Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality. Although schizophrenia is not as common as other mental disorders, the symptoms can be very disabling.

1. Department of Psychiatry
Region 1 Medical Center
Mukesh sah, MD
Junior Intern

2. Introduction
■ Most common of serious mental disorders
■ The schizophrenic disorders are characterized in general by
fundamental and characteristic distortions of thinking and
perception, and affects that are inappropriate or blunted.
■ with constellations of abnormalities in thinking, emotion and
behavior
■ Typically chronic, with significant psychosocial and medical
consequences to the patient.
■ According to 5th edition of the Diagnostic and Statistical Manual
of Mental disorders (DSM-5), it is referred to as a syndrome as
schizophrenia spectrum.
■ Dx is based entirely on psychiatric Hx and MSE.
■ No lab test for schizophrenia

3. History
■ Eugene Bleuler (1857-1939)- coined the term schizophrenia
■ Summarized the four As:
 associations,
 affect,
 autism and
 Ambivalence
■ Emil Kraepelin (1856-1926) – translated Morel’s demence
precoce into dementia precox, a term that emphasized the
change in cognition (dementia) and early onset (precox) of the
disorder.
■ He saw a major indicators of dementia precox: hallucinations
and delusions

4. Etiology of Schizophrenia
■ The etiology and pathogenesis of schizophrenia is not known
■ It is accepted, that schizophrenia is „the group of
schizophrenias“ which origin is multifactorial:
– internal factors – genetic, inborn, biochemical
– external factors – trauma, infection of CNS, stress

5. Dopamine Hypothesis
■ The most influential and plausible are the hypotheses, based on
the supposed disorder of neurotransmission in the brain, derived
mainly from
1. the effects of antipsychotic drugs that have in common the ability to inhibit
the dopaminergic system by blocking action of dopamine in the brain
2. dopamine-releasing drugs (amphetamine, mescaline, diethyl amide of
lysergic acid - LSD) that can induce state closely resembling paranoid
schizophrenia
■ Classical dopamine hypothesis of schizophrenia: Psychotic
symptoms are related to dopaminergic hyperactivity in the
brain. Hyperactivity of dopaminergic systems during
schizophrenia is result of increased sensitivity and density of
dopamine D2 receptors in the different parts of the brain.

6. Etiology of Schizophrenia -
Neurodevelopmental Model
■ Neurodevelopmental model supposes in schizophrenia the
presence of “silent lesion” in the brain, mostly in the parts,
important for the development of integration (frontal,
parietal and temporal), which is caused by different factors
(genetic, inborn, infection, trauma...) during very early
development of the brain in prenatal or early postnatal period
of life.
■ It does not interfere too much with the basic brain functioning
in early years, but expresses itself in the time, when the
subject is stressed by demands of growing needs for
integration, during formative years in adolescence and young
adulthood.

7. Genetics of Schizophrenia
■ Many psychiatric disorders are multifactorial
(caused by the interaction of external and genetic
factors) and from the genetic point of view very
often polygenically determined.
■ Relative risk for schizophrenia is around:
– 50% for monozygotic twins
– 40% for parents (both)
– 12% for first degree relative
– 10.1% for siblings
– 12.8% for children

8. Epidemiology
■ In the US, the lifetime prevalence is about 1%
■ Gender and age
■ Equally prevalent in men and women
Men – early mid-20s
Women-late 20s
■ Rare before age 10 or after age 60
■ Medical Illness
■ Persons with schizophrenia have a higher mortality
rate from accidents and natural causes than the
general population.

9. Epidemiology
■ Infection and birth season
High incidence of schizophrenia after prenatal exposure to
influenza
■ Substance Abuse
prevalence of any drug abuse other than tobacco is >50%
■ Population density
The social stressors in the urban settings may causes a persons
at risks
■ Economics and Hospitalization
– Begins early in life so make heavy demands for hospital care,
clinical care, rehabilitation
Downward drift hypothesis
postulates that people suffering from schizophrenia are unable to function well in society
and hence end up in lower socioeconomic groups. Many homeless people in urban areas
suffer from schizophrenia

10. TYPICAL FINDINGS in MSE
The typical findings in schizophrenic patients include:
■■ Disheveled appearance
■■ Flat affect
■■ Disorganized thought process
■■ Intact procedural memory and orientation
■■ Auditory hallucinations
■■ Paranoid delusions
■■ Ideas of reference
■■ Lack of insight into their disease

11. Course of Illness
■ Course of schizophrenia:
– continuous without temporary improvement
– episodic with progressive or stable deficit
– episodic with complete or incomplete remission
■ Typical stages of schizophrenia:
– Prodromal phase: decline in functioning
– Socially withdrawn and irritable
– Active phase/Psychotic phase: perceptual disturbances,
delusions and disordered thought
– Residual phase: mild hallucinations or delusions, and
negative symptoms

