SCHIZOPHRENIA

INTRODUCTION

• Schizophrenia is derived from modern Latin, from Greek skhizein ‘to split’ + phrēn ‘mind’.
• Schizophrenia can be defined as a psychotic disorder in which personal, social, and
occupational functioning deteriorate as a result of strange perceptions, unusual emotions, and
motor abnormalities (Comer, 2007)
 HISTORY
Schizophrenia emerged as a medical condition worthy of study and treatment in the 19th
century.

2 major figures in psychiatry and neurology who studied the disorder were EMIL
KRAEPLIN (1856-1926) AND EUGENE BLEULER(1857-1939).

EMIL KRAEPLIN described the disorder as dementia precox referring to patients having a
long-term deteriorating course and the clinical symptoms of hallucinations and delusions.

BLEULER coined the term schizophrenia, which replaced dementia precox.

He chose the term to express the presence of schisms among thought, emotion, and
behavior in patients with the disorder.
BLEULER stressed that, unlike Kraepelin’s concept of dementia precox, schizophrenia need
not have a deteriorating course.
• OTHER THEORISTS
• Ernst Kretschmer (1888–1926): He compiled data to support the idea that schizophrenia
occurred more often among persons with asthenic (i.e., slender, lightly muscled physiques),
athletic rather than among persons with pyknic (i.e., short, stocky physiques) body types.
• Kurt Schneider (1887–1967): He contributed a description of first-rank symptoms, which,
he stressed, were not specific for schizophrenia and were not to be rigidly applied but were
useful for making diagnoses.
• Karl Jaspers (1883–1969): His work paved the way toward trying to understand the
psychological meaning of schizophrenic signs and symptoms such as delusions and
hallucinations.
• Adolf Meyer (1866–1950). Meyer, the founder of psychobiology, saw schizophrenia as a
reaction to life stresses. It was a maladaptation that was understandable in terms of the patient’s
life experiences.
 FIRST RANK SYMPTOMS (SFRS) OF SCHIZOPHRENIA
- KURT SCHNEIDER

1. Audible thoughts/ 2. Voices heard 3. Voices 4. Thought

thought echo arguing. commenting on withdrawal
one’s action.

6. Thought diffusion 7. ‘ Made’ feelings

5. Thought insertion or broadcasting or affect 8. ‘Made’ impulses.

9. ‘Made’ volition or 10. Somatic 11. Delusional

acts passivity perception
SCHNEIDER’S 11 FIRST RANK SYMPTOMS (SFRS)
 EPIDEMIOLOGY

• PREVALENCE:

Ø Lifetime Prevalence of schizophrenia is about 1 percent, which means that about 1 person in 100 will develop schizophrenia
during their lifetime.

• GENDER AND AGE:

Ø Schizophrenia is equally prevalent in men and women. Onset is earlier in men than women.
Ø Age of Onset (MEN): 10 to 25 years
Ø Age of Onset (WOMEN): 25 to 35 years
 ETIOLOGY

Genetic factors
Biochemical Factors
Neuropathology
Neural Circuits
Brain Metabolism
Applied Electrophysiology
Eye Movement Dysfunction
Psychoneuroimmunology
Psychoneuroendocrinology
Psychoanalytic theory
Learning theories
Family Dynamics
v Genetic Factors

• The likelihood of a person having schizophrenia is correlated with the closeness of the relationship to an affected relative (e.g.,
first- or second-degree relative).

• In the case of monozygotic twins who have identical genetic endowment, there is an approximately 50 percent concordance
rate for schizophrenia. This rate is four to five times the concordance rate in dizygotic twins or the rate of occurrence found in
other first-degree relatives (i.e., siblings, parents, or offspring).

v Biochemical Factors

• Dopamine Hypothesis: It posits that schizophrenia results from too much dopaminergic activity. The theory evolved from
two observations.

• First, the antipsychotic drugs like the dopamine receptor antagonists [DRAs] are correlated with their ability to act as
antagonists of the dopamine type 2 (D2) receptor.

