Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. It's characterized by psychosis, a type of mental illness that makes it difficult to distinguish between reality and imagination. People with schizophrenia may appear to have lost touch with reality, which can be distressing for them and their loved ones. Schizophrenia can result in a combination of hallucinations, delusions, and disordered thinking and behavior that can impair daily functioning. It can affect all areas of life, including personal, family, social, educational, and occupational functioning. Schizophrenia is usually treated with a combination of talking therapy and medicine. With ongoing treatment, most people can live normal or almost-normal lives. Most patients will get better but still have occasional episodes, but about 20 percent will recover within five years Schizophrenia is a mental illness that affects how you think and behave. The symptoms of schizophrenia include: Psychotic symptoms including hallucinations, hearing voices, or believing someone or something is out to get you Negative symptoms such as a lack of interest or an inability to take pleasure in daily activities and spending time with others Cognitive symptoms including trouble focusing and making decisions Many of the symptoms of schizophrenia are also symptoms of other conditions. Because of this, people often get misdiagnosed. Other disorders and conditions that are sometimes mistaken for schizophrenia include: Schizoaffective disorder. Schizoaffective disorder causes many of the symptoms of schizophrenia, like delusions. But people with schizoaffective disorder also have periods of depression or periods where they feel extremely energized or happy (called mania). That’s not usually the case with schizophrenia. Schizoid personality disorder. A person with schizoid personality disorder avoids social situations and interacting with others. They usually have a hard time feeling and expressing emotions. Even though schizoid personality disorder sounds a lot like schizophrenia, people who have schizoid personality disorder don’t have delusions or hallucinations. Anti-NMDAR encephalitis. This autoimmune disease causes swelling in the brain. That swelling can lead to behaviors and thought patterns that look like schizophrenia, such as paranoia and hallucinations. But most people with anti-NMDAR encephalitis have other symptoms such as seizures and suddenly passing out. Bipolar disorder. Bipolar disorder is another form of mental illness. It causes severe mood swings that impact a person’s mood, energy, concentration, behavior, and ability to do daily tasks. People with bipolar disorder often have periods of being “up” or “on” when they’re extremely energized or happy, then fall into periods of deep depression. Some people with severe bipolar disorder have delusions or hallucinations. That’s why they may be misdiagnosed with schizophrenia. Delusional disorder.

1. Schizophrenia and similar
mental disorders

2. • Of all the major psychiatric syndromes,
schizophrenia is the most difficult to define
and describe.
• schizophrenia remains a clinical diagnosis
• with a broad range of symptoms and a
variable course.

3. The history of the concept of
schizophrenia.
• In 1856, Benedict
Morel coined the
term ‘demence
precoce’ to describe
deteriorated patients
whose illnesses
began in
adolescence.

4. Emil Kraepelin (1856-1926)
‘dementia praecox’
aggregates
catatonia, hebephrenia,
and ‘dementia
paranoides’

5. Eugen Bleuler (1857-1939)
• Coined the term
schizophrenia in 1911;
• Identified specific
fundamental symptoms of
schizophrenia:
1)associational disturbances
of thought
2)affective disturbances
3)autism
4)ambivalence
• Accessory symptoms:
hallucinations and delusions

6. Kurt Schneider (1887-1967)
• Kurt Schneider
published a list of the
symptoms, that he
considered to be of
first-rank importance to
make a diagnosis of
schizophrenia

7. first-rank symptoms of schizophrenia
• Voices commenting – hallucinatory voice
commenting on one’s actions in the third
person;
• Voices discussing or arguing – hallucinations
of two or more voices discussing or arguing
about oneself;
• Audible thought – hearing one’s thoughts out
loud;

8. first-rank symptoms of schizophrenia
• Thought insertion – the insertion, by alien
sources, of thoughts that are experienced as
not being one’s own;
• Thought withdrawal – the withdrawal of
thoughts from one’s mind by an alien agency;
• Thought broadcast – the experience that one’s
thoughts are broadcast so as to be accessible
to others;

9. first-rank symptoms of schizophrenia
• Made will - the experience of one’s will being
controlled by an alien influence;
• Made acts - the experience that acts executed
by one’s own body are the actions of an alien
agency, rather than oneself;
• Made affect - the experience of emotion that
is not one’s own, attributed to an alien
influence;

10. first-rank symptoms of schizophrenia
• Somatic passivity – bodily function is
controlled by an alien influence;
• Delusional perception – the attribution of a
totally unwarranted meaning to a normal
perception.

