
o Obsessions o Circumtantiality (get to point)
o Compulsions o Neoligism
o Words salad
o Clangs of association (word similar
in word but not in meaning, no
logical connection)
o Thoughts blocking
 DISORGANIZED MOTOR DISTURBANCES

• Extreme activity levels (unusually high or low),

peculiar body movements or postures (e.g.,
catatonic schizophrenia), strange gestures and
grimaces
 NEGATIVE Symptoms
• Anhedonia
– inability to feel pleasure; lack of interest or enjoyment in activities or relationships
• Avolition
– inability or lack of energy to engage in routine (e.g., personal hygiene) and/or goal-
directed (e.g., work, school) activities
• Alogia
– lack of meaningful speech, which may take several forms, including poverty of speech
(reduced amount of speech) or poverty of content of speech (little information is
conveyed; vague, repetitive)
• Asociality
– impairments in social relationships; few friends, poor social skills, little interest in being
with other people
• Flat Affect
– No stimulus can elicit an emotional response
– Patient may stare vacantly, with lifeless eyes and expressionless face.
– Voice may be toneless.
– Flat affect refers only to outward expression, not necessarily internal experience.
 TYPICAL FINDINGS IN MSE
Auditory
Disheveled
hallucination
appearance
Flat effect

Ideas of
reference
Concrete
thinking
Lack of
insight
 DSM 5 for SCHIZOPHRENIA
A. 2 or more criteria must be present for at least 1 month
i. Delusions
ii. Hallucinations
iii. Disorganized speech
iv. Grossly disorganized/catatonic behaviour
v. Negative symptoms
B. Causing significant social/occupational functional
deterioration
C. Duration at least 6 months (include prodromal and
residual period)
D. Not due to medical condition/neurological/substances
PHASE OF SCHIZOPHRENIA
PRODROMAL
• Decline in function, socially withdrawn or easily irritable
• ± newfound interest in religion/occult

PSYCHOTIC (acute phase)

• Symptoms of psychosis
• Lasted for 4-8 weeks

RESIDUAL (in between psychosis)

• Occur in between episode of psychosis
• Interruption in treatment
• Lasted for 6 months from recovery of acute phase

REMISSION
• Improvement in symptoms (partial)
• Or no symptoms at all (full remission)
 Course of Schizophrenia

Good

Function
Psycho-
pathology

Premorbid Progression Stable

Relapsing
Poor
15 20 30 40 50 60 70
Age (Years)
Sheitman BB, Lieberman JA. The natural history and pathophysiology of treatment-resistant schizophrenia.
J Psychiatr Res. 1998(May-Aug);32(3-4):143-150
 PROGNOSIS
BETTER WORSE
• Late onset • Early onset
• Good social support • Poor support
• Positive symptoms • Negative symptoms
• Acute onset • Gradual onset
• Female • Male
• Few relapse • Frequent relapse
• Good premorbid function • Poor premorbid function
 MANAGEMENT
• Diagnostic evaluation
– History and MSE (weight, waist circumference, PR, BP)
– Based on DSM 5 criteria
• Investigations
– Blood ix: FBC, RP, FBS, FLP, LFT, RP, TFT
– Pregnancy in women
– ECG (prolonged qTC)
– TRO organic cause; CT brain
– Drug: Urine for drug
• Treatment
– Pharmacological or non pharmacological or combined
 HOSPITALIZATION
• Indications
– Diagnostic purpose
– Stabilization of medications
– For safety (suicidal or homicidal ideations)
– For grossly disorganized or inappopriate behaviour
(including inability to take care of basic need:
food, clothing, shelter)
 Therapeutic goals
• Minimize symptoms
• Minimize medications side effect
• Prevent relapse
• Maximize function
• Recovery
 TREATMENT
• Pharmacological therapy- antipsychotic mainstay
treatment (effective for reducing impact of psychotic
symptoms)
– FIRST generation (TYPICAL):
• Dopamine receptor antagonists
• Sulpiride, haloperidol
• More prone for EPS
– SECOND generation (Atypical):
• Serotonin dopamine antagonists
• Amisulpride, aripriprazole, clozapine, olanzapine, risperidone
• Benzodiazapines- for agitation during psychosis
• Therapy
– Family therapy
– Behaviour/Skills training
– Token economy interventions
– Assertive community treatment
– Supportive environment
• Psychoeducations