Schizophrenia

1. SCHIZOPHRENIA
NG BOON KEAT
MOHD HANAFI RAMLEE

2. To Know Schizophrenia is to
know Psychiatry
 The most devastating
illness that psychiatrist
treat.
 One of the most
challenging disease in
medicine
 1% of population has
schizo.
 An enormous economic
burden
 ? A major health concern

3. StoriesofSchizophrenia

4. History
 Emil Kraepelin- original term-
dementia praecox-early age,
chronic deteriorating course.
 Eugen Bleuler- coined the term
schizophrenia (split mind) 
affective blunting, loosening of
associations, autism (withdrawal)
and ambivalence (coexisting
conflicting ideas) - 4 As- earned
acceptance in USA
 Kurt Schneider  first rank
symptom

5. Definition
Psychotic mental disorder of
unknown aetiology
characterized by
disturbances in
 Thinking (e.g. distortion of
reality, delusions and
hallucinations)
 Mood (e.g. ambivalence,
inappropriate affect)
 Behaviour (e.g. Apathetic
withdrawal, bizarre activity)
at least 6 months

6. Epidemiology
•Lifetime prevalence 1-1.5%
•There is 7351 cases had been reported from 2003-2005
•The incidence was noted higher in males, urban and migrant
population
Incidence and prevalence(In Malaysia)
•60% of the schizophrenia cases are man
Sex ratio
•Prevalence > low socioeconomic groups
Socioeconomic status
•Common between 15 and 35, rare before 10 and after 40
years old. Earlier onset for ♂
Age of onset

7. Epidemiology: Sex

8. Epidemiology: Race
54
28
9
9
Malay Chinese
Indian Others
BUT IT CAN ALSO
AFFECT ANYONE
WITHOUT
PREDISPOSITIONS !

9. Aetiology
Uncertain; however there is
evidence for several risk
factors.
Several models which can be
grouped into….
Biological Social
Psychological

10. Aetiology – Bio
Genetics Consideration
 1st degree & 2nd degree relative
Environmental
 Abnormalities of pregnancy and delivery
[2%]
 Maternal Influenza – 2nd trimester [2%]
 Fetal Malnutrition [2%]
 Winter & Low Social Class birth [1.1%]

12. Social
 Studies have shown an excess of
schizophrenic patients in lower
socioeconomic groups and in urbanised
areas. This used to be attributed to “social
drift”
 Cannabis abusers [2%]

13. Psychological
 abnormalities in
processing sensory
information, in
separating “signal from
background noise”, or in
manipulating abstract
information
 Excess life traumas
against controls at first
presentation

14. Pathophysiology
 disorder of dopaminergic
function:
 related to increased dopamine
activity in certain neuronal
tracts.
 Other neurotransmitter
abnormalities implicated in
schizophrenia:
 elevated serotonin.
 elevated norepinephrine.
 decreased gamma-
aminobutyric acid (GABA).

15. Schizophrenia
Subtypes
Classically divided into five
subtypes
 Paranoid [stable, often persecutory
delusion/hallucinations only]
 Hebephrenic [thought/affective changes +
-ve symptoms]
 Undifferentiated [psychosis w/out clear
predominance]
 Catatonic [prominent psychomotor
disturbances]
 Residual [low intensity +ve symtoms]

16. THREE PHASES OF SCHIZOPHRENIA
Prodromal
•Decline in
functioning that
precedes 1st
psychotic
episode
•Socially
withdrawn,
irritable
•Physical
complaints
•Newfound
interest in religion
/ the occult
Psychotic
(acute phase)
•Positive
symptoms
•Perceptual
disturbances
(e.g. auditory
hallucinations)
•Delusions (usually
secondary,
delusion of
reference
common)
•Disordered
thought process
/ content
Residual
(chronic phase)
•Occurs between
episodes of
psychosis
•Marked by
negative
symptoms (flat
affect, social
withdrawal)
•odd thinking and
behaviour

17. Clinical Features
Acute syndrome
(positive symptoms)
• Hallucinations
• Delusion
• Disorganised
speech/thinking/
behaviour
• Catatonic behaviours
• Delusion of reference
Chronic syndrome
(negative symptoms)
• Affective Flattening
• Alogia
• Avolition
• Anhedonia
• Attention(poor)

