Schizophrenia; understanding and issues

It include the defination of schizophrenia, causes and types of schizophrenia, and issues related to schizophrenia.

1. Schizophrenia
Sushma Rathee
Assistant Clinical Psychologist, PGIMER,
Chandigarh
Email [email protected]

Schizophrenia;
understanding and issues

2. Schizophrenia
Definition – mental condition involving distorted
perceptions of reality and inability to function in most
aspects of life

3. Schizophrenia
The term schizophrenia was introduced into the medical
language at the beginning of this century by the Swiss
psychiatrist Bleuler.
So far, no society or culture anywhere in the world has
been found free from schizophrenia and there is
evidence that this puzzling illness represents a serious
public health problem.

4. Schizophrenia
The most debilitating mental illnesses
Greek terms - "splitting of the mind”
do not have more than one distinct personality
distortions in their perceptions, feelings, and
relationships with the world around them.
1% of the population suffer (in 12 m period)
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5. History
Emil Kraepelin: This illness develops relatively early in life,
and its course is likely deteriorating and chronic; deterioration
reminded dementia (“Dementia praecox”), but was not followed
by any organic changes of the brain, detectable at that time.
Eugen Bleuler: He renamed Kraepelin’s dementia praecox as
schizophrenia (1911); he recognized the cognitive impairment in
this illness, which he named as a “splitting of mind”.
Kurt Schneider: He emphasized the role of psychotic
symptoms, as hallucinations, delusions and gave them the
privilege of “the first rank symptoms” even in the concept of the
diagnosis of schizophrenia.

6. 4 A (Bleuler)
Bleuler maintained, that for the diagnosis of schizophrenia are
most important the following four fundamental symptoms:
Affective Blunting
Disturbance of Association
Autism
Ambivalence
These groups of symptoms, are called four A “s” and Bleuler
thought, that they are primary for diagnosis.

7. 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

8. Course
Age (Years)
Good
Function of
Psychopathology
Poor
15 20 30 40 50 60 70
Premorbid Progression
Stable
Relapsing
Psycho-logical
Functioning

9. Progression of Schizophrenia

10. Clinical Picture
Diagnostic manuals:
lCD-10 (International Classification of Disease, WHO)
DSM-IV (Diagnostic and Statistical Manual, APA)
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).

11. Two Categories of Symptoms in
Schizophrenia
Positive symptoms
Negative symptoms

12. Positive Symptoms
Distortions or excesses of normal functioning
delusions,
hallucinations,
disorganized speech,
thought disturbances,
motor disturbances
Positive symptoms are generally more responsive
to treatment than negative symptoms

13. Delusions
False beliefs that are firmly and consistently held
despite disconfirming evidence or logic
Individuals with mania or delusional depression
may also experience delusions.
However, the delusions of patients with
schizophrenia are often more bizarre (highly
implausible).

14. Types of Delusions
Delusions of Grandeur
 Belief that one is a famous or powerful person from
the past or present
Delusions of Control
 Belief that some external force is trying to take
control of one’s thoughts (thought insertion), body,
or behavior

15. Cont….
Thought Broadcasting
Belief that one’s thoughts are being broadcast or
transmitted to others
Thought Withdrawal
Belief that one’s thoughts are being removed from one’s
mind
Delusions of Reference
Belief that all happenings revolve around oneself, and/or
one is always the center of attention
Delusions of Persecution
Belief that one is the target of others’ mistreatment, evil
plots, and/or murderous intent

16. Hallucinations
Sensory experiences in the
absence of any stimulation
from the environment
Any sensory modality may
be involved
Auditory (Hearing);
Visual (Seeing);
Olfactory (Smelling);
Tactile (Feeling);
Gustatory (Tasting);
Auditory hallucinations are
most common.

17. Common Auditory Hallucinations in
Schizophrenia
Hearing own thoughts spoken by another voice
Hearing voices that are arguing
Hearing voices commenting on one’s own
behavior

18. Disorganized Speech /
Thought Disturbances
Problems in organizing ideas and speaking so that
a listener can understand.
Loose Associations (cognitive slippage)
 continual shifting from topic to topic without any
apparent or logical connection between thoughts.
Neologisms
 new, seemingly meaningless words that are formed
by combining words.