• Second, drugs that increase dopaminergic activity, notably cocaine and amphetamine, are psychotomimetic.
 Serotonin Norepinephrine GABA

• Current hypotheses posit • Anhedonia has long • Studies have shown that
serotonin excess as a been noted to be a some patients with
cause of both positive prominent feature of schizophrenia have a
and negative symptoms schizophrenia. loss of GABAergic
in schizophrenia. • A selective neuronal neurons in the
• The robust serotonin degeneration within hippocampus.
antagonist activity of the norepinephrine • GABA has a regulatory
clozapine and other reward neural system effect on dopamine
second-generation could account for this activity, and the loss of
antipsychotics coupled aspect of schizophrenic inhibitory GABAergic
with the effectiveness of symptomatology. neurons could lead to
clozapine to decrease the hyperactivity of
positive symptoms in dopaminergic neurons.
chronic patients has
contributed to the
validity of this
proposition.
v Neuropathology:

Eye Movement
Limbic System. Dysfunction
Studies of Various studies have
Cerebral Ventricles Reduced postmortem brain reported abnormal
Symmetry samples from eye movements in
Computed
schizophrenia patients 50 to 85 percent of
tomography (CT) There is a reduced
have shown a patients with
scans of patients with symmetry in several
decrease in the schizophrenia
schizophrenia have brain areas in size of the region, compared with about
consistently shown schizophrenia, including the 25 percent in
lateral and third including the amygdala, the psychiatric patients
ventricular temporal, frontal,
hippocampus, and without schizophrenia
enlargement. and occipital lobes.
the and fewer than 10
parahippocampal percent in non
gyrus. psychiatrically ill
control participant.
 vPSYCHOSOCIAL AND PSYCHOANALYTIC THEORIES

Learning Theories:
Psychoanalytic Theories: Children who later have schizophrenia learn
irrational reactions and ways of thinking
Sigmund Freud postulated that schizophrenia by imitating parents who have their
resulted from the early fixations and the own significant emotional problems.
ego defect, which may have resulted
from poor early object relations, fuel The poor interpersonal relationships of
the psychotic symptoms. persons with schizophrenia develop because
of poor models for learning during
childhood
 In a study of British 4- It was formulated by Theodore Lidz
year-old children, those Gregory Bateson and described two abnormal
who had a poor Donald Jackson to patterns of family behavior.
mother–child describe a hypothetical In one family type, with a
relationship had a six family in which prominent schism
fold increase in the risk children receive between the parents,
of developing conflicting parental one parent is overly close
schizophrenia, and messages about their to a child of the opposite

Schisms and Skewed

offspring from behavior, attitudes, and gender.
Family Dynamics

schizophrenic mothers feelings.

Double Bind.
who were adopted away In the other family type, a
In Bateson’s hypothesis, skewed relationship

Families
at birth were more likely children withdraw into a
to develop the illness if between a child and
psychotic state to escape one parent involves a
they were reared in the unsolvable confusion
adverse circumstances power struggle between
of the double bind. the parents and the
compared with those
raised in loving homes by resulting dominance of
stable adoptive parents. one parent.
These dynamics stress the
tenuous adaptive capacity
of the person with
ETIOLOGY- FAMILY FACTORS IN SCHIZOPHRENIA schizophrenia
ETIOLOGY- FAMILY FACTORS IN SCHIZOPHRENIA
ETIOLOGY- FAMILY FACTORS IN SCHIZOPHRENIA

Pseudomutual and Pseudohostile Families: As described by Lyman

Wynne, some families suppress emotional expression by consistently using
pseudomutual or pseudohostile verbal communication. In such
families, a unique verbal communication develops, and when a child leaves
home and must relate to other persons, problems may arise. The child’s
verbal communication may be incomprehensible to outsiders.

Expressed Emotion: Parents or other caregivers may behave with overt

criticism, hostility, and overinvolvement toward a person with schizophrenia.
Many studies have indicated that in families with high levels of expressed
emotion, the relapse rate for schizophrenia is high. The assessment of
expressed emotion involves analyzing both what is said and the manner in
which it is said.
• Stress-Vulnerability Hypothesis: Increased number of stressful life events before the onset or
relapse probably has a triggering effect on the onset of schizophrenia, in a genetically vulnerable
person.

• Sociocultural Theories: Prevalence of schizophrenia is found to be more common in lower

socioeconomic status in some studies. This has now been explained due to a ‘ downward social
drift’, which is a result of having developed schizophrenia rather than causing it.
 SUICIDE IN SCHIZOPHRENIA – Neeraj Ahuja, 6 th Ed. (shor t textbook of
psyc hiatr y)
• Suicide can occur in schizophrenia due to several reasons.

• Some of the common reasons can include the presence of co-morbid depressive symptoms,
command hallucinations commanding the patient to commit suicide, impulsive behaviour,
presence of anhedonia, and/or return of insight in the illness (with the painful awareness that
one has suffered from schizophrenia or psychosis).

• The life-time risk of suicide is about 5-10 times higher in schizophrenia as compared to normal
population.

