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SCHIZOPHRENIA

SCHIZOPHRENIA. SCHIZOPHRENIA Dr Nadira Khamker Senior Consultant Department Psychiatry Weskoppies Hospital University of Pretoria , Faculty of Health & Science. SCHIZOPHRENIA. Schizophrenia is a psychiatric disorder with unknown aetiology.

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SCHIZOPHRENIA

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  1. SCHIZOPHRENIA • SCHIZOPHRENIA • Dr Nadira Khamker • Senior Consultant • Department Psychiatry • Weskoppies Hospital • University of Pretoria , Faculty of Health & Science

  2. SCHIZOPHRENIA • Schizophrenia is a psychiatric disorder with unknown aetiology. • It is characterized by psychotic symptoms which incapacitate the patient’s level of functioning. • It is a chronic condition with a prodromal, acute and residual phase, or remission.

  3. Psychosis ? • ill-defined,generic term • Lack of insight is a core feature • Delusions and hallucinations are often present

  4. History of schizophrenia • Emil Kraepelin ( 1856-1926) • Eugen Bleuler ( 1857-1939) • “Dementia precox” • Bleuler coined the term “schizophrenia”

  5. Epidemiology • 0,5-1% of population • Genetic predisposition • Women=men • Women : mean age of 1st episode is 26,8 years • Men : mean age of 1st episode is 21,4 years

  6. Epidemiology contd • Genetic factors- 10x ↑ risk in persons with 1st degree relatives for developing the disease. • Medical illnesses- c • comorbid conditions , • upto 50% may be undiagnosed • Substance abuse- • common in schizophrenia, • association between cannabis and schizophrenia • Infection and Birth Season

  7. Aetiology • Unknown • Diathesis-vulnerability • Eco-genetic factors • Dopaminergic hypothesis

  8. CLINICAL FEATURES POSITIVE SYMPTOMS POSITIVE SYMPTOMS NEGATIVE SYMPTOMS COGNITIVE SYMPTOMS AGGRESSIVE SYMPTOMS AFFECTIVE SYMTOMS

  9. Symptom clusters • Reality distortion • Psychomotor poverty • Disorganisation • Cognitive domain

  10. Reality distortion • Hallucinations • Delusions

  11. Hallucination : definition • False sensory perception not associated with real external stimuli; there may or may not be a delusional interpretation of the hallucinatory experience. • Auditory, visual, olfactory, tactile and somatic hallucinations.

  12. Hallucinations in Schizophrenia • Ask the patient if he / she is hearing voices, other people can’t hear and ask in detail about the quality, frequency, intensity and reaction towards these voices

  13. Delusions : definition • False, fixed belief, based on incorrect inference about external reality, not consistent with patient’s intelligence and cultural background; cannot be corrected by reasoning. • Somatic, paranoid ( persecutory and of reference), erotomania, of control / poverty/self-accusation

  14. Delusions • Overvalued idea is NOT a delusion but an unreasonable, sustained false belief maintained less firmly than a delusion. • Bizarre delusion is absurd and implausible • Nihilistic delusion is the false feeling that self, others or the world is nonexistent or coming to an end

  15. Delusions • Delusions of poverty :they believe they are bereft or will be deprived from all property • Somatic delusions: involving body (brain is rotting) • Persecutory delusions: being harassed, cheated, or percecuted • Delusion of grandeur: exaggerated concept of • power or intelligence

  16. Delusions • Delusions of reference: the behaviours of others refers to them, people are talking about him / her. • Delusions of self-accusation: feelings of remorse and guilt. • Delusions of control: their thoughts, will or feelings are controlled by external forces

  17. Delusions of control (bizarre) • Thought withdrawal • Thought insertion • Thought broadcasting • Thought control

  18. Form of thought disturbances • Neologism : new words by combining syllabes • Word salad: inhorent mixture of words • Perseveration: persisting response to previous stimulus • Verbigaration:meaningless repetition of words • Echolalia: repeating of words • Blocking: abrupt interruption in train of thinking

  19. Thought content in schizophrenia • Delusions • Preoccupation • Ideas of reference and influence • phobias • Poverty of content • Obsessions and compulsions • Suicidal or homicidal ideas

  20. Psychomotor poverty • Lack of affective responsiveness • Loss of drive or volition • Poverty of speech and movement • Social withdrawal

  21. Negative symptoms(5As) • Affective blunting / flat affect • Alogia –relative absence in amount/ content of speech • Avolition-inability to initiate and persist in activities • Anhedonia-loss of enjoyment for activities • Attention impaired

  22. Disorganisation • Inappropriate affect • Disorganised behaviour

  23. Grossly disorganized or catatonic behavior • Aggressive,violent outbursts • Bizarre clothing appearance • Inappropriate social / sexual behavior • Catatonic behavior ,ranging from extreme excitement to stupor

