SCHIZOPHRENIA

M . MWEEMBA
Introduction
• F-20 has puzzled physicians, philosophers and general
public for centuries.
• Has been called “arguably the worst disease affecting
mankind.
• Cancer of the mind
• F-20 = mental spliting
• To understand what F-20 is

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Historical background
• We have brief look at history its evolution.
• Descriptions of F-20 like illness were
recorded in literature way back.
• Emil came up with two major psychiatric
illness-
-Dementia precox and manic depressive
psychosis

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Historical background Contd;
• He recognized characteristic features of
dementia such as delusions, hallucination,
disturbances of affect and motor.

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Historical background Contd;
• Eugen Bleuler (1911) renaming dementia to F-
20
• Meaning (mental splitting)
• Recognised it as a group of disorders
• Hence the term “a group of schizophrenias”.
• He came up with fundamental and accessory
symptoms
• Fundamental . (4As)
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Definition
• Schizophrenia is a syndrome that consists
of characteristic experiences and overt
behavioural signs.
• Behavioural disturbances
• Intellectual deterioration
• Impaired social functioning

The most serious of all mental

disorders 6
Definition Contd;
• Schizophrenia is a chronic and severe
mental disorder that affects how a person
thinks, feels, and behaves.
• People with schizophrenia loose touch with
reality.
• loss of cognitive abilities such as memory
and decision making.

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• psychotic disorder characterized by loss of
contact with the environment, by
noticeable deterioration in the level of
functioning in everyday life and
disintegration of personality.
• Expressed as disorder of feeling, thought
and behavior

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Epidemiology
• Prevalence rate:
• 1% in the general population
• Higher rates among first degree relatives
of those affected
• Male to female ratio 1:1
• Can occur at any age but commonly starts
at 15-25 years of age (slightly later in
females)
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Etiology of schizophrenia
• No single theory
• Environmental and social
• Neurodegenerative (Parkinson’s
disease, Huntington disease and
Alzheimer’s disease).

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Etiology of schizophrenia

• Neurotransmitters involved could be

• Dopamin (hallucinations + delusion)
• ketamine can lead to psychotic
symptoms in health people
• Serotonin
• Gamma-aminobutyric acid (GABA)
• Norepinephrine

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Etiology of schizophrenia Contd;
• Trauma at birth due to poor obstetrics
care
• Organic causes;Infective agents

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Etiology of schizophrenia Contd;
• Genetic predisposition
• 2.5% if second degree relative is
affected
• 4% if a parent, sibling or child is
affected
• 10-14% if a dizygotic twin is affected
• 40-50% if a monozygotic twin is
affected
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Aetiology: other risk factors
• Alcohol abuse
• Cannabis
• Childhood abuse
• Discrimination

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Symptoms
• Loosening of associations; Generally
described as illogical and bizarre thinking
• Idiosyncratic shifting from one frame
of reference to another
• Derailment: wandering off the point
during the free flow of conversation

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Symptoms Contd;
• Tangentiality: answers to questions that are off the
point (Digress from topic)
• Incoherence: a breakdown of the relationship between
words within a sentence so that the words no longer
make sense
• Loss of goal: failure to reach a conclusion or achieve a
point

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 Symptoms Contd;

•Unusual use of language;

• Neologisms: new words used by the patients or
usual words used to in a different way.

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 Symptoms Contd;
• Negative thought disorder;
• Poverty of speech: a disorder in which the rate of speech
production is reduced
• Poverty of content: a disorder in which the amount of
information conveyed is relatively little in proportion to
the number of words uttered

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 Symptoms Contd;
•Psychomotor excitation
•Pressure of speech, irritability
•Attentional impairment, disorientation, anxiety,
sleep disturbance, somatic complaints

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 delusions
• Delusions
• Persecutory delusions and ideas of reference (common
but not specific to schizophrenia)
• Delusions of grandiose
• Nihilistic delusions

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hallucinations
• Hallucinations
• Auditory hallucinations (Ears)
• Second person hallucinations
• Third person hallucinations

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hallucinations Contd;
• Visual hallucinations (Eyes)
• Olfactory hallucinations (Nose)
• Somatic hallucinations (Skin)
• Gustatory Hallucinations (Taste)
• Pseudohallucinations

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 Disorganisation
poverty of content, unelaborated ideas.
-Inappropriate affect
-Bizarre behaviour

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 Others symptoms
• Suicide ideation
• Decreased fxn in work
• Lacking insight

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 Schizophrenia types
• Paranoid
• Disorganized/Hebephrenic
• Catatonic
• Simple
• Residual
• Undeferentiated

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 Paranoid schizophrenia
• Characterized by the following in addition to the general
features.
• Delusion of persecution, reference, grandiose, control,
infidelity
• Hallucinations with persecutory or grandiose content
• Less personality deterioration
• Apprehensive and guarded on MSE

