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

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.

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

History of schizophrenia
Emil Kraepelin ( 1856-1926)
Eugen Bleuler ( 1857-1939)
“Dementia precox”
Bleuler coined the term “schizophrenia”

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

Epidemiology contd
Genetic factors10x ↑ 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

Aetiology
Unknown
Diathesis-vulnerability
Eco-genetic factors
Dopaminergic hypothesis

CLINICAL FEATURES
AFFECTIVE
SYMTOMS
COGNITIVE
SYMPTOMS
NEGATIVE
SYMPTOMS
AGGRESSIVE
SYMPTOMS

Symptom clusters
Reality distortion
Psychomotor poverty
Disorganisation
Cognitive domain

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

Reality distortion
Hallucinations
Delusions

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.

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

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

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

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

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

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

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

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

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

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

Disorganisation
Inappropriate affect
Disorganised behaviour

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

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

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)

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

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.

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

Schizophrenia sub types
Paranoid
Catatonic
Residual
Undifferentiated
Disorganized

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

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

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

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

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

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.

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

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

Psychological interventions
Cognitive behavioural therapy
Psychoeducation
Family therapy
Social skills training

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

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

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

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

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

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

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