By Doon psychotherapeutic centre
Schizophrenia is a chronic and severe mental disorder
that affects how a person thinks, feels, and behaves.
People with schizophrenia may seem like they have lost
touch with reality.
Although schizophrenia is not as common as other
mental disorders, the symptoms can be very disabling.
The expression of these manifestation varies across patient
and overtime, but the affect of the illness is always severe and
is usually long lasting.
The disorder usually begins before age 25 years, persist
throughout life, and affects persons of social classes.
Both patients and there family often suffer poor care and
social ostracism because of widespread ignorance about the
disorder.
Schizophrenia is one of the most common the serious mental
disorders, but its essential nature remains to be clarified: thus,
1. it is some time referred to as a sign of syndrome,
2. as a group of schizophrenias,
3. or as in the fifth edition of the diagnostic and statistical
manual of mental disorders (DSM-5),
4. the schizophrenia spectrum.
• The diagnosis of schizophrenia is based entirely on the
psychiatric history and mental status examination.
There is no laboratory test for schizophrenia.
The origin of the term SCHIZOPHRENIA has been
derived from the Greek word “Skhizein” meaning “to
split”,and “phren” meaning “mind”.
The German psychiatrist Emil Kraepelin (1856–
1926)who is best known for his careful description of
what we now regard as schizophrenia.
Kraepelin used the Latin version of Morel‟s term
(dementia praecox) to refer to a group of
conditions that all seemed to feature mental deterioration
beginning early in life.
It was a Swiss psychiatrist named Eugen Bleuler
(1857-1939) who gave us the diagnostic term we still
use today.
Kurt Schneider (1959) described symptoms which,
though not specific of schizophrenia, were of great help
in making a clinical diagnosis of schizophrenia. These
are popularly called as Schneider’s first rank symptoms
of schizophrenia (FRS or SFRS).
1. Audible thoughts: Voices speaking out thoughts
aloud or „ thought echo’.
2. Voices heard arguing: Two or more hallu cinatory
voices discussing the subject in third person.
3. Voices commenting on one’s action.
4. Thought withdrawal: Thoughts cease and subject experiences
them as removed by an external force.
5. Thought insertion: Experience of thoughts imposed by some
external force on person‟s passive mind.
6. Thought diffusion or broadcasting: Experience of thoughts
escaping the confines of self and as being experienced by others
around.
7. „ Made’ feelings or affect.
8. „Made’ impulses.
9. „Made’ volition or acts: In ‘made’ affect, impulses and volitions,
the person experiences feelings, impulses or acts which are
imposed by some external force. In „made‟ volition, for example,
one‟s own acts are experienced as being under the control of
some external force.
10. Somatic passivity: Bodily sensations, especially sensory
symptoms, are experienced as imposed on body by some external
force.
11. Delusional perception: Normal perception has a private and
illogical meaning.
According to the World (Mental) Health Report
2001, about 24 million people worldwide suffer from
schizophrenia.
The point prevalence of schizophrenia
is about 0.5-1%.
Characterized by disturbances in thought, verbal
behavior, perception, affect, motor behavior, loss of
touch with reality.
Schizophrenia, by definition, is a disturbance that must
last for six months or longer, including at least one
month of delusions, hallucinations, disorganized
speech, grossly disorganized or catatonic behavior, or
negative symptom.
Delusions
Hallucinations
Distortions or exaggerations in language and
communication
Disorganized speech
Disorganized behaviour
Affective disorder
Catatonic behaviour
Alogia – dysfunction of communication;
restrictions in the fluency and productivity of
thought and speech
Affective blunting or flattening – restrictions in the
range and intensity of emotional expression
Asociality – reduced social drive and interaction
Anhedonia – reduced ability to experience pleasure
Avolition – reduced desire, motivation or
persistence; restrictions in the initiation of goal-
directed behavior .
Disorganized thinking
Poor attention and concentration
Poor memory
Difficulty expressing thoughts
Difficulty integrating thoughts, feelings and
behavior
Between 25% and 50% of schizophrenia
patients attempt suicide; 10% eventually
succeed, contributing to a mortality rate eight
times greater than that of the general
population
•Common reasons may include co morbid
Depresssive Symptoms, Command
hallucinations, Impulsive behaviour,
anhedonia, insight of illness
Social withdrawal
Hostility or suspiciousness
Deterioration of personal hygiene
Flat, expressionless gaze
Inability to cry or express joy
Inappropriate laughter or crying
Depression
Oversleeping or insomnia
Odd or irrational statements
Forgetful; unable to concentrate
Extreme reaction to criticism
Strange use of words or way of speaking
Genetic factors
It includes twin studies and adoption study
Twin study - concordance rate of identical twins are
routinely and consistently found to be significantly
higher than those of fraternal twins or ordinary
siblings.
