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SchizophreniaSCHIZOPHRENIA

HISTORICAL OVERVIEWEmil Kraeplin:- He classified mental illness as a) Manic depressive illnessb) Dementia Praecox :- emphasise the distinct cognitive decline (dementia) & early onset of disorder (praecox)

Eugene Bleueler coined the term schizophrenia that is a Greek word derived from Greek word Schizo means splitting and phrenia means mind, which indicates splitting of mind. Bleuler made a distinction between fundamental and accessory symptoms of schizophrenia

The fundamental symptoms of bleuler was also designated as 4 As1. Disturbance of Association2. Affective Disturbance3. Autism4. Ambivalence

Kurt Schneider tried to make diagnosis more reliable by identifying group of symptoms characteristics of schizophrenia, but rare in disorderSchneider First Rank symptoms1. Audible Thoughts2. Voice Arguing3. Voice Commenting4. Thought Alienation Phenomena5. Somatic Passivity Phenomena

DEFINITION Schizophrenia is a group of mental disorders that is characterised by disturbances in thinking, mood and affect with a disorganized personality

EPIDEMIOLOGY 1. Schizophrenia affects around 0.30.7% of people at some point in their life.2. It occurs 1.4times more frequently in males than females and typically appears earlier in men. The peak ages of onset are 25 years for males and 27 years for females.COURSE OF SCHIZOPHRENIATHE 1/4TH , 1/4TH , RuleEnormous individual variability1. About 1/4th of those who experience episode of schizophrenia recover completely2. Another 1/4th experience recurrent episodes, but often with only minimal impairment of functioning3. The other schizophrenics become chronic mental illness and the ability to function in society may be severely impaired

SCHIZOPHRENIA F20F20 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

TYPES1. Paranoid type: The word paranoid means delusional. Paranoid schizophrenia is the most common type of schizophrenia. Delusions or auditory hallucinations are present, but thought disorder, disorganized behavior, or affective flattening are not. Delusions are persecutory and/or grandiose, but in addition to these, other themes such as jealousy, religiosity, orsomatizationmay also be present. 2. Disorganized type: Namedhebephrenic schizophreniain the ICD. It has an early and insidious onset and is often associated with poor pre-morbid personality. Where thought disorder and flat affect are present together and extreme social impairment is present.3. Catatonic type: Catatonic schizophrenia is characterized by marked disturbance of motor behaviour. This may take the form of catatonic stupor, catatonic excitement and catatonia alternating between excitement and stupor.4. Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met. (DSM code 295.9/ICD code F20.3)5. Residual type: Where positive symptoms are present at a low intensity only. This category should be used only if when there is at least one episode of schizophrenia in the past but without prominent psychotic symptoms at present.

The ICD-10 defines two additional subtypes:[76]1. Post-schizophrenic depression: A depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present. (ICD code F20.4)2. Simple schizophrenia: Insidious and progressive development of prominent negative symptoms with no history of psychotic episodes.

CAUSES

1. Genetic Factors :- The greatest risk for developing schizophrenia is having afirst-degree relativewith the disease (risk is 6.5%); more than 40% ofmonozygotic twinsof those with schizophrenia are also affected.If one parent is affected the risk is about 13% and if both are affected the risk is nearly 50%.

2. Environmental factors associated with the development of schizophrenia include the living environment, drug use and prenatal stressors. Childhood trauma, death of a parent, and being bullied or abused increase the risk of psychosis.Living in an urban environment during childhood or as an adult has consistently been found to increase the risk of schizophrenia by a factor of two, even after taking into accountdrug use,ethnic group, and size ofsocial group.Other factors that play an important role includesocial isolationand immigration related to social adversity, racial discrimination, family dysfunction, unemployment, and poor housing conditions3. Substance use :- About half of those with schizophrenia use drugs or alcohol excessively. Amphetamine, cocaine, and to a lesser extent alcohol, can result in psychosis that presents very similarly to schizophrenia Cannabis can be a contributory factor in schizophrenia, but cannot cause it alone;its use is neither necessary nor sufficient for development of any form of psychosis. Early exposure of the developing brain to cannabis increases the risk of schizophrenia.4. Developmental factors :- Factors such as hypoxia and infection, or stress and malnutrition in the mother duringfetal development, may result in a slight increase in the risk of schizophrenia later in life

