General overview on schizophrenia : epidemiology,etiology,clinical features,course and outcome & treatment modalities.

1. SCHIZOPHRENIA
Speaker : Dr. Sajjadur Rehman
Specialist ( Psychiatrist), Dept. of Psychiatry
Lady Hardinge Medical College
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2. PLAN OF PRESENTATION
 Introduction
 Historical background
 Epidemiology
 Etiology
 Clinical Features
 Diagnosis
 Prognosis
 Course
 Outcome
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3. INTRODUCTION
 Schizophrenia is a clinical syndrome of variable and profoundly
disruptive psychopathology that is characterized by disturbances
of thought and perception along with emotional and behavioral
disturbances causing significant impairment in socio-occupational
functioning.
 The word schizophrenia has been derived from Greek with
“schizo” meaning split & “phrene” meaning mind, to describe the
fragmented thinking of people with this disorder
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4. HISTORICAL BACKGROUND
Benedict Morel (1852) : Demence Precoce
Emil Kraepelin (1896): Dementia Praecox & Manic Depressive
Psychosis.
Eugene Bleuler (1911)
 coined the term ‘schizophrenia’
 Schism between thought, emotion and behavior
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5. HISTORICAL BACKGROUND (CONTD.)
 Four A’s
 Association disturbances of thought
 Autism
 Affective disturbance and
 Ambivalence
Ernest Kretschmer : based on body built
Asthenic and Atheletic > Pyknic
Kurt Scheider :
Description of First Rank Symptoms ( FRS) of Schizophrenia.
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6. FIRST RANK SYMPTOMS
i. Audible thoughts, thought echo
ii. Voices heard arguing
iii. Voices commenting on one’s action
iv. Thought withdrawal
v. Thought insertion
vi. Thought diffusion or broadcasting.
vii. Made feeling.
viii. Made impulses
ix. Made volition or act
x. Somatic passivity
xi. Delusional perception
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7. EPIDEMIOLOGY
 Affects 21 million population worldwide ( WHO , 2015)
 Point Prevalence : 0.5 -1 %
 Incidence : 0.5/ 1000 population
 Indian context :
 Prevalence : 2-3 /1000 population ( ICMR , Madras, 1988)
 Incidence : 4.2 / 10,000 population in rural areas ( Sartorius , 1986)
3/ 10,000 population in urban areas ( Rajkumar, 1995)
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8. EPIDEMIOLOGY ( CONTD.)
 Age of Onset :
 Male : 10-25 years
 Female : 25-35 years ( bimodal pattern)
 Onset before 10 years and after 45 years is not common.
 Gender : equal prevalence , earlier onset in males.
 Seasonality of Birth : chances more in winter months
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9. EPIDEMIOLOGY ( CONTD.)
 Medical and Mental Illness :
 high mortality than general population
 10 % die of suicide
 increased risk of metabolic problems ( diabetes, weight
gain).
 > 50% abuse drugs and alcohol. 90 % abuse tobacco.
 Socio Economics :
 more in lower socio economic group
 more in immigrant populations
rates in single > married patients.
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10. ETIOLOGY
 Stress Diathesis Model often implicated
Genetic Factor
Polygenic inheritance
 Family studies :
Population Prevalence
Non twin Sibling with
schiz
8%
One parent with schiz 12%
Both parents with Schiz 40 %
Dizygotic twin 12%
Monozygotic twin 47%
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11. ETIOLOGY (CONTD.)
 Adoption studies :
Higher prevalence in biological parents in adoptees with schizophrenia
Biochemical Factors :
 Dopamine Hypothesis :
increased dopaminergic activity in limbic and decreased
dopaminergic function in frontal areas.
 Glutamate Hypothesis :
hypofunction of Glutamate NMDA type receptor.
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12. ETIOLOGY (CONTD.)
Other implicated Neurotransmitters : Serotonin, GABA, Epinephrine
Neurodevelopmental theory :
Abnormal neuronal migration in second trimester of fetal
life
Neuro Imaging :
 Enlarged ventricles, mild cortical atropy, reduced symmetry of
frontal , temporal and occipital areas.