Adoption study - in monozygotic twins who are
genetically identical , though they are adopted by
different family members they shows same genetic
background.
Quality of adoptive family
Research shows that dysfunctional family situation
shows increase in risk of schizophrenia.
Molecular genetics
Linkage analysis – inheritance of genetic diseases
Researchers found that some of the chromosomes such as
1,2,6,8,13 and 22 are responsible for causing schizophrenia.
Why chromosomes are such important?
It is because host genes are aberrant in schizophrenia and
they are known as candidate genes.
Prenatal exposures
Viral infections
Rhesus incompatibility – damage in mother‟s immune
system and blood related diseases
Pregnancy and birth complications
Early nutritional deficiency
Maternal stress
Neuro developmental perspectives
Structural and functional brain abnormalities
Neuro-cognition
Loss of brain volume
Affected brain areas – regions of memory,
language and other sensory inputs
Brain functioning
low frontal lobe functioning (hypofrontality)
cytoarchitecture
Disruption of migration of neurons
Brain development in adolescence
problem in brain development during the period
of adolescence.
Synthesis
Problem in “functional circuits”
Neurochemistry
Dopamine and glutamite
Ketamine
Psycho social and cultural factors
Destructive parental interactions
Families and relapse
Higher emotionality leads to relapsed conditions
Expressed emotions (EE) and family conditions
are correlated
Urban living
Raised in urban environment seems to be
increased risk of schizophrenia
Immigration
• First generation immigrants shows 2.7% risk
of developing schizophrenia
• Discrimination among whites and blacks
shows risks
Cannabis abuse
• Predictor of later schizophrenia
• COMT gene
It involves disturbances in persons movement
Affected people may exhibit a dramatic reduction in
activity
They shows stupor ( a state of close to
unconsciousness)
Catalepsy ( trance seizure with rigid body)
Waxy flexibility ( limbs stay in position another
person put them in)
Mutism ( lack of verbal response)
Negativism (lack of response stimuli or instruction)
Person exhibits behaviors which fit into two
or more of the other types of schizophrenia,
It includes delusions, hallucinations,
disorganized speech behavior, catatonic
behavior.
Person has a past history of atleast one
episode of schizophrenia
But currently has no symptoms
If the active phase is left untreated,
symptoms can last for weeks, even months.
Relapses may occur more prevalent
Although called simple, it is one of the subtypes which
is the most difficult to diagnose.
It is characterised by an early onset (early 2nd decade), very
insidious and progressive course, presence of
characteristic „negative symptoms‟ of residual
schizophrenia (such as marked social withdrawal, shallow
emotional response, with loss of initiative and drive),
vague hypochondriacal features, a drift down the social
ladder, and living shabbily and wandering aimlessly.
Delusions and hallucinations are usually absent, and
if present they are short lasting and poorly systematised.
The prognosis is usually very poor.
Schizoaffective
Schizophreniform
Delusional disorder
Shared psychotic disorder
Brief psychotic disorder
SCHIZOAFFECTIVE
• uninterrupted period of illness during which , at sometimes
major depressive episodes , a manic episode or mixed episodes.
• Delusions or hallucination for atleast 2 or more weeks in the
absence of major mood episodes.
• It is characterized by abnormal thought process.
SCHIZOPHRENIFORM
It is type of psychotic illness with symptoms similar to those of
schizophrenia , but lasting for less than 6 months.
Psychosis
• Perceptual dysregulation
• Unusual beliefs or experiences
• Disorganized speech or behavior
• Lack of insight
Detachment
• Social withdrawal
• Intimacy avoidance
• Restricted emotions
• Loss of interest
DELUSIONAL DISORDERS
o Persistent false belief of persecution
o Delusions often about finances or marital fidelity
Types of delusional disorder -
Erotomanic – having belief that someone is in love
with him or her
Grandeous – over – inflated sense of worth , power,
knowledge or identity
Jealous- having belief that his or her spouse is
unfaithful
Persecutory - having belief that they are mistreated, or
someone spying on them.
Somatic – believes that he or she may have any kind of
health issues.
Mixed – 2 or more kind of symptoms listed above
SHARED PSYCHOTIC DISORDER
It is delusion that is develops in an individual who is
involved in the close relationship with another person
who already have a psychotic disorder.
The term folio a deux means “shared madness” or “
madness for two” in French
BRIEF PSYCHOTIC DISORDER
It is characterized by sudden temporary periods of
psychotic behavior, such as delusions, hallucinations,
confusion.
The disturbance is not better explained by major
depressive or bipolar disorders or other psychotic
disorders.
