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This is a very basic presentation for anyone who would like to have more information about schizophrenia. This was intended for the third year medical students. The criteria described are based on fourth edition of the DSM ( DSMIV). All these demarcations (types of) schizophrenia will be scrapped by the DSM V (this is the proposal as of now). But this could serve a historical puspose if seen after 2013.

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  1. 1. Schizophrenia <ul><li>Pallav Pareek M.D </li></ul>
  2. 2. HISTORY <ul><li>Benedict Morel French 1809-1873, gave the term Demence Precoce </li></ul><ul><li>Emil Kraepelin German 1856-1926, furthered Morel’s work. </li></ul><ul><li>Father of Psychiatry , first doctor to differentiate the two major types of Psychosis , Maniac Depressive Psychosis, and Dementia ( Distinct Cognitive Process) Precox ( early onset) : He described them as having an early age of onset, long term detiriorating course and common symptoms of Hallucinations and delusions </li></ul>
  3. 3. <ul><li>Eugen Bleuler Swiss 1857-1939 Bleuler realized the condition was neither a dementia nor did it always occur in young people ( praecox meaning early) and so gave the condition the purportedly less stigmatising but still controversial name from the Greek roots schizein &quot;to split“ and phrēn , &quot;mind“ . By Schizophrenia he meant a schism between thought, emotion and behavior </li></ul>
  4. 4. <ul><li>Kretschmer compiled data about personality types schizophrenia occurs more in the Asthenic a.k.a Leptosomic ( slender, lightly muscled physiques) Athletic or Dysplastic( a mixture of a few body types) body types, while the Pyknik body types (short, stocky) more commonly have mania/depression </li></ul>
  5. 5. Epidemiology <ul><li>Prevalence : 1% except certain pockets like Ireland. </li></ul><ul><li>Equal distribution: M & F </li></ul><ul><li>M: MAO : 15-25 </li></ul><ul><li>F : MAO : Bimodal 25-35 , and then a second peak near menopause </li></ul><ul><li>Onset before and after 10-60 years extremely rare, If the onset is after 45 it’s called late onset SCZ </li></ul>
  6. 6. Etiology <ul><li>Birth Season: Jan to April, Southern July to September VIRAL HYPOTHESIS talks about viral (retroviruses) infection or virally activated autoimmune reactions which produce antibrain antibodies. </li></ul>
  7. 7. Cigarette smoking <ul><li>75% SCZ patients are smokers , compare to 50% All Psych Patients , and 20.8% in General Population ( United states 2007 Source: Center for Disease Control and Prevention) </li></ul><ul><li>Smoking increases the metabolism – High Antipsychotic requirement </li></ul>
  8. 8. FACTS <ul><li>WHY SCZ SMOKE SO MUCH </li></ul><ul><li>Smoking reduces the drug related parkinsonian effects ( Nicotine activates the DA in NIgrostriatal pathways) </li></ul><ul><li>Nicotine also Increases the threshold for perception of outside stimuli ( is very low in SCZ), thereby relieves symptoms such as Hallucinations, thus acts as a self medication for Patients </li></ul>
  9. 9. Socioeconomic factors <ul><li>Downward Drift Hypothesis: ( More popular hypothesis) Affected people move into or fail to rise from Low SE Status </li></ul><ul><li>Social Causation Hypothesis: Stress experienced in Low SE groups may be a cause </li></ul>
  10. 10. Neurobiological Models <ul><li>Pruning Hypothesis: Several lines of evidence support the notion that a substantial reorganization of cortical connections, involving a programmed synaptic “pruning”, takes place during adolescence in humans( Proposed reason for SCZ starting after a certain age). A review of neurobiological abnormalities in schizophrenia indicates that the neurobiological parameters that undergo peripubertal regressive changes may be abnormal in SCZ. An excessive pruning of certain areas of the Brain, may underlie schizophrenia. </li></ul>
  11. 11. DOPAMINE Hypothesis <ul><li>Too much Dopaminergic activity </li></ul><ul><li>Reasons to support </li></ul><ul><li>Efficacy of antidopaminergic( antipsychotic) drugs which act on D2 Receptors </li></ul><ul><li>Drugs which Increase DA, viz Amphetamines are Psychotomimetic </li></ul><ul><li>Plasma HVA levels , are proportionately higher in symptom severity of SCZ </li></ul>
  12. 12. Other NT’s Variously IMPLICATED <ul><li>NE </li></ul><ul><li>Serotonin </li></ul><ul><li>GABA </li></ul><ul><li>Glutamate </li></ul>
