SCHIZOPHRENIA FIRST RANK SYMPTOMS OF SCHNEIDER ETIOLOGY OF SCHIZOPHRENIA PATHOGENESIS PSYCHIATRY REVISION NOTES BASED ON LECTURE NOTES AND HIGH YIELD FACTS BASED ON PREVIOUS YEAR QUESTIONS

1. Psychoses
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2. Psychotic disorder
• Includes
• Schizophrenia
• Delusional disorder
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3. Kraeplin classified psychiatric illness in to
• Dementia praecox
• Older name of schizophrenia
• c/c & deteriorating course
• Gradual decline of cognitine fns
• Manic depressive psychoses
• Distinct episodes of illness alternating with period of normal functioning
• No cognitive decline
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4. Bleuler coined term schizophrenia instead of
dementia parecox
• Eugen Bleuler ’s fundamental symptoms of schizophrenia
• (Also called as 4 A ’s of Bleuler)
• a. Ambivalence Marked inability to decide for or against.
• b. Autistic thinking & Withdrawal into self.
• c. Affect disturbances For example, inappropriate affect.
• d. Association disturbances Loosening of associations; thought disorder.
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5. TONY SCARIA 2010
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6. Schneider first rank symptoms of
schizophrenia
• First-rank symptoms
• 3 auditory hallucination
• Thoughts spoken aloud(thought echo)
• Voices commenting
• Third-person voices arguing
• 3 made
• Made volition
• Made actions(impulse)
• Made feelings (AFFECT)
• 3 thought
• Thought broadcasting
• Thought withdrawal
• Thought diffusion
• Delusional perception
• Somatic passivity
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7. First rank symptoms
• BADS Made VIA
• Broadcasting, insertion and withdrawal of thought
• Auditory hallucinations
• Thought echo – thoughts spoken aloud (echo de la pensee)
• 3rd person arguing – 2 or more voices arguing about the patient: “He’s a bad man.” “No, he’s good!”
• Commentary – “he is folding his arms now”
• Delusional perception (i.e. taking a normal sensory perception to mean a bizarre situation such as taking seeing an aeroplane as
indicating that the president has been shot)
• Somatic passivity / delusions of control
• Made:
• Volition – someone controlling the action, usually completed act
• Impulses – someone controlling the desire to act
• Affect – someone controlling mood/affectTONY SCARIA 2010
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8. TONY SCARIA 2010
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9. Etiology of schizophrenia
Heredity factors Environmental factors Biochemical factors
• High heritability
• Maxmm heritability
Socioeconomic • Low socioeconomic
status
• Families with high
expressed emotions
• Schism & skewed
families
• Dopamine hypothesis
• Increased serotonin
• Increased NE
Drugs • Amphetamine
• LSD
• Phencyclidine
• Ketamine
• Cocaine
• Cannabis
Metabolic &
neurological disorder
• Hungitons chorea
• Homocystinuria
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10. Schizophrenia
• High heritability
• Maxmm heritability
• Schizophrenia >>>mania>>depression
• Usual age of onset in adolescence & young adult hood
• If after 45 yrs  late onset schizophrenia
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11. Genetic risk of schizophrenia
General population 1%
One schizophrenic parent 12 %
Two schizophrenic parent 40 %
Monozygotic twin 47%
Dizygotic twin 12%
First degree relative 12 %
Second degree relative 5-6%
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12. Endophenotypic markers of genetically
transmitted schizophrenia
• Smooth pursuit eye movements
• Anti saccadic eye movement
• P50 auditory evoked potential
• Pre pulse inhibition
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13. TONY SCARIA 2010
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14. Excess of dopamine & serotonin
Decreased GABA & glutamate
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15. • Reduction in corticalngrey
matter
• Limbic system
• Prefrontal cortex
• Thalamus
• Gasal ganglia & cerebellum
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16. • Homovanillic acid
• a metabolite of dopamine is not elevated in a patient with schizophrenia
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17. Theories for pathogenesis of schizophrenia
Marital skewism One of the parent is dominating over the other
Marital schism Constantly undermine each other
Double bind theory Family members communicate in a destructively
ambiguous manner
Schizophrenogenic mother
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18. CF of schizophrenia
Thought disturbance Disorders of perception Disorders of affect
Thought content • Delusion persecution (MC)
• Delusion of reference
• Delusion of control (thought
insertion /withdrawal /broad
casting
Hallucination
• Auditory hallucination
MC type of
hallucination
 First person hallucination
/ thought echo
 Second person
hallucination 
commanding
/commenting
 Third person
hallucination
characteristic of
schicophrenia
• Apathy
• Emotional blunting
• Emotional shallowness
• Anhedonia
• Inappropriate affect
Formal thought
disorders
• Loosening of association
• Circumstantiality
• Tangentiality
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19. Symptoms
• Positive symptoms
• Negative symptoms
• Disorganisation symptoms
