Schizophrenia

Dr Rajni Chatterji
Professor and HOD
Department of Psychiatry
BMHRC
Mob No: 9826424725
 Introduction
Schizophrenia is a chronic, severe and disabling brain disorder. The
disorder is characterised by distortions of thinking and perception,
inappropriate or blunted affect. Clear consciousness and intellectual
capacity are usually maintained although certain cognitive deficits
may evolve in the course of time. People with schizophrenia may
suffer terrifying symptoms such as hearing internal voices not heard
by others, or believing that other people are controlling their
minds, controlling their thoughts, or trying to plot against them.
These symptoms may leave them fearful or withdrawn. They start
living in a make-believe world and loose touch with reality.

Schizophrenia is found all over the world. The first signs of

schizophrenia appear as confusion and strange changes in
behaviour. It is characterised by disturbances of thinking,
perception, mood and volition.
 Introduction Contd
Schizophrenia is defined by
• a group of characteristic positive and
negative symptoms
• deterioration in social, occupational,
or interpersonal relationships
• continuous signs of the disturbance
for at least 6 months
Benedict Morel
(1809 to 1873)

In 1852 he described
Demence Precoce
‘’hich is the first
reference to
schizophrenia, also
called the
"discovery“ of
Schizophrenia
 History
1852 Benedict Morel Demence precoce
1896 Emil Kraeplin Dementia preacox
1868 Kahlbaum Katatonia
1868 Sander Paranoia
1870 Hecker Hebephrenia
1908 Eugene Bleuler
 Emil Kraepelin
(1856 to 1926)
The Founder of Modern
Scientific Psychiatry
Kraepelin believed the chief
origin of psychiatric disease
to be biological and genetic
malfunction.
He gave the term “dementia
preacox”.
He said there were two types
of psychosis; manic
depression and dementia
preacox.
 Autism
Ambivalence
Eugene Bleurer Loosening of Association
Bleuler introduced the term Affective flattening
"schizophrenia" to the world
in a lecture in Berlin on April
24, 1908. He said it was a
group of disorders and coined
the word schizophrenia from
‘schitz’ which means a
difference, and not split,
indicating the difference
between emotion, thought or
behaviour.
He described the features as
the four “As” of Schizophrenia
First Rank Symptoms of Schizophrenia
Kurt Schneider stressed on the psychopathological approach.
He gave the first rank symptoms of schizophrenia which are
• 1. Audible thoughts
• 2. Voices arguing
• 3. Voices commenting
• 4. Thought withdrawal
• 5. Thought insertion
• 6. Thought broadcasting
• 7. Made feelings (feels that feelings are not his own)
• 8. Made impulses
• 9. Made volitional acts
• 10. Delusional perceptions (perception is true but not the
attribute e.g. sees traffic lights which to him may mean that
aliens will land)
• 11. Somatic passivity
Audible thoughts
The patient would think 'I must put the kettle on', and after a pause
of not more than one second would hear a voice say 'I must put the
kettle on'.
Voices arguing
Patient A B heard one voice say ‘A B. is a dirty thief'; another voice
says, 'He is, he should be locked up'; and a third say 'He is not, he
is a lovely man'.
Voices commenting on one's actions
A voice in a flat monotone describing everything the patient was
doing: 'She is peeling potatoes, got hold of the peeler, she does not
want that potato...'
Thought withdrawal
'I am thinking about my mother, and suddenly my thoughts are
sucked out of my mind vacuum extractor, and there is nothing in my
mind.’
Thought insertion
'The thoughts of Vivekanand come into my mind. He treats my mind
like a screen and flashes his thoughts on to it like you flash a
picture.'
Thought Broadcasting
My thoughts leave my head on a type of mental ticker or get recorded
on a tape. Everyone around me has only to pass the tape through their
mind and they know my thoughts.'
'Made' feelings
'It is not me who is unhappy, but they are projecting unhappiness into
my brain. Sometimes I am made to laugh, sometimes cry’
‘Made' impulses
'It came to me from the X-ray department. It was nothing to do with me,
they wanted it so I picked up the bottle and poured it.’
'Made' volitional acts (delusions of control)
It is my hand and arm that move, and my fingers pick up the pen, but I
don't control them. What they do is nothing to do with me.
Delusional perception
One of the other boys in the hostel pushed the salt cellar towards him,
and the patient knew that he must return home 'to greet the PM who is
visiting his home town to see his family and reward them'.
An influence on the body (somatic passivity)
'X-rays enter the back of my neck, where the skin tingles and feels
warm, they pass down the back in a hot tingling strip about six inches
wide to the waist.'
 Course of Illness

Course of schizophrenia
– continuous without temporary improvement
– episodic with progressive or stable deficit
– episodic with complete or incomplete remission