18. DIAGNOSIS
CRITERIA OF
SCHIZOPHRENIA
The diagnosis of
schizophrenia is based
entirely on the clinical
presentation – history and
examination.
(ICD-10)
(DSM-
IV)

19. ICD diagnostic criteria –
1 of the following
At least one of the symptoms a-d or
two of the symptoms e- i
a. Thought echo, insertion, or
withdrawal and thought
broadcasting
b. Delusions of control, influence, or
passivity; delusional perception
c. Hallucinatory voices-running
commentary or other < part of body
d. Persistent delusions of other kinds

20. ICD diagnostic criteria –
2 of the following
e. Persistent hallucinations in any modality
occurring everyday for weeks or months
f. Breaks or interpolation in the train of thought >
incoherence or irrelevant speech, or
neologism
g. Catatonic behavior, such as excitement,
posturing, or waxy flexibility, negativism,
mutism, stupor
h. ‘negative’ symptoms; apathy, paucity of
speech, blunting of emotional response
i. A significant and consistent change in
behavior > aimless, idle, self-absorbed att

21. DSM-IV diagnostic criteria
A. Characteristic
symptoms. At least 2 of
the following; each for
1- month period:
a. delusions
b. hallucinations
c. disorganized speech
d. grossly disorganized
or catatonic behavior
e. negative symptoms,
i.e. avolition, flattening
of affect, alogia
(poverty of speech)
F. Social/occupational
dysfunction
G. Continuous signs of the
disturbance persists for
at least six months
H. Schizoaffective and
mood disorder exclusion
I. Substance/medical
condition exclusion
J. Relationship to pervasive
developmental disorder
autism+ schiz.<D/H-1 m

22. Difference between DSMIV
and ICD 10
DSMIV ICD-10
The classification of
schizophrenia
Course and
functional
impairment
Schneider’s first
rank sign
The duration of illness 6 months 1 month
Prodromal and residual
period
included Not included
Occupational and social
functional deficiency
Expected since the
onset of the
disorder
Expected in the
course of the
disorder

23. Kurt Schneider (German psychiatrist) ’s
symptoms of first rank
1. Auditory hallucinations:
audible thought or thought
echo ; referring third person;
running commentary.
2. Alienation of thought: thought
insertion or withdrawal
3. Diffusion of thought (thought
broadcasting)
4. Sensation of feelings, impulses
or acts being controlled by
external forces
5. Somatic passivity < external
agency (e.g. X-rays, hypnosis)
6. Delusional perception

24. Schneider first rank symptoms
of schizophrenia
 Individual symptoms that
are highly specific for
schizophrenia
 Occur in about 80% of
schizo pts, 40% in bipolar
mood disorder ( only
mania)& 20% in severe
major depression

25. DIFFERENTIALS &
MANAGEMENTS

26. Differential diagnosis
 Organic syndrome
 Drug
 Temporal lobe epilepsy
 Delirium
 Dementia
 Diffuse brain disease
 Psychotic mood disorder
 Personality disorder
 Schizoaffective disorder

27. Course
• Complete recovery20%
• Recurrent acute illness
20%
• Chronic disease
starting acutely20%
• Chronic disease
starting insidiously20%
• Suicide10-15%

28. Prognosis
 Recover completely/long
term minimal symptoms-
30%(The percentage on
the rise)
 Recurrent illness -poorer
prognosis
 Young patient -high risk
of suicide

29. Predictors for poor outcome
Features of the illness Insidious onset
Long 1st episode
Previous psychiatric history
Negative symptoms
Younger age at onset
Features of the patient Male
Single, separated, widowed or
divorced
Poor psychosexual adjustment
Poor employment
Social isolation
Poor compliance

30. Assessment
 No confirmatory laboratory
studies.
 Diagnosis made based on
psychotic symptoms and
functional deterioration.
 Diagnostic evaluation: aim
 Establish the presense of
psychosis
 Eliminate other differential
diagnosis

31. Component of Evaluation
Evaluation of of
psychosis
Medical evaluation
Mental status and
siucidality

32. Evaluation of of psychosis

33. Medical evaluation

34. Mental status and siucidality

35. Management
 Treatment of Schizophrenia
 Acute phase
 Relapse prevention phase
 Stable phase
 Psychosocial care and
rehabilitation