• It is therefore important to be aware of possibility of suicide whilst treating a patient with

schizophrenia so that the various risk factors can be addressed in management.
 CLINICAL PICTURE OF SCHIZOPHRENIA

• EUGEN BLEULER’S FUNDAMENTAL SYMPTOMS OF SCHIZOPHRENIA (ALSO

CALLED AS 4 A’S OF BLEULER)
• FIRST RANK SYMPTOMS (SFRS) OF SCHIZOPHRENIA - KURT SCHNEIDER
• DSM 5 diagnostic criteria
• ICD 10 diagnostic criteria
• CLINICAL FEATURES
ØThought and Speech disorders
ØDisorders of perception
ØDisorders of Affect
ØNegative symptoms
ØDisorders of Motor Behaviour
ØOther symptoms
CATATONIA
 CLINICAL FEATURES

ØThought and Speech disorders

ØDisorders of perception

ØDisorders of Affect

ØNegative symptoms

ØDisorders of Motor Behaviour

ØOther symptoms
 THOUGHT AND SPEECH DISORDERS

Autistic thinking - thinking is governed by private and illogical rules. The patient may consider
two things identical because they have identical predicates or properties
For e.g., Lord Hanuman was celibate, I am celibate too; So, I am Lord Hanuman.

Loosening of associations is a pattern of spontaneous speech in which things said in association

lack a meaningful relationship or there is idiosyncratic shifting from one frame of reference to
another.
The speech is often described as being ‘disjointed’. If the loosening becomes very severe, speech
becomes virtually incomprehensible. This is then known as incoherence.
Thought blocking is a characteristic feature of schizophrenia.
There is a sudden interruption of stream of speech before the thought is completed. After a
pause, the subject cannot recall what he had meant to say. This may at times be associated with
thought withdrawal.
Neologisms are newly formed words or phrases whose derivation cannot be understood.
These are created to express a concept for which the subject has no dictionary word.
These are called word approximations or paraphasias; for example, describing stomach
as a ‘food vessel’.

A patient with schizophrenia may show complete mutism (with no speech production),
poverty of speech (decreased speech production), poverty of ideation (speech amount
is adequate but content conveys little information), echolalia (repetition or echoing by
the patient of the words or phrases of examiner), perseveration (persistent repetition of
words beyond their relevance), or verbigeration (senseless repetition of same words or
phrases over and over again). These are disorders of verbal behaviour or speech.

The other clinical features of schizophrenic thought disorder include: overinclusion

(tending to include irrelevant items in speech), impaired abstraction (loss of ability to
generalize), concreteness (due to impaired abstraction), perplexity and ambivalence.
• Delusions are false unshakable beliefs which are not in keeping with patient’s socio-cultural and educational
background. These are of two types: primary and secondary.

1. Primary delusions: cannot be explained on the basis of other experiences or perceptions. Also known as
autochthonous delusions, these are thought to be characteristic of schizophrenia and are usually seen in early stages.

2. Secondary delusions are the commonest type of delusions seen in clinical practice and are not diagnostic of
schizophrenia as these can also be seen in other psychoses. Secondary delusions can be explained as arising from
other abnormal experiences.

• The commonly seen delusions in schizophrenia include:

1. Delusions of persecution (being persecuted against, e.g. ‘people are against me’).
2. Delusions of reference (being referred to by others; e.g. ‘people are talking about me’).
3. Delusions of grandeur (exaggerated self-importance; e.g. ‘I am God almighty’).
4. Delusions of control (being controlled by an external force, known or unknown; e.g. ‘My neighbor is controlling
me”).
5. Somatic (or hypochondriacal) delusions (e.g. ‘there are insects crawling in my scalp’).
 DISORDERS OF PERCEPTION

• Hallucinations: (perceptions without stimuli) are common in schizophrenia.

Auditory hallucinations are by far the most frequent. These can be:

Elementary ‘Third person

auditory ‘ Thought echo’ hallucinations’
hallucinations (i.e. (‘voices heard Voices
(‘audible arguing’, discussing commenting on
hearing simple
thoughts’) the patient in third one’s action’.
sounds rather than
voices) person)

• Visual hallucinations can also occur, usually along with auditory hallucinations.
• The tactile, gustatory and olfactory types are less common.
 DISORDERS OF AFFECT
• It refers to emotional responses that are out of context.

• The disorders of affect include apathy, emotional blunting, emotional shallowness,

anhedonia (inability to experience pleasure) and inappropriate emotional response
(emotional response inappropriate to thought).

• The difficulty of a patient with schizophrenia in establishing emotional contact with other
individuals.

• For e.g. patient may laugh on hearing that his/her family member’s death news.
 DISORDERS OF MOTOR BEHAVIOUR

Stupor: Extreme hypoactivity or immobility (akinesis) and minimal responsiveness to stimuli.

Excitement: Extreme hyperactivity which is usually non goal directed ( i.e. the patient is
very active but does not do any meaningful work).