11. • Thought insertion, thought withdrawal,
thought broadcast – experience of loss of
autonomy over thought
• Made acts, made affect, somatic passivity -
experience of loss of autonomy over action
• Experience of loss of autonomy delusional
attribution to alien influence.

12. Clinical features of schizophrenia
1. Disorders of thought and perception
• Delusions
• Hallutinations
• Disorders of the form and flow of thought
• Lack of insight (a failure to accept that one is
ill and to appreciate that symptoms are due to
illness)
• Impaired cognition

13. Clinical features of schizophrenia
2. Disorders of emotion
• Blunted affect (decreased responsiveness to
emotional issues, loss of vocal inflection,
diminished facial expression);
• Inappropriate affect
• Excitation and depression (irritability,
sleeplessness, agitation, motor overactivity)

14. Clinical features of schizophrenia
3. Motor disorders and catatonia
• Immobility, posturing, waxy flexibility,
negativism, stereotypy, mannerisms, echo
phenomena, excitement.
4. Disorders of volition
• Disruptions of motivation and will

15. Dimensions of psychopathology in
schizophrenia
• Schizophrenia is heterogeneous in its clinical
presentation
• Several different pathophysiological processes
might contribute to the illness
• There are two dimensions:
a. Positive and negative symptom dimensions
b. Three dimensions of characteristic symptoms

16. Positive and negative symptom dimensions
• Positive symptoms reflect the presence of an
abnormal mental process
i. Delusions tend to be
ii. Hallucinations transient
iii. Formal thought disorder
• Negative symptoms reflect the diminution or
absence of a normal mental function
I. Poverty of speech tend to be
II. Blunted affect
III. Avolition/apathy
IV. Anhedonia-asociality chronic

17. Three dimensions of characteristic
symptoms
1. Reality distortion
• Delusions
• Hallucinations
2. Disorganization
• Thought form disorder
• Inappropriate affect
• Bizarre behaviour
3. Psychomotor poverty (core negative symptoms)
• Poverty of speech
• Blunted affect
• Decreased spontaneous movement

18. COGNITIVE DEFICITS
Impaired abilities of :
• attention/vigilance,
• working memory,
• visual and verbal learning,
• psychomotor,
• reasoning and problem solving,
• speed of processing,
• executive functions,
• social cognition.

19. COGNITIVE DEFICIT
• Working memory is a concept closely related
to attention and executive functioning, and
involves the ability to hold and manipulate
information in one’s mind for short periods of
time
• deficits in working memory may underlie
some of the other aspects of schizophrenia,
including executive dysfunction and some
aspects of thought disorder

20. COGNITIVE DEFICIT
• Executive skills involve those cognitive processes which
permit an adaptive balance of initiation, maintenance,
and shifting of responses to environmental demands
permitting goal-directed behavior.
Executive skills:
• abstraction,
• planning,
• mental flexibility,
• response inhibition,
• self-monitoring,
• evaluation,
• decision making.

21. Classification (ICD-10)
Schizophrenia
Paranoid schizophrenia
Hebephrenic schizophrenia
Catatonic schizophrenia
Undifferentiated schizophrenia
Post-schizophrenic depression
Residual schizophrenia
Simple schizophrenia

22. The course of schizophrenia
• Continuous
• Episodic with progressive deficit
• Episodic with stable deficit
• Episodic remittent

23. DSM - 5
• First episode, currently in acute episode
• First episode, currently in partial remission
• First episode, currently in full remission
• Multiple episodes, currently in acute episode
• Multiple episodes, currently in partial
remission
• Multiple episodes, currently in full remission
• Continuous
• Specify if: With catatonia

24. The epidemiology of schizophrenia
1. Prevalence
• Point prevalence (refers to the ‘active’ cases
on a given date) – median value - 4.6 per
1000 population.
• Lifetime prevalence – at 7.2 per 1000.
2. Incidence (an estimate of the annual number
of first-onset cases per 1000 persons at risk)
– 0.24 per 1000 population per year.
3. Disease expectancy (morbid risk) ~ 1%

25. The epidemiology of schizophrenia
4. Associations with age and sex
• Sch. is equally prevalent in men and women
• Onset is earlier in men than in women
• The peak ages of onset are 10 to 25 years for
men and 25 to 35 - for women.
• Approximately 3% to 10% of women with
Sch. present with disease onset after age 40
years.
• Onset of Sch. before age 10 years or after age
60 years is extremely rare.