CLINICAL PICTURE

Thought & Speech Disorders

Autistic ThinkingThought BlockingNeologismPoverty of SpeechDelusionsLoosening of Association

Disorders of PerceptionHallucinations Auditory & Visua

Disorders of Affect

ApathyEmotional BluntingAnhedoniaDisorders of Motor BehaviourIncrease or decrease in psychomotor activityMannersimsStereotypesDecreased self-care and poor groomingOther FeaturesImpaired Social RelationsLoss of ego boundariesLoss of insightPoor judgementNo disturbance of consciousness, orientation, attention and memory.POSITIVE SYMPTOMS Those that appear to reflect an excess or distortion of normal functions. Positive symptoms are those that have a positive reaction from some treatment. In other words, positive symptoms respond to treatment. Hallucinations. Distortions or exaggerations of perception in any of the senses.

NEGATIVE SYMPTOMSThose that appear to reflect a diminution or loss of normal functions.

16POSITIVE SYMPTOMSNEGATIVE SYMPTOMSHallucinationsAlogiaDelusionsAvolitionBizzare BehaviourFlattening of AffectAnhedoniaAttentional ImpairmentSCHIZOPHRENIA TREATMENTTherapeutic Goals1. Minimise Symptoms2. Minimise Side-Effects3. Prevent Relapse4. Maximise Function5. RecoveryTypes of Treatment1. Biological Treatment A) Pharmacotherapy B) ECT C) Deep Brain Stimulation2. Psychological /Psychotherapeutic Treatment

TYPES OF DRUG TREATEMENT1. AntiPsychotics a) First Generation Antipsychotics b) Second Generation Antipsychotics c) Third Generation Antipsychotics2. Adjunctive Medications a) Lithium Carbonate b) Anti-Depressants c) Anti-Convulsants d) Benzodiazepines3. Other Medications a) Anti-Parkinsons b) Beta- BlockersIPS GUIDELINE RECOMMENDATIONSTherapy include 3 phases1. Acute Phase:- ( Goal- Symptom Reduction, Improvement of Functioning)2. Post-Acute Phase or Continuation Phase:- (Goal- Consolidation of remission, Relapse Prevention). It usually lasts 6 months3. Stable Phase or Maintenance Phase:- (Improving or maintaining functioning or prevention of recurrence)Choice of Drug depends upon1. Side-Effect Profile2. Response Pattern3. Patient preferences and Cost4. Preferred Route of AdministrationDURATION OF TREATMENT

It should be individualised. The suggested guidelines are:-1. First Episode Patients:- 1-2 yrs of maintenance2. Patient with several episode or exacerbation :- >/ 5 yrs of maintenance3. Patient with h/o aggression or suicide :- Indefinite Period even life longECTSchizophrenia itself is not a primary indication for ECT.The indications for ECT in schizophrenia are :- 1. Catatonic Stupor2. Uncontrolled Catatonic Excitement 3. Acute Exacerbations not controlled with drug4. Severe side-effects with drugs in presence of untreated or resistant schizophrenia5. Risk of suicide, homicide or physical assault

PSYCHOLOGICAL THERAPIES1. Group Therapy

2. Behaviour Therapy

3. Family Therapy

4. Social Skill Training

5.RehabilitationCASE SCENARIO Mr. Ali aged 26 yr male, admitted in psychiatric ward on 18-1-15 is a diagnosed case of paranoid schizophrenia since 5 yrs. On asking, client often gives delusional description about self and others. On conversation client verbalises that You have to rule the world, because you cannot trust anyone. He always maintain a in-secured position saying that people are planning to kill him. Clients relative complained that he often gets irritated on asking him to brush or bath. Also verbalised that client gives odd description of self and others On examination, general appearance of client was found to be unkempt, inadequate hygiene with evidence of body odour and dirty , delusional thinking and derealisation was identified. Draw a concept map care plan for Ali.