  24. Cognitive domain • Impaired attention and concentration • Impaired memory and learning • Impaired executive functioning ( e.g. abstract thinking, problem solving)

  25. Disorganized speech • Disturbance in form of thought: • Circumstantiality ( delays in reaching answer) • Irrelevant answer Derailment (deviates from train of thought) Tangentially( never gets back to desired goal) Loosening of associations(shift in unrelated manner) Incoherence(thoughts not understandable)

  26. SCHIZOPHRENIA: SYMPTOLOGY DSM IV CRITERIA A: • TWO OR MORE OF THE FOLLOWING: Delusions Hallucinations Disorganized speech Grossly disorganized behavior Negative symptoms Present for at least one month

  27. CRITERIA A • If the delusion is bizarre, only one of the A Criteria is required. • For example if you believe the microchip in your front tooth controls world’s events • A voice keeping up a running commentary on the person’s behavior or thoughts or….. • Two or more voices conversing with each other.

  28. DIAGNOSIS • B. Social and occupational dysfunction • C Duration • D Exclusion criteria • E Substance abuse

  29. Schizophrenia sub types • Paranoid • Catatonic • Residual • Undifferentiated • Disorganized

  30. CLINICAL FEATURES • No symptom or sign is definitive for schizophrenia • Careful history important as symptoms change with time • Premorbid symptoms and signs appear before the prodromal phase • Patients may have shcizoid or schizotypal personalities • May be quiet, passive and introverted children • Few friends, solitary activities • May present with somatic complaints • Family and friends may notice changes in social, occupational, personal activities • May then present with peculiar behaviour, abnormal affect, unusual speech, bizarre ideas, perceptual disturbances

  31. MENTAL STATE EXAMINATION • GENERAL APPEARANCE AND BEHAVIOUR • May be unkempt, poor self-care • Psychomotor activity • SPEECH • Monotonous, poverty of speech • Disorganised speech • MOOD AND AFFECT • Reduced emotional responsiveness • Inappropriate emtions • PERCEPTUAL DISTURBANCES • Hallucinations • THOUGHT FORM DISTURBANCES • Loosening of associations • Tangentiality • THOUGHT CONTENT DISTURBANCE Delusions • IMPULSIVENESS,VIOLENCE,SUICIDE, HOMICIDE • SENSORIUM AND COGNITION • Memory, • JUDGEMENT AND INSIGHT

  32. Good prognosis in schizophrenia • Obvious precipitating factors • Acute onset • Good premorbid history / later onset • Mood symptoms or family history of moodsx • Married and / or good support system • Positive symptoms

  33. Longitudinal course • Symptoms start in adolescence • Prodromal symptoms may last for 1 year • Exacerbations and remissions • Baseline functioning deteriorates • Positive symptoms less severe with age but negative symptoms may increase in severity

  34. Chronic illness • Premorbid symptoms • Relapsing and remitting course • Deterioration in functioning over time

  35. Course and prognosis • 10-20% suffer one episode and remain symptom free • 60% follow a course of relapses and remissions, of which half achieve full remission and half partial remission.

  36. Indications for referral • Frequent relapses • Resistance to treatment • Co-morbid conditions • Lack of sufficient support / resources at primary level

  37. Psychoeducation • It is a biological disease of the brain • The precise etiology is unknown • Genetic vulnerability • Environmental factors • Long-term treatment • Rehabilitation necessary

  38. Psychological interventions • Cognitive behavioural therapy • Psychoeducation • Family therapy • Social skills training

  39. Social interventions • Halfway houses / step down facilities • Supervised group houses • Unsupervised houses • Day centres • Supported employment • Disability grants

  40. Other Psychotic Disorders • Psychotic disorders due to GMC • Substance-induced psychotic disorders • Shared psychotic disorder • Psychotic disorder not otherwise specified • Delusional disorder • Schizophreniform disorder • Schizoaffective disorder • Brief Psychotic Disorder

  41. Compared with schizophrenia • Sx <1month = brief psychotic disorder • ………………………….. • >1<6months= • Schizophreniform • ………………………….. • >6months= • schizophrenia

  42. Delusional disorder • Nonbizarre delusions • No marked impairment in functioning • Types include: erotomania, grandiose, jealous, persecutory,somatic and mixed

  43. Schizoaffective disorder • Substantial period of illness also mood symptoms • Bipolar type versus depressive type • Better prognosis than schizophrenia

  44. Differential diagnosis of PSYCHOTIC symptoms • Substance-related disorders • Epilepsy- TLE • Cerebral tumours / trauma • AIDS, Neurosyphilis,herpes encephalitis • Porphyria • SLE, Wilson’s disease, B12 deficiency

  45. Conclusion • Psychotic disorders cause extreme distress and diability over periods of time • Disorder is treatable and relapses can be limited • Primary health care worker has an important role to play

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