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SCHIZOPHRENIAS
A group of common major psychoses with a
complex syndromal presentation, affecting young
adults, showing chronic changes in behavior,
perception, thoughts and emotions, causing a
fundamental disorganization in personality and
deterioration from previous levels of functioning
Epidemiology
It is a universal disease found in all countries
and all times with constant prevalence rates
 Incidence – 15-20/ 100,000/year
 Prevalence – 0.5 – 1%
 Normal risk (life time) – 0.7 – 1.3% (1%)
Exceptions to Universal Epidemiology
 Some communities have high incidence
Northern Sweden, Western Ireland, Catholics in
Canada, Tamils of South India and Sri Lanka
 In Northern Sri Lanka 34.6 / 100,000 / yr*
 Some communities have low incidence
Hutterites, Anabaptist section of United States
*Somasundaram D.J., Yoganathan S. & Ganeshvaran T.
(1993) Schizophrenia in Northern Sri Lanka, Ceylon
Medical Journal, 38, 131- 135.
Epidemiology ctd..
 Age – 15 -45 years
 Sex – Male : Female 1 : 1
 Onset is earlier in men
Aetiology- Multifactorial
Variable Phenotypic Expression
Hereditary
40% of the Pts have a family history
In Jaffna – 63 %
Relationship Likelihood of dev. Sch.
Both parents 46%
One parent 15%
One sibling 10 – 14%
MZ twin 42%
DZ twin 10 – 14%
2nd degree relatives 2 -3 %
Not related 1%
Genetic Markers- Molecular Genetics: COMT gene
Environmental factors
 Family
 Disorders in relationship and communication
 Emotional family, Double bind messages,
dominant mother
 High Expressed Emotion (EE)
- hostility
- critical
- over involvement
 Viral infection
- In utero influenza like virus
 Birth trauma
- hypoxia, cerebral injuries
 Endocrine Factors
Postpartum psychosis
Later onset in females
 Stress
Psychological – life events, trauma, migration
Physical – Viral encephalitis, Pyrexia,
anti-malarials, surgery
 Sensory loss / deprivation
 Head injury
 Epilepsy
 Drugs – amphetamines, L dopa, cannabis
 Multisystem CT disorders
 Socio – cultural
low socioeconomic state, urban (homeless,
prostitutes, prisons)
single, unemployed
?cause or ‘drift’
Neurotransmitters in Schizophrenia
 Dopamine Hypothesis
 Dopamine Hyperactivity in Mesolimbic pathways
Hypofunction in Mesocortical pathways
 Glutamate Hypothesis
 NMDA hypofunction
 The role of Serotonin
 Dysfunction in DA release
DA Pathways in Schizophrenia
Neurodevelopmental theory
 Observations
 Neuro imaging
 Neurological soft signs
 Hypofrontality
 Neurocognitive and social cognitive impairments-
poor functional outcome
 Hypothesis
 Pathological changes laid down in early life
 Non progressive damage
Cognitive and social impairment
Genetic
predisposition
Neurodevelopmentalabnormalities
Biochemical abnormalities
(DA, 5HT)
Env. factors
- In utero infection
- Obst. injury
- Social adversity
- Life stress
Neurological soft signs
SCHIZOPHRENIA
Symptoms of Schizophrnia
 Positive Symptoms
 Hallucinations
 Delusions
 Passivity
 Negative symptoms
 Apathy
 Amotivation / Avolition
 Asocialization
 Disorganization
 Thoughts
 Emotions
The Puzzle of Schizophrenia
Disorganized thoughts
Diagnosis of Schizophrenia
 Schneider's First rank symptoms
 Auditory Hallucinations –3rd person, thought echo,
commenting voices
 Thought - insertion, withdrawal, broadcasting
 Delusional perception
 Passivity
 Somatic hallucinations
 ICD 10
 DSM IV
Differential diagnosis
 Medical
 Epilepsy
 Cerebro vascular
disorders
 Cerebral neoplasms
 Head injury
 Infections
 Encepalitis, AIDS,
Systemic infections,
 Substances
 Amphetamines,
Hallucinogens,
alcohol
 Psychiatric
 Brief/Reactive
psychosis
 Schiz. Affective dis.
