Schizophrenia
The following is a list of schizophrenia and the related conditions of it
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schizophrenia
schizophreniform disorders
schizoaffective disorders
delusional disorders
brief psychotic disorders
shared psychotic disorders
substance induced psychoses
psychoses due to medical conditions
psychoses not otherwise specified (or classified)
Definition
In fact, schizophrenia is regarded as the heart island of the psychiatry
and the core of its clinical practice while all other psychiatric disorder are
regarded to be secondary. It's a very grave disease because its prevalent
more than the other psychiatric disorder and effect young people ( at the
reproductive age) with economic complication. The pt. who's affected by
schizophrenia. Continues normally in his life consuming the same
services of any other member in the society. In fact the pt. consumes
without production (not giving any service or help for the society), in
addition the patient causes also severe distress on the members of his
family and other relatives or friends.
It had been found that 10% of the hospital beds in Great Britain were
occupied by schizophrenic. Another study was made on the Gross
National Product of America, the result of this study was that about 2% of
(GNP of America= 400 trillion $) goes to schizophrenic patients.
Notes about schizophrenia:
 It occurs before the age 0f (45 years) and affects n mainly
clever young people
 The patient has an own inner life dominated by fantastic
ideas, delusions, hallucinations… etc an he is usually cut
off from his follows and from reality as whole.
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 The disorders develop gradually in the patients leading
ultimately to fragmentation of personality.
 Certain changes in life can precipitate schizophrenia.
 Schizophrenia occurs in person who are susceptible to be
affected (schizoid personality), seclusions, abnormal
shyness, hypochondriasis, emotional coolness, etc… but it
can occur in normal individuals.
 The first psychiatrist who used the term " schizophrenia" was
Bleuler in 1912
History of Schizophrenia
However writing about schizophrenia began 19th century and the
first one who talked about schizophrenia was Morel 1856 at time which a
young, clever, active and brilliant student with deterioration of
personality came to him seeking for help (advise) …morel called that
condition as " dementia praecox"
 Later on, Kalburn used catatonia for the first time
 After that , Hecker used for the first time the term "hebephrnia"
 While in 1896, Kraeplin used the term paranoid for the first time.
In fact Kraeplin believed that the condition " schizophrenia" was
organic in nature and occurs due to long term deterioration which
leads to the disorder to personality (disintegration of personality).
In addition to that, he regarded all types of this condition that had
been described by other psychiatrist (catatonia, paranoid,
hebephrenia, etc…) as one disease.
Note: Kraeplin described the condition and illustrated it under the
name of dementia praecox and he divided psychoses into mania and
dementia praecox
 Then Bleuler came and he was the first who used the term
" schizophrenia". This psychiatrist confirmed Freud in his believing
and regarded the condition as a psychogenic illness… (a loose
association and imbalance in psychic function like thinking, talking
a decision, etc..)
‫ اعتبر المرض العضوي المنشا نتيجة تلف مزمن في الخاليا العصبية‬Kraeplin ‫ان‬
‫للدماغ مؤديا بذلك الى تحطم شخصية المريض وقد قام بوصف نظريته للمرض تحت‬
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‫ فانه على النقيض اذا اعتبر الحالة‬Bleuler ‫عنوان " الخرف المبكر" اما بالنسبة للعالم‬
‫ تفسير تحطم‬organic ‫ في ذلك قد تعدى نظريته ال‬Freud ‫نفسية المنشأ مؤيدا بذلك العالم‬
‫شخصية المريض‬
The fundamental symptoms: (of Bleuler) 4 A's
1. association loosening
2. affective incongruity or blunting
3. autism: is a brain development disorder that impairs social
interaction and communication, and causes restricted and
repetitive behavior .
