seminar on schizophrenia

1. Seminar on approach to
schizophrenia
Moderator –Dr ABDI B.(MD,Assistant Prof.of Psychiatry)
Presenter –Dr FIRAOL G.(MD,IMR-I)

2. OUTLINE
• Introduction
• Definition
• Clinical diagnosis
• Management principles

3. Introduction
• Schizophrenia is among the most disabling and economically catastrophic
medical disorders.
• It is ranked by the World Health Organization as one of the top 10 illnesses
contributing to the global burden of disease

4. Cont…
• The prevalence of schizophrenia approaches 1 percent internationally.
• The incidence is about 1.5 per 10,000 people .
• Age of onset is typically during adolescence
• childhood and late-life onset (over 45 years) are less common.
• Slightly more men are diagnosed with schizophrenia than women (1.4:1)
and women tend to be diagnosed later in life than men

5. Definition
• Chronic, sever, debilitating mental illness.
• It is characterized by symptoms of thought, behaviour, and functional
problems

6. Clinical manifestations
• Schizophrenia is a syndrome.
• Individuals with schizophrenia generally present with several symptoms
-Positive symptoms
-Negative symptoms
- Cognitive impairment
-Mood and anxiety symptoms

7. • Positive symptoms —
-This group of symptoms includes the reality distortion symptoms of hallucinations and
delusions, as well as disorganized thoughts and behavior
Hallucinations — Hallucinations are defined as the perception of a sensory process in the
absence of an external source.
-They can be auditory, visual, somatic, olfactory, or gustatory
-Auditory hallucinations are the most common form of hallucination, with prevalence
estimates between 40 and 80 percent in people with schizophrenia

8. • Delusions — Delusions are defined as a fixed, false belief and are present
in approximately 80 percent of people with schizophrenia
• Delusions are broadly categorized as bizarre or nonbizarre
-Bizarre delusions are clearly implausible (ie, they have no possibility of
being true
- A nonbizarre delusion is one that while not true is understandable and has
the possibility of being true.

9. • Disorganization — People with schizophrenia typically display some
disorganization in behavior or thinking
• The symptoms of disorganization are -
-Tangential speech – The person gets increasingly further off the topic without
appropriately answering a question.
-Circumstantial speech – The person will eventually answer a question, but in a
markedly round about manner.
-Derailment – The person suddenly switches topic without any logic
-Neologisms – The creation of new, idiosyncratic words.
-Word salad – Words are thrown together without any sensible meaning.

10. • Negative symptoms — Negative symptoms are usually one of the first
manifestations of schizophrenia.
• up to 70 percent of patients experience negative symptoms prior to their
first positive symptom

12. Abnormal motor activity
Extreme motor agitation or retardation
Stereotyped behaviors
Waxy flexibility
Stupor
Negativism
Ecopraxia

13. Cognitive symptoms
• Inattention, easily distracted
• Impaired memory
• Poor problem-solving skills
• Poor decision-making skills
• Illogical thinking
• Impaired judgment
• Impaired learning

14. Mood and anxiety symptoms
• Depressed mood
• Anxious mood
• Guilty feeling
• Irritability
• Worry and tension
25-30% of schizophrenics develop depression in any phase of the
illness.

15. Functional impairment
• Decreased ability to work
• Problem in interpersonal relationships
• Poor self care
• Social functioning

18. Outcome of schizophrenia
Devastating illness
>50% of patients- long-term incapacity
>10% of patients commit suicide
Bad prognostic signs
Insidious onset
Long duration of episode
Childhood behavioral problems
Family history of schizophrenia
Unmarried, male
Low social class

19. Etiology
• Multifactorial causation
• Biologic,
• Non-biologic
• 1. BIOLOGIC
• Genetic
• Biochemical Factors
• Structural changes
• Physiological changes
• Psychoneuroendocrinology/immunology

20. Genetic -Twin studies-Adoption studies - Family studies
Prevalence of Schizophrenia in Specific Populations
Population Prevalence (%)
General population 1
Non-twin sibling of a schizophrenia patient 8
Child with one parent with schizophrenia 12
Dizygotic twin of a schizophrenia patient 12
Child of two parents with schizophrenia 40
Monozygotic twin of a schizophrenia patient 47

21. Biochemical Factors
Dopamine Hypothesis
Schizophrenia results from too much dopaminergic activity
Revised Dopamine hypothesis – increased dopamine at mesolimbic,
and decreased dopamine at mesocortical pathway
Other neurtransmitters- Glutamate, GABA, Serotonine, norepinephrine,
neuropeptides

22. Structural changes
Neuropathological basis for schizophrenia,
• Lateral and third ventricular enlargement
• Some reduction in cortical volume
• Reduced symmetry in schizophrenia
• the temporal, frontal, and occipital lobes