26. The epidemiology of schizophrenia
5. Mortality
• The single most common cause of death
among schizophrenia patient at present is
suicide – 28% of the excess mortality in
schizophrenia.

27. The epidemiology of schizophrenia
6. Comorbidity
• HIV/AIDS, hepatitis C, tuberculosis, epilepsy,
diabetes, arteriosclerosis, ischaemic heart
disease, obesity;
• Substance abuse (cannabis, stimulants).

28. Factors associated with a poor
outcome in schizophrenia
• Male gender
• Early onset of illness
• Strong family loading for schizophrenia
• Insidious onset of illness
• Long prodrome
• Poor pre-morbid functioning
• Lack of affective symptoms at onset
• Prominent negative symptoms at onset
• Lack of obvious precipitating factors at onset
• Neurological soft signs
• Significant neurocognitive deficits at onset
• Structural brain abnormalities (somewhat inconsistent
findings).

29. Etiology and pathogenesis

30. Etiology and pathogenesis
• The etiology and pathophysiology of
schizophrenia remain incompletely understood.
• The most powerful know risk factor for
schizophrenia are genetic
• environmental factors, expressly those afflicting
early neurodevelopment
• social risk factors for schizophrenia include urban
birth and upbringing, and being an ethnic migrant

31. Risk factors and antecedents
I. Genetic risk:
• heritability commonly estimated at about
80%;
• Schizophrenia is a complex polygenic
disorder with incomplete or variable
expression of the genotype, and widespread
locus and allelic heterogeneity.

32. Gradient of genetic risk for
schizophrenia
• General population risk: ~1%
• Uncle, aunt, nephew, or niece with
schizophrenia: ~3%
• Grandparent with schizophrenia: ~4%
• Brother or sister with schizophrenia: ~10%
• Dizygotic twin with schizophrenia: ~10%
• One parent with schizophrenia: ~13%
• Both parents with schizophrenia: ~46%
• Monozygotic twin with schizophrenia: ~50%.

33. Risk factors and antecedents
II. Environmental insults during early
development
• Season of birth (winter-spring birth)
• Prenatal exposure to infection (influenza in II
trimester, rubella, herpes simplex,
cytomegalovirus, toxoplasmosis)
• Pregnancy and birth complications ( hypoxic
perinatal brain damage, low birth weight)

34. Risk factors and antecedents
III. Developmental antecedents of schizophrenia
a. Brain development and neurobehavioural
markers
• Abnormal motor and speech development
before 2 years of age
• Soft neurological signs (poor motor control,
coordination, and balance)
• Non-right handedness and speech defects
between ages 2-15.

35. Risk factors and antecedents
b. Cognitive and neuropsychological markers
before onset of clinical symptoms
• Deficit in verbal memory
• Sustained attention and executive functions
• Abnormalities in event-related brain
potentials and oculomotor control;
c. Premorbid intelligence (IQ)
• Poor performance on verbal tasks and test of
reasoning.

36. Risk factors and antecedents
VI. Premorbid social impairment
• Difficulties in social interaction during
childhood and adolescence
• School problems
• Social anxiety
• Preference for solitary play
V. The social environment
• The urban environment
• Migrants and ethnic minorities

37. Etiology and pathogenesis
A complex interaction
of multiple genes
guiding
neurotransmission and
neurodevelopment may
create a vulnerability to
environmental
influences that lay the
groundwork for
schizophrenia before or
at birth.

38. Neurochemical abnormality hypotheses
The dopamine hypothesis
• The symptoms of schizophrenia result from
dopaminergic overactivity
• Pre-synaptic dopamine abnormality: elevated
dopamine synthesis, release, and higher dopamine
receptor occupancy in the striatum
• Dysregulation and hyperresponsiveness of
dopaminergic neurons
• These abnormalities are present in patient with acute
psychosis, bat not in remission.