 Hypofrontality and decreased glucose utilization if temporal lobe.
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13. ETIOLOGY (CONTD.)
Psychosocial factors :
 Expressed Emotions ( EE) : high EE as cause of relapse
 Family theories : double bind theory , schism & skewed family
 Psychoanalytic factors :
 Loss of ego boundaries .
 Use of defense mechanism like projection, reaction formation
and denial
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14. CLINICAL FEATURES
1 . Thought and Speech Problems :
 Formal thought disorders :
• Loosening of associations
• Derailment
• Neologism
 Abnormal thought content and Delusions :
• Primary delusions
• Secondary Delusion
• Illogical thought
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15. CLINICAL FEATURES (CONTD.)
 Thought Alienation :
 Thought withdrawal
 Thought broadcasting
 Thought Insertion
2. Disorders of Perception :
 Hallucincations
 Thought echo
 Voices commenting of one’s action
 Voices discussing about the patient ( in third person).
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16. CLINICAL FEATURES (CONTD.)
3. Disorders of Affect :
Emotionally shallow , blunt or flat response
 Inappropriate emotional expression.
4. Disorder of Motor Behavior :
Increased / Decreased Psychomotor activity
 Mannerisms, Stereotypies, Grimacing
Catatonic features
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17. CLINICAL FEATURES (CONTD.)
5. Negative Symptoms :
 asociality,
 alogia,
 anhedonia,
 avolition-apathy
 affective flattening,
 attentional impairment
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18. CLINICAL FEATURES (CONTD.)
Types of Schizophrenia
1. Paranoid
2. Disorganised / Hebephrenic
3. Catatonic
4. Undifferentiated
5. Residual
6. Simple
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19. CLINICAL FEATURES (CONTD.)
Other types of Schizophrenia
1. Pseudoneurotic Schizophrenia
2. Oneiroid Schizophrenia
3. Pfropf Schizophrenia
4. Type 1 and Type II Schizophrenia
5. Late Paraphrenia
6. Deficit Schizophrenia
7. Post Psychotic Schizophrenia
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20. DIAGNOSIS
By ICD -10 and DSM V Classificatory systems
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21. PROGNOSIS
1. Acute and abrupt onset
2. Age of onset after 35 years
3. presence of precipitating stressor
4. Good premorbid functioning
5. Catatonic type
6. Short duration of symptoms
7. Predominant positive symptoms
8. family h/o of mood disorder
9. female sex
10. good social support
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22. COURSE
 Premorbid pattern of symptoms : attentional , emotional and
cognitive problems
 Prodromal phase : Irritability, suspiciousness, social withdrawal
 Active phase : active psychotic symptoms
 Residual phase : cognitive and residual symptoms leading
deterioration in functioning
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23. OUTCOME
 Remission rates vary from 10-60 %
 As per an Indian Study ( SOFACOS under ICMR, 1981-86)
 Very favourable outcome : 27%
 Favourable outcome : 40%
 Intermediate Outcome : 31 %
 Unfavourable Outcome : 2 %
So 2/3 rd of the patients can lead a functional life
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24. TREATMENT
May be indoor /outdoor
Hospitalization required
 Posing danger to others
 Suicidality
 Severe Symptomatology
 Diagnostic evaluation
 Complicating comorbidities
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25. TREATMENT (CONTD.)
Pharmacologic & Non Pharmacologic.
I. Antipsychotics
 1st generation/ 2nd generation
 Haloperidol = 5-20 mg/day
 Olanzapine = 10-20 mg/day
 Risperidone = 4-6 mg/day
 Acute phase
 Maintainence phase
Long acting Antipsychotic Injections
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26. TREATMENT (CONTD.)
II. Other drugs
 Benzodiazepines,
 Lithium,
 Valproic acid,
 Carbamazepine
III. Electroconvulsive Therapy
Suicidality
Aggression
Catatonia
Add on treatment
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27. TREATMENT (CONTD.)
IV. Psychosocial Treatment
 Behavior Therapy
 Group Therapy
 Family Therapy
 Social Skill training
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28. THANK YOU
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