23. Physiological changes
• EEG
• Evoked Potentials
• Magnetic resonance spectroscopy- decreased brain metabolism
Psychoneuroimmunology - Immunological abnormalities
Psychoneuroendocrinology
 Hormonal abnormality- hypothalamic-pitutary axis

24. Non biologic causes
Psychoanalytic Theories
 Schizophrenia resulted from developmental fixations that occurred
earlier
odefects in ego development
Affects Interpretation of reality and the control of inner drives(sex and aggression)
oA disturbance in interpersonal relatedness
Learning Theories
 poor models for learning during childhood
learn irrational reactions and ways of thinking by imitating parents

25. Family Dynamics
 A poor mother-child relationship - increase in the risk of developing
schizophrenia
 A specific family pattern plays a causative role in the development of
schizophrenia
Pathological family behavior that can significantly increase the emotional stress
Psychosocial
 Low social class
 Immigration
 Social isolation

26. DIAGNOSIS
Psychosis is first and foremost a diagnosis of exclusion
• Relevant and known causes of psychosis should be ruled out before
diagnosing primary psychiatric disorders
• A comprehensive history
• Physical examination
• Neurological examination

27. Excluding medical illnesses
Blood tests
• TSH -exclude hypo or hyperthyroidism,
• Basic electrolytes and serum calcium to rule out a metabolic disturbance
• OFT
• CBC including ESR to rule out a systemic infection or chronic disease
• Blood film; titers of thyphoid/typhus
• Serology to exclude syphilis or HIV infection
Other investigations include:
• EEG to exclude epilepsy
• MRI or CT scan of the head to exclude brain lesions
Substance/ medication screening – urinalysis, serum toxicology- as indicated

28. MANAGEMENT
The treatment of psychosis depends on the specific diagnosis
1. Treating primary condition- medical illness/ substance use disorder/primary
psychiatric disorder
2. Antipsychotic medications
• The first line psychiatric treatment for many psychotic disorders is
antipsychotic medications
• Can reduce the positive symptoms of psychosis
3. Adjunctive drugs
4. ECT

29. Hospitalization- is indicated for
• diagnostic purposes
• for stabilization of medications
• for patients' safety because of suicidal or humicidal
ideation
• for grossly disorganized or inappropriate behaviour
• Short stays of 4 to 6 weeks are just as effective as long-term
hospitalizations

30. ACUTE TREATMENT
The goal is immediate control of psychosis.
Treatment principles for to treat someone with first episode of
schizophrenia
- start treatment as soon as possible
-decrease stress and other risk factors
-start with low dose and titrate to initial dose range.
-best use Second generation antipsychotics, if possible

31. Pharmacological treatment be initiated promptly
Antipsychotic medications- selection guided by
• the patient’s previous experience with antipsychotics
Adjunctive medications
• Benzodiazepines may be used to treat catatonia, anxiety and agitation
• Antidepressants -for treating co-morbid major depression
• Mood stabilizers and beta-blockers may be used for reducing the severity of
recurrent hostility and aggression
Psychosocial interventions - Reducing over stimulating or stressful relationships,
environments

32. –The dose may be titrated as quickly as tolerated to the target
therapeutic dose of the antipsychotic medication
• Monitoring of the patient’s clinical status for 2–4 weeks
• Avoid the temptation to prematurely escalate the dose for patients
who are responding slowly

33. II-Stabilization phase
• Goals - to enhance the patient’s adaptation to life
• Premature lowering of dose or discontinuation of medication during
this phase may lead to a recurrence of symptoms and possible relapse
III-Stable Phase
• Goal- ensure that symptom remission or control is sustained
• Regular monitoring for adverse effects

34. During the stable phase of treatment - routinely monitor
• Extrapyramidal side effects
• Weight, waist circumference, and BMI
• Blood pressure
• Symptoms of diabetes- Fasting glucose
• Evaluate whether residual negative symptoms are present or
prominent
• Hematology
• Blood chemistries, lipid abnormalities

35. Drug discontinuation
• No reliable indicator to differentiate the minority from the majority who will
relapse with drug discontinuation.
• Warn early signs of relapse;
• attend outpatient visits on a regular basis
• Indefinite maintenance antipsychotic medication - patients who have had
multiple prior episodes or two episodes within 5 years

36. Psychotherapy in Psychosis
Psychosocial treatments during the stable phase.
• Family intervention
• Supported employment
• Assertive community treatment,
• skills training, and
• cognitive behaviorally oriented psychotherapy

37. REFERENCES
• Kaplan and Sadock’s, Synopsis of Psychiatry 11th edition
• ONLINE UPTODATE

38. THANK YOU