39. Neurochemical abnormality hypotheses
• The hypothesis of glutamatergic dycfunction:
Disturbance of NMDA receptor-mediated
glutamate transmission in schizophrenic patients.
• There is lowered 5-HT2a receptor expression in
the frontal cortex in schizophrenia.
• Alterations in specific markers of GABAergic
neurons and their connections as well as changes
in GABA receptors.

40. Features of cerebral activity in
schizophrenia
• Dynamic disturbance of frontal cortex function
and regulation;
• Deficits in activity in a circuit involving the
cerebral cortex, thalamus, and cerebellum are
key and underlie the memory difficulties of
schizophrenia.

41. Dopaminergic system

42. Neurobiological theories of schizophrenia
1. Schizophrenia as a neurodevelopmental
disorder (prevailing pathogenic hypothesis):
the pathology of schizophrenia originates in
early age.
2. Schizophrenia as a disorder of connectivity:
physiological basis of schizophrenia is a
subtle change in the precise molecular
composition, location, or activity of
subpopulation of synapses.

43. Diagnosis of schizophrenia

44. Diagnostic Criteria (DSM-V)
A. Two (or more) of the following, each present for
a significant portion of time during a 1 -month
period (or less if successfully treated). At least
one of these must be (1 ), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional
expression or avolition).

45. Diagnostic Criteria (ISD-10)
One or more for 1 month:
a) Thought echo/insertion/ withdrawal/ broadcasting.
b) Delusions of control
c) Hallucinatory voices
d) Persistent delusions
Or two or more:
e) Persistent hallucinations
f) Thought block/disorder
g) Catatonic behavior
h) Negative symptoms
I) Significant personality change

46. EARLY-ONSET PSYCHOTIC DISORDERS
• Functional outcome in schizophrenia may be
worse when the onset of the disorder occurs
during childhood and adolescence.
• In adolescent schizophrenia can either have an
acute or insidious onset.
• In children schizophrenia is usually
characterized by gradual onset.
• Patients with an insidious onset usually have
“prodromal phase symptoms”

47. EARLY-ONSET PSYCHOTIC DISORDERS
“Prodromal phase symptoms”:
• social withdrawal or isolation,
• irritability,
• bizarre behaviors,
• decline in academic performance and/or personal
hygiene,
• affective or anxiety symptoms,
• changes in personality.
These patients often have strong family history of
psychosis.

48. EARLY-ONSET PSYCHOTIC DISORDERS
• Hallucinations are the most common
perceptual abnormality which often begins as
elementary sounds
• Delusions are vague and not systematized
• Disorganized speech and behavior is also
commonly seen
• impairment in IQ, attention, memory and
executive function

49. ACUTE AND TRANSIENT PSYCHOTIC DISORDER
• Acute onset is defined as a change from a state without
psychotic features to a clearly abnormal psychotic
state, within a period of 2 weeks or less.
• Typical syndromes – rapidly changing and variable
state, called "polymorphic“ and presence of typical
schizophrenic symptoms.
• Associated acute stress. It means that the first
psychotic symptoms occur within about 2 weeks of one
or more events, that would be regarded as stressful to
most people in similar circumstances

50. ACUTE AND TRANSIENT PSYCHOTIC DISORDER
Typical stress events
• bereavement,
• unexpected loss of partner or job,
• marriage,
• the psychological trauma of combat,
• terrorism,
• Torture,
• Complete recovery usually occurs within 2 to 3
months, often within a few weeks or even days

51. PERSISTENT DELUSIONAL DISORDER
• Еhe development either of a single delusion or of a set
of related delusions which are usually persistent and
sometimes lifelong
• The delusions are highly variable in content
• The content of the delusion can often be related to the
individual's life situation
• They must be present for at least 3 months
• There must be no evidence of brain disease, history of
schizophrenic symptoms

52. Treatment and management

53. The acute phase
• Control of intrusive, non-specific symptomatology
(anxiety, agitation, insomnia)
• Maximizing safety and well-being of the patient
and other by containing chaotic, socially
damaging behaviours
• Engaging the patient in therapeutic
recommendations and gaining consent for
treatment plans
• Implementing an appropriate foundation drug
regime
• Stabilizing positive symptomatology
• Preventing or treating psychiatric emergencies