4. ambivalence simultaneous of conflicting emotional attitudes
toward a goal, object or person. While the secondary
symptoms are:
1- delusion
2- hallucination
 After Bleuler the psychiatrist came who was :Schneider" and
illustrated the followings are the rank symptoms that are
pathognomic of schizophrenia in the absence of organic brain
disorder:
1- Thought echo: his thoughts are loudly felt by the patient
2- Running commentary: the patient hears one voice
commenting continuously on his work and behavior
‫يحس المريض بان شخص واحد يعلق بصورة مستمرة على تصرفاته واعماله‬
)‫(شخص واحد يتكلم في راسه‬
3- Third person hallucination: two voices are heard by the
patient talking with each other about the patient behavior,
in this condition the patient considered as the 3rd person
4- Delusions of control (insertion)
5- Delusions of control (withdrawal or deprivation)
6- Delusions of control (broadcasting)
7- Passivity delusions of emotion
8- Passivity delusions of thinking
9- Passivity delusions of action
‫في النقاط الثالث السابقة يحس المريض بان عواطفه وتفكيره وتصرفاته تقع تحت‬
‫سيطرة خارجية او ان احد ما يوجها المريض في عواطفه وتفكيره وتصرفاته وفي‬
robot‫هذه الحالة يشعر المريض وكانه‬
10- Somatic passivity , his internal sensation are affected by
external forces (nerves, stomach, ect…)
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11- Delusional perception, the presence of the two
memberedness is essential
Types of schizophrenia
 Simple schizophrenia : is poverty in activity, thinking, volition, etc..
and this condition is sometimes confused with mental subnormality
 Hebephrenia :this is seen in younger age group (disorganized
schizophrenia)
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Paranoind schizophrenia : it is seen in older age group and
characterized by paranoid delusions
Catatonic schizophrenia
Residual schizophrenia
Undifferentiated schizophrenia : there are neither delusions nor
hallucinations and the disease is not diagnosed well
Epidemiology
 The prevalence of schizophrenia is 1/100, the Iraqi people is
about 25 million individuals (250.000 No. of schizophrenia )
while in America they are 3 million in No. and in China they are
20 million in No.
Note: the prevalence record (old + new) cases
 The incidence of schizophrenia is 15/100.000 so if we have one
million then the incidence is 150 new cases per year.
 The onset of schizophrenia is usually insidious but may be acute
in certain occasions.
 Male/female ratio is equal but the mail usually affected (4-5)
years earlier than female. If females are effected at 30 years of
age the males will be at 25 of age.
 It occurs usually more in low socioeconomic status and in the
centre of cities more than the rural areas. It is more prevalent
prevalent in emigrants.
‫لقد لوحظ بان االشخاص المصابين بهذا الداء يتركزون في مراكز المدن اكثر من‬
‫المناطق الريفية وقد اعتقد البعض بان هذا يعود الى االرهاق الذي يتعرض له الناس‬
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‫ ولكن بعد البحث وجد بان المرضى المصابين‬..‫في داخل المدن عن المناطق الريفية‬
‫بانفصام الشخصية يلجأون الى الهجرة الى مراكز المدن بعد االصابة بالداء السباب‬
.‫نفسية واجتماعية واسباب اخرى‬
 The winter born infants are more liable (susceptible) to be
affected by schizophrenia than others, but this relation ship
between seasonal birth and the disease is not necessarily true, it
may be due to hidden factors such as
 Influenza
 Poor diet
 Viral infection
 Birth trauma
 Others
 Schizophrenia are with low fertility
Psychiatry
Before the demonstration of diagnostic of schizophrenia, there are
certain notes that must be put in mind:
 Understimulation :increases the negative symptoms such as
poverty of speech, apathy, catatonia, etc….
While overstimulation induces positive symptoms such as
hallucinations, delusions, restlessness, etc..
 High expressed emotional families are considered as an
overstimulant leading to relapse and this is the cause that
makes those persons prefer a hostel rather than their home
 The prevalence of schizophrenia is higher than the incidence
because some of the patients become chronic cases
 Multifactorial inheritance is responsible for schizophrenia .
This means that the disorder is or may be transmitted to
children through the genetic material but needs certain
environmental factors to be expressed.
It does not always appear especially when the environmental factors
has been provided during the life of the person
 Schneider rank symptoms :
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The first rank symptoms are :
Thought echo, running commentary, 3rd person hallucination,
disorders of possession ( insertion, withdrawal, broadcasting),
passivity delusions of emotion, thinking and action, somatic
passivity, delusion perception.