  13. 13. Various Structural abnormalities in SCZ Brains <ul><li>Increased Ventricle Size </li></ul><ul><li>Reduced Frontal lobe size ( and activity) </li></ul><ul><li>Decrease in Limbic System Size </li></ul>
  14. 14. Genetic Factors <ul><li>Almost half the chromosomes have been implicated </li></ul><ul><li>Current Research focuses on </li></ul><ul><li>Long Arm 5 11 18 </li></ul><ul><li>Short Arm 19 and X </li></ul>
  15. 15. Freud’s Explanation EGO DEFECT <ul><li>According to Freud, schizophrenia is a form of regression “ back to the oral stage of development.  The oral stage is the first stage of psychosexual development.  A baby is born a bundle of id “ is self-indulgent and concerned only with a satisfaction of his/her needs.  People with schizophrenia are overwhelmed by anxiety because their egos are not strong enough to cope with id impulses.  In schizophrenia, this can lead to self-indulgent symptoms such as delusions of grandeur </li></ul>
  16. 16. Prevalence <ul><li>General Population </li></ul><ul><li>Nontwin Sibling </li></ul><ul><li>One Parent with </li></ul><ul><li>Dizygotic Twin </li></ul><ul><li>Two Parents </li></ul><ul><li>Monozygotic Twin </li></ul><ul><li>1% </li></ul><ul><li>8% </li></ul><ul><li>12% </li></ul><ul><li>12% </li></ul><ul><li>40% </li></ul><ul><li>47% </li></ul>
  17. 17. DSM IV TR Criteria for Schizophrenia <ul><li>A) ( The criterion A ) Characteristic Symptoms: Two ( or more ) of the following each present for a significant portion of time during a one month period ( or less if treated successfully) </li></ul><ul><li>Delusions </li></ul><ul><li>Hallucinations </li></ul><ul><li>Disorganized Speech ( e.g frequent derailment or incohrence) </li></ul><ul><li>Grossly disorganised or catatonic behavior </li></ul><ul><li>Negative Symptoms ( flat affect, social withdrawl, poverty of speech, </li></ul>
  18. 18. <ul><li>B) Social/Occupational Dysfunction: for a significant portion of time since illness, disturbance in work, interpersonal relations, and self care. </li></ul><ul><li>C) Duration: Persists for at least 6 months,with 1 Month of Active symptoms ( May be less if the pt recieve RX) </li></ul><ul><li>D) Exclude Schizoaffective and Mood disorders </li></ul><ul><li>E) Report Substance/GMC </li></ul><ul><li>F) No History of Autism/PDD </li></ul>
  19. 19. Classification Of Longitudinal Course (If duration is > 1 Year) <ul><li>Episodic with interepisode residual symptoms </li></ul><ul><li>Episodic with no interepisodic Symptoms </li></ul><ul><li>Continous ( prominent psychotic symptoms throughout observed period) </li></ul><ul><li>Single episode in full remission </li></ul><ul><li>Single episode in partial remission </li></ul><ul><li>Other or Unspecified Pattern </li></ul>
  20. 20. Types of SCZ <ul><li>Paranoid </li></ul><ul><li>Disorganised </li></ul><ul><li>Catatonic </li></ul><ul><li>Undifferentiated </li></ul><ul><li>Residual </li></ul>
  21. 21. Paranoid type <ul><li>Following criteria are met </li></ul><ul><li>A) Preoccupation with one or more delusions or auditory hallucinations </li></ul><ul><li>B) None of the following is prominent – disorganised speech, disorganised or catatonic behaviour , flat or inaapropriate effect </li></ul>
  22. 22. Disorganised Type <ul><li>* Following criteria are met </li></ul><ul><li>A) All of the following are prominent </li></ul><ul><li>Disorganised speech </li></ul><ul><li>Disorganised behavior </li></ul><ul><li>Flat or inappropriate effect </li></ul><ul><li>B) Criteria for catatonic are not met </li></ul>
  23. 23. Catatonic Type <ul><li>Two of the following are present </li></ul><ul><li>Motoric immobility as evidenced by catalepsy or stupor ( including Waxy Flexibility) </li></ul><ul><li>Excessive Motor Activity. Is apparently purposeless and not influenced by external stimuli </li></ul><ul><li>Extreme Negativism( an apparently motiveless resistance to all instuction ot maintenance of a rigid posture against attempts to be moved) or Mutism </li></ul><ul><li>Peculiarities of Voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms or prominent grimacing </li></ul><ul><li>Echolalia or Echopraxia </li></ul>
  24. 24. Undifferentiated Type <ul><li>Symptoms of Schizophrenia are met, but criteria for Paranoid, Disorganised or Catatonic type are not met </li></ul>
  25. 25. Residual Type <ul><li>Following criteria are met </li></ul><ul><li>Absence of prominent delusions, hallucinations, disorganised speech , and grossly disorganised or catatonic behavior </li></ul><ul><li>There is evidence of disturbance, as indicated by Negative Symptoms , or two or more symptoms listed in Criterion A </li></ul>