Lecture  № 8 Schizophrenia. Etiology and pathogenesis. Clinical pictures and types of motion  schizophrenia .  Nuclear for...
Schizophrenia  <ul><li>are characterized in general by fundamental and characteristic distortions of thinking and percepti...
Suggested  factors in the etiology of schizophrenia <ul><li>I. Predisposing  (genetic, social circumstances).  </li></ul><...
GENETICS. <ul><li>Evidence for inheritance.   Schizophrenia is more common in the families of schizophrenic patients than ...
Two main mechanisms have been suggested: <ul><li>1.Disordered brain biochemistry  has been suggested for three reasons; fi...
<ul><li>2.Abnormal   brain development.  Several strands of evidence suggest that some kind of disorder of brain developme...
Predisposing factors: <ul><li>it has been suggested that adverse living conditions contribute to etiology, since rates of ...
Precipitating (trigger) factors <ul><li>-  are stressful events occurring shortly before the onset of the disorder. Mainta...
Epidemiology. <ul><li>The annual incidence of schizophrenia is between 0.1 and 0.5 per 1,000 of the population, with the  ...
The types of debut of schizophrenia: <ul><li>I. Acute beginning of disease: </li></ul><ul><li>1. Maniac-like debut. </li><...
The types of debut of schizophrenia: <ul><li>II. Gradually beginning of disease: </li></ul><ul><li>1. Affective willing im...
Basic form of  schizophrenia <ul><li>Paranoid schizophrenia </li></ul><ul><li>Hebephrenic schizophrenia </li></ul><ul><li>...
Paranoid schizophrenia <ul><li>Paranoid schizophrenia is dominated by relatively stable, often paranoid delusions, usually...
Hebephrenic schizophrenia   <ul><li>A form of schizophrenia in which affective changes are prominent, delusions and halluc...
Catatonic schizophrenia <ul><li>Catatonic schizophrenia is dominated by prominent psychomotor disturbances that may altern...
Simple schizophrenia   <ul><li>A disorder in which there is an insidious but progressive development of oddities of conduc...
Types of flowing of schizophrenia: <ul><li>I. Chronic flowing – continuous-progredient type. It develops during many years...
Types of remission of schizophrenia: <ul><li>I. Complete (remission A) – total disappear positive symptoms and preserves i...
Treatment of  schizophrenia <ul><li>Antipsychotic drugs. </li></ul><ul><li>Anxiolytics. </li></ul><ul><li>Electro-convulsi...
ANTIPSYCHOTICS   (Neuroleptics, Major Tranquillisers)  <ul><li>Antipsychotics are used principally in the treatment of psy...
ANTIPSYCHOTICS – GENERAL PRECAUTIONS <ul><li>All antipsychotics are central nervous system depressants  and metabolised in...
TYPICAL ANTIPSYCHOTICS <ul><li>SHORT  ACTING INJECTIBLES </li></ul><ul><li>GENERIC NAME  BRAND NAME   </li></ul><ul><li>ch...
ATYPICAL ANTIPSYCHOTICS <ul><li>GENERIC NAME  BRAND NAME(S) </li></ul><ul><li>amisulpride  Solian  </li></ul><ul><li>aripi...
ANTICHOLINERGICS  (Side Effect Drugs, Antiparkinsonians)   <ul><li>These drugs are used principally for the treatment of P...
ANXIOLYTICS  (Antianxiety Drugs) <ul><li>These compounds are effective in relieving the symptoms of anxiety.  The main com...
BENZODIAZEPINES  <ul><li>  GENERIC NAME BRAND NAME(S)  </li></ul><ul><li>alprazolam  Xanax, Kalma  </li></ul><ul><li>broma...
Electroconvulsive therapy (ECT) <ul><li>Electroconvulsive therapy , also known as electroshock, is a well-established, alb...
Psychotherapy   <ul><li>Psychoanalytic   </li></ul><ul><li>Cognitive behavioral  </li></ul><ul><li>Psychodynamic   </li></...
Social treatment and rehabilitation <ul><li>Much of the skill in treating schizophrenia is in arranging an environment   t...
