Schizophrenia | Anatomy2Medicine
schizophrenia

Schizophrenia

  • Eugen Bleuler coined the term Schizophrenia:
    • According to Bleuler, the primary symptoms of Schizophrenia include

 

  • Ambivalence
  • Affective Flattening
  • Associations’ loosening

 

    • Ambivalence. Co-existence of two opposing impulse toward the same thing in the same person at the same time.
    • Flat Affect. Absence or near absence of any signs of affective expression; voice remains monotonous, and face immobile.

 

  • Loosening of Associations. Flow of thought in which ideas shift from one subject to another in a completely unrelated way; when severe, speech may be incoherent

 

  • Automatism. Automatic performance of an act or acts generally representative of unconscious symbolic activity.
  • Autism, i.e., pre-occupation with inner, private world is another primary feature, according to Bleuler.
  • “Mesocortical” and “Mesolimbic” tracts are theorized in genesis of Schizophrenia. Dopamine is found in increased quantities in these tracts:
  • Prevalence rate of Schizophrenia in monozygotictwin of a schizophrenic patient is 47.0%
  • Features weighing towards good prognosis in Schizophrenia include
    • Abrupt onset
    • Onset after 35 years of age
    • Presence of precipitating factors
    • Good premorbid social, sexual, and work histories
    • Presence of depressive symptoms
    • Married
    • Family history of mood disorders
    • Good support system
    • Positive symptoms
    • First episode
    • Fatty (Pyknic) physique
    • Female Gender
    • Atypical symptoms
  • Poor prognostic features of Schizophrenia
    • Negative symptoms
    • Neurological signs and symptoms
    • No precipitating factors
    • Young age of onset
    • Insidious onset
    • Withdrawn autistic behaviour
    • Single, divorced or widow
    • Family history of Schizophrenia
    • Poor support system

 

    • Characteristic symptoms of Schizophrenia
      • Delusion
      • Disorganized speech
      • Disorganized behaviour
    • Hebephrenic (Disorganized) type of Schizophrenia is associated with bad prognosis:
    • Prevalence of Schizophrenia in India is . 0.5-1.0%
    • Most common hallucination in Schizophrenics is Auditory
    • Best prognosis is expected in Catatonic Schizophrenia
    • Chlorpromazine is antipsychotic that  has lowest potency among typical antipsychotics – Haloperidol ,Trifluperazine ,Risperidone
    • “Folie a deux”, i.e. shared paranoid disorder
    • Shneider’s first rank symptoms of Schizophrenia include

 

  • Auditory Hallucinations
  • Passivity phenomenon
  • Delusional perception

 

 

    • Positive symptoms of Schizophrenia are

 

  • Bizarre behaviour
  • Circumstantiality
  • Delusions

 

    • Circumstantiality. Disturbance in the associative thought and speech processes, in which the patient digresses into unnecessary details and inappropriate thoughts, prior to communicating central idea. It is observed in schizophrenia, obsessional disturbances, and certain cases of dementia.
    • “Pseudo – community” is a feature seen in Paranoid Schizophrenia

 

  • Classical Clinical vignette on Schizophrenia

 

      • Rani, 26 years old college student was on a trip to Munnar with her college friends. On her way to Munnar, while in bus, she started crying saying that one of the boys sitting behind her tried to molest her. She also heard voice of her old boy-friend asking her to return as she will not be safe at Munnar. She did not talk to anybody for two days, nor did she eat. She was found grimacing and muttering to self by her college teacher. Later on, parents gave history of similar episode 8 months ago when she was given some treatment by her physician. The most probable diagnosis in this case will be  Schizophrenia
    • Characteristic features of catatonic schizophrenia

 

  • Echolalia
  • Mannerism
  • Negativism
  • Automatic obedience
  • Waxy Flexibility
  • Catalepsy BUT NOT Cataplexy

 

 