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 Paranoid schizophrenia
•Onset in 4th decade
•Run a progressive course and complete
recovery is not possible

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 Hebephrenic/Disorders
• Disorganized /Hebephrenic Schizophrenia; behavior is
typically regressive and primitive. Affect is inappropriate,
with common characteristics being silliness, incongruous
senseless giggling, mirror gazing for long periods, facial
grimaces, and extreme social withdrawal. Communication
is consistently incoherent. Emotional disturbances, Poor
self-care, impaired social and occupational fxning with
disinhibited behavior. Early onset 2nd decade. There is
severe personality deterioration and worse prognosis
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Catatonic
• Is Characterized by marked disturbances of motor
behavior and manifests itself in the form of
stupor (marked psychomotor retardation, mutism,
waxy flexibility [posturing], negativism, and
rigidity) or excitement (extreme psychomotor
agitation, leading to exhaustion or the possibility
of hurting self or others if not curtailed).

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Catatonic Contd;
• In retarded catatonia
• Mutism
• Stupor ,rigid posture against effort to be
moved
• Echolalia, repeat or mimic of
phrases/words heard
• Echopraxia, action observed
• Slow movements
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Undifferentiated Schizophrenia
• Undifferentiated schizophrenia is
characterized by disorganized behaviors and
psychotic symptoms (e.g., delusions,
hallucinations, incoherence, and grossly
disorganized behavior) that may appear in
more than one category.

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 Simple schizophrenia
• Early onset
• Living shabbily and wandering aimlessly
• Very insidious and progressive course
• Characterized by negative symptoms of f-20
• Social withdrawal, shallow emotion, no initiative +drive
• Delusion and hallucination are uncommon
• Poor prognosis
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 Diagnosis

• Eugen Bleuler’s criteria

• 4 As + accessory symptoms
• Loosening of Associations
• Affective disturbance
• Autism
• Ambivalence

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 Diagnosis Contd;

• Accessory symptoms
• Delusions
• Hallucinations
• Catatonic symptoms

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 Diagnosis Contd;

• Schneiderian first rank symptoms of schizophrenia

A. Auditory hallucinations
• Third person auditory hallucinations
• Running commentary

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 Diagnosis Contd;
• Schneiderian first rank symptoms of schizophrenia
Contd;
B. Alienation of thought
• Thought insertion
• Thought withdrawal
• Thought broadcasting
C. Passivity phenomenon (delusions of control)
• Made will
• Made acts
D. Delutions
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Diagnostic and Statistical Manual (DSM
IV) criteria
• Disorganised speech (frequent
derailment or incoherence)
• Grossly disorganized or catatonic
behavior
• Negative symptoms (affective
flattening, avolition)

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 Differential diagnosis
• Other psychiatric disorders
• Affective disorders
• Organic conditions – any disease that causes psychosis
especially those affecting the temporal lobes

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 Organic conditions
• Degenerative disorders: presenile dementia
• Chronic infections: syphilis, AIDS
• Space occupying lesions: tumours or abscess
• vitamin deficiencies

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Organic conditions
• Head trauma
• Acute infections: viral encephalitis
• Cerebrovascular accidents
• Substance abuse cannabis, alcohol,
Epilepsy

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Management
• Indications for admission
• Investigations
• Pharmacotherapy
• Electro-convulsive therapy
• Psychosocial treatments

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 Indications for hospital admission
• Unstable mental state
• Neglect of food and water intake
• Danger to self and others
• Inadequate social support
• Medical state; Concurrent physical illness
• Substance misuse/dependency

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 Investigations
• Base line investigation
• X- ray
• Scan
• MRI
• EEG

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 Antipsychotics
• Depot preparations (slow release)
• Fluphenazine decanoate (Modecate)
25mg IM monthly
• Haloperidol decanoate (serenace/ Haldol) 100-
250mg IM monthly
• Risperidone (Risperdal Consta)

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Antipsychotics
• Chlorpromazine 50-150mg PO/IM

• Trifluoperazine (Stelazine) 5-I5mg PO

• Haloperidol 5-10mg P/O,IM/IV

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 Antipsychotics
• Atypical
• Clozapine 10-25 mg PO
• Olanzapine 5-10 mg PO
• Quetiapine
• Risperidone 2-4mg PO
•
•

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Electro-convulsive therapy ECT
• Usually 8-12 ECTs given three times a week

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Psychosocial treatment
• Family therapy
• Group therapy
• Psychotherapy
• Milieu therapy
• Rehabilitation

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Complications
• Medical illness: difficult to diagnose
• Suicide:
• 50% attempt suicide
• 15-20% died by suicide in a 20 year
follow up
• Substance abuse
• Alcohol
• Cigarette smoking
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Nursing Management
• Impaired communication
• Social isolation
• Poor hygiene
• Disturbed thought process
• Potential for violence

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