schizophrenia 2

schizophrenia:

schizophrenia Haresh Mehta MD

Overview:

Overview A devastating and very debilitating mental illness affects individual and the rest of the family members Characterized by disorder of thoughts, affect perception and bizarre behaviors Occurs in 1% of the populations in all cultures Equally affects male and female Carries high risk of suicide (10%)

Historical perspective:

Historical perspective 1856 Morel coined the term “ demence precoce” 1871 Hecker identified and describe condition of “ Hebephrenic” 1874 Kahlboum described “catatonia” 1896 Emil Kraepline coined the term “ Dementia Praecox” He described the condition in detailed and differentiated it from Manic Depressive disorder psychosis Early 1900 Schneider established so called “schneiderian criteria” 1922 Eugene Bleuler named the disorder as Schizophrenia

Etiology :

Etiology 1% prevalence rate in all cultures Equally common in men and women In men typical age of onset late teens to early 20s while in women late 20s to early 30s Polygenic with mediation of environmental and developmental factors The finish adoptive family study of schizophrenia shows genetic s plays major role

Inheritability :

Inheritability Family history Approximate life time incidence (%) None 1 Third degree relative e.g. first cousin 2 Second degree relatives e.g. niece or nephew 2 to 6 First degree relatives e.g. .parent, child, sibling 6 to 17 Diazygotic twin 17 Monozygotic twin 50

DSM IV (Modified):

DSM IV ( Modified) A two or more of the following ( duration at least one month or less if successfully treated) 1…delusions 2…hallucinations 3…disorganized speech 4…grossly disorganized behaviors or catatonia 5…negative symptoms B social and occupational dysfunction C Duration of disturbances for six month including one month of acute symptoms, may have prodromal symptoms D Exclude schizo affective disorder, mood disorder, psychosis due to medical problems or substance induced and PDD

Clinical signs and symptoms:

Clinical signs and symptoms Positive symptoms Negative symptoms Disorganized symptoms

Positive symptoms:

Positive symptoms Hallucinations auditory more common than visual Delusions persecutory, grandiose, Religious, erotomanic, somatic , thought insertion, thought broadcasting ,thought control, thought withdrawal Tactile and olfactory hallucinations have also been reported

Negative symptoms:

Negative symptoms General “blunting” or flattening of affective expressions Anhedonia A sociality A logia (poverty of speech) Poverty of speech contents Attention disturbances Loss of volition Apathy Differentiate “primary” negative symptoms from “Secondary” caused by positive symptoms, depression, and medications side effects (pseudoparkinsonism)

Disorganized symptoms:

Disorganized symptoms Derailment (loose association) Illogicality Thought blocking Neologisms Clang associations Incoherence (word salad ) Idiosyncratic speech Catatonia Mutism Negative mannerisms Stereotypic movements excitement

Types of schizophrenia:

Types of schizophrenia Paranoid schizophrenia Disorganized schizophrenia Catatonic schizophrenia Undifferentiated schizophrenia Residual schizophrenia

Differential diagnosis :

Differential diagnosis Brief psychotic disorder ( duration at least one day but less then one month) Delusional disorder (delusions are not bizarre and no other features of schizophrenia ) Mood disorders with psychotic features Schizophreniform disorder ( similar features but duration of 1 to 6 months, no decline in functioning) Schizotypal personality disorder (pervasive pattern of social and interpersonal deficits, eccentric behaviors, cognitive and perceptual distortions) Substance abuse disorder

Differential diagnosis:

Differential diagnosis Medical illnesses (hepatic encephalopathy, electrolytes imbalance, sepsis) Medication induced (anticholoinergic,anxiloytics,digoxin,steroids,dilantin,narcotics and cimetidine ) Pervasive developmental disorder

Schizoaffective disorder:

Schizoaffective disorder The key feature is a major depressive disorder , manic or depressive or mixed episode occurring with DSM IV criteria A symptoms of schizophrenia Delusions or hallucinations persist for at least two weeks without any predominant mood symptoms