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schizophrenia

  1. 1. Lecture № 8 Schizophrenia. Etiology and pathogenesis. Clinical pictures and types of motion schizophrenia . Nuclear forms of schizophrenia. Differential diagnosis. Treatment and rehabilitation. Lecturer Savka Svitlana Dmitryvna
  2. 2. Schizophrenia <ul><li>are characterized in general by fundamental and characteristic 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. 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. </li></ul>
  3. 3. Suggested factors in the etiology of schizophrenia <ul><li>I. Predisposing (genetic, social circumstances). </li></ul><ul><li>II. Precipitating (trigger) - acute life stress. </li></ul><ul><li>III. Maintaining (chronic life stress, f amily emotional reactions). </li></ul>
  4. 4. GENETICS. <ul><li>Evidence for inheritance. Schizophrenia is more common in the families of schizophrenic patients than in the general population (where the lifetime risk is a little less than 1%). Thus among the siblings of schizophrenics the risk is about 14%; among the children of one schizophrenic parent it is about 13%, and among the children of two schizophrenic parents it is about 37%. Twin stu­dies indicate that a major part of this familial loading is likely to be due to genetic rather than to environmental factors. The strik­ing finding is that among monozygotic twins the concordance rate (the frequency of schizophrenia in the sibling of the affected twin) is consistently higher (about 50%) than among dizygotic twins (about 17%). </li></ul>
  5. 5. Two main mechanisms have been suggested: <ul><li>1.Disordered brain biochemistry has been suggested for three reasons; first, many genetic disorders are caused by this mechanism; second, the response of some schizophrenic symptoms to antipsychotic drugs suggests that they have a biochemical basis; third, the abuse of amphetamine, a drug which increases dopamine functions, can induce a disorder like schizophrenia. A disorder of dopamine transmission has been suggested, mainly because effective antipsychotic drugs reduce dopaminergic func­tion in the brain. Despite extensive research, there is still no convincing evidence that disordered activity of dopaminergic systems is the cause of schizophrenia . </li></ul>
  6. 6. <ul><li>2.Abnormal brain development. Several strands of evidence suggest that some kind of disorder of brain development could be important in the etiology of schizophrenia, but the ideas are speculative. First “soft signs” (neurological signs which do not point to a local lesion in the brain) have been reported in adults with schizophrenia, suggesting a neurological abnormality of some kind. Second, schizophrenics are more likely than other people to have a history of obstetric complications, and these could have caused brain damage. </li></ul>
  7. 7. Predisposing factors: <ul><li>it has been suggested that adverse living conditions contribute to etiology, since rates of schizophrenia are higher among people living in areas of social deprivation. However, this association could arise because people who are developing schizophrenia tend to be ineffective socially and therefore move into socially deprived residential areas (“social drift”). Schizophrenia is more frequent among people of low social class and this association could be explained similarly: either life in a lower social class environment is stressful, or people who are developing schizophrenia tend to move into jobs that are of lower social class. </li></ul>
  8. 8. Precipitating (trigger) factors <ul><li>- are stressful events occurring shortly before the onset of the disorder. Maintaining factors include chronic family stress, particularly strongly expressed feelings among family members (“high emotional expression”, often referred to as “high EE”). Some schizophrenics are highly aroused (as judged by physiological measures). It has been suggested that social withdrawal is a protective mechanism to reduce arousal, and that strongly expressed feelings within the family provoke relapse by increasing arousal. </li></ul>
  9. 9. Epidemiology. <ul><li>The annual incidence of schizophrenia is between 0.1 and 0.5 per 1,000 of the population, with the highest rates be­ing among young men and women aged between 35 and 39 years. The point prevalence of schizophrenia is between 2.5 and 5.3 per thousand (substantially higher than the incidence because some cases become chronic). The lifetime risk of developing schizophre­nia is about 1 in 100 (7.0-9.0 per thousand). </li></ul>
