SCHIZOPHRENIA

INTRODUCTION

• Schizophrenia is a mental disorder often

characterized by abnormal social behavior and
failure to recognize what is real.
• Schizophrenia is discussed as if it is a single
disease, it probably comprises a group of
disorders with :
1.heterogeneous etiologies,
2. and it includes patients whose clinical presentation,
treatment response, and courses of illness vary.
Person’s experience of DISTORTED
PERCEPTION of reality and impairment in
–Thinking
–Behavior
–Affect
–Motivation
The expression of these manifestation varies
across patient and overtime, but the effect of the
illness is always severe and is usually long
lasting.
The disorder usually begins before age 25 years,
persist throughout life, and affects persons of
social classes.
 DIAGNOSTIC CRITERIA

A. Two (or more) of the following, each present for a significant portion of time during
a 1 -month period (or less if successfully treated). At least one of these must be (1), (2),
or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more
major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the
onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of
interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1
month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may
include periods of prodromal or residual symptoms.
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out
because either
1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or
2) if mood episodes have occurred during active-phase symptoms, they have been present for minority of the
total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the
additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the
other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).
SYMPTOMS
1) Positive symptoms :
are those that most individuals
do not normally experience but
are present in people with
schizophrenia. Positive (things
that start to happen)
2) Negative :
things that stop happening
3)Cognitive:
related to processing
information
Positive symptoms

ØHallucinations :
They might hear, see, smell, or feel things no one else does. Most often
they'll hear voices inside their heads. These might tell them what to do,
warn them of danger, or say mean things to them. The voices might talk
to each other.
ØDelusions :
It is a distortion of reality. These are beliefs that seem strange to most
people and are easy to prove wrong. The person affected might think
someone is trying to control their brains through their TVs or that the
FBI is out to get them. They might believe they're someone else, like a
famous actor or the president, or that they have superpowers.
ØDisorganized thoughts and speech :
People with schizophrenia can have a hard time organizing their
thoughts. They might not be able to follow along when you talk
to them. Instead, it might seem like they're zoning out or
distracted. When they talk, their words can come out all
jumbled and not make sense. They can also have trouble
concentrating. For example, they might lose track of what's
going on in a TV show as they're watching.
ØDisorganized movements :
Someone with the condition can seem jumpy. Sometimes they'll
make the same movements over and over again. But sometimes
they might be perfectly still for hours at a stretch, which is
called being catatonic. Contrary to popular belief, people with
the disease usually aren't violent.
HALLUCINATION
•AUDITORY : Hearing voices : The client may sense that the sounds
are coming from inside or outside their mind. They might hear the
voices talking to each other or feel like they're telling them to do
something.
•VISUAL : Seeing things : They might see insects crawling on their
hand or on the face of someone they know.
•OLFACTORY : Smell things that aren't there : The client may
think an odor is coming from something around them, or that it's
coming from their own body.
•GUSTATORY : False sense of taste : They may feel that something
they eat or drink has an odd taste.
•TACTILE : Feel things that don't exist : It might seem to them that
they’re being tickled even when no one else is around, or they may
have a sense that insects are crawling on or under their skin. They
might feel a blast of hot air on their face that isn't real.
 DELUSION
•Delusion of Persecution : The most common type of
delusion associated with schizophrenia involves persecutory
delusions. The schizophrenic believes that he/she is being
followed or is under surveillance, or that he/she is being made
fun of, tricked, or treated very unfairly by others. When
schizophrenics experience this type of delusion, they may feel
very frightened or paranoid. As a result, they will often do
things to protect themselves from the persecutor.
•Delusions of Reference : This is when the person believes,
for example, that things written in a newspaper or stated in a
newscast, passages found in a book, or the words in a song are
about him/her.
•Delusions of Grandeur : These delusions involve the belief
that he/she has exceptional power, talent or worth, or is
someone famous. He/she may believe he/she is God or some
other type of deity.
•Delusions of Erotomania :
This type of delusion involves the belief that a
particular person, usually a celebrity or someone
especially important ( of a higher status), is
romantically or sexually involved with or in love with
him/her.
•Delusion of Somatomania :
This involves the belief that he/she has a medical
condition or other physical problem or flaw.
•Delusion of Jealousy :
A delusional belief that one’s spouse or lover is
unfaithful, based on erroneous inferences from
innocent events imagined to be evidence
•Delusion of Infidelity :
A belief or suspicion that one’s spouse or lover may
be disloyal or cheating on the client.
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DISORGANIZED
BEHAVIOUR :