54. The post-acute phase
Stability in both mental state and behaviour
• Consolidation of clinical improvements
• Rationalization of treatment regimes
• Resocializacion

55. The maintenance phase
• Maximum well-being with minimum adverse
effects
• Monitoring efficacy/effectiveness and
tolerability
• Continuing or extending rehabilitation and
social integration

56. ANTIPSYCHOTIC MEDICATIONS
• Typical antipsychotics
 butyrophenone
(Haloperidole)
 phenothiazine
(Chlorpromazine,
Thioridazine,
Trifluoperazine)
 thioxanthene
(Fluphentixol)
 benzamide (Sulpiride)
mechanism of action
antagonizing dopamine
receptors in the
mesolimbic pathway
↓
decreasing positive
symptoms.

57. ANTIPSYCHOTIC MEDICATIONS
• Atypical antipsychotics
• Clozapine,
• Risperidone,
• Olanzapine,
• Quetiapine,
• Ziprasidone,
• Aripiprazole,
• Sertindole.
mechanism of action
 antagonize dopamine (D2)
receptors in the mesolimbic
pathway
 antagonize serotonin
(5-HT2A) receptors in the
mesocortical pathway
↓
increasing dopamine activity in
the frontal cortex
↓
potentially alleviates the negative
symptoms of schizophrenia

58. ANTIPSYCHOTIC MEDICATIONS

59. SIDE EFFECTS OF ANTIPSYCHOTICS
1. NEUROLOGICAL SIDE EFFECTS
Extrapyramidal side effects (EPS)
• Acute dystonia (muscular rigidity and cramping
that usually involves muscles of the face, tongue,
and neck).
• Antipsychotic-induced Parkinsonism (rigidity,
tremor, and bradykinesia).
• Akathisia (is experienced subjectively as an
unpleasant sensation of restlessness and
observed objectively as restlessness, anxiety, and
agitation).

60. SIDE EFFECTS OF ANTIPSYCHOTICS
Tardive Dyskinesia (TD) is a syndrome of chronic or
permanent abnormal, involuntary movements that
presents usually with athetoid movements of the tongue,
facial, and neck muscles, extremities, or trunk.
Neuroleptic Malignant Syndrome
• rigidity,
• fever,
• autonomic instability,
• delirium,
• renal failure, cardiac arrhythmias, seizures, and coma.

61. SIDE EFFECTS OF ANTIPSYCHOTICS
2. HYPOTHALAMIC- AND PITUITARY-RELATED SIDE
EFFECTS
• Hyperprolactinemia → gynecomastia,
galactorrhea, sexual dysfunction, amenorrhea
3. METABOLIC SIDE EFFECTS
• Weight Gain
• Dyslipidemia
• Diabetes/Glucose Intolerance
4. CARDIAC SIDE EFFECTS
• Orthostatic hypotension
• QT interval prolongation and predisposing
patients to arrhythmias

62. ELECTROCONVULSIVE THERAPY
ECT is recommended for patients with
schizophrenia and/or schizoaffective disorder
who have:
• persistent severe psychosis
• suicidal ideation
• prominent catatonic features
• comorbid depression
• medication resistance.

63. ELECTROCONVULSIVE THERAPY
Side effects of ECT:
• Medical
 hyper- or hypotension
 tachy- or bradycardia
 headache,
 muscle ache and nausea
• Cognitive impairments
 anterograde and retrograde transient
amnesia

64. ECT Procedure
• Monitoring vital signs
• Intravenously is administered a
short-acting barbiturate
• the electrodes are placed
• a bite block is placed in the
patient’s mouth to avoid tongue
bite
• seizure activity is monitored by
EEG
• procedure takes ~ 15 minutes
and is followed by a recovery
time of 20–30 minutes

65. PSYCHOSOCIAL TREATMENT
• ENVIRONMENTAL
SUPPORTS
• FAMILY INTERVENTION
• COGNITIVE-
BEHAVIORAL THERAPY
• SOCIAL SKILLS
TRAINING
• COGNITIVE
REHABILITATION