The treatment of schizophrenia can be
discussed
under the following major headings :-
1. Psychiatric Treatment
a. Pharmacological therapy
b. Electro-Convulsive therapy
c. Surgical Methods
2. Psycho-social Therapy and Rehabilitation
Typical/ Traditional/First
Generation Antipsychotics
1.Chlorpromazine
2.Flupentixol
3.Haloperidol
4.Loxapine
5.Pimozide
6.Prochlorperazine
7.Sulpiride
8.Thioridazine
9.Trifluoperazine
10.Zuclopenthicol
11.Triflupromaxine
Atypical/Second Generation Antipsychotics
1. Amisulpride
2. Aripiprazole
3. Clozapine
4. Olanzipine
5. Paliperidone
6. Quetiapine
7. Risperidone
8. Ziprasidone
9. Zotepine
Drugs are given to the following patients in
the OPD :-
1.Few no. of psychiatric beds in India.
2. Majority willing to take care of patient at
home.
3.Majority of patients do not require
hospitalization
ECT is not the primary treatment of choice for
schizophrenia
The indications of ECT include:-
1.Catatonic Stupor
2.Uncontrolled Catatonic Excitement
3.Acute exacerbation not controlled with drugs
4.Severe side-effects with drugs in the presence of
schizophrenia
Usually 8-12 ECT‟S are needed (upto 18 in poor
responders), administered 2-3 times a week.
Psychosurgery is not routinely practiced in patients of
schizophrenia in the clinical practice.
When used the treatment of choice is Limbic
Leucotomy and in some cases with severe and
prominent depression , anxiety or obsessional
symptoms.
Deteriorated patients are less benefited.
Maximum benefit in acute episodes
PSYCHO-EDUCATION
It is for the patient and specially the family (with
consent of patient)
Nature of illness, course and treatment is explained
in it.
Helps in establishing a good therapeutic approach
with patient.
Involves explaining the stress-vulnerability model of
schizophrenia to patients and carer(s).
GROUP PSYCHOTHERAPY
Aimed at problem solving and communication skills
Conducted in a form known as “social skills training
package”
FAMILY THERAPY
Family members provided with social skill training
Helps decrease intrafamilial tensions
Attempts are made to decrease “expressed emotions” of
“significant others” in the family.
Awareness is raised regarding lowering expectations and
avoiding critical remarks, emotional over-involvement and
hostility
MILIEU THERAPY
Also known as therapeutic community
Includes treatment in a living ,learning or a working
environment
This ranges from IPD to Day care hospitals and half-way
homes
E.g. Co-therapist or self help group who works in
accordance with the therapist
INDIVIDUAL PSYCHOTHERAPY
Supportive in nature
Psychoanalytically oriented psychodynamic
psychotherapy is not much recommended.
Many centers suggest the use of Cognitive
Behavior Therapy(CBT)
Group of therapies to assume persons
thought,behaviour and emotions which became
distorted
This was because they weren't able to understand
what motivates them
This theory thus increases the awareness of
motivation that will improve the thought,
behavior and the emotions of people.
Goal of the therapy is help individual discover the
reason and motivation of their feelings, behavior
and thinking so that they can make changes in
their life.
Used so the patient improves cognitive
distortions, reduce distractibility and correct
errors in judgment.
Reports of ameliorating delusions and
hallucinations through this method
Usually those patients benefit from this who
have a insight of this illness.
Usually along with milieu therapy.
This includes:-
o Activity therapy
o Vocational therapy
o Vocational guidance
o Independent job placement
o Occupational therapy
o Art therapy
However, usually these psychotherapies are not given
without the antipsychotic drugs.(Specially in the acute
cases)
CASE STUDY
Case name : Rajat dhillion
Age :52
Sex :male
Chief complaints : talks to oneself and smile, fearfulness,
aggressive, suspicious, make gestures while being alone.
History :
Rajat dhillion is 52 years old man and brought to the
hospital by his son the chief complaints faced by the
family are mentioned above the patient was weak in
studies since he joined school usually complaints
regarding his aggressive behavior towards the classmate
and smiling and talking while sitting alone in the class
When asked what was he doing alone he used to reply he
can cars around and he was playing with the cars and
there are many children of his age which play along
Due to his weird behavior he was disowned from the
family.
According to the mental status examination :
He had a shabby appearance not well groomed,
his behavior was not aggressive as told by the
family he made gestures while taking the MSE
he lacked eye contact he was cooperative
answered well
he was vigilant and alert he was not much
spontaneous while
answering the questions he lacked insight
he saw 3 boys and 1 girl which constantly talk to
him regarding every move and becomes offensive
when anyone comment upon the living being of
the people he talks to.
:
patient is appointed in day care
as he has poor hygiene his energy needs t be
channelized in that direction
CBT with medicines is given as the client has
poor attention and concentration an along
with that he is given
Social interaction training as he does not mix
with people so easily
