Schizophrenia

Dr. PATRICIA NANKUNDA

Introduction

• The schizophrenic disorders are characterized in

general by
• distortions of thinking and perception, and
• affects that are inappropriate or blunted.
• Clear consciousness and intellectual capacity are
usually maintained although certain cognitive
deficits may evolve in the course of time.
Cont’

• The most important psychopathological

phenomena include
• thought echo
• thought insertion or withdrawal
• thought broadcasting
• delusional perception and delusions of control
• influence or passivity
• hallucinatory voices commenting or discussing the patient
in the third person
• thought disorders and negative symptoms.
Definition

• Schizophrenia occurs with regular frequency nearly

everywhere in the world in 1 % of population and
begins mainly in young age (mostly around 16 to 25
years).
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
Positive and Negative
Symptoms

Negative Positive
Alogia (no speech) 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
Cont’

Acute > positive Chronic > negative

• Lack of insight • Social withdrawal
• Under activity
• Auditory hallucinations • Lack of conversation
• Ideas of reference • Few leisure interests
• Suspiciousness • Slowness
• Over activity
• Flatness of affect • Odd ideas
• Voices speaking to patient • Depression
• Delusional mood • Odd behaviour
• Thought alienation • Neglect of appearance
• Odd postures/movements
• Thoughts spoken aloud • Threats/violence 6
• Poor meal time behaviour
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
Natural history

• Pre-psychotic
• Shy, sensitive, awkward socially, introspective traits,
inability to make friends easily – schizoid personality
• Academic difficulties and low IQ as well as other
problems in social functioning

• Fluctuating course
• Failed satisfactory relationships, fewer married, poor
job history, responsible job positions rare, in
neighbourhood considered eccentric, socially
isolated.
Natural history

• Good prognostic indicators

• Acute onset, good pre-morbid personality,
precipitating factors evident, retained affectivity
and affective symptoms, absence of family
history, lack of negative symptoms

• Complications:
• Missed education, unemployment; social
isolation; prolonged hospital stay, risk of suicide
[life time risk 10%], arrests for vagrancy
Epidemiology.

• Prevalence and life time risk 1%

• Exists in all cultures
• Similar rates for males and females.
• The incidence(the number of new cases annually ) is
about 1.5 per 10,000 people.
• Age of onset is typically during adolescence,
childhood and late-life onset (over 45 years) are
rare.
DSM-5 Diagnostic Criteria for
Schizophrenia
• A. two (or more) of the following, each present for a significant
portion of time during a 1 month period (or less if successfully
treated). At least one of these must be (1), (2), or (3)
• 1. delusions
• 2. hallucinations
• 3. disorganized speech (e.g. frequent derailment or incoherence)
• 4. grossly disorganized or catatonic behavior
• 5. negative symptoms (i.e. diminished emotional expression or
avolition)
DSM-5 Diagnostic Criteria for
Schizophrenia
• B. decreased level of function: for a significant portion of
time since onset, one or more major areas affected (e.g.
work, interpersonal relations, self-care) is markedly
decreased (or if childhood/adolescent onset, failure to
achieve expected level).
• C. at least 6 month of continuous signs of the disturbance.
Must include at least 1 moth of symptoms (or less if
successfully treated) that meet Criterion A (i.e. active-phase
symptoms) and may include periods of prodromal or
residual symptoms, during which, disturbance may manifest
by only negative symptoms or by two or more Criterion A
symptoms present in an attenuated form (e.g. odd beliefs,
unusual perceptual experiences).
DSM-5 Diagnostic Criteria for
Schizophrenia
• D. rule out schizoaffective disorder and depressive
or bipolar disorder with psychotic features because
either 1) no major depressive or manic episodes
have occurred concurrently with the active-phase
symptoms, or 2) if mood episodes have occurred
during active-phase symptoms, they have been
present for a minority of the total duration of the
active and residual periods of the illness.
DSM-5 Diagnostic Criteria for
Schizophrenia
• E. rule out other causes: GMC, substances (e.g. drug
of abuse, medication)
• F. if history of autism spectrum disorder or
communication disorder of childhood onset, the
additional diagnosis of schizophrenia is made only if
prominent delusions or hallucinations are also
present for at least 1 month (or less if successfully
treated)
Types of schizophrenia
Paranoid Schizophrenia

