The lecture has been given on Oct. 19th & 26th, 2010 by Dr. Nazar M. Mohammad Amin.

1. Schizophrenia
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2. Schizophrenia
History
It is a disease of thoughts, action and emotions.
In the year 1860, Morel used the term demence
precoce to describe a state of bizarre behavior and
abnormal mental functions.
Emil kraeplin 1899 used the term dementia precox
and differentiated it from manic depressive illness.
Bleuler 1911, coined the term schizophrenia and
he thought that it resulted from splitting of psychic
functions particularly affective and cognitive.
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3. Schizophrenia
Etiology
There are a variety of etiological factors
including:
Biological
Psychological
Social “ Biopsychosocial”
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4. Schizophrenia
Etiology
Biological factors:
Genetics:
The risk of developing schizophrenia in the
general population is 1%.
The risk becomes 10% if one parent or a sibling in
the family is schizophrenic.
The risk is 40% if both parents are schizophrenic.
It is 10-15% for a dizygotic co twin of an affected
individual and 40% for a monozygotic co twin.
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5. Schizophrenia
Etiology
Biological factors:
Genetics:
The effect of the environment is controlled for
by adoption studies because individuals of the
same family have different environments.
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6. Schizophrenia
Etiology
Biological factors:
Neurochemistry:
Dopamine based on the effect of amphetamine
which releases dopamine causing psychosis and
classical antipsychotic drugs which block dopamine
receptors.
Serotonin based on the atypical antipsychotics
which block both dopamine and serotonin
receptors.
Glutamate based on the antagonism of glutamate
receptors by phencyclidine leading to psychosis.
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7. Schizophrenia
Etiology
Psychological factors:
Cognitive factors including impairments of
attention and memory.
Personality factors: adults with