The second rank symptoms are: paranoid delusions, auditory
hallucinations in the form of noises, 2nd person (here the
voices talks directly with him rather than commenting on his
behavior as in running commentary
 It has been found that schizophrenia is more common among
people born in the winter months. This can be explained by
the greater risk of maternal virus infection in autumn and
winter, with the probability that such an infection could
interfere with the brain development of fetus. It's not the
winter itself responsible for that but the hidden factors.
 Bleuler considered schizophrenia as a psychogenic disorder
and said that the delusions and hallucination are 2ndary
symptoms of this disorder but they are the primary and main
symptoms of schizophrenia (and this was his mistake) the
word "mistake" refer to the symptoms only.
 While Kraeplin considered schizophrenia to be organic in
nature (not psychogenic). So the differ from Freud and
Bleuler who did not confirm the "organic nature of
schizophrenia. Lastly, Schneider considered the hallucination
and delusions as the main symptoms (more accurate)
The diagnostic criteria of schizophrenia:
Depending on the DSM IV
I-characteristic symptom: primary symptoms:
 Delusions
 Hallucinations
 Disorganized behavior
 Negative symptoms
Note : two (at least) or more must be found to say that the characteristic
symptoms are present , but the presence of either 3 rd person on running
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commentary or bizarre delusions is enough to say that the characteristic
symptoms are present [according to Schneider]
II- social and occupational deterioration (dysfunction)
‫المريض تضطرب عالقاته االجتماعية مع االسرة واالقارب واالصدقاء وكذلك فان‬
‫المريض يصبح غير قادر على االستمرار في وظيفته او عمله او دراسته‬
III- The symptoms of the patient must continue for six months or more
Note : If the symptoms last less than 6 months then the disorder may be
either brief psychotic disorder (1 day- 1 month) or
schizophreniform disorder (1-6 months)
IV- the disturbance is not due to effects of a substance (e.g. drug abuse,
medication ) or a general medical condition.
V- relationships to pervasive developmental disorders like autistic
disorders . In which addition diagnosis of schizophrenia is made
on if prominent hallucination and delusion are present.
The difference diagnosis of schizophrenia is:
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Schizophreniform disorders
Schizoaffective disorders
Delusion disorders
Brief psychotic disorders
Shared psychotic disorders
Substance induced psychoses
Psychoses due to medical conditions
Psychoses not otherwise specified
Etiology of schizophrenia:
The cause of this disorder is unknown until now, but the huge studies
that had been made about this subject in the last century led to many
theories:
However, it had been found that schizophrenia has biological basis plus
environmental factors "social and psychological causes"
so
schizophrenia is " biopsychosocial in origin" which means that the
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biological causes are essential and must be present as a basis and the
environmental causes either precipitate or maintain the disorder. In fact,
life changes like marriage, entrance into college, going into a new house
have a profound effect in precipitating the psychotic disorder or maintain
it.
I- Biological causes
II- Environmental factors
I-Biological causes:
Hereoittary causes (Genetics):
Three types of studies had been made on schizophrenics to confirm
that the disorder has a genetic basis (i. e. that is transmitted from
parents to children by genetic factors) and that include:
A- Family studies
B- Twin studies
C- Adopted children studies
So in details:
A- In family studies, it had been found that the :
 2nd and 3rd degree relatives have a 2.5% more possibility
than the general population to be affected by the disorder (5
in every 200 are affected).
 In the children of one schizophrenic parent have 12% more
possibility.
 If both parents are schizophrenics, the 25% will be affected
of their children (i.e. if the schizophrenic parents have 4
children then one of them will be affected).
It's not clear if the presence of one schizophrenic patient in
the family will affect the other members of the family or
relative by a genetic basis or environmental one because the
presence of this patient may have an effect on rearing up of
the other members of the family and relatives.
B- Twin studies:
The twins are either identical (the twin have the same genetic
material) or non identical (the twins have different genetic
material).