• Motor symptoms
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20. TONY SCARIA 2010
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21. positive symptoms Negative symptoms
• Hallucination
• Delusions
• Bizarre motor acts
Avolition
Apathy
Anhedonia
Affective flattening
Attention deficit
Alogia
• In a/c schizophrenia In c/c schizophrenia
• Respond well to typical antipsychotics poor Response to typical antipsychotics
• Hyperactivity of dopaminergic system in
mesolimbic system
• Hypoactivity of dopaminergic neurons in
dopaminergic neurons in mesocortical
• Increased serotonergic hyperactivity
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22. Symptoms
Positive symptoms
• Responds well to medications
• Presence  good prognostic
factor
• Dopamine excess(↑↑) in
mesolimbic tract
• Delusions
• Hallucinations
Negative symptoms
• Responds poorly to medications
• Presence  bad prognostic
factor
• Loss of normal function
• Dopamine decrease (↓↓)in
mesocrtical pathway
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23. Dopamine excess in mesolimbic tract +ve
symptoms
Mesolimbic tract Neural pathway from ventral tegmental tract to nucleus accumbens
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24. Positive symptoms
• Delusions
• Bizarre delusions
• Hallucination
• Auditory ***>> visual
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25. Negative symptoms
• Affective flattening
• Anhedonia 😶
• Alogia 🙊
• Decrease in verbal communication
• Asociality 🙅
• Indifference to social relationships & decrease in drive
to socialize
• Apathy 😐
• Avolition
• Loss of will or drive to indulge in goal directed
activities (hygiene) TONY SCARIA 2010
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26. Apathy  loss of concern for an idea or task
or results
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27. Negative symptoms Dopamine decrease
(↓↓)in mesocortical pathway
mesocortical pathway ventral tegmental area to prefrontal cortex
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28. Disorganization symptoms
• Formal thought disorders
• Disorganised behaviour
• Odd & inappropriate behaviour
• Inappropriate affect
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29. • Inappropriate affect
• Affect does not sync with social situation
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30. Motor symptoms / catatonia
• Stupor
• Extreme hyperactivity /immobility /minimal responsiveness t stimuli
• Excitement
• Extreme hyperactivity  non goal directed
• Posturing / catalepsy
• Echolalia (mimicking examiners speech )
• Echopraxia (mimicking examiners movements)
• Automatic obedience
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31. Waxy flexibility
• When examiner makes a passive movment  feeling of plastic
reistance (like bending soft wax candle)
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32. Gegenhalten
• Resistance to passive movement
• Directly proportional to strength of force applied
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33. Catalepsy  maintenance of posture for long
periods
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34. Automatic obedience
• Excessive cooperation with examiners commands
• Despite unpleasant consequences & even when repeated
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35. Mannerisms
• Spontaneous repetition of Odd purposeful movements
• Repeatedly saluting passerby
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36. Stereotypy
• Spontaneous repitition of odd purpose less movemnts
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37. preservation
• Induced movement which is senselessly repeated
• In respose to stimulation
• Also sign of brain damage
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38. Grimacing 😬
• Maintenance of odd facial expressions
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39. Ambivalency in motor movements
• Inability to decide the desired motor movement
• When offered for hand shake
• Repeatedly bring his hand forward or backward whether he wants to shake hands or not
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40. Diagnosis
• According to DSM-5
• 2 or more symptoms for( >1 month in ICD -10 )or >6 months in DSM-5
• Delusions
• Hallucinations
• Formal thought disorder
• Catatonia
• Negative symptoms
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41. Timothy crowe divided schizophrenia into
type I & II
Type I Type II
a/c illness c/c illness
No intelligence impairement Intelligence impairment +
d/t dopamine overreactivity Structural changes in brain (dilated ventricle)
Positive symptoms mainly Negative symptoms mainly
Good prognosis Bad prognosiss
CT scan normal Abnormal radiological finding
Responds to Rx Poor response to Rx
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42. Types
• Paranoid
• Catatonic
• Hebephrenic (disorganised )
• Undifferentiated
• Residual
• Simple
• Post schizophrenic depression
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43. Paranoid
schizophrenia
Hebephrenic
schizophrenia
(disorganised)
Catatonic type Residual Simple
• Most common
• Better prognosis
• Prominent first rank
symptoms
• + & - ve symptoms
• Bad prognosis
• Wanderers in sreet
• Silly smiles
• Silly affect
• Formal thought
disorder
• BEST PROGNOSIS • Very rare
• Worst prognosis
• Only negative
