Schizophrenia

Schizophrenia is made up of two words i.e., (Schizo + phrenia) ‘schizo’ means split and ‘phrenia’ means mind
Therefore schizophrenia can be called as split of mind. Schizophrenia is a functional psychotic disorder with most common cause as stress.
Definition :- Schizophrenia is a group of mental disorder which is characterised by psychotic features like distorted thought process, inability to trust and disrupted interpersonal relationship for at least 6 months.

Who coined the word schizophrenia ?
Schizophrenia word was coined by Eugen Bleuler in 1912. (Is is the same year in which Indian Lunacy act also came)
Thus, Eugen Bleurel was also known as the founder of schizophrenia.

Previously :-
Schizophrenia was called by the name – Dementia Precox. It is made up of 3 words i.e., (De + Mentia + precox). ‘De’ means decreased, ‘Mentia’ means Mental ability, and ‘Precox’ means early stage of life say in early adolescence i.e., from 13-35 yrs.
collectively Dementia Precox is tearmed as – Decreased mental ability in early stage of life or in early adolescence.
Dementia Precox word was given by ‘Kraeplin’. Also Kreaplin was the first scientist who gave the classification of mental disorders.
Heritability risk of schizophrenia –
Maximum chances of developing schizophrenia in offspring from parents is 40%
Here comes two conditions:-

• If single parent is having schizophrenia – chances of developing schizophrenia in children is 12%
• If both parents are having schizophrenia – chances of developing schizophrenia in children is 40%

Some other facts about schizophrenia –
• Life time risk of developing schizophrenia is only 1%
• Chances of having Depression is 20%
• Chances of having Mania is 1%
• Incidence rate of having schizophrenia is 0.15-0.25 per 1000 population
• Risk of suicidal attempt in schizophrenic patient – 10%
• Risk factor which is more prevalent for schizophrenia is – low socio economic status.
• Catatonic symptoms of schizophrenia are given by – Karl Ludwig Kahlbaum.
• First rank symptoms of schizophrenia are given by – Kurt Schneider.

Clinical Features
There are majorly 2 types of symptoms occur in schizophrenia. They are as follows :

A) Primary symptoms – also known as functional symptoms or Bleuler’s four A’s :
• Autistic thinking / Autism – No thought formation is seen in this condition.
Name changed to – Autism by Leo Kanner.
Therefore, this is also known as Kanner Syndrome.
NOTE:- Is thought formation is absent in children by birth, it is known as Autism
And if thought formation is absent in adult, it is known as Autistic thinking.
• Affective incongruity / Affect disturbance – mood of patient is inappropriate.
• Association disturbance – Thought disorder in which person unable to think logically and idea shift from one point to another without connection.
• Ambivalence – Opposite feeling, attitude or wishes towards the same person, object or situation.

B) Secondary symptoms or accessory symptoms.

1. Abnormal motor behaviour –
   • Waxy flexibility
   • Anergia ( inability to initiate activity)
   • Akathisia (A movement disorder that makes it hard for you to stay still. It causes an urge to move that you can’t control).
   • Echolalia (meaningless repetition of words) and Echopraxia (involuntary repetition or imitation of another person’s actions).
2. Emotional disturbance –
   • Apathy (the feeling of not being interested)
   • Mistrust
3. Altered thought process –
   • Blocking
   • Paranoia (thinking and feeling like you are being threatened, even if there is no evidence, or very little evidence)
   • Magical thinking
   • Looseness of association
   • Neologism
   • Delusions like grandiosity, somatic and delusion of persecution.
   • Client believe that his/her body is changing unusually.
4. Disorder of perception.
   • Illusion
   • Hallucination
5. Disorder of consciousness.
   • Stupor
6. Disorder of insight
   • Insight absent

Types of schizophrenia :

1. Paranoid schizophrenia
• It is most common type of schizophrenia.
• Onset of this type of schizophrenia is late. i.e., it occurs in later age majorly in 35-45 years.
• It is mainly characterised by delusion of persecution, jealousy or grandeur, hallucination, suspiciousness, aggressiveness and hostility.

NOTE :-

• Most common type of delusion seen in schizophrenia – Delusion of persecution
• Most common type of hallucination seen in schizophrenia – Auditory hallucination.

2. Catatonic schizophrenia
• It is mainly characterised by significant psychomotor disturbance. Motor symptoms are seen in this type of schizophrenia, examples like – flexibility, stupor or excitement, echolalia and echopraxia
• This type of schizophrenia is having best prognosis.

NOTE :-
Antipsychotic medicines are used to treat all types of schizophrenia except catatonic.
Treatment of choice for Catatonic schizophrenia is – Injection Lorazepam + ECT.

Based on motor activity catatonic symptoms in schizophrenia are of two types, they are as follows:-

• Catatonic excitement – This happens due to increased motor activity. Example – Mania
  Drug of choice in this type is Haloperidol
• Catatonic stupor – This happens due to decreased motor activity.
  Example – Depression.
  Drug of choice in this type is lorazepam.

3. Disorganised schizophrenia or hebephrenic schizophrenia
• Onset of this type of schizophrenia is early, i.e., it occurs in early age say before 25 years.
• Prognosis of this type of schizophrenia is very poor as compared to other types.
• It is mainly expressed by disorganised thought, speech and behaviour, extreme social withdrawal and stereotype behaviour.
• Ect is not effective in this type of schizophrenia.

4. Undifferentiated schizophrenia
If schizophrenic patient does not meet the criteria of paranoid, catatonic and disorganised or if meet the criteria, then will show symptoms of more than one subtype of schizophrenia, it is called undifferentiated schizophrenia.

5. Residual schizophrenia
Patient took treatment for schizophrenia in the past and has some residual symptoms like social isolation, impersonal hygiene and inappropriate affect.

Diagnosis –
Schizophrenia is diagnosed by following methods:
• Mental status examination (MSE)
• Psychiatry history and careful clinical observation.

According to International classification of diseases (ICD)
Schizophrenia subtype is classified on the basis of cause of disease. And sign and symptoms of more than 1 month can be diagnosed as schizophrenia.

According to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
• If sign and symptoms are from less then 1 month – diagnosed as Brief psychotic disorder also known as acute psychosis.
• If sign and symptoms of schizophrenia are from 1-6 months – diagnosed as schizophrenic form disorder.
• If sign and symptoms are for more then 6 months – conformed diagnosis as schizophrenia.

Management :

• Assess the physical needs of the patient and try to fulfill.
• Don’t make false promises that cannot be fulfilled.
• Administer atypical antipsychotic drugs or major tranquillizers.

NOTE :- All schizophrenia types can be treat with antipsychotic drugs except Catatonic schizophrenia which requires Lorazepam + ECT as treatment.

• Psychological therapy including group therapy, behavioural therapy, cognitive therapy and family therapy.
• Usually 8 – 10 ECT are useful mainly in Catatonic stupor.
• Approach from front and speak clearly especially for paranoid schizophrenia.