Schizophrenia is a group of psychoses affecting young adults that causes changes in behavior, perception, thoughts and emotions. It has a prevalence of 0.5-1% globally. Genetics plays a role, with a higher risk for those with a family history. Environmental factors like family dynamics, stress, drugs and infections during pregnancy may also contribute. Symptoms include hallucinations, delusions, disorganized speech and behavior. Treatment involves antipsychotic medication, psychosocial support, rehabilitation and family education. Outcomes vary, with about 30% making a good recovery and 30% remaining handicapped long-term.

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

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

17. Disorganized thoughts

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

27. Mental Asylum

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

32. Occupational Therapy-
Vocational training
Agrotherapy

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