36. 36
Need rapid
tranquilisation
Urgent
No
Yes Combination of
parenteral treatment
Yes
Yes
No
Identify Phases of Illness
No
Adequate
dose &
duration
 Oral medication is preferred
 When parenteral needed, use a single agent
•Provide comprehensive plan (pharmacological, psychosocial & service level interventions)
•Offer conventional APs (300-1000mg CPZ equivalent) or AMS or OLZ
•Monitor clinical response, side effects & treatment adherence
Poor
response
Optimise APs usage
•Exclude substance abuse, treatment
non-adherence & concurrent other
general medical conditions
•Optimise psychosocial interventions
•Refer to psychiatrist for trial of
clozapine
Yes
No
•Plan for recovery (ACT, family intervention, psychoeducation, social skills training & supported employment)
•APs usage to continue with single oral agent from acute phase; use depot when non-adherent
•Monitor for clinical response, side effects & treatment adherence
Acute
phase
Relapse
prevention
ALGORITHM FOR MANAGEMENT OF SCHIZOPHRENIA
Diagnosis of
Schizophrenia
Stable
phase
 Follow-up at primary care
 Follow manual on Garispanduan
Perkhidmatan Rawatan Susulan
Pesakit Mental di Klinik Kesihatan
Prevention & management of side effects of APs at all phases
aonitor EPS/akathisia/weight gain/diabetes/heart
disease/sexual dysfunction
Follow schedule of physical care as per follow-up manual

37. Acute phase
 From home to hospital
 Restrain
 Aid from policemen
 Safety of care provider, family members
and patient is crucial
 In the hospital
 Room of seclusion
 Consider involuntary admission

38. Physical restrain
Family education and
counselling
Emergency medication
Antipsychotic
Combination: antipsychotic
+ benzodiazepine
Administered parenterally
If cooperative, oral
administration allowed.

39. Relapse prevention phase
 Started on routine anripsychotic as early
as possible.
 Maintenance doses of medication
established and side effect reviewed.
 Patient education and reassurance.
 Building a therapeutic alliance with
patient and family
 Treatment resistance – Clozapine
 Assertive Community Therapy(ACT)

40. ACT?
 Combined medication and
psychosocial treatments with
aggressive delivery and
follow-up.
 Activities:
 Daily home visit
 “eyes-on” medication
administration
 Transportation to clinician
appointment

41. Stable phase
Follow up at primary care
clinic.
Life long medication
Remission for at least 1
year achieve in 70 – 80%
of patient taking
antipsychotic at full doses
Psychosocial support

42. Psychosocial and
rehabilitation care
 Social skill training
 Employment training
 Cognitive remediation therapy
 Psychoeducation
 Family therapy
 Don’t forget medical illness too…

43. Medications
Traditional Atypical
Haloperidol (2-30 mg) Risperidone (4-16mg)
Chlorpromazine (100-600mg) Olanzapine (5-20mg)
Trifuoperazine (5-30mg) Sertindole (12-20mg)
Sulpiride (400-800 mg) Clozapine (100-900 mg)

44.  Benzodiazepine - Lorazepam
 Atypical antipsychotic for treatment
resistant schizophrenia
- Clozapine

45. THANK YOU
NG BOON KEAT
MOHD HANAFI RAMLEE

46. Differential
Diagnosis
Psychotic
Symptom
Time
Course
Ruled out
secondary
causes
Primary
Psychosis
Chronic
(>1 mo)
Schizoaffective
Disorder
Schizophrenia
Delusional
Disorder
Psychosis NOS
Brief
(<1 mo)
Brief Psychotic
Disorder
Psychosis NOS

47. DiagnosisSpecifiers
Chronic
Primary
Psychosis
Criterion A Sx
and 6 mo
dysfunction?
Simultaneously
meet criteria for
mood disordes?
Schzioaffective
Disorder
Schizophrenia
Prominent
Delusions?
Delusional
Disorder
Psychosis NOS
yes
no
no
no
yes
yes

48. Diagnosis
Brief Primary
Psychosis
Between 1 day
and 1 mo Sx with
full recovery
Brief Psychotic
Disorder
Psychosis NOS
yes
no