Schizophrenia disrupts goal-directed activity,

causing impairments in a person’s ability to
take care of him or herself, work, and interact
with others. Disorganized behavior appears as:

-A decline in overall daily functioning

-Unpredictable or inappropriate emotional
responses
-Behaviors that appear bizarre and have no
purpose
-Lack of inhibition and impulse control
NEGATIVE
SYMPTOM
Negative Symptoms of schizophrenia represent the
absence or diminution of normal intellectual function and
expression. They are disruptions to normal emotions and
behaviors and are also known as negative deficits.
The negative symptoms are:
●AFFECT
The external expression of emotion attached to ideas and
mental representation of objects. Schizophrenics have flat
(lack of expression), blunt (severe reduction in intensity),
or inappropriate (incongruent with situation) affect.
●ALOGIA
It is characterized by poverty of speech, A reduction in the
amount of speech, speech content, blocking or late replies.
•ANHEDONIA
It is the inability to feel pleasure in normally pleasurable
activities. Schizophrenics experience no pleasure in their daily
life or even otherwise.
•AVOLITION
It is the loss of motivation. Deficits in the initiation and
maintenance of goal-directed behaviours like work, study, sport,
personal hygiene and daily tasks, especially when requiring an
effort (cognitive or physical) and significant organisation. Also
deficits in desire to undertake such activities.
•ASOCIALITY
It is the diminished interest in, motivation for, and
appreciation of social interactions with others, like family and
friends. Also, loss of interest in intimate (sexual) relationships
independent of any somatic problems.
COGNITIVE are
Cognitive symptoms are subtle and
often detected only when
neuropsychological tests are performed.
SYMPTOMS Cognitive impairments often interfere
with the patient's ability to lead a normal
life and earn a living. They can cause
great emotional distress. They include the
following:
•Poor “executive functioning” (the ability
to absorb and interpret information and
make decisions based on this information)
•Trouble focusing or paying attention
(difficulty in sustaining attention)
•Problems with “working memory” (the
ability to keep recently learned
information in mind and use it right
away)
 • Social withdrawal
OTHER EARLY • Hostility or suspiciousness
SYMPTOMS • Deterioration of personal hygiene
• Flat, expressionless gaze
• Inability to cry or express joy
• Inappropriate laughter or crying
• Depression
• Oversleeping or insomnia
• Odd or irrational statements
• Forgetful; unable to concentrate
• Extreme reaction to criticism
• Strange use of words or way of
speaking
ICD 10 SPECIFIERS OF
SCHIZOPHRENIA
F20 Schizophrenia :
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
 Hebephrenic Schizophrenia
Paranoid Schizophrenia (F20.0): (F20.1): Also known as Catatonic Schizophrenia (F20.2):
Characterized by prominent disorganized schizophrenia, this Marked by disturbances in motor
delusions and auditory subtype is characterized by behavior, ranging from stupor (lack
hallucinations, often with themes disorganized speech, behavior, and of movement and response) to
of persecution or grandiosity. affect. Hallucinations and excessive, purposeless activity.
Cognitive functions and emotions delusions might be present but are Catatonia can significantly affect
might appear relatively intact. not as prominent as the daily functioning.
disorganization.

Simple Schizophrenia (F20.4):

Undifferentiated Schizophrenia Characterized by gradual and Residual Schizophrenia (F20.5):
(F20.3): Used when symptoms insidious development of negative Refers to cases where the acute-
don't fit well into one specific symptoms, such as social withdrawal, phase symptoms have diminished
subtype but still meet the criteria reduced motivation, and flattened but some residual negative
for schizophrenia. It represents a emotional responses. Unlike other symptoms or mild positive
mix of different symptoms without subtypes, simple schizophrenia does symptoms (such as odd beliefs)
a clear dominant pattern. not include prominent hallucinations remain.
or delusions.

