Schizophrenia – At A Glance

Schizophrenia is a severe brain disorder which is considered as a psychotic condition where the patient abnormally interpret the reality. 

It may result in a combination of hallucinations, delusions and extreme disorder of thinking and behaviour. 

This is a slowly progressing disease, where the initial symptoms such as social withdrawal, changes in sleep pattern can easily be missed as they start to develop in teenage years and may attributed as adolescent changes 


Causes Of Schizophrenia

Exact cause is unknown and it is believed to be multifactorial.
Mostly it is triggered after a stressful or following an emotional event in life. 

  • Genetic factors
    • Researches have found that schizophrenia tends to run in the family
    • Schizophrenia in first-degree relatives – Risk is about 10%
    • Both parents have schizophrenia – Risk is about 40% for their child to develop schizophrenia
    • Monozygotic twins have about 40% risk, if one child develop schizophrenia
  • Perinatal factors
    • Obstetric complications increases the risk of developing schizophrenia
      • Viral infections
      • Malnourishment
    • LBW / premature babies
    • Hypoxic ischemic encephalopathy
  • Drugs
    • Marijuana, Cocaine, Amphetamines increases the risk 
  • Trigger factors
    • Stress
    • Bereavement
    • Losing a job
    • Failing an exam
    • End of relationships
 


Clinical Presentation Of Schizophrenia

Usually affects late teens and early twenties
Symptoms are divided into two categories 

  • Positive symptoms 
    • These symptoms are seen in patients with acute attacks or relapses
  • Negative symptoms 
    • These symptoms appear several years before the first acute attack 
    • Initial negative symptoms prior to the first attack is called prodromal period of schizophrenia
    • Prodromal period is a slow progressing stage


First Rank Symptoms Of Schneider / Positive Symptoms 

  1. Hallucinations
    • Auditory hallucinations are the most commonest 
    • It can be second person hallucinations or third person hallucinations 
    • These voices are mostly rude, abusive and annoying but some patients have described as friendly and kind
    • These voices can be interacting with the patient, giving instructions and sometimes can be as a commentary 
  2. Thought disorder
    • Thought withdrawal 
      • Patient thinks that they are unable to think because someone has removed his thoughts 
    • Thought insertion
      • Patient thinks that these thoughts were planted in there mind by someone else
    • Thought broadcasting 
      • Patient thinks that his thoughts can be heard by others who are passing close by 
  3. Delusional perception
    • Patient sees a true external stimulus but attribute that stimulus incorrectly
    • Ex : Patient sees a rope but think of it as a snake
    • Sometimes other forms of delusion can occur
    • Persecutory delusion – Firm belief that someone is going to harm him
  4. Somatic passivity
    • A feeling or an action was made to be experienced by an external agent
    • Patient thinks that he is being controlled by someone else
    • Ex : An alien made me lift my arm 
  5. Disorganized speech / Word salad
    • Patient uses abnormal meaningless words during conversations


Negative Symptoms / Chronic Schizophrenia

  1. Social withdrawal / isolation 
  2. Blunting of mood
  3. Anhedonia
  4. Lack of interest and motivation
  5. Loss of libido
  6. Lack of speech
  7. Loss of concentration
  8. Changes in the sleep pattern
 


Complications Of Schizophrenia

  1. Substance abuse
  2. Violence
  3. Depression
  4. Obsessive compulsive disorder
  5. Family issues



Diagnosis Of Schizophrenia

Schizophrenia is a clinical diagnosis and the diagnosis is made by a specialist in Psychiatry 
Investigations should be carried out to exclude the differential diagnoses, such as….

  • Other psychiatric illnesses 
    • Bipolar disorder
    • Schizoaffective disorders
  • Anatomic lesions
    • Brain tumor
  • Metabolic illnesses 
    • Wilson’s disease
  • Infections
    • Neurosyphilis
    • HIV



Treatment Of Schizophrenia

Treatment plan is tailored individually which includes a combinations of talk therapy and medication.
Family support is very important in the treatment of schizophrenia as these patients are primarily cared by their family members.

Anti psychotics are used in the treatment of Schizophrenia

Anti psychotics

  • There are two types of anti psychotics
    • Typical antipsychotics – Chlorpromazine, Haloperidol
      • First generation drugs
    • Atypical antipsychotics – Olenzapine, Risperidone, Quetiapine 
      • Newer drugs 
      • Has less side effects
  • These drugs help the patients to cope with symptoms like hallucinations and delusion 
  • Also these drugs reduce the negative symptoms 
 
Psychosocial Interventions
  • Congnitive behaviour therapy 
  • Cognitive remediation 
  • Family therapy
  • Art therapy 
 


Side Effects Of Drugs

  • Can occur with typical Anti psychotics and high doses of atypical anti psychotics
    • Akathisia 
      • Motor restlessness with repetitive movements 
    • Dystonia
      • Painful muscle cramps 
    • Hyperprolactinemia 
      • Inhibition of dopamine with elevate level of prolactin leading to galactorrhea, gynecomastia
    • Neuroleptic malignant syndrome (NMS) 
      • Associated with high fever, muscle rigidity, altered mental state, AKI
    • Parkinsonism 
      • Associated with tremor, rigidity and bradykinesia
    • Tardive dyskinesia (TD)
      • Involuntary, non rhythmic movements of the mouth, lips tongue and jaw 
    • Loss of libido
    • Drowsiness
    • Weight gain 
  • Occur particularly with atypical anti psychotics 
    • Shaking
    • Muscle twitching
    • Muscle spams 
    • Anticholinergic side effects (Less likely to see with atypical anti psychotics)
      • Dry mouth
      • Blurred vision 
      • Constipation 
      • Agitation 
  • Clozapine
    • Agranulocytosis
    • Arrhythmia
    • Seizures
  • Risperidone
    • Weight gain
  • Olanzepine
    • Diabetes mellitus
    • Weight gain 
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