symptoms
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44. Paranoid schizophrenia
• Most common type
• Good prognosis
• Best is in catatonic
• Amphetamine can cause paranoid like
symtoms
• Dominated by hallucination & delusions
• Delusion of persecution
• Auditory hallucination
• Late onset (3rd-4th decade)
• Personality is usually preserved
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45. Catatonic schizophrenia
• best prognosis
• Dominated by catatonic (motor symptoms)
• 3 subtypes
• Excited catatonia
• Stuporous catatonia
• Catatonia alternating b/w excited & stuporous
• Best prognosis
• First line of Rx
• IV lorazepam & ECT TONY SCARIA 2010
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46. Bush francis catatonic
scale
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47. Subtypes of catatonia
• Excited catatonia
• Increased psychomotor activity
• Purposeless no relation with external environment
• Impulsive activity in response to hallucination & delusion
• Increase in speech production
• Stuporous catatonia
• Mutism rigidity negativism posturing echolalia echopraxia
• Cataplexy gegenhalten stupor
• Catatonia alternating b/w excited & stuporous
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48. Hebephrenic (disorganised schizophrenia)
• Dominated by prominent disorganisation symptoms
• Neologism +
• Early onset & bad prognosis
• Severe deterioriation of personality
• No hygiene poor social interaction odd behaviours +
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49. Undifferentiated
• Not confirming to any of above /exhibiting features of more than one
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50. Residual schizophrenia
• Charcrerised by progression from an early stage (with prominent
delusions & hallucinations) to a later stage where the delusions &
hallucinations have become minimal (minimal positive symptoms )
• Incomplete remission & residual negative symptoms
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51. Simple schizophrenia
• Prominent negative symptoms with out any history of positive
symptoms
• Slow & progressive withdrawal from social & work situations
• Worst prognosis
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52. Others
• Van gogh syndrome
• Self mutilation (injuring self)
• Pfopf schizophrenia
• Schizophrenia in a patient with mental retardation
• Schizophrenia like symptoms
• Amphetamine / cocaine/phencyclidine/cannabis
• Oneiroid schizophrenia
• SZP with a/c onset of cloding of consciousness & dream like state
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53. Self mutilation
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54. Paraphrenia
• Late onset schizophrenia
• Above 45 years
• More common in women
• Premorbid schizoid or paranoid personality
• Predominantly paranoia & auditory hallucination
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55. Prognosis
Good
• a/c or abrupt onset
• After 35 yrs (late onset)
• Presence of precipitants /stressors/depression/positive
symptoms
• Positive symptoms
• Affective symptoms
• Good family support
• Good drug response
• Family h/o mood disorders
• Catatonic type
• First episode
• Female
• CT normal
Bad
• Family h/o of schizophrenia
• past h/o
• Negative symptoms
• Male with asthetic physique
• Premorbid personality disorders
• Hospitalisation
• Poor drug responseTONY SCARIA 2010
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56. Bad prognosis
• Family h/o of schizophrenia
<20 yrs
Insidious onset
c/c course
Single or divorced
Past h/o
Predominance of negative symptoms
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57. Good prognosis
• Fat
• Female
• First episode
• Positive symptoms
Married
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58. Prognosis in schizophrenia
Good prognosis Bad prognosis
Acute or abrupt onset Insidious onset
Late onset (after 35 yrs) Early onset (<20 yrs)
Short duration < 6 months c/c course > 2 years
Presence of precipitating stressor Absence of stressor
Presence of depression Absence of depression
Family h/o mood disorder Family h/o of schizophrenia
Positive symptom s Negative symptoms
Female sex Male sex
Pyknic (fat) Asthenic
Married Single/divorced
Catatonic type Disorganised
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59. Suicide is the most common cause of death in
a pt with SZP
• d/t depression
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60. TONY SCARIA 2010
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61. Antipsychotics
• Typical antipsychotics / first generation antipsychotics
• D2 receptor antagonists
• Act on D2 receptors on mesolimbic tract effective against +ve symptoms
• Minimal effect on negative symptoms
• Atypical antipsychotics / 2nd generation antipsychotics /serotonin
dopamine antagonis
• Antagonism of 5HT2 receptors & D2 receptors
• Have effect on both positive & negative symptoms
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62. TONY SCARIA 2010
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63. First generation antipsychotics
• Phenothiazines
• Chlorpromazine
• Thioxanthenes
• Thiothixenes
• Butyrophenones
• Haloperidol
• Miscellaneous
• Pimozide
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64. TONY SCARIA 2010
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65. Extrapyramidal S/E of antipsychotics