  10. 10. The types of debut of schizophrenia: <ul><li>I. Acute beginning of disease: </li></ul><ul><li>1. Maniac-like debut. </li></ul><ul><li>2. Depressive debut. </li></ul><ul><li>3. Delirious debut. </li></ul><ul><li>4. Epileptic form debut. </li></ul>
  11. 11. The types of debut of schizophrenia: <ul><li>II. Gradually beginning of disease: </li></ul><ul><li>1. Affective willing impoverishing of person. </li></ul><ul><li>2. Anti social debut. </li></ul><ul><li>3. Mannered-bizarrerie debut </li></ul><ul><li>4. Psychoasthenic debut. </li></ul><ul><li>5. Neurosthenic (asthenohypochondrical) debut </li></ul><ul><li>6. Hysteric debut </li></ul><ul><li>7. Hallucination-delusion debut. </li></ul>
  12. 12. Basic form of schizophrenia <ul><li>Paranoid schizophrenia </li></ul><ul><li>Hebephrenic schizophrenia </li></ul><ul><li>Catatonic schizophrenia </li></ul><ul><li>Simple schizophrenia </li></ul>
  13. 13. Paranoid schizophrenia <ul><li>Paranoid schizophrenia is dominated by relatively stable, often paranoid delusions, usually accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances. Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous. </li></ul>
  14. 14. Hebephrenic schizophrenia <ul><li>A form of schizophrenia in which affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and mannerisms common. The mood is shallow and inappropriate, thought is disorganized, and speech is incoherent. 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. </li></ul>
  15. 15. Catatonic schizophrenia <ul><li>Catatonic schizophrenia is dominated by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism. Constrained attitudes and postures may be maintained for long periods. Episodes of violent excitement may be a striking feature of the condition. The catatonic phenomena may be combined with a dream-like (oneiroid) state with vivid scenic hallucinations. </li></ul>
  16. 16. Simple schizophrenia <ul><li>A disorder in which there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance. The characteristic negative features of residual schizophrenia (e.g. blunting of affect and loss of volition) develop without being preceded by any overt psychotic symptoms. </li></ul>
  17. 17. Types of flowing of schizophrenia: <ul><li>I. Chronic flowing – continuous-progredient type. It develops during many years and finishes specific dementia. </li></ul><ul><li>II. Fits-like progredient type – with acute fits and periods remission. Result in defect of personality. </li></ul><ul><li>III. Fits-like type (reccurent) - with acute fits (flashes, as maniac and depressive phase) and periods remission after its. Result in defect of personality. Defect of personality is insignificant. </li></ul><ul><li>IV. Constant (stationary) – flowing of disease is unchanged during years. </li></ul>
  18. 18. Types of remission of schizophrenia: <ul><li>I. Complete (remission A) – total disappear positive symptoms and preserves insignificant negative symptoms. </li></ul><ul><li>II. Incomplete (remission B) – significant lowering positive symptoms and preserves temperate negative symptoms (work ability is limited). </li></ul><ul><li>III. Incomplete (remission C) - temperate lowering positive symptoms, significant defect of personality (work ability is total lost). </li></ul><ul><li>IV. Partially (remission D) – lowering of acuity flowing of disease (patients need in treatment). </li></ul>
  19. 19. Treatment of schizophrenia <ul><li>Antipsychotic drugs. </li></ul><ul><li>Anxiolytics. </li></ul><ul><li>Electro-convulsive therapy. </li></ul><ul><li>Psychotherapy. </li></ul>
  20. 20. ANTIPSYCHOTICS (Neuroleptics, Major Tranquillisers) <ul><li>Antipsychotics are used principally in the treatment of psychoses. They diminish the agitation, delusions, hallucinations and thought disorder of these illnesses. The drugs have less effect on the symptoms of apathy and withdrawal. Treatment response is most dramatic during the first six weeks thereafter it tapers off. </li></ul>