Typical stages of schizophrenia

– prodromal phase
– active phase
– residual phase
 Epidemiology
Life time prevalence is 1% to 1/5 %

Annual incidence is 0.5 to 5 per 10,000The severity and

morbidity is observed to be more in urban areas
The male to female ratio is 1:1. It occurs at an earlier age in
males.
The prevalence increases as the socioeconomic status
decreases
The age of onset is 15 to 25. Fifty percent of the cases
occur below 25 years. It is rare before the age of ten
and after the age of 45.
 Etiology
Genetics
Family studies indicate that schizophrenia is more
in the first degree relatives of schizophrenics.
Twin studies reveal that the concordance rate
for monozygotic twins is about 50% and for
dizygotic it is 15%.
The mode of inheritance is not known. Both
monogenic and polygenic theories have been
postulated
Relative risk for schizophrenia is around
1% for normal population
5.6% for parents
10.1% for siblings
12.8% for children
 Biochemical Factors
Dopamine hypothesis
Psychotic symptoms in schizophrenia are related to dopamine
hyperactivity in the brain. This hyperactivity is a result of increased
sensitivity and density of dopamine D2 receptors in the different parts of
the brain.
Nor-epinephrine hypothesis
Increased nor-epinephrine activity is associated with increased dopamine
activity and causes the symptoms.
GABA hypothesis
GABA activity is reduced with resultant increase in dopamine activity.
Serotonin hypothesis
The metabolism of serotonin is abnormal in schizophrenic patients. Both
excess and deficiency of serotonin cause psychological disturbances.
Excess causes excitement and perceptual disturbances whereas deficiency
causes retardation and stupor as seen in catatonia.
 Neuro-developmental and structural
abnormalities
Brains of patients are lighter and smaller than normal. Non-
progressive cortical atrophy is seen in 10 to 35% of patients,
particularly in the temporal and frontal lobes. The lateral and
third ventricles are enlarged in almost 50 % of patients.
The Neuro-developmental model supposes in schizophrenia the
presence of “silent lesion” in the brain, mostly in the parts,
important for the development of integration (frontal, parietal
and temporal), which is caused by different factors (genetic,
inborn, infection, trauma...) during very early development of
the brain in prenatal or early postnatal period of life.
It does not interfere too much with the basic brain functioning in
early years, but expresses itself in the time, when the subject
is stressed by demands of growing needs for integration,
during formative years in adolescence and young adulthood.
 Psycho-social Factors

Family as a cause of schizophrenia

Broken home, unstable parents, eccentric child
rearing practices
Deviant role relationship: marital schizm and
marital skew
Disordered Communication
Migration and Life changes

Psychosocial Stresses and Social Isolation

F20-F29 Schizophrenia, Schizotypal and
Delusional Disorders
F20 Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified
 The Criteria of Diagnosis
For the diagnosis of schizophrenia is necessary
• presence of one very clear symptom - from point a) to d)
• or the presence of the symptoms from at least two groups - from point e) to
h)
for one month or more

a) the hearing of own thoughts, the feelings of thought withdrawal, thought

insertion, or thought broadcasting
b) the delusions of control, outside manipulation and influence, or the feelings
of passivity, which are connected with the movements of the body or
extremities, specific thoughts, acting or feelings, delusional perception
c) hallucinated voices, which are commenting permanently the behavior of the
patient or they talk about him between themselves, or the other types of
hallucinatory voices, coming from different parts of body
d) permanent delusions of different kind, which are inappropriate and
unacceptable in given culture
 The Criteria of Diagnosis
e) lasting hallucinations of every form
f) blocks or intrusion of thoughts into the flow of thinking and resulting
incoherence and irrelevance of speech, or neologisms
g) catatonic behavior
h) “the negative symptoms”, for instance the expressed apathy, poor speech,
blunting and inappropriateness of emotional reactions
e) expressed and conspicuous qualitative changes in patient’s behavior, the
loss of interests, hobbies, aimlesness, inactivity, the loss of relations to
others and social withdrawal

• Diagnosis of acute schizophreniform disorder (F23.2) – if the conditions

for diagnosis of schizophrenia are fulfilled, but lasting less than one month
• Diagnosis of schizoaffective disorder (F25) - if the schizophrenic and
affective symptoms are developing together at the same time
 Clinical Picture
Diagnostic manuals
lCD-10
DSM-IV and DSM 5
Clinical picture of schizophrenia is according to lCD-10, defined from
the point of view of the presence and expression of primary
and/or secondary symptoms (at present covered by the terms
negative and positive symptoms)
the negative symptoms are represented by cognitive disorders, having its
origin probably in the disorders of associations of thoughts, combined
with emotional blunting and small or missing production of hallucinations
and delusions
the positive symptom are characterized by the presence of hallucinations and
delusions
the division is not quite strict and lesser or greater mixture of symptoms from
these two groups are possible
 Positive and Negative Symptoms