    • Echolalia. Involuntary parrot-like repetition of words spoken by others, often accompanied by the twitching of muscles; frequently seen in catatonic schizophrenia.
    • Flight of Ideas. Continuous but fragmentary stream of talk. The general train of thought can be followed but direction is frequently changed, often by chance stimuli from the environment. May be seen in acute manic states.
    • Mannerism. A peculiar modification or exaggeration of style or habit of dress, speech or action
    • Negativism. Behaviour peculiarity marked by not per forming suggested actions (passive negativism); or in doing the opposite (active negativism), as seen in schizophrenia.
    • Waxy Flexibility, (cerea flexibilitas). A condition of a person who can be molded into a position that is then maintained; when an examiner moves the person’s limbs, they feel, as if were made of wax.
    • Catalepsy. A condition of diminished responsiveness usually characterized by trance like states and by a waxy rigidity of the muscles (flexibilitas cerea) so that the patient tends to remain in any position in which he is placed. It occurs in organic and psychological disorders, and under hypnosis.
    • Cataplexy: A condition marked by abrupt attacks of muscular weakness and hypotonia, triggered by such emotional stimuli as mirth, anger, fear etc. Often associated with narcolepsy.
    • Defect of conation is typically seen in Catatonic Schizophrenia
    • Conation (L. conatio, an attempt), i.e. Motor Behaviour. The aspect of psyche that includes impulses, initiatives, motivations, wishes, drives, instincts, and cravinges, arising from inside oneself, expressed by person’s behaviour or motor activity.All of these may be diminished in cerebral diseases, especially those involving the medical orbital parts of the frontal lobes.
    • Features of retarded Catatonic Schizophrenia

 

  • Mutism
  • Waxy flexibility
  • Rigidity
  • ‘Mirror Gazing’ and ‘Grimacing’ are commonly seen in Hebephrenic Schizophrenia
  • Benedict Morel coined the term “Demence precoce”:
  • ‘Photosensitivity’ and ‘Cholestatic Jaundice’ are adverse effects of treatment with Chlorpromazine
  • The minimun duration of psychotic illness, to be categorized as schizophrenia, is  2 months
  • The first symptom/s to improve with initiation of antipsychotics in Schizophrenics is Auditory Hallucinations
  • Most common negative symptom of Schizophrenia is Unchanging facial expression
  • Most common positive symptom of Schizophrenia is Auditory Hallucinations
  • Clang Association. Association of words similar in sound but not in meaning; words have no logical connection.
  • Schizophrenics, who are deeply engaged in their hallucinatory experiences to the exclusion of involvement in real world, are known to be in Oneiroid state
  • Risk factors for suicide in Schizophrenics
  • Young age
  • Improvement after relapse
  • Poor social support

 

      • Patient’s awareness of the illness
      • Male sex
      • College education
      • A change in the course of disease
      • Dependence on hospital, etc.
    • About 50% of all schizophrenics attempt suicide and 10% 15% die by suicide.
    • Nonpsychiatric medical illneses that can present with psychotic symptoms,
      • Acute Intermittent Porphyria
      • B12 deficiency
      • Creutzfeldt-Jakob disease
      • Neurosyphilis
      • Wilson’s disease
      • Pellagra
      • Temporal lobe epilepsy
      • Cerebral neoplasms, trauma or disease, esp., frontal or limbic
      • Acquired Immune Deficiency Syndrome
      • Herpes encephalitis
      • Huntington’s disease
      • Homocystinuria, etc.
    • Personality disorders, which may exhibit features of Schizophrenia include
      • Borderline personality disorder
      • Schizotypal personality disorder
      • Schizoid personality disorder
    • Drug induced Akathisia may be treated with:
      • Amantadine
      • Benzhexol
      • Propanolol
    • Akathisia. A condition marked by motor restlessness, ranging from anxiety, to inability to lie or sit quietly or to sleep, as commonly seen in toxic reactions to phenothiazines.
    • Drug of choice for treating “Rabbit Syndrome” is: Amantadine
    • Rabbit Syndrome. An adverse effect of neuroleptics, characterized by rhythmic, involuntary, approximately 5 Hz, perioral movement that resembles the masticatory movements of a rabbit
    • ‘Shared psychotic disorder’,i.e folie a deux
      • Described by Ernst Charles Lasegue and Jules Falret in 1877
      • Patient’s psychotic symptoms develops during a long term relationship with another person who had a similar psychotic syndrome
      • More common with LOWER socioeconomic status
      • Separation of affected person from the source of psychosis result in improvement
    • Classical clinical Vignette on  Autoscopic psychosis
      • Raju from Bangalore, 46 years old, unemployed, married male presented with complaints that for the last 9 months he could see colourless and transparent image of his own body. This appears suddenly and starts imitating whatever he does, and then disappears. Six episodes have occurred till now. He has become fear ful because of this. Probable diagnosis in this case will be Autoscopic psychosis
    • Classical clinical Vignette on Capgras’s Syndrome  
      • Priyanka from Mumbai , 23 years old, college student presented with complaints that her mother and sister have been replaced by exact doubles, whom she considers are imposters. She is suffering from Capgras’s Syndrome
      • Capgras Syndrome: Tillusion des sossies”, i.e., the illusion of doubles
      • Described by French psychiatrist “Jean Marie Joseph Capgras” in 1923.
      • Patients get delusions that other people, usually related to the affected person, have been replaced by exact doubles, who are imposters.
    • Cotard’s Syndrome, i.e. delire de riegation (nihilistic delusional disorder) described by French psychiatrist, Jules Cotard.
      • Patients complain of having lost all of their possessions, status, and strength along with their body parts, i.e. heart, blood, etc. The world beyond them is reduced to nothingness.

