Schizophrenia

(affects 1% of the population)

DSM-IV Diagnostic Criteria
A. Characteristic symptoms: Two (or more) of the following,
each present for a significant portion of time during a 1-month
period (or less if successfully treated):
(1) delusions
(2) hallucinations
(3) disorganized speech (eg, frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, I e, affective flattening, alogia, or
avolition
Note: Only one Criterion A symptom is required if
delusions are bizarre or hallucinations consist of a voice
keeping up a running commentary on the person's
behavior or thoughts, or two or more voices conversing
with each other.

 B. Social/occupational dysfunction: For a significant

portion of the time since the onset of the disturbance,
one or more major areas of functioning such as work,
interpersonal relations, or self-care are markedly below
the level achieved prior to the onset (or when the onset
is in childhood or adolescence, failure to achieve
expected level of interpersonal, academic, or
occupational achievement).
C. Duration: 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 (ie, active-phase
symptoms) and may include periods of prodromal or
residual symptoms. During these prodromal or residual
periods, the signs of the disturbance may be manifested
by only negative symptoms or two or more symptoms
listed in Criterion A present in an attenuated form (eg,
odd beliefs, unusual perceptual experiences).

 D. Schizoaffective and mood disorder exclusion:

Schizoaffective disorder and mood disorder with
psychotic features have been ruled out because either (1)
no major depressive, manic, or mixed episodes have
occurred concurrently with the active-phase symptoms; or
(2) if mood episodes have occurred during active-phase
symptoms, their total duration has been brief relative to
the duration of the active and residual periods.
E. Substance/general medical condition exclusion: The
disturbance is not due to the direct physiological effects
of a substance (eg, a drug of abuse, a medication) or a
general medical condition.
F. Relationship to a pervasive developmental disorder: If
there is a history of autistic disorder or another pervasive
developmental disorder, the additional diagnosis of
schizophrenia is made only if prominent delusions or
hallucinations are also present for at least a month (or
less if successfully treated).

The concept of schizophrenia

Emil Kraepelin (dementia praecox): an early-onset
psychosis (usually occurring in the second or third
decade), which could affect cognition permanently and
usually led to poor outcome.
Eugen Bleuler (Schizophrenia): splitting of thought
and affect was the central feature of the illness. Bleuler
four essence component of the syndrome:
1. Autism
2. Ambivalence
3. Flat affect
4. Disturbance of volition.
5. Kurt Schneider (concept of first-rank symptoms).
Thought diffusion, thought insertion, voices arguing
and commenting are pathognomonic of schizophrenia.

The Three Syndromes

There are three independent syndromes or types
of psychopathology in schizophrenia.
Positive symptoms symptoms include
delusions, hallucinations, and formal thought
disorder. Delusions in schizophrenia are most
often paranoid and suspicious, or bizarre in
nature. Hallucinations are usually auditory in
nature and are experienced as coming from
within the brain or from external sources
Disorganization symptoms (hebephrenia) :
incoherence, loose associations, inappropriate
affect, and poverty of thought content . This
disorder consists of loose associations and
poverty of speech content.

 Negative symptoms: affective

flattening, loss of spontaneity, lack of
initiative or willed action, anergia,
and anhedonia.

 Schizophrenia subtypes
Paranoid schizophrenia is characterized by
prominent persecutory or grandiose delusions. It is the
most common form of the illness.
Disorganized schizophrenia is characterized by the
absence of systematized delusions and the presence of
incoherence and inappropriate affect.
Catatonic schizophrenia (rare form of the illness).
Motor disturbance is the dominant feature, consisting
of either agitated hyperactivity or a decrease in gross
motor activity
Undifferentiated schizophrenia (2-nd by the
frequency form): delusions and hallucinations of any
type are prominent and are accompanied by
incoherence and grossly disorganized behavior.
Residual schizophrenia is a form of the illness in
which positive symptoms are minimal and negative
symptoms predominate.

Etiology
Psychological theories (schizophrenia is
the result of specific disturbances in
child-rearing).
Expressed emotion (family members
express hostility and/or are overly
controlling). latter leads to an increase in
relapse rates.
Double bind theory (a situation
between mother and her child in which
the latter is unconsciously confronted
with two irreconcilable demands or a
choice between two undesirable courses

 Biological theories
1. Dopamine hypothesis: schizophrenia
is due to an excess of DA activity in
limbic brain areas, especially the nucleus
accumbens, as well as the stria
terminalis, lateral septum, and olfactory
tubercle.
2. Serotonin hypothesis.
3. Glutamine hypothesis.
4. Neurodevelopmental hypothesis.

 Genetics: Schizophrenia is a familial

disorder with a complex mode of
inheritance.
1. Twin studies: concordance rates of 46%
for MZ twins and 14% for DZ twins.
2. Among first-degree relatives, lifetime
expectancies are as follows:
. 5.6% for a parent
. 10.1% for a sibling
. 16.7% for a sibling with one
schizophrenic parent
. 46.3% for children with two
schizophrenic parents

Treatment
A.Pharmacological treatment
(neuroleptics or antipsychotic drugs )
1. Typical antipsychotic drugs (decrease
positive symptoms of schizophrenia, but
they have a limited effect on negative
symptoms (eg, apathy, anhedonia,
asociality, avo-lition, loss of affect,
alogia, or poverty of thought) or on
cognition or mood disturbance. )
Chlorpromazine(200-800)
Haloperidol (5-30)
Thrifluoperazine (5-20). .

Most common side effect:

neuroleptics produce neurologic side
effects such as EPS. These effects are
secondary to their ability to decrease
dopaminergic activity due to blockade of
the D2 receptor family.

2. Atypical antipsychotics
(effectively reduce positive and
negative symptoms in patients who
fail to respond to typical neuroleptic
drugs. They also produces almost no
EPS, including akathisia). They are
more potent as 5-HT(serotonin)
then the D2 (dopamine recepror in
limbic and stiatal regions) receptor
antagonist .
Clozapine (100-900)
Riperidone (4-8)
Olanzapine (10-20)

B. Psychosocial treatment is aimed at

1. Improving compliance with drug
therapy
2. Supporting the patients, fostering
independent living skills
3. Improving psychosocial and work
functioning
4. Reducing caretaker burden. Providing
education and support to family
members is a crucial component of a
comprehensive treatment approach.
C. Electroconvulsive therapy is
indicated for patient with limited