Negative Positive
Alogia Hallucinations
Affective flattening Delusions
Avolition-apathy Bizarre behaviour
Anhedonia-asociality Positive formal
thought disorder
Attentional impairment

Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In: Schizophrenia, Hirsch S.R. and
Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995
 Clinical Features
Disorders of perception
Disturbances of Thinking
Volitional disturbances
Disturbances of Mood
Other disturbances
 Disorders of Perception
Hallucinations in all sensory modalities are
observed, auditory hallucinations are the most
common e.g. hearing familiar or unfamiliar
voices, hearing voices commenting on him,
threatening him, ridiculing him etc.
Hallucinations of more than one sensory
modality can occur together
 Disturbances of Thinking
Thought Disorder is the hallmark of
Schizophrenia. All types of disorders are
observed: form (disorganised), stream,
possession and content (paranoid).
Others are poverty of thought, sudden
thought block, delusions of persecution,
grandeur, jealousy,.
 Volitional Disturbances
Hyperactivity
Hypoactivity
Tics, mannerisms, bizarre mannerisms,
sterotypy, echopraxia, negativism, automatic
obedience, lack of drive
Ambitendency
 Disturbances of Affect
Shallow
Blunted
Apathetic
Talking to a wall (praecox feeling)
Strange emotions: religious ecstasy
Silly and uninhibited
Affective incongruity or Inappropriate affect
 Other Disturbances
Personality changes
Social withrawal,poor personal hygiene,
preference for solitude,
Vegetative Functions
Sleep disturbances, effect on libido, poor
appetite,
Lack of Insight
Negative symptoms
 F20.0 Paranoid Schizophrenia

This is the commonest type of schizophrenia. Paranoid

schizophrenia is characterized mainly by delusions of
persecution, feelings of passive or active control,
feelings of intrusion, and often by megalomanic
tendencies also. The delusions are not usually
systemized too much, without tight logical
connections and are often combined with
hallucinations of different senses, mostly with
hearing voices.
Disturbances of affect, volition and speech, and
catatonic symptoms, are either absent or relatively
inconspicuous.
 F20.1 Hebephrenic Schizophrenia
Hebephrenic schizophrenia is characterized by disorganized
thinking with blunted and inappropriate emotions. It begins
mostly in adolescent age, the behavior is often bizarre. There
could appear mannerisms, grimacing, inappropriate laugh and
joking, pseudophilosophical brooding and sudden impulsive
reactions without external stimulation. There is a tendency to
social isolation.

Usually the prognosis is poor because of the rapid development of

"negative" symptoms, particularly flattening of affect and loss of
volition. Hebephrenia should normally be diagnosed only in
adolescents or young adults.

• Denoted also as disorganized schizophrenia

 F20.2 Catatonic Schizophrenia
Catatonic schizophrenia is characterized mainly by
motoric activity, which might be strongly increased
(hypekinesis) or decreased (stupor), or automatic
obedience and negativism.
Two forms:
productive form: which shows catatonic excitement, extreme
and often aggressive activity. Treatment by neuroleptics or
by electroconvulsive therapy.
stuporose form — characterized by general inhibition of
patient’s behavior or at least by retardation and slowness,
followed often by mutism, negativism, flexibilitas cerea or by
stupor. The consciousness is not absent.
F20.3 Undifferentiated Schizophrenia
Psychotic conditions meeting the general diagnostic
criteria for schizophrenia but not conforming to any
of the subtypes in F20.0-F20.2, or exhibiting the
features of more than one of them without a clear
predominance of a particular set of diagnostic
characteristics.

This subgroup represents also the former diagnosis of

atypical schizophrenia.
 Management of Schizophrenia
Drugs
The acute psychotic schizophrenic patients will respond usually to
antipsychotic medication.
According to current consensus we use in the first line therapy the
newer atypical antipsychotics, because their use is not
complicated by appearance of extrapyramidal side-effects, or
these are much lower than with classical antipsychotics.

chlorpromazine, thioridazine
conventional
antipsychotics
(classical droperidol, flupentixol, fluphenazine,
neuroleptics) haloperidol, penfluridol, perphenazine,
pimozide, prochlorperazine, trifluoperazine
atypical ziprasidone, clozapine, olanzapine,
antipsychotics quetiapine, risperidone, amisulpiride
 Management
Electro Convulsive Therapy

Psychosocial Methods of Treatment

Individual psychotherapy
Supportive Psychotherapy
Family psychotherapy
Group psychotherapy
Psychosocial Rehabilitation
Cognitive Behaviour therapy
Social Skills development
RECOVERY
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