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SCHIZOPHRENIA
WHAT DOES IT MEAN ?
Schizophrenia which translates roughly as "splitting of the mind" and comes from the
Greek roots Schizein "to split“ and phren-"mind“.
It is a mental disorder where the patient suffers from abnormal social behavior and
cant differentiate between what is real or false and loses touch with reality.
SYMPTOMS
Schizophrenia affects around 0.3–0.7% of people at some point in their life, or 24 million people
worldwide as of 2011.It occurs 1.4 times more frequently in males than females and typically
appears earlier in men the peak ages of onset are 25 years for males and 27 years for females
The patient may experience hallucinations such as hearing voices or delusions and having disorganized
speech and when severe may result in something called
“Word Salad” in which words make sentences that have no sense or meaning.
Other symptoms may include short attention span, difficulties in working , long term memory problems
and may have a high rate of irritable bowel syndrome but most of the times don’t mention it until
asked.
About 30 to 50 percent of people with schizophrenia fail to accept that they have an illness or comply
with their recommended treatment
POSITIVE AND NEGATIVE
Schizophrenia is often described in terms of positive and negative symptoms.
Positive symptoms are those which normal people don’t usually experience such as :
•Delusions
•Disordered thoughts or speech
•Auditory ,tactile ,visual or olfactory hallucinations
Positive symptoms respond well to medications
As for negative symptoms are associated with disruptions to normal emotions
and behaviors and they include :
•Flat emotions
•Lack of speech
•Inability to feel pleasure
•Lack of desire to form relationships
•Lack of motivation
Negative symptoms affect quality of life more than positive one and are less
responsive to medication
COGNITIVE SYMPTOMS
For some patients, the cognitive symptoms of schizophrenia are subtle, but for others,
they are more severe and patients may notice changes in their memory or other
aspects of thinking. Symptoms include:
•Poor “executive functioning” (the ability to understand information and use it to
make decisions)
•Trouble focusing or paying attention
•Problems with “working memory” (the ability to use information immediately after
learning it)
ETIOLOGY
The cause of schizophrenia is a combination of many factors
which are environmental and genetic in nature. We will start
to speak about the genetic part of the disease.
Symptoms of schizophrenia usually start between ages 16
and 30. In rare cases, children have schizophrenia too
Genetics:
The single most risk factor is having a first degree relative with the disease (risk is 6.5%)
and more than 40% in monozygotic twins
Also, If one parent is affected the risk rises to 13% and if two parents it rises up to 50%
Environment:
Environmental factors associated with the development of schizophrenia include the living
environment, drug use, and prenatal stressors
Living in an urban environment during childhood or as an adult has consistently been
found to increase the risk of schizophrenia by a factor of two.
Substance use:
Of those with schizophrenia use drugs or alcohol excessively. Amphetamine, cocaine,
and to a lesser extent alcohol, can result in a transient stimulant psychosis or alcoholrelated psychosis that presents very similarly to schizophrenia. Although it is not
generally believed to be a cause of the illness, people with schizophrenia use
nicotine (smoking) at much higher rates than the general population
Developmental factors:
Factors such as hypoxia and infection, or stress and malnutrition in the mother
during fetal development, may result in a slight increase in the risk of schizophrenia
later in life. People diagnosed with schizophrenia are more likely to have been born
in winter or spring, which may be a result of increased rates of viral exposures in
utero. The increased risk is about five to eight percent.
DIAGNOSIS
There is no single test for schizophrenia. The condition is usually diagnosed after
assessment by a specialist in mental health.
If you are concerned you may be developing symptoms of schizophrenia, see your GP as
soon as possible. The earlier schizophrenia is treated, the more successful the outcome
tends to be.
In 2013, the American Psychiatric Association released the fifth edition of the DSM
(DSM-5). To be diagnosed with schizophrenia, two diagnostic criteria have to be met
over much of the time of a period of at least one month, with a significant impact on
social or occupational functioning for at least six months
 Delusions, hallucinations, hearing voices, incoherent speech or negative symptoms, such as a
flattening of emotions
 your symptoms have had a significant impact on your ability to work, study or perform daily
tasks
 all other possible causes, such as recreational drug use or bipolar disorder, have been ruled
out
As a result of their delusional thought patterns, people with schizophrenia may be
reluctant to visit their GP if they believe there is nothing wrong with them.
If someone is having an acute schizophrenic episode for the first time, it may be
necessary for a friend, relative or other loved one to persuade them to visit their GP.
A picture of a PET scan of a normal brain on the left and another of a schizophrenic patient
on the right. As we can see from the picture the schizophrenic patient’s image shows that his
brain is more active especially the occipital lobe and he might be experiencing visual
hallucinations.
TREATMENTS AND THERAPIES
Because the causes of schizophrenia are still unknown, treatments focus on
eliminating the symptoms of the disease. Treatments include:
Antipsychotics:
They are the first-line of medications used and usually taken daily in pill or liquid
form. Some antipsychotics are injections that are given once or twice a month.