 Affective disorder
 Delusional disorder
 Dissociative conditions
 Possession
 PD
 OCD
Co-morbidity
 Depression
 OCD
 Anxiety disorders
 Substance abuse
Management
1. Pharmacological management
2. Other physical management
3. Psychological management
4. Rehabilitation
5. Family work
Biopsychosocial approach
Pharmacological management
 Antipsychotics
1. Typical antipsychotics
– Chlorpromazine, Trifluoperazine, Haloperidol,
Droperidol, Pimozide,
2. Atypical antipsychotics
 Olanzapine, Risperidone, Quetieapine,
Amisulpiride, Ziprasidone, Aripiprazole,
Clozapine
 Selection of drugs depends on
 Availability
 Side effect profile
 Symptoms
 Specific contra indications
 Familiarity
 Cost
Management
 Initial tranquilization
 Control of acute psychotic symptoms
 Resistant Schizophrenia- Clozapine
 Long term maintenance treatment- depot
Mental Asylum
Psychosocial management
 PsychoEducation
 Supportive psychotherapy
 CBT for resistant hallucinations and delusions-
Cognitive remediation
 Social skills training
Rehabilitation
 Helps to reintegrate
 Training in
 Self care, ADLs
 Attending skills, Communication skills, Ability to
concentrate…
 Vocational training, working in a supportive environment
 Helps in the management of
 Negative symptoms
 Dealing with resistant symptoms
 Dependency / institutionalized syndrome
Rehabilitation – ctd
 Day care centers / hospitals
 Half way homes / Supported accommodation
 Occupational Therapy
 Vocational training
 Supportive working environments
 Home environment
Occupational Therapy-
Vocational training
Agrotherapy
Family work
 Psycho education
 Learning better coping strategies
 Familiarizing with medications, symptoms,
risk assessments and limit settings
 Dealing with expressed emotions (EE)
 Need for optimal stimulation
 Family groups
 Supportive counselling to the family members
EE
 Hostility
 Critical
 Over involvement
Study of relapse rate over a period of 9 months
Total group
Low EE High EE
<35 hrs. / wk. >35 hrs./wk.
On drugs Not on drugs
12% 15% On drugs Not on drugs On drugs Not on drugs
15% 42% 53% 92%
Community
 Awareness
 Reducing stigma
 Avoiding provoking behaviours
 Rehabilitation
 Community Care
Early signs of relapse
Outcome
 30% - good recovery with previous level
of functioning
 30% - good recovery with residual
symptoms. able to function socially without
help.
 30% - handicapped by the illness. getting
frequent relapses and exacerbations. need
long term, closely supervised care
 10% - get worse, suicide
Reactive/ Brief Psychosis
Periodic Schizophrenia
Episodic Schizophrenia
Sluggish/ Deteriorating Schizophrenia
Course
Prognosis
 Good Prognosis
 Sudden onset
 Late onset
 Ass. with precipitators
 Good premorbid personality
and work record
 No F/H or P/H
 Prominent affective symptoms
 Early Treatment
 Quick response to treatment
 Compliance with medication
 Low EE
 Work, marriage,
 Family support
 Bad Prognosis
 Insidious onset
 Early onset
 No precipitators
 Schizotypal personality,
poor work records
 A positive F/H or P/H
 Negative symptoms
 Delayed Treatment (DUP)
 Poor response to treatment
 Poor drug compliance
 High EE
 Unemployment, social drift
 Lack of family support
Schizophrenia ppt

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Schizophrenia ppt

  • 1. SCHIZOPHRENIAS A group of common major psychoses with a complex syndromal presentation, affecting young adults, showing chronic changes in behavior, perception, thoughts and emotions, causing a fundamental disorganization in personality and deterioration from previous levels of functioning
  • 2. Epidemiology It is a universal disease found in all countries and all times with constant prevalence rates  Incidence – 15-20/ 100,000/year  Prevalence – 0.5 – 1%  Normal risk (life time) – 0.7 – 1.3% (1%)
  • 3. Exceptions to Universal Epidemiology  Some communities have high incidence Northern Sweden, Western Ireland, Catholics in Canada, Tamils of South India and Sri Lanka  In Northern Sri Lanka 34.6 / 100,000 / yr*  Some communities have low incidence Hutterites, Anabaptist section of United States *Somasundaram D.J., Yoganathan S. & Ganeshvaran T. (1993) Schizophrenia in Northern Sri Lanka, Ceylon Medical Journal, 38, 131- 135.
  • 4. Epidemiology ctd..  Age – 15 -45 years  Sex – Male : Female 1 : 1  Onset is earlier in men
  • 5. Aetiology- Multifactorial Variable Phenotypic Expression Hereditary 40% of the Pts have a family history In Jaffna – 63 % Relationship Likelihood of dev. Sch. Both parents 46% One parent 15% One sibling 10 – 14% MZ twin 42% DZ twin 10 – 14% 2nd degree relatives 2 -3 % Not related 1% Genetic Markers- Molecular Genetics: COMT gene
  • 6. Environmental factors  Family  Disorders in relationship and communication  Emotional family, Double bind messages, dominant mother  High Expressed Emotion (EE) - hostility - critical - over involvement
  • 7.  Viral infection - In utero influenza like virus  Birth trauma - hypoxia, cerebral injuries  Endocrine Factors Postpartum psychosis Later onset in females  Stress Psychological – life events, trauma, migration Physical – Viral encephalitis, Pyrexia, anti-malarials, surgery
  • 8.  Sensory loss / deprivation  Head injury  Epilepsy  Drugs – amphetamines, L dopa, cannabis  Multisystem CT disorders  Socio – cultural low socioeconomic state, urban (homeless, prostitutes, prisons) single, unemployed ?cause or ‘drift’
  • 9. Neurotransmitters in Schizophrenia  Dopamine Hypothesis  Dopamine Hyperactivity in Mesolimbic pathways Hypofunction in Mesocortical pathways  Glutamate Hypothesis  NMDA hypofunction  The role of Serotonin  Dysfunction in DA release
  • 10. DA Pathways in Schizophrenia
  • 11.