12. Positive and Negative Symptoms
Negative Positive
Alogia Hallucinations
Affective flattening Delusions
Avolition-apathy Bizarre behaviour
Anhedonia Positive formal
thought disorder
Attentional impairment Disorganized speech
Cognitive symptoms: Impairments in attention, executive
function, and working memory.These symptoms may → poor
work and school performance

13. Pathophysiology
• ↑ dopamine activity in certain neuronal tracts
• Example cocaine and amphetamines ↑ dopamine activity and
can → schizophrenic-like symptoms.
• Elevated serotonin
• Elevated norepinephrine
• Decrease gamma-aminobutyric acid (GABA)
• Decrease levels of glutamate receptors
Theorized Dopamine Pathways Affected in Schizophrenia
■■ Prefrontal cortical: Inadequate dopaminergic activity responsible for negative
symptoms.
■■ Mesolimbic: Excessive dopaminergic activity responsible for positive symptoms

14. Prognostic factors
BETTER PROGNOSIS WORSE PROGNOSIS
Later onset Early onset
Good social support Poor social support
Positive symptoms Negative symptoms
Acute onset Gradual onset
Female gender Male gender
Mood symptoms Family history
Good premorbid functioning Poor premorbid functioning,
social isolation

15. Two or more of the following must be present for at least 1 month:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
■ Note:At least one must be 1, 2, or 3.
■ ■■ Must cause significant social, occupational, or self-care
functional deterioration.
■ ■■ Duration of illness for at least 6 months (including prodromal or
residual periods in which the above full criteria may not be met).
■ ■■ Symptoms not due to effects of a substance or another medical
condition
DIAGNOSIS: DSM-5 Criteria

16. Subtypes

17. Subtypes of schizophrenia
Schizophrenia
Paranoid schizophrenia
Hebephrenic schizophrenia
Catatonic schizophrenia
Undifferentiated schizophrenia
Post-schizophrenic depression
Residual schizophrenia
Simple schizophrenia
Other schizophrenia
Schizophrenia, unspecified

18. Paranoid Schizophrenia
■ Characterized by preoccupation with one or more
delusions or frequent auditory hallucinations
■ The delusions are not usually systemized too much,
without tight logical connections and are often
combined with hallucinations of different senses,
mostly with hearing voices.
■ Disturbances of affect, volition and speech, and
catatonic symptoms, are either absent or relatively
inconspicuous.

19. Hebephrenic Schizophrenia
■ Hebephrenic schizophrenia is characterized by disorganized
thinking with blunted and inappropriate emotions.
■ It begins mostly in adolescent age, the behavior is often
bizarre.There could appear mannerisms, grimacing,
inappropriate laugh and joking, pseudo philosophical brooding
and sudden impulsive reactions without external stimulation.
There is a tendency to social isolation.
■ Usually the prognosis is poor because of the rapid development
of "negative" symptoms, particularly flattening of affect and
loss of volition.
■ Hebephrenia should normally be diagnosed only in
adolescents or young adults before age 25 years.
■ Denoted also as disorganized schizophrenia

20. Catatonic Schizophrenia
■ Catatonic schizophrenia is characterized mainly by
motoric activity, which might be strongly increased
(hyperkinesia) or decreased (stupor), or automatic
obedience and negativism, rigidity, excitement or
posturing.
■ We recognize two forms:
– productive form — which shows catatonic excitement,
extreme and often aggressive activity.Treatment by
neuroleptics or by electroconvulsive therapy.
– stuporose form — characterized by general inhibition of
patient’s behavior or at least by retardation and slowness,
followed often by mutism, negativism, fexibilitas cerea or by
stupor.The consciousness is not absent.

21. Undifferentiated Schizophrenia
■ Psychotic conditions meeting the general diagnostic
criteria for schizophrenia but not conforming to
any of the subtypes, or exhibiting the features of
more than one of them without a clear
predominance of a particular set of diagnostic
characteristics.
■ This subgroup represents also the former diagnosis
of atypical schizophrenia.

22. Postschizophrenic Depression
■ A depressive episode, which may be prolonged, arising
in the aftermath of a schizophrenic illness. Some
schizophrenic symptoms, either „positive“ or
„negative“, must still be present but they no longer
dominate the clinical picture.
■ These depressive states are associated with an
increased risk of suicide.

23. Residual Schizophrenia
■ A chronic stage in the development of schizophrenia
with clear succession from the initial stage with one or
more episodes characterized by general criteria of
schizophrenia to the late stage with long-lasting
negative symptoms and deterioration (not necessarily
irreversible).

24. Simple Schizophrenia
or Simple Deteriorative Disorder
■ Simple schizophrenia is characterized by early and
slowly developing initial stage with growing social
isolation, withdrawal, small activity, passivity, avolition
and dependence on the others.
■ The patients are indifferent, without any initiative and
volition.There is not expressed the presence of
hallucinations and delusions.