Some people have side effects when they start taking medications, but most side
effects go away after a few days. Doctors and patients can work together to find
the best medication or medication combination. Furthermore, medications should be
stopped if there is no side effects for more than a year.
Risperidone (trade name Risperdal) is a common atypical antipsychotic
medication.
Psychosocial Treatments:
These treatments are helpful after patients and their doctor find a medication that
works. Learning and using coping skills to address the everyday challenges of
schizophrenia helps people to pursue their life goals, such as attending school or
work. Individuals who participate in regular psychosocial treatment are less likely to
have relapses or be hospitalized.
Coordinated specialty care (CSC):
This treatment model integrates medication, psychosocial therapies, case
management, family involvement, and supported education and employment services,
all aimed at reducing symptoms and improving quality of life
Research:
There have been trials on drugs with anti-inflammatory activity, based on the premise
that inflammation might play a role in the pathology of schizophrenia.
PROGNOSIS
Schizophrenia has great human and economic costs. It results in a decreased life
expectancy by 10–25 years. This is primarily because of its association with obesity,
poor diet, sedentary lifestyles, and smoking, with an increased rate of suicide playing
a lesser role
But with the correct intervention and treatment
Many can lead a normal life and even
Extraordinary lives.
THE 5 SUBTYPES OF SCHIZOPHRENIA
Paranoid Schizophrenia: This is widely regarded as the most common
type of schizophrenia. Among individuals with the paranoid-type, they
commonly experience delusions and hallucinations in the form of “voices.”
The delusions may involve the fact that other people are conspiring against
them and or plotting their demise. They may hear voices that say mean
things, curse them, and make life difficult.
DSM diagnosis:
A. Preoccupation with one or more delusions or frequent auditory hallucinations.
B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior,
or flat or inappropriate affect.
Disorganized Schizophrenia:
In this particular subtype, the dominant symptoms revolve around disorganization. The person will
experience disorganized behavior, speech, and thinking. In other words, they will act odd, make no sense
when they talk, and their thinking will be highly unfocused, nonsensical, and completely random. Individuals
with this subtype tend to have difficulties performing basic tasks that are part of daily living.
They may neglect their personal hygiene and not understand that they need to take care of themselves. In
many cases there is also an emotional impairment in the person in which they exhibit odd emotional
responses. For example, the person may laugh or smile in a very serious situation. In other words, the emotion
that they show and/or express doesn’t usually fit the given situation.
DSM diagnosis:
A. All of the following are prominent:
(1) disorganized speech
(2) disorganized behavior
(3) flat or inappropriate affect
B. The criteria are not met for Catatonic Type
Catatonic Schizophrenia:
In this subtype, the symptoms involve motor disturbances, disturbances in movement, and
“catatonia.” Usually individuals with this subtype will experience a major reduction in
overall activity to the point that they stop moving, and may appear “frozen.” This frozen
state with a complete lack of movement is called a “catatonic stupor.” They also may
significantly increase movement and appear to be hyperactive – this is known as
“catatonic excitement.”
They may stay stuck in one position for hours at a time. This subtype is also characterized
by the symptom of “waxy flexibility” in which another person may move the person’s
arm and they hold it locked in the position that it was moved into. In other words, they
can be molded like a “wax” figure.
It is also common to witness echolalia and echopraxia – mimicking speech and
movements of other people.
According to the DSM it is a type of Schizophrenia in which the clinical picture
is dominated by at least two of the following:
(1) motoric immobility as evidenced by catalepsy (including waxy flexibility)
or stupor
(2) excessive motor activity (that is apparently purposeless and not influenced
by external stimuli)
(3) extreme negativism (an apparently motiveless resistance to all instructions
or maintenance of a rigid posture against attempts to be moved) or mutism
(4) peculiarities of voluntary movement as evidenced by posturing (voluntary
assumption of inappropriate or bizarre postures), stereotyped movements,
prominent mannerisms, or prominent grimacing
(5) echolalia or echopraxia
Undifferentiated Schizophrenia:
The undifferentiated subtype is diagnosed when individuals exhibit general
symptoms of schizophrenia, but do not meet specific diagnostic criteria for
another subtype. Individuals with the undifferentiated subtypes may have
symptoms that fall into multiple categories of other subtypes. For example, a
person may have disorganized thinking, paranoia, hallucinations, low energy,
and cognitive deficits.
Residual Schizophrenia:
This subtype is diagnosed when a person with schizophrenia has gone for an
extended period of time without any symptoms. In other words, the patient has been
in remission and symptom free for up to a full year (12 months). In cases of residual
schizophrenia, the symptoms may be completely non-existent or have lessened in
severity to the point that they do not interfere with the daily functioning of the
individual.
DSM diagnosis:
A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly
disorganized or catatonic behavior.