Simple Schizophrenia (F20.6):

Characterized by insidious and
gradual development of negative
symptoms, such as social
withdrawal, poverty of speech, and
flattened affect, without
prominent delusions or
hallucinations.
ETIOLOGY
GENETIC
PREDISPOSITION:

• Schizophrenia occur at an increased rate among

the biological relatives of patients with
schizophrenia.
• If one parent has the disorder, there are 46%
chances that the offspring might have them.
• If both the parents are suffering from the disorder,
there are 52% chances of the offspring might
suffer from.
• In the case of monozygotic twins who have
identical genetic endowment, there is an
approximately 50% concordance rate of
schizophrenia.
BIOCHEMICAL FACTORS
• Dopamine Dysregulation: The dopamine hypothesis
suggests that an over activity of dopamine transmission in certain
brain regions, particularly the mesolimbic pathway, contributes to
positive symptoms of schizophrenia such as hallucinations and
delusions. This hypothesis is supported by the effectiveness of
antipsychotic medications that target dopamine receptors.
• Glutamate Dysfunction: Glutamate is a major excitatory
neurotransmitter in the brain. NMDA receptor hypofunction, which
leads to decreased glutamate activity, has been linked to cognitive
deficits and negative symptoms of schizophrenia. Abnormalities in
glutamate signaling may contribute to impaired neural
communication and information processing.
BIOCHEMICAL FACTORS
• Serotonin (5-HT) Imbalance: Serotonin is another
neurotransmitter that has been implicated in schizophrenia. Abnormalities in
serotonin receptors and levels have been associated with cognitive and
emotional disturbances seen in the disorder.
• GABAergic Dysfunction: GABA (gamma-aminobutyric acid) is
the primary inhibitory neurotransmitter in the brain. Disruptions in
GABAergic signaling have been suggested to contribute to the cognitive
deficits and altered sensory processing observed in schizophrenia.
• Neuroinflammation: Growing evidence suggests that
neuroinflammation, involving immune responses in the brain, could
contribute to the development of schizophrenia. Inflammatory markers and
cytokines have been found to be elevated in individuals with schizophrenia,
possibly affecting neurotransmitter systems and neural circuits.
BRAIN
METABOLISM :
• studies using resonance
spectroscopy, a technique that
concentration of specific
molecules in the brain, found that
patients with schizophrenia had
lower levels of
phosphomonoester and inorganic
phosphate and higher levels of
phosphodiester than a control
group.
NEUROPATHOLOGY/ BRAIN
STRUCTURE ABNORMALITY: ​
1. CEREBRAL VENTRICLES: patients with
schizophrenia have consistently shown lateral and third
ventricular enlargement and some reduction in cortical
volume. Reduced volumes of cortical gray matter have
been demonstrated during the earliest stages of the disease.
2. REDUCED SYMMETRY: There is a reduced
symmetry in several brain areas in schizophrenia,
including the temporal, frontal, and occipital lobes. This
reduced symmetry is believed by some investigators to
originate during fetal life and to be indicative of a
disruption in brain lateralization during
neurodevelopment.
3. THALAMUS: Some studies of the thalamus show
evidence of volume shrinkage or neuronal loss,
in particular subnuclei.
NEUROPATHOLOGY/BRAIN
STRUCTURE ABNORMALITY:

4. PREFRONTAL CORTEX: brain

studies that supports anatomical
abnormalities in the prefrontal cortex
in schizophrenia. Functional deficits in the
prefrontal brain imaging region have also
been demonstrated. It has long been noted
that several symptoms of schizophrenia
mimic those found in persons with
prefrontal lobotomies or frontal
lobe syndromes.
NEUROPATHOLOGY/ BRAIN
STRUCTURE ABNORMALITY:

