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This is a very basic presentation for anyone who would like to have more information about schizophrenia. This was intended for the third year medical students. The criteria described are based on fourth edition of the DSM ( DSMIV). All these demarcations (types of) schizophrenia will be scrapped by the DSM V (this is the proposal as of now). But this could serve a historical puspose if seen after 2013.
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Schizophrenia
Pallav Pareek M.D
HISTORY
Benedict Morel French 1809-1873, gave the term Demence Precoce
Emil Kraepelin German 1856-1926, furthered Morel’s work.
Father of Psychiatry, first doctor to differentiate the two major types of Psychosis , Maniac Depressive Psychosis, and Dementia( Distinct Cognitive Process) Precox( early onset) : He described them as having an early age of onset, long term detiriorating course and common symptoms of Hallucinations and delusions
Eugen Bleuler Swiss 1857-1939 Bleuler realized the condition was neither a dementia nor did it always occur in young people (praecox meaning early) and so gave the condition the purportedly less stigmatising but still controversial name from the Greek roots schizein "to split“ and phrēn, "mind“ . By Schizophrenia he meant a schism between thought, emotion and behavior
Kretschmer compiled data about personality types schizophrenia occurs more in the Asthenic a.k.a Leptosomic ( slender, lightly muscled physiques) Athletic or Dysplastic( a mixture of a few body types) body types, while the Pyknik body types (short, stocky) more commonly have mania/depression
Epidemiology
Prevalence : 1% except certain pockets like Ireland.
Equal distribution: M & F M: MAO: 15-25 F : MAO: Bimodal 25-35 ,
and then a second peak near menopause
Onset before and after 10-60 years extremely rare, If the onset is after 45 it’s called late onset SCZ
Etiology
Birth Season: Jan to April, Southern July to
September VIRAL HYPOTHESIS talks about viral (retroviruses) infection or virally activated autoimmune reactions which produce antibrain antibodies.
Cigarette smoking
75% SCZ patients are smokers , compare to 50% All Psych Patients , and 20.8% in General Population ( United states 2007 Source: Center for Disease Control and Prevention)
Smoking increases the metabolism – High Antipsychotic requirement
FACTS
WHY SCZ SMOKE SO MUCH Smoking reduces the drug related
parkinsonian effects ( Nicotine activates the DA in NIgrostriatal pathways)
Nicotine also Increases the threshold for perception of outside stimuli ( is very low in SCZ), thereby relieves symptoms such as Hallucinations, thus acts as a self medication for Patients
Socioeconomic factors
Downward Drift Hypothesis: ( More popular hypothesis) Affected people move into or fail to rise from Low SE Status
Social Causation Hypothesis: Stress experienced in Low SE groups may be a cause
Neurobiological Models
Pruning Hypothesis: Several lines of evidence support the notion that a substantial reorganization of cortical connections, involving a programmed synaptic “pruning”, takes place during adolescence in humans( Proposed reason for SCZ starting after a certain age). A review of neurobiological abnormalities in schizophrenia indicates that the neurobiological parameters that undergo peripubertal regressive changes may be abnormal in SCZ. An excessive pruning of certain areas of the Brain, may underlie schizophrenia.
DOPAMINE Hypothesis
Too much Dopaminergic activity Reasons to support1. Efficacy of
antidopaminergic( antipsychotic) drugs which act on D2 Receptors
2. Drugs which Increase DA, viz Amphetamines are Psychotomimetic
3. Plasma HVA levels , are proportionately higher in symptom severity of SCZ
Other NT’s Variously IMPLICATED NE Serotonin GABA Glutamate
Various Structural abnormalities in SCZ Brains Increased Ventricle Size Reduced Frontal lobe size ( and
activity) Decrease in Limbic System Size
Genetic Factors
Almost half the chromosomes have been implicated
Current Research focuses onLong Arm 5 11 18Short Arm 19 and X
Freud’s Explanation EGO DEFECT According to Freud, schizophrenia is a form
of regression “ back to the oral stage of development. The oral stage is the first stage of psychosexual development. A baby is born a bundle of id “ is self-indulgent and concerned only with a satisfaction of his/her needs. People with schizophrenia are overwhelmed by anxiety because their egos are not strong enough to cope with id impulses. In schizophrenia, this can lead to self-indulgent symptoms such as delusions of grandeur
Prevalence
General Population
Nontwin Sibling One Parent with Dizygotic Twin Two Parents Monozygotic Twin
1% 8% 12% 12% 40% 47%
DSM IV TR Criteria for SchizophreniaA) ( The criterion A ) Characteristic Symptoms: Two
( or more ) of the following each present for a significant portion of time during a one month period ( or less if treated successfully)
1. Delusions2. Hallucinations3. Disorganized Speech ( e.g frequent
derailment or incohrence)4. Grossly disorganised or catatonic
behavior5. Negative Symptoms ( flat affect, social
withdrawl, poverty of speech,
B) Social/Occupational Dysfunction: for a significant portion of time since illness, disturbance in work, interpersonal relations, and self care.
C) Duration: Persists for at least 6 months,with 1 Month of Active symptoms ( May be less if the pt recieve RX)
D) Exclude Schizoaffective and Mood disorders
E) Report Substance/GMC F) No History of Autism/PDD
Classification Of Longitudinal Course (If duration is > 1 Year) Episodic with interepisode residual
symptoms Episodic with no interepisodic Symptoms Continous ( prominent psychotic
symptoms throughout observed period) Single episode in full remission Single episode in partial remission Other or Unspecified Pattern
Types of SCZ
Paranoid Disorganised Catatonic Undifferentiated Residual
Paranoid type
Following criteria are met A) Preoccupation with one or more
delusions or auditory hallucinations B) None of the following is prominent
– disorganised speech, disorganised or catatonic behaviour , flat or inaapropriate effect
Disorganised Type
* Following criteria are met A) All of the following are prominent1. Disorganised speech2. Disorganised behavior3. Flat or inappropriate effect
B) Criteria for catatonic are not met
Catatonic Type
Two of the following are present1. Motoric immobility as evidenced by catalepsy or
stupor ( including Waxy Flexibility)2. Excessive Motor Activity. Is apparently
purposeless and not influenced by external stimuli
3. Extreme Negativism( an apparently motiveless resistance to all instuction ot maintenance of a rigid posture against attempts to be moved) or Mutism
4. Peculiarities of Voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms or prominent grimacing
5. Echolalia or Echopraxia
Undifferentiated Type
Symptoms of Schizophrenia are met, but criteria for Paranoid, Disorganised or Catatonic type are not met
Residual Type
Following criteria are metA. Absence of prominent delusions,
hallucinations, disorganised speech , and grossly disorganised or catatonic behavior
B. There is evidence of disturbance, as indicated by Negative Symptoms , or two or more symptoms listed in Criterion A
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