B. There is continuing evidence of the disturbance, as indicated by the presence of
negative symptoms or two or more symptoms
Simple-type schizophrenia
Has possibly the earliest onset compared to all other schizophrenias,
considered to begin in some within childhood. Symptomatic of the simplex is
an absence of will, impoverished thinking and flattening of affect. There is a
gradual deterioration of functioning with increased amotivation and
reduced socialization. It is considered to be rarely diagnosed and is a
schizophrenia without psychotic symptoms
Definition of this type is without unity or is controversial, or else is within a
divided opinion. The classification was discontinued in the U.S. DSM
system
SCHIZOPHRENIA RELATED DISORDERS
Schizophreniform Disorder
Delusional Disorder
Schizoaffective disorder
Acute Psychotic Disorder
SCHIZOPHRENIFORM DISORDER
It is diagnosed when symptoms of schizophrenia are present for a
significant portion of the time within a one-month period, but signs
of disruption are not present for the full six months required for
the diagnosis of schizophrenia.
Schizophrenia and Schizophreniform disorder, as defined by the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IVTR), have the same symptoms and essential features except for the
time difference where in schizophreniform it must last for one month
but not more than 6 month while in schizophrenia it must be present
for at least 6 months.
Treatment is generally the same as for schizophrenia
SCHIZOAFFECTIVE DISORDER
It is a condition in which a person experiences a combination of
schizophrenia symptoms such as hallucinations or delusions and
mood disorder symptoms, such as mania or depression.
Schizoaffective disorder is not as well understood or well defined
as other mental health conditions. This is largely because
schizoaffective disorder is a mix of mental health conditions
including schizophrenic and mood disorder features that may run a
unique course in each affected person.
According to the DSM-5 criteria its diagnosed if the following is
present:
•A mood disorder (major depression or mania) along with
schizophrenia
•Delusions or hallucinations for at least two weeks, even when
mood disorder symptoms are under control
•A mood disorder present for the majority of time over the entire
course of the schizophrenic illness
DELUSIONAL DISORDER
It is a mental illness in which the patient presents with delusions, but
with no accompanying prominent hallucinations, thought disorder,
mood disorder, or significant flattening of affect. Delusions can be
bizarre or non-bizarre in content. Non-bizarre delusions are fixed
false beliefs that involve situations that could potentially occur in
real life; examples include being followed or poisoned. Apart from
their delusions, people with delusional disorder may continue to
socialize and function in a normal manner and their behavior does
not generally seem odd or bizarre. According to the DSM there
are seven subtypes
Erotomanic type (erotomania): delusion that another person, often a prominent figure, is in love
with the individual. The individual may breach the law as he/she tries to obsessively make contact
with the desired person.
Grandiose type: delusion of inflated worth, power, knowledge, identity or believes
himself/herself to be a famous person, claiming the actual person is an impostor or an
impersonator.
Jealous type: delusion that the individual's sexual partner is unfaithful when it is untrue. The
patient may follow the partner, check text messages, emails, phone calls etc. in an attempt to find
"evidence" of the infidelity.
Persecutory type: This delusion is a common subtype. It includes the belief that the person (or
someone to whom the person is close) is being malevolently treated in some way. The patient may
believe that he/she has been drugged, spied upon, harassed and so on and may seek "justice"
by making police reports, taking court action or even acting violently.
Somatic type: delusions that the person has some physical defect or general medical condition
Mixed type: delusions with characteristics of more than one of the above types but with no one
theme predominating.
Unspecified type: delusions that cannot be clearly determined or characterized in any of the
categories in the specific types
BRIEF PSYCHOTIC DISEASE
They come on suddenly but last only for a short time -- less than 1 month. After that,
people usually recover completely.
There are three basic forms of brief psychotic disorders:
1. Brief psychotic disorder with obvious stressor (also called brief reactive psychosis):
This type happens shortly after a trauma or major stress, such as the death of a loved
one, an accident, assault, or a natural disaster. It's usually a reaction to a very
disturbing event.
2. Brief psychotic disorder without obvious stressor: With this type, there is no
apparent trauma or stress that triggers it.
3. Brief psychotic disorder with postpartum onset: This type only happens in women,
usually within 4 weeks of having a baby.
USMLE 2014 Question
A 23 year old woman was seen today after she complained her neighbors were talking about
her. According to her neighbors her condition started 3 weeks ago after she was involved in a
car accident since then she has been following the neighbors for several days and harassing
them at work. She believes the neighbors are putting poison in her food and wan to kill her.
When asked why she is unable to give a clear explanation but insists on what she is saying is
true.
She insists that the voice in her head told her it was true and that you should stop asking
questions.
While in the waiting room you observe her to be dressed bizarrely and laughing
inappropriately.
If her symptoms don’t improve in the next week which of the following is she at greatest risk of
developing:
A-Schizophrenia (paranoid type)
B-Schizoaffective disorder
D- Delusional Disorder
C-Schizophreniform disorder
The answer is C as the patient has diagnosis of brief psychotic
disorder but should the symptoms persist for one month her
diagnosis would be schizophreniform disorder and if more than 6
month then it will be schizophrenia.
What is the first line of treatment for this patient ?
A-Haloperidol
B- Clozapine C-Lorazepam D-Risperidone
THANK YOU FOR LISTENING
References:
National Health Service (UK)
National Institute of Mental Health (USA)