Case 1:

Case 1 A 21 year-old man is brought to the emergency department by the police after he was found sitting in the middle of a busy street. The patient told the officers, “The voices told me to do it.” The patient states that for the past year he has felt that “ people are not who they say they are.” he began to isolate himself in his room and dropped out of school. He claims that he hears voices telling him to do “bad things.” there are often two or three voices talking, and often commenting to each other on his behavior. He denies that he currently uses drugs or alcohol, although he reports that he occasionally smoked marijuana in the past. He says that he has discontinued this practice over the past 6 months because “it makes the voices louder.” He denies any medical problems and is taking no medications.

Case 2 :

Case 2 A 46-year-old man presents with a long-standing belief that his thoughts are being taken from his head and used to create a blockbuster movie. He is certain that the government is involved because they often communicate with him through a microchip they have implanted in his brain. Although he feels frustrated at being taken advantage of, he denies any significant depressive symptoms and is often able to enjoy playing cards with his peers at the group home.

Case 3:

Case 3 A 27-year-old woman states that for approximately 6 months she has believed that Michael Jackson is in love with her. She insists that he professed his intentions to marry her through messages in his song lyrics. She has written numerous letters to him and loitered around his home, resulting in several arrests. She is irritated because, although he won’t meet with her in person, he often calls her name outside her window when no one else is around. For the past several weeks, she has slept approximately only 2 hours a night but still has enough energy to continuously redecorate her apartment in preparation for her wedding to Mr. Jackson. She admits to feeling “on top of the world” because Michael Jackson has chosen her and that she “can’t stop talking about it.”

Case 4:

Case 4 A 24-year-old woman was admitted to the obstetrical service for the delivery of a full-term baby boy. One day after the delivery, the obstetrics service requested a consultation from the psychiatrist on duty to “rule out schizophrenia.” The psychiatrist interviews the patient and finds out that the pregnancy was a result of a rape the patient suffered 9 months previously. The patient is planning to give the baby up for adoption. She claims that she has never seen a psychiatrist and has never felt a need to do so. She speaks at length about how the rape was “written in the stars”: for all to see; she is an avid astrologer. She denies having recurrent thoughts or nightmares about the rape itself. She states tat she has very few close friends, preferring to study astrology and astral projection at home by herself. She believes strongly in reincarnation, although she know that her family thinks the belief is strange. She admits that she worked intermittently as a “crystal ball gazer” but has never held a steady, full-time, paying job.

Case 5:

Case 5 64 –years- old man was screaming that there were strange men in his hospital room. He had gone through hip replacement sugary 3 days ago and was recovering well. He claims that previous evening he had seen same men sitting out side his room by the window. They did not say any thing to him but he feels per sure that they are going to hurt him. He has no prior psychiatric history. Nurses has documented that during the evening he was agitated, confused and disoriented and stuporous. At the time of consultation pt was alert and oriented X 3His MSE was other wise normal. There were no hallucination or delusions

Case 6:

Case 6 A 28 years old single female teacher met a married college professor during visit to Boston and had brief affair with him. She later returned to her home town and got job in California. Although she had no further contact with him she began to believe that he loved her and wants her to be with him in Boston. She impulsively bought plane ticket and showed up at his door step where he lived with his wife and children. She refused to believe that he did not have any thing to do with her and leave him alone.

The Dopaminergic Pathways of the Brain:

Mesocortical dopamine pathway Basal ganglia Tuberoinfundibular dopamine pathway Tegmentum Substantia nigra Mesolimbic dopamine pathway Nigrostriatal dopamine pathway Hypothalamus The Dopaminergic Pathways of the Brain

Treatment :

Treatment Psychopharmaco therapy Psycho social treatments

Prognosis :

Prognosis Better prognosis in women Paranoid subtype has somewhat better outcome Being married and having higher intelligence has better outcome Schizoid personality has poor social outcome 25% has full recovery, 25% has residual symptoms, 50% has moderate to severe symptoms