• Paranoid schizophrenia is characterized mainly by

delusions of persecution, feelings of passive or
active control, feelings of intrusion.
• 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.
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, 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

Catatonic Schizophrenia
• Catatonic schizophrenia is characterized mainly by
motoric activity, which might be strongly increased
(hypekinesis) or decreased (stupor), or automatic
obedience and negativism.
• We recognize 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. The consciousness is
not absent.
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.
Postschizophrenic Depression

• A depressive episode, which may be prolonged,

arising in the aftermath of a schizophrenic illness.
Some schizophrenic symptoms, either „positive“ or
„negative“, must still be present but they no longer
dominate the clinical picture.
• These depressive states are associated with an
increased risk of suicide.
Simple Schizophrenia

• Simple schizophrenia is characterized by early and

slowly developing initial stage with growing social
isolation, withdrawal, small activity, passivity,
avolition and dependence on the others.
• The patients are indifferent, without any initiative
and volition. There is not expressed the presence of
hallucinations and delusions.
Delusional Disorder

• A disorder characterized by the development of one

delusion or of the group of similar related
delusions, which are persisting unusually long, very
often for the whole life.
• Other psychopathological symptoms —
hallucinations, intrusion of thoughts etc. are not
present and are excluding this diagnosis.
• It begins usually in the middle age.
Brief Psychotic Disorders

• The criteria should meet the following features:

• acute beginning ( upto 1 month)
• presence of typical symptoms (quickly changing
“polymorphic symptoms”)
• presence of typical schizophrenic symptoms.

• Complete recovery usually occurs within a few months,

often within a few weeks or even days.

• The disorder may or may not be associated with acute

stress, defined as usually stressful events preceding the
onset by one to two weeks.
Schizoaffective Disorders

• Episodic disorders in which both affective and

schizophrenic symptoms are prominent (during the
same episode of the illness or at least during few
days) but which do not justify a diagnosis of either
schizophrenia or depressive or manic episodes.
• Patients suffering from periodic schizoaffective
disorders, especially with manic symptoms, have
usually good prognosis with full remissions without
any remaining defects
Etiology of Schizophrenia

• The etiology and pathogenesis of schizophrenia is

not known

• It is accepted, that schizophrenia is „the group of

schizophrenias“ which origin is multifactorial:
• internal factors – genetic, inborn, biochemical
• external factors – trauma, infection of CNS,
stress, substance use
Genetics

• accounts for 2/3rds of variance in liability to

schizophrenia
• Familial tendency 8% prevalence in siblings;
• 46% and 12% in children if both or one parent
has illness respectively
• Twin & adoption studies: concordance rates
amongst twins
• monozygotic = 45%,
• dizygotic=14%;
 Etiology of Schizophrenia -
Dopamine Hypothesis
• The most influential and plausible are the hypotheses, based on
the supposed disorder of neurotransmission in the brain, derived
mainly from
1. the effects of antipsychotic drugs that have in common the
ability to inhibit the dopaminergic system by blocking action
of dopamine in the brain
2. dopamine-releasing drugs (amphetamine, mescaline, diethyl
amide of lysergic acid - LSD) that can induce state closely
resembling paranoid schizophrenia

• Classical dopamine hypothesis of schizophrenia: Psychotic

symptoms are related to dopaminergic hyperactivity in the brain.
Hyperactivity of dopaminergic systems during schizophrenia is
result of increased sensitivity and density of dopamine D2
receptors in the different parts of the brain.
Etiology of Schizophrenia -
Contemporary Models

• Dopamine hypothesis revisited: various

neurotransmitter systems probably takes place in
the etiology of schizophrenia (
• norepinephric,
• serotonergic,
• glutamatergic,
• some peptidergic systems);
• based on effects of atypical antipsychotics
especially.
Etiology of Schizophrenia -
Neurodevelopmental Model
• Neurodevelopmental 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.
 Treatment of Schizophrenia
• 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, chlorprotixene,
clopenthixole, levopromazine, periciazine,
conventional thioridazine
antipsychotics
(classical droperidole, flupentixol, fluphenazine,
neuroleptics) fluspirilene, haloperidol, melperone,
oxyprothepine, penfluridol, perphenazine,
pimozide, prochlorperazine, trifluoperazine

atypical amisulpiride, clozapine,

antipsychotics olanzapine,Aripiprazole quetiapine,
risperidone, sertindole, sulpiride