Posturing: Spontaneous maintenance of posture for long periods of time.

Waxy flexibility: When examiner makes a passive movement on patient, there is a feeling of
plastic resistance which resembles bending of a soft wax candle.

Catalepsy: when examiner makes a passive movement (e.g. abduction at shoulder joint) on
the patient, no resistance is experienced. As the examiner stops the movement, whatever
position the patient has reached, that position is maintained.
Automatic obedience: excessive cooperation with examiner’s commands despite unpleasant
consequences. E.g., a patient kept on protruding his tongue in response to examiner’s commands,
despite the fact that his tongue would be pricked by a pin every time he protruded.

Echopraxia: Mimicking of examiner’s movements.

Negativism: An apparently motiveless resistance to all commands and attempts to be moved,

or doing just the opposite.

Grimacing: Maintenance of odd facial expressions.

Stereotypy: Spontaneous repetition of odd, purposeless movements. For e.g. making strange
movements of fingers repeatedly.
Mannerisms: Spontaneous repetition of odd, purposeful movements. For e.g.
repeatedly saluting the passer by.

Perseveration: It is induced movement which is senselessly repeated. It

occurs in response to an instruction. When it affects speech, the patient may
keep on repeating the same word or phrase.

Ambitendency: inability to decide the desired motor movement. For e.g.

when offered a hand for handshake, patient may repeatedly bring his hands
forward and backward as he is not able to decide whether he wants to shake
the hands or not. It is ambivalence in motor movements.
Rigidity: maintenance of a rigid posture against efforts to be moved
 NEGATIVE SYMPTOMS
Avolition: loss of will or
drive to indulge in goal Apathy: loss of concern for
Anhedonia: loss of ability
directed activities (such as an idea or task results.
to derive pleasure from
grooming and hygiene, (unconcern about exam
activities or relationships.
educational and occupational results, even after failing)
activities).

Affective flattening/
A sociality: indifference to
blunting: inability of patient
social relationships and Alogia: Decrease in verbal
to understand emotions of
decrease in drive to communication.
others and inability to
socialize.
express own emotions.

Attentional Impairment:
Attentional deficits have
been seen in studies with
schizophrenic patients
v Course
• The classic course of schizophrenia is one of exacerbations and remissions.
• After the first psychotic episode, a patient gradually recovers and may then function relatively
normally for a long time.
• Patients usually relapse, however, and the pattern of illness during the first 5 years after the
diagnosis generally indicates the patient’s course.
• Further deterioration in the patient’s baseline functioning follows each relapse of the
psychosis. This failure to return to baseline functioning after each relapse is the major
distinction between schizophrenia and the mood disorders.
• Positive symptoms tend to become less severe with time, but the socially debilitating negative
or deficit symptoms may increase in severity.
• Although about one-third of all schizophrenia patients have some marginal or integrated
social existence, most have lives characterized by aimlessness; inactivity; frequent
hospitalizations; and, in urban settings, homelessness and poverty.
v Prognosis: Several studies have shown that over the 5 to 10 year period after the first
psychiatric hospitalization for schizophrenia, only about 10 to 20 percent of patients can be
described as having a good outcome.
v More than 50 percent of patients can be described as having a poor outcome, with repeated
hospitalizations, exacerbations of symptoms, episodes of major mood disorders, and suicide
attempts.
 CONCLUSION
• Schizophrenia—a bizarre and frightening disorder—was studied intensively throughout the twentieth century.

• Clinical theorists now believe that schizophrenia is probably caused by a combination of factors (Riley & Kendler,
2011).

• While biological investigations have closed in on specific genes, abnormalities in brain biochemistry and structure,
most of the psychological and sociocultural research has been able to cite only general factors, such as the roles of
family conflict and diagnostic labeling.

• Clearly, researchers must identify psychological and sociocultural factors with greater precision if we are to gain a
full understanding of the disorder.

• Psychotherapy is often employed successfully in combination with antipsychotic drugs. Helpful forms include
cognitive-behavioral therapy, family therapy, and social therapy. Family support groups and family
psychoeducational programs are also growing in number.
 REFERENCES

• Niraj, Ahuja, A Short text book of Psychiarty,5th Edition, Jaypee Brothers

publisher.

• Carson, R. C., Butcher, J. N., & Mineka, S. (2000). Abnormal Psychology and
Modern Life. (11th ed.) New York: Allyn & Bacom.

• Benjamin J. Sadock, Virginia A. Sadock. (2000). Kaplan & Sadock's

comprehensive textbook of psychiatry. Philadelphia :Lippincott Williams &
Wilkins.

• Comer, R. J. (2007). Abnormal psychology. New York: Worth Publishers.