 

  • Couvade’s syndrome.
  • The occurrence in the mate of a pregnant woman, of the symptoms that are related to pregnancy, such as pregnancy nausea, vomiting and abdominal pain.

 

  • Classical clinical Vignette on  Koro
    • Bijoy prasad, 27 years old, married, Assamese man consulted Sexologist with the complaints that his penis has started shrinking for the last few months and now he fears that it may disappear into abdomen after some time. He was afraid that he is going to die. No positive findings were noted on physical

examination and same were conveyed to him. But his belief was unshakeable. Koro is culture bound syndrome that he might be suffering from .

 

  • Amok.

 

      • A sudden, unprovoked outburst of wild rage, in which affected person run about madly and may indiscri-mately attack and maim any person or animal in their way.
      • After the attack, the person feels exhausted, has no memory of the attack, and often commits suicide.
      • Commonly seen in Southeast Asia and Malaysia.

 

  • Brain fag.

 

      • A culture bound syndrome, common in Sub-Saharan Africa, characterized by frequent complaints of male students of headache, agnosia, chronic fatigue,visual difficulties and anxiety.

 

  • Colera.

 

      • A culture bound syndrome, seen in Mayan Indians (Guatemala), which is characterized by temper-tantrums, violent outbursts, gasping, stuporousness,delusions and hallucinations.

 

  • Koro.

 

      • A culture bound syndrome, occurs amongst males in South- East Asia and in some areas of China. (Where it is known as “Suk-Yeong”), characterized by delusion that penis is shrinking and may disappear into the abdomen of deluded male.
    • Schizophreniform disorder
      • The term ‘Schizophreniform’ was coined by “Gabriel Langefeldt”
      • Symptoms are identical to Schizophrenia, but of atleast 1 month and always of less than 6 months’ duration
      • Generally, the prognosis is good
    • Delusional disorders may arise as a result of
      • Normal response to abnormal experiences in the environment

 

  • Situations that increase distrust and suspicion

 

    • Situations that lower self esteem
  • The most common type of delusional disorder is Persecutory  delusion
    • Persecutory  delusion : The situations that cause people to see their own defects in others can lead to development of delusional disorder.
  • Clinical Vignette on Erotomanic delusions
    • Ramesh, 29 years old college student was caught by police with allegations of harassing a bollywood actress for the last few months. He had seen that actress in a party 10 months ago and since then he feels that she had been in love with him. So he started reciprocating by either calling her on phone or writing letters repeatedly. These attempts to communicate with her has not been successful. He has Erotomanic delusions
  • Clinical Vignette on Somatic delusions
    • Rakesh 52 years old clerk came to psychiatry OPD with a handkerchief on his chin, which he is keeping there whenever he is out of home. His complain was that his chin has become larger in size because of which his face appears distorted. He had visited four surgeons, one of whom advised him for psychiatry opinion. He has been reassured about, his chin being normal, not only by his relatives but also by surgeons. But he believed that all the surgeons he has visited were trying to “get rid of him”. He is having Somatic delusions