Schizophrenia

  • Emil Kraepelin (1893)
    • dementia praecox
    most severe mental illness
    • early age of onset
    • severity of symptoms
  • Lifetime prevalence 1-2% (US)

History

  • Prodromal phase
    • loss of interest
    • poor hygiene
    • Change in mood
    • Decline in function
  • Bleuler's 4 'A's
    • Autism
      • withdrawal into inner fantasy world
    • Ambivalence
    • Affective incongruence
    • Associative loosening
  • "Negativisms"
    • Emotional withdrawal
    • Poverty of speech/movement
    • Anhedonia
    • Loss of initiative
  • Mannerisms
  • Stereotypes
  • Disturbances of volition
  • Disturbances of judgement
    • Disorganised behaviour
  • Confusions of the real/unreal
    • Delusions
    • Hallucinations
  • Thinking/attention disorders
    • Disorganised speech

Schneider's First Rank Symptoms

Diagnosis

Precipitants

  • Recent life events

Exclude

  • Mania
  • Depression
  • Intoxication
  • Organic brain syndromes
    • epilepsy

PMHx

  • Previous psychiatric disease
  • In elderly
    • Deafness
    • Blindness

FHx

  • commonly positive

Personal

  • birth trauma
  • erratic performance at school (esp. boys)
  • unable to have long term relationship
  • poor employment record
  • criminal record
  • low income, etc.
  • Poor housing / living rough

Premorbid personality

  • Schizoid
  • Schizotypical personality
  • Withdrawn
  • Eccentric
  • Paranoid

Drugs

  • Treatment
    • depot
  • Street drugs
    • cannabis
    • amphetamines
  • Prescribed
    • IV steroids
  • Smoking
  • Alcohol

ROS

  • ?Epilepsy
  • Headaches
  • Alcohol withdrawal

Examination

Mental state Exam

  • Behaviour
    • self-neglect
    • abnormal movements
  • Speech
    • varied
    • incomprehensible
    • neologisms
  • Mood
    • blunted affect
    • inappropriate
    • affect
  • Thought 
    • insertion
    • withdrawal
    • broadcasting
    • abnormal beliefs
    • in contact with TV set
  • Perception
    • Auditory hallucinations in 3rd Person
    • Thought Echo
    • Running commentary
    • Passivity feelings
  • Orientation
    • Often normal
  • Attention
    • often poor
  • Memory 
    • decreased due to poor attention
  • Insight
    • dependant on degree of treatment

Physical Examination

  • General
    • signs of drug use
    • brain tumour

Investigations

  • Psychosocial
  • Drug screen
  • EEG
  • CT scan

Further classification

Crow

  • Type 1 (Positive)
    • acute onset
    • delusions
    • hallucinations
    • formal thought disorder
    • normal brain brain ventricular size
    • good prognosis & response to neuroleptics
    • dopamine / neurotransmitter abnormalities
  • Type 2 (negative)
    • chronic
    • cognitive impairment
    • flat affect
    • social withdrawal
    • enlarged ventricles
    • poor prognosis & response to neuroleptics

Also

Paranoid Catatonic hebephrenic (disorganised) simple
  • delusions
  • auditory hallucinations

 
  • motor immobility
  • excessive activity
  • rigidity
  • posturing
  • echolalia
  • echopraxia
  • early onset
  • thought incoherence
  • disorganised behaviour
  • blunted / incongruous affect
  • deterioration
  • defect state

 

Differential diagnosis

Epidemiology

  • 15-20 / 100,000 per year
  • M=F (median onset 4 years earlier in males)
  • Peak incidence late teens early adulthood

Aetiology

  • ?neurodevelopmental (48% monozygotic concordance)
  • Decreased volume of parahippocampus, thalamus, superior temporal gyri, frontal lobes
  • Neurotransmitter theories - dopamine, glutamine (NMDA)
  • Dopaminergic over activity
  • Other Catecholamines abnormality
  • Indoleakylamine abnormality
  • Genetic factors
  • Viral disease
  • Auto-immune disease
  • Structural brain abnormalities
  • Environment

Management

  • Always try to involve carers
  • Physical examination and special investigations needed to exclude general medical conditions
  • Risk assessment
  • Biological
  • Psychological
    • Cognitive therapy
    • Crisis management
    • Social skills training
  • Social
    • Assertive outreach
      • community psychiatric nurses
      • occupational therapists
    • family therapy
    • vocational rehabilitation
    • education

Care Programme Approach

Complications

  • Personal and social cost
  • Suicide - 10% die, 50% attempt
  • Homicide - not increased risk

Prognosis

  • Prognosis variable
    • 20-30% good (but ? diagnosis correct)
    • 20-30% experience mild symptoms
    • 40-60% do badly (even higher under DSM-IV criteria)

Predictors of good outcome

  • clear precipitant
  • older age at onset
  • acute onset
  • 'positive' symptoms
  • strong affective component
  • paranoid subtype
  • good premorbid personality
  • history of birth trauma
  • higher intelligence
  • normal CT
  • 'Atypical'

Predictors of poor outcome

  • person
    • male
    • single
    • abnormal pre-morbid personality
    • low IQ
    • low social class
  • onset
    • early age onset
    • insidious onset
    • absence of obvious precipitant
  • type
    • negative features
    • hebephrenic
    • lack of affective component
  • family
    • family history of schizophrenia
    • high level of expressed emotion in family (Vaughn and Leff)
  • substance abuse

Other information

 

[ Home ] [ Up ]