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In fact, the study of identical twins gives more accurate
information about the genetic role towards this disorder.
 It has been that 45% of the identical twins share in the disorder (if
patiens have schizophrena the 45 of their identical twins have also
the disease)
 While only 12% of non identical twins share the disease and in this
condition, the two have a weaker link.
So genetics have a role in etiology of the disease, but the environmental
factors must be present to complete the final picture of schizophrenia i.e.
genetic has no 100% role in etiology
C-adopt children
It had been found that children of schizophrenia parents (we depend
mainly on the mother because the father may be not known) if they are
adopted and taken into live in a place which different and far from their
parents, they will acquire schizophrenia in their adulthood
The study of adopt children confirms the genetic basis of schizophrenia
far away from the environmental factors, but still the environment has its
effect in completing the picture.
Conclusion: genetics has its role in etiology of the disorder but its not
transmitted from parents to children in mandelian way but its
multifactorial
2. biochemical causes
The etiology of schizophrenia may be rated to the neurotransmission of
the brain. It has been found to have a relationship with the disorder. The
neurotransmitters that can be found in the brain are numerous like
dopamine, ACH, adrenaline, histamine, serotonin, and prostaglandins
etc…
Notes:
1- The vesicles contain neurotransmitters
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2- The electrical messages in the brain are actually the thoughts,
emotions, … etc. Of ourselves and these electrical messages pass
usually across numerous neurons via the synapses
3- The neurotransmitter that is worthy to get our attention is the
dopamine which is closely related to the etiology of schizophrenia.
This is usually by either its exaggeration effect due to its exces
amount or its imbalance with other neurotransmitters.
4- The dopamine neurotransmitter is found in the following places of
the brain:
 Mesolimbic system (between midbrain and limbic system)
 Mescortical (between midbrain and cortex)
 Between the hypothalamus and anterior pituitary in which
the dopamine is the prolactin inhibitory hormone which is
released in the hypothalamus and work on anterior pituitary
gland.
 Between the substantia nigra and the striate body ( the two
are located within the basal ganglion) this connection
between them is called the nigrostriatal tract (pathway).
5- Social stress (daily life events) causes imbalance or excess of
dopamine according to the study that had been made. So the drugs
that antagonize the effect of dopamine will reduce the symptoms of
schizophrenia and these drugs are called neuroleptic drugs like
chlorpromazine, however the biochemical theory in etiology of
schizophrenia has become weak recently because of :
a) The appearance of drugs that work on receptors rather than the
dopamine receptors with reduction of psychotic symptoms
b) The drug (dopamine antagonist) works within 1 hour but the
effect (therapeutic effect) appears after 2 weeks
3- Birth and pregnancy :
It had been found that winter born babies are more susceptible to be
affected by schizophrenia but this may be due to hidden factors as we
mentioned previously.
In common (viral infection, dietary factors, birth complication) may
lead to schizophrenia in later life (adolescent and adulthood).
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Note: a weak study said that atrophic changes in schizophrenia may be
due to slowly progressive viral infections
4-Medical illness:
Schizophrenia like symptoms may appear in association with certain
medical illnesses like:
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Carcinoma of lungs.
SLE
Sarcoidosis
Stroke
Immune multi systems disease
Syphilis
Thyrotoxicosis
But the mood of the action by which the symptoms of schizophrenia are
stimulated to appear is unknown.
Note: parkinsonism is not a cause of schizophrenia
5- Organic Brain Disorders:
Radiological investigation like CT scan, MRI have revealed the
following (about schizophrenia)
Certain changes (structural and functional) may be associated with the
etiology of schizophrenia which are:
1- Dilation of ventricular systems
2- Atrophy of brain tissue specially the temporal lobe and its medical
part which is called the hippocampus
3- Decrease weight of brain becoming less than normal
4- Decrease of blood supply to the frontal lobe leading to frontal
hypoplasia
5- Decrease of glucose metabolism in the frontal lobe and disturbing
its function.
6- Defect in the functional connection between the different parts of
brain (between the lobes).
III- Environmental factors will be discussed in the next lecture
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