5. LIMBIC SYSTEM: decrease in the size of the

region, including the amygdala, the hippocampus, and
the para-hippocampal gyrus. The hippocampus is not
only smaller in size in schizophrenia but is
also functionally abnormal as indicated by disturbances
in glutamate transmission.
6. BASAL GANGLIA INVOLVEMENT:
Abnormalities in the basal ganglia, which play a role in
motor control and reward processing, have been
associated with certain symptoms of schizophrenia,
including movement disorders and cognitive deficits.
Dysregulation of dopamine signaling in the basal
ganglia's circuits is linked to the positive symptoms of
the disorder, such as hallucinations and delusions.
TREATMENT
The treatment of schizophrenia can be discussed
under the following major headings :-
1. Psychiatric Treatment
a. Pharmacological therapy
b. Electro-Convulsive therapy
c. Surgical Methods
2. Psycho-social Therapy and Rehabilitation
Pharmacological therapy
ELECTRO-CONVULSIVE
THERAPY
ECT is not the primary treatment of choice
for schizophrenia
The indications of ECT include:-
1.Catatonic Stupor
2.Uncontrolled Catatonic Excitement
3.Acute exacerbation not controlled with drugs
4.Severe side-effects with drugs in the presence
of schizophrenia

• Usually 8-12 ECT’S are needed (upto 18 in

poor responders), administered 2-3 times a
week.
 SURGICAL METHODS

• Psychosurgery is not routinely practiced in

patients of schizophrenia in the clinical
practice.
• When used the treatment of choice is Limbic
Leucotomy and in some cases with severe and
prominent depression, anxiety or obsessional
symptoms.
• Deteriorated patients are less benefited.
• Maximum benefit in acute episodes

• Antipsychotics are far better at the end of

it, both in efficacy and safety.
 PSYCHO-SOCIAL
THERAPIES
•PSYCHO-EDUCATION
It is for the patient and specially the family (with consent
of patient)
Nature of illness, course and treatment is explained in it.
Helps in establishing a good therapeutic approach with
patient.
Involves explaining the stress-vulnerability model of
schizophrenia to patients and carer(s).
•GROUP PSYCHOTHERAPY
Aimed at problem solving and communication skills
Conducted in a form known as “social skills training
package”
•FAMILY THERAPY
Family members provided with social skill training
Helps decrease intrafamilial tensions
Attempts are made to decrease “expressed emotions” of
“significant others” in the family.
Awareness is raised regarding lowering expectations and
avoiding critical remarks, emotional over-involvement
and hostility

•INDIVIDUAL PSYCHOTHERAPY
Supportive in nature
Psychoanalytically oriented psychodynamic
psychotherapy is not much recommended.
Many centers suggest the use of Cognitive Behavior
Therapy(CBT)
INSIGHT ORIENTED THERAPY
• Group of therapies to assume persons thought,behaviour and
emotions which became distorted
• This was because they weren't able to understand what
motivates them
• This theory thus increases the awareness of motivation that will
improve the thought, behavior and the emotions of people.
• Goal of the therapy is help individual discover the reason and
motivation of their feelings, behavior and thinking so that they
can make changes in their life.

COGNITIVE BEHAVIOR THERAPY

• Used so the patient improves cognitive distortions, reduce
distractibility and correct errors in judgment.
• Reports of ameliorating delusions and hallucinations through
this method
• Usually those patients benefit from this who have a insight of
this illness.
 PSYCHOSOCIAL
REHABITATION
Psychosocial rehabilitation plays a vital role in the comprehensive
treatment of schizophrenia. This approach focuses on improving an
individual's functional abilities, social integration, and overall quality
of life. Through a combination of therapy, skills training, and
community support, psychosocial rehabilitation aims to enhance the
individual's ability to manage symptoms, engage in daily activities, and
establish meaningful relationships. Programs may include social skills
training to improve interpersonal interactions, vocational rehabilitation
to facilitate employment opportunities, and psychoeducation to
enhance understanding of the illness. By addressing various aspects of
life beyond symptom management, psychosocial rehabilitation
empowers individuals with schizophrenia to regain a sense of
independence, purpose, and social connectedness.
 "Schizophrenia's puzzle is solved
with empathy, knowledge, and a
THANKYOU tapestry of interventions that
weave hope into every thread."