  • 12. Neurodevelopmental theory  Observations  Neuro imaging  Neurological soft signs  Hypofrontality  Neurocognitive and social cognitive impairments- poor functional outcome  Hypothesis  Pathological changes laid down in early life  Non progressive damage
  • 13. Cognitive and social impairment Genetic predisposition Neurodevelopmentalabnormalities Biochemical abnormalities (DA, 5HT) Env. factors - In utero infection - Obst. injury - Social adversity - Life stress Neurological soft signs SCHIZOPHRENIA
  • 14. Symptoms of Schizophrnia  Positive Symptoms  Hallucinations  Delusions  Passivity  Negative symptoms  Apathy  Amotivation / Avolition  Asocialization  Disorganization  Thoughts  Emotions
  • 15. The Puzzle of Schizophrenia
  • 16.
  • 18.
  • 19.
  • 20. Diagnosis of Schizophrenia  Schneider's First rank symptoms  Auditory Hallucinations –3rd person, thought echo, commenting voices  Thought - insertion, withdrawal, broadcasting  Delusional perception  Passivity  Somatic hallucinations  ICD 10  DSM IV
  • 21. Differential diagnosis  Medical  Epilepsy  Cerebro vascular disorders  Cerebral neoplasms  Head injury  Infections  Encepalitis, AIDS, Systemic infections,  Substances  Amphetamines, Hallucinogens, alcohol  Psychiatric  Brief/Reactive psychosis  Schiz. Affective dis.  Affective disorder  Delusional disorder  Dissociative conditions  Possession  PD  OCD
  • 22. Co-morbidity  Depression  OCD  Anxiety disorders  Substance abuse
  • 23. Management 1. Pharmacological management 2. Other physical management 3. Psychological management 4. Rehabilitation 5. Family work Biopsychosocial approach
  • 24. Pharmacological management  Antipsychotics 1. Typical antipsychotics – Chlorpromazine, Trifluoperazine, Haloperidol, Droperidol, Pimozide, 2. Atypical antipsychotics  Olanzapine, Risperidone, Quetieapine, Amisulpiride, Ziprasidone, Aripiprazole, Clozapine
  • 25.  Selection of drugs depends on  Availability  Side effect profile  Symptoms  Specific contra indications  Familiarity  Cost
  • 26. Management  Initial tranquilization  Control of acute psychotic symptoms  Resistant Schizophrenia- Clozapine  Long term maintenance treatment- depot
  • 28. Psychosocial management  PsychoEducation  Supportive psychotherapy  CBT for resistant hallucinations and delusions- Cognitive remediation  Social skills training
  • 29. Rehabilitation  Helps to reintegrate  Training in  Self care, ADLs  Attending skills, Communication skills, Ability to concentrate…  Vocational training, working in a supportive environment  Helps in the management of  Negative symptoms  Dealing with resistant symptoms  Dependency / institutionalized syndrome
  • 30. Rehabilitation – ctd  Day care centers / hospitals  Half way homes / Supported accommodation  Occupational Therapy  Vocational training  Supportive working environments  Home environment
  • 31.
  • 33. Family work  Psycho education  Learning better coping strategies  Familiarizing with medications, symptoms, risk assessments and limit settings  Dealing with expressed emotions (EE)  Need for optimal stimulation  Family groups  Supportive counselling to the family members
  • 34. EE  Hostility  Critical  Over involvement Study of relapse rate over a period of 9 months Total group Low EE High EE <35 hrs. / wk. >35 hrs./wk. On drugs Not on drugs 12% 15% On drugs Not on drugs On drugs Not on drugs 15% 42% 53% 92%
  • 35. Community  Awareness  Reducing stigma  Avoiding provoking behaviours  Rehabilitation  Community Care
  • 36. Early signs of relapse
  • 37. Outcome  30% - good recovery with previous level of functioning  30% - good recovery with residual symptoms. able to function socially without help.  30% - handicapped by the illness. getting frequent relapses and exacerbations. need long term, closely supervised care  10% - get worse, suicide
  • 38. Reactive/ Brief Psychosis Periodic Schizophrenia Episodic Schizophrenia Sluggish/ Deteriorating Schizophrenia Course
  • 39. Prognosis  Good Prognosis  Sudden onset  Late onset  Ass. with precipitators  Good premorbid personality and work record  No F/H or P/H  Prominent affective symptoms  Early Treatment  Quick response to treatment  Compliance with medication  Low EE  Work, marriage,  Family support  Bad Prognosis  Insidious onset  Early onset  No precipitators  Schizotypal personality, poor work records  A positive F/H or P/H  Negative symptoms  Delayed Treatment (DUP)  Poor response to treatment  Poor drug compliance  High EE  Unemployment, social drift  Lack of family support

Editor's Notes

  1. Aggressive symptoms such as assaultiveness and verbal abuse frequently occur in association with positive symptoms. Impairment in attention and executive functioning as well as affective symptoms such as loss of interest occur with negative symptoms