  21. 21. ANTIPSYCHOTICS – GENERAL PRECAUTIONS <ul><li>All antipsychotics are central nervous system depressants and metabolised in the liver therefore care should be taken when: </li></ul><ul><li>• prescribing them for persons with respiratory or cardiac problems; </li></ul><ul><li>• using with other central nervous system depressants including alcohol; </li></ul><ul><li>• driving a car or as reaction times can be slowed. </li></ul><ul><li>• prescribing for persons with liver problems; </li></ul><ul><li>• prescribing with other drugs metabolised in the liver. </li></ul><ul><li>Lower doses are usually required in the elderly. </li></ul><ul><li>They should be used with caution in children and adolescents. </li></ul><ul><li>These drugs should not be prescribed for persons with known hypersensitivity to the drugs. </li></ul>
  22. 22. TYPICAL ANTIPSYCHOTICS <ul><li>SHORT ACTING INJECTIBLES </li></ul><ul><li>GENERIC NAME BRAND NAME </li></ul><ul><li>chlorpromazine Largactil </li></ul><ul><li>haloperidol Serenace </li></ul><ul><li>trifluoperazine Stelazine </li></ul><ul><li>LONG ACTING INJECTIBLES </li></ul><ul><li>GENERIC NAME BRAND NAME </li></ul><ul><li>flupenthixol decanoate Fluanxol </li></ul><ul><li>fluphenazine decanoate Modecate </li></ul><ul><li>haloperidol decanoate Haldo </li></ul><ul><li>zuclopenthixol decanoate Clopixol Depot </li></ul>
  23. 23. ATYPICAL ANTIPSYCHOTICS <ul><li>GENERIC NAME BRAND NAME(S) </li></ul><ul><li>amisulpride Solian </li></ul><ul><li>aripiprazole Abilify </li></ul><ul><li>clozapine Clozaril, Clopine </li></ul><ul><li>olanzapine Zyprexa, Zydis (wafers) </li></ul><ul><li>quetiapine Seroquel </li></ul><ul><li>risperidone Risperdal </li></ul>
  24. 24. ANTICHOLINERGICS (Side Effect Drugs, Antiparkinsonians) <ul><li>These drugs are used principally for the treatment of Parkinson’s Disease. In this context, they are used to treat drug-induced parkinsonism and other movement disorders caused by the administration of antipsychotic medications. They may be taken orally or given by injection as the situation warrants. </li></ul>
  25. 25. ANXIOLYTICS (Antianxiety Drugs) <ul><li>These compounds are effective in relieving the symptoms of anxiety. The main compounds in this category are the benzodiazepines. </li></ul><ul><li>SIDE EFFECTS </li></ul><ul><li>Drowsiness </li></ul><ul><li>Impairment of concentration and reaction times </li></ul><ul><li>Impairment of some memory functions </li></ul><ul><li>Muscle incoordination – especially in the elderly which can lead to falls </li></ul><ul><li>Muscle weakness </li></ul><ul><li>Blurred vision </li></ul>
  26. 26. BENZODIAZEPINES <ul><li> GENERIC NAME BRAND NAME(S) </li></ul><ul><li>alprazolam Xanax, Kalma </li></ul><ul><li>bromazepam Lexotan </li></ul><ul><li>clobazam Frisium </li></ul><ul><li>clonazepam Rivotril, Paxam </li></ul><ul><li>diazepam Antenex, Ducene, Valium </li></ul><ul><li>lorazepam Ativan </li></ul><ul><li>oxazepam Alepam, Murelax, Serepax </li></ul>
  27. 27. Electroconvulsive therapy (ECT) <ul><li>Electroconvulsive therapy , also known as electroshock, is a well-established, albeit controversial, psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Today, ECT is most often used as a treatment for severe major depression which has not responded to other treatment, and is also used in the treatment of mania (often in bipolar disorder), catatonia and schizophrenia. </li></ul>
  28. 28. Psychotherapy <ul><li>Psychoanalytic </li></ul><ul><li>Cognitive behavioral </li></ul><ul><li>Psychodynamic </li></ul><ul><li>Existential </li></ul><ul><li>Humanistic </li></ul><ul><li>Transpersonal </li></ul><ul><li>Hypnotherapy </li></ul><ul><li>Gestalt Therapy </li></ul>
  29. 29. Social treatment and rehabilitation <ul><li>Much of the skill in treating schizophrenia is in arranging an environment that is optimally stimulating. With insufficient stimulation negative symptoms increase; with too much stimulation positive symptoms become more pronounced. To achieve the desired balance, attention has to be given to the patient's accommodation his work, and his leisure activities. As explained above, strong emotional reactions by relatives are a potent form of stress; therefore an effort should be made to reduce such reactions with family counseling. If this effort is unsuccessful, the patient may choose to live in a hostel, a group home, or lodgings. A homeless patient may also live in such accommodation. Similar attention needs to be given to finding suitable work and suitable leisure activities for the patient. </li></ul>
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