25. Paraphrenia
■ Sometimes used as a synonym for paranoid
schizophrenia
■ Progressively deteriorating course of illness
or the presence of a well-systematized
delusional system
■ Ineffectual in communicating information.

26. Schizotypal disorder
■ According to lCD-10 this disorder is characterized by
eccentric behavior and by deviations of thinking and
affectivity, which are similar to that occurring in
schizophrenia, but without psychotic features and
expressed symptoms of schizophrenia of any type.

27. Persistent Delusional
Disorders
■ Includes a variety of disorders in which long-
standing delusions constitute the only, or the
most conspicuous, clinical characteristic and
which cannot be classified as organic,
schizophrenic or affective.
■ Their origin is probably heterogeneous, but it
seems, that there is some relation to
schizophrenia.

28. Delusional Disorder
■ A disorder characterized by the development of one
delusion or of the group of similar related delusions,
which are persisting unusually long, very often for
the whole life.
■ Other psychopathological symptoms —
hallucinations, intrusion of thoughts etc. are not
present and are excluding this diagnosis.
■ It begins usually in the middle age.

29. Acute andTransient Psychotic
Disorders
■ The criteria should be the following features:
– acute beginning (to two weeks)
– presence of typical symptoms (quickly changing
“polymorphic symptoms”)
– presence of typical schizophrenic symptoms.
■ Complete recovery usually occurs within a few
months, often within a few weeks or even days.
■ The disorder may or may not be associated with
acute stress, defined as usually stressful events
preceding the onset by one to two weeks.

30. Induced Delusional Disorder
■ A delusional disorder shared by two or more people
with close emotional links. Only one of the people
suffers from a genuine psychotic disorder; the
delusions are induced in the other(s) and usually
disappear when the people are separated.
■ The psychotic disorder of the dominant member of
this dyad is mainly, but not necessarily, of
schizophrenic type.The original delusions of
dominant member and his partner are usually
chronic, either persecutory or megalomanic.

31. Schizoaffective Disorders
■ Episodic disorders in which both affective and schizophrenic
symptoms are prominent (during the same episode of the
illness or at least during few days) but which do not justify a
diagnosis of either schizophrenia or depressive or manic
episodes.
■ have usually good prognosis with full remissions without any
remaining defects.

32. Schizoaffective Disorders
■ Diagnosis and DSM-5 criteria
■ Meet criteria for either a major depressive or manic episode during
which psychotic symptoms consistent with schizophrenia are also met.
■ Delusions or hallucinations for 2 weeks in the absence of mood disorder
symptoms.
■ Mood symptoms present for a majority of the psychotic illness.
■ Symptoms not due to the effects of a substance or another medical
condition.
■ Treatment
■ Hospitalizations and supportive therapy
■ Antipsychotics (2nd generations may target both psychotic and mood
symptoms) or ECT for mood symptoms

33. Schizophreniform Disorder
■ Diagnosis and DSM-criteria
■ Diagnosis is made using the same DSM-5 criteria as schizophrenia.
■ The only difference between the two is that schizophreniform disorder
lasts between 1 and 6 months, whereas schizophrenia must be present
for >6 months.
■ Prognosis: Good
■ Treatment
■ Hospitalizations if necessary
■ 6 months course of antipsychotics
■ Supportive psychotherapy

34. Compare time course and
prognosis
■ <1 month – brief psychotic disorder
■ 1-6 months – schizophreniform disorder
■ >6 months – schizophrenia
■ Prognosis from best to worst
1. Psychotic disorder Best
2. Schizoaffective disorder
3. Schizophreniform disorder
4. Schizophrenia Worst

35. Treatment
First-generation (or typical) antipsychotic medications
(e.g., chlorpromazine, fluphenazine, haloperidol,
perphenazine):
■■These are primarily dopamine (mostly D2)
antagonists.
■■Treat positive symptoms with minimal impact on
negative symptoms.
■■ Side effects include extrapyramidal symptoms,
neuroleptic malignant syndrome, and tardive
dyskinesia

36. Second-generation (or atypical) antipsychotic
medications
(e.g., aripiprazole, asenapine, clozapine, iloperidone, lurasidone,
olanzapine, quetiapine, risperidone, ziprasidone):
■■These antagonize serotonin receptors (5-HT2) as well as
dopamine (D4>D2) receptors.
■■ Research has shown no signifcant difference between first-
and second generation antipsychotics in efficacy.The
selection requires the weighing of benefts and risks in
individual clinical cases.
■■ Lower incidence of extrapyramidal side effects, but ↑ risk for
metabolic syndrome.
■■ Medications should be taken for at least 4 weeks before
efficacy is determined.
■■ Clozapine is reserved for patients who have failed multiple
antipsychotic trials due to its ↑ risk of agranulocytosis.

37. Thank you