• Blockade of D2 on nigrostriatal pathways
• High potency Typical antipsychotics
• a/c dystonia
• Acute akathisia
• Drug induced parkinsonism
• Tardive dyskinesia
• Neuroleptic malignant syndromeTONY SCARIA 2010
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67. Acute dystonia
• Earliest s/e antipsychotics
• Sudden contraction of group of muscles
• Torticollis
• Trismus
• Deviation of eyeballs
• Laryngospasm
• Rx
• Immediate administration of parenteral
anticholinergic
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68. Acute akathisia
• Commonest S/E of antipsychotics
• Inner sense of restlessness
• Inability to sit or stand in one place
• Pacing around
• Fidgeting of legs
• Rx
• B blockers
• Anticholinergics
• BZD
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69. Tardive dyskinesia
• Tardive  after prolonged exposure
• Involuntary movemnts of jaw
• Tongue
• Lips
• Trunk or extremities
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70. Drug induced parkinsonism
• Rigidity
• Bradykinesia
• Resting tremors
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71. Neuroleptic malignant syndrome
• Muscle rigidity
• Elevated temperature (>38*c)
• Increased CPK
• Leukocytosis
• d2 receptor blockade
• In hypothalamus failure of temp regulation
• In spinal neurons  autonomic features
• In corpus striatum rigidity
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74. Rx of NMS
• Stop antipsychotics
• Rigidity  myoglobinuria  renal F
• Dantrolene
• Dopamine agonist
• Amanitidine
• Bromocriptine
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75. TONY SCARIA 2010
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76. D2 blockade in tuberoinfundibular tract 
hyperprolactinemia  galactorrhea / menustral
disturbances impotence in female
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77. Thioridazine
• cardiotoxicity (torsades) prolongation of QT interval  cardiac
arrhythmia
• irreversible retinal pigmentation  retinitis pigmentosa,
• ↓↓↓EPS among typical
• EPS is Least is with clozapine
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78. Chlorpromazine
• Can cause corneal & lenticular deposits
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79. Penfluridol
• Longest acting antipsychotic
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80. Atypical antipsychotics
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81. Atypical antipsychotics
• Higher ratio of 5 HT2 to D2 blockade
• less risk of EPS /endocrine S/E
• clozapine
• Olanzapine
• Risperidone
• Aripiprazole
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84. TONY SCARIA 2010
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85. • Atypical Antipsychotics:
• Clozapine:
• AGRANULOCYTOSIS (weekly WBC), increased salivation (wet pillow syndrome)
• Quetiapine:
• QT prolongation, drug monitoring
• Ziprasidone:
• elders w/ dementia increased mortality, IM
• Risperidone:
• Insomnia, PRL↑
• Aripiprazole:
• partial agonist D2 & 5HT1, antagonist 5HT-2, adjunct tx for depression, akathisiaTONY SCARIA 2010
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86. Clozapine
• DOC for Rx reistant schizophrenia
• Low affinity for D2 receptors
• Lack of EPS preferred in patients with EPS TD
• A/E
• Agranulocytosis  dose independant
• WBC & neutrophil count should be checked every week for 6 months
• If WBC <3500 or Nphil <1500 stop Rx
• Seizures dose dependent (only in higher doses)
• Myocarditis  dose independant
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87. Long acting antipsychotics depot
antipsychotics
• In patients having poor compliance
• IM injn once a month or fortnight
• Risperidone
• Haloperidol
• aripiprazole
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88. Acute psychotic disorder
• Similar to schizophrenia but do not meet duration criteria
• Preceeded by stressor (stressful life event)a/c onsetresolve
completely
• May be precipitated by fever
• a/c to DSM- 5
• If symptoms <1 month  a/c & transient psychotic disorder
• a/c to ICD-10
• <1month  brief psychotic disorder
• 1-6 month schizophreniform disorderTONY SCARIA 2010
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89. Shared psychotic disorder/ induced delusional
disorder
• Spread of delusions from one person to another
• Individual who has the delusion (primary case) is typical influential
member of close relationship
• Functions normally in domains which are unaffected by the delusion
• Folie a dieux sharing of delusion b/w 2 person
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90. Delusional disorder
• Only persistent and some times life long delusions
• No hallucination/disorganisation/negative symptoms
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91. Delusional disorder Schizophrenia
CF Delusions only Delusions + other psychotic
phenomenon
Nature of delusion Simple Complex
Functionality & vegetative
symptoms
Not impaired Impaired
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92. Duration Psychosis
Upto 1 month Brief psychotic disorder
More than 1 month Schizophrenia
1 month – 6 month Schizophreniform illness
> 6 months Schizophrenia
Schizoaffective disorder  schizophrenia + BPD
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93. Acute & transient psychotic disorder
• Less than 2 weeks
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