19. Disorganized Motor Disturbances
Extreme activity levels (unusually high or low),
peculiar body movements or postures (e.g.,
catatonic schizophrenia), strange gestures and
grimaces.

20. Negative Symptoms
Behavioral deficits that endure beyond an acute
episode of schizophrenia
More negative symptoms are associated with a
poorer prognosis
Some negative symptoms might be secondary to
medications and/or institutionalization

21. Types of Negative Symptoms
Anhedonia
 inability to feel pleasure;
lack of interest or enjoyment
in activities or relationships
Avolition
inability or lack of energy to
engage in routine (e.g.,
personal hygiene) and/or
goal-directed (e.g., work,
school) activities
Alogia
lack of meaningful speech,
poverty of speech (reduced
amount of speech) or
poverty of content of speech
(little information is
conveyed; vague, repetitive)
Asociality
Impairments in social
relationships; few friends,
poor social skills, little
interest in being with other
people

22. Cont…
Flat Affect
No stimulus can elicit an emotional response
Patient may stare vacantly, with lifeless eyes
and expressionless face.
Voice may be toneless.
Flat affect refers only to outward expression, not
necessarily internal experience.

23. Common subtypes of Schizophrenia
1) Paranoid:
Delusions or hallucinations are prominent
2) Hebephrenic:
Sustained flattened or incongruous affect
Lack of goal directed behaviour
Prominent thought disorder

24. Cont….
3) Catatonic:
Sustained evidence over at least two weeks of
catatonic behaviour including stupor, excitement,
posturing, and rigidity
4) Simple:
Considerable loss of personal drive
Progressive deepening of negative symptoms
Pronounced decline in social, academic, or
employment performance

25. Causes of Schizophrenia

26. Causes of Schizophrenia
Genetic factors
Chemical imbalance & physical abnormalities –
neurotransmitters, brain structures
Biological factors – age, virus.
Environmental factors – chronic life stressors,
changes.
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27. What causes schizophrenia?
Are genes important?
While the lifetime risk in the general population in
just below 1%, it is 6.5% in first degree relatives
of patients, and it rises to more than 40% in
monozygotic twins of affected people.

29. Causes - genetic influences
Identical twin affected 50%
Fraternal twin affected 15%
Both parent affected 35%
One parent affected 15%
Brother or sister affected 10%
No affected relative 1%
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30. Early onset schizophrenia: Wave of gray matter loss -
begins in parietal cortex and spreads forward

31. Can drug abuse cause schizophrenia?
We know that stimulants like cocaine and amphetamines
can induce a picture clinically identical to paranoid
schizophrenia, and recent reports have also implicated
cannabis.

32. 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

33. 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

34. 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.

35. 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.
Contemporary models of schizophrenia conceptualize it as
a neurocognitive disorder, with the various signs and
symptoms reflecting the downstream effects of a more
fundamental cognitive deficit:
the symptoms of schizophrenia arise from “cognitive
dysmetria” (Nancy C. Andreasen)
concept of schizophrenia as a neurodevelopmental
disorder (Daniel R. Weinberger)

36. Neurodevelopmental Model
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.

37. Causes…
4.Neurotransmitters (Biological)
*too much dopamine, low levels of serotonin and
glutamate

38. Causes…
Brain Abnormalities (Biological):
* Reduced number of neurons
* Enlarged ventricles
* Thalamus abnormalities

40. Causes…
Prenatal Damage
* Malnutrition
* Viruses

41. Causes…
Environment
* Family Stress
* Poor Social Interactions
* Infections or Viruses at an early age
* Trauma at an early age

42. Causes…
Reinforcement of a bizarre behavior (Behaviorists)

43. KH2F0905
09_05
Percentage
of Risk
General
Population
Offspring of
Two
Schizophre-
nic Parents
Spouse
First
Cousin
Uncle
or Aunt
Nephew
or Niece
Grand-
child
Half
Sibling
Parent
Sibling
Fraternal Twin
Offspring of
One
Schizophre-
nic Parent
Identical
Twin
50
40
30
20
10
0
Second-Degree Relative
First-Degree Relative
1%
2%2%2%
4%
5%
6%6%
9%
Relationship to Schizophrenic Person
60
Third-Degree Relative
Unrelated Person
13%
17%
46%
48%

44. Environmental Factors
Family
Characteristics
Social Class

45. Incidence and prevalence:
Incidence studies of relatively rare disorders, such
as schizophrenia, are difficult to carry out. Surveys
have been carried out in various countries,
however, and almost all show incidence rates per
year of schizophrenia in adults within a quite
narrow range between 0.1 and 0.4 per 1000
population.

46. Consequences of schizophrenia
95% of sufferers – lasts a lifetime
1/3 of homeless suffer from Schizophrenia
15% no respond to medicine; 75% partial effective
20-50% attempt suicide, 10% kill themselves
20% shorter life expectancy
25% experience secondary depression

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47. Comorbidity
In recent years, a number studies of diagnostic
patterns in both clinical and community samples
have shown that comorbidity among mental
disorders is fairly common (Kessler, 1995).
Schizophrenia is no exception: the risk in people
with schizophrenia of meeting criteria for other
mental disorders is many times higher than in the
general population. In relation to treatment and
prognostic issues, comorbidity with depression
and substance abuse is especially relevant.

48. Issues with Schizophrenia

49. Clinical issues:
Current operationalized diagnostic systems, while
undoubtedly very reliable, leave the question of
validity unanswered in the absence of external
validating criteria. Diagnosis of schizophrenia
should therefore be considered a provisional tool
that organizes currently available scientific
knowledge for practical purposes, but leaves the
door open to future developments.

50. Cont…
Since the boundaries between schizophrenia and
other psychotic disorders are ill-defined,
differential diagnosis, particularly during the early
stages, can be difficult.
No single sign or symptom is specific of
schizophrenia so the diagnosis always requires
clusters of symptoms to be recognized over a
period of time.
Careful standardized diagnostic assessment, while
useful for research, may not be necessary in
clinical practice.

51. Cont…
The diagnosis of schizophrenia does not carry
enough information for treatment planning.
Symptoms suggestive of schizophrenia can be
found in a number of neurological and psychiatric
disorders.
Non-compliance with medical regimen.
Caregiver’s needs - cope with strange and
frightening behaviors i.e. apathy, poor personal
hygiene, violence.

52. Cont…
Depression - part of the symptoms, be masked
during acute stage
Relapse - stressors, noncompliance
Stress & coping -
Substance abuse -30% have dual diagnosis, cause
negative effect on the treatment & poor outcomes
Work - no work, inability, no motivation
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53. Common in all cultures, genders, and races
Men tend to develop symptoms earlier

54. Other issues:
Mortality: Although schizophrenia is not in itself a fatal
disease, death rates of people with schizophrenia are at
least twice as high as those in the general population.
Suicide: However, recent studies of people with
schizophrenia living in the community showed suicide
and other accidents as leading causes of death in both
developing and developed countries.
Social disability: self-care, which refers to personal
hygiene, dressing and feeding.
Occupational performance: Which refers to expected
functioning in paid activities, studying, homemaking.

55. Cont…
Functioning in relation to family and household
members, which refers to expected interactions with
spouses, parents, children or other relatives.
Functioning in a broader social context, which refers
to socially appropriate interaction with community
members, and participation in leisure and other social
activities.
Social stigma: Social stigma refers to a set of deeply
discrediting attributes, related to negative attitudes and
beliefs towards a group of people, likely to affect a
person’s identity and thus leading to a damaged sense of
self through social rejection, discrimination and social
isolation.

56. Impact on caregivers
The economic burden related to the need to
support the patient and the loss of productivity of
the family unit.
Emotional reactions to the patient’s illness, such as
guilt, a feeling of loss and fear about the future.
The stress of coping with disturbed behaviour.
Disruption of household routine.
Problems of coping with social withdrawal or
awkward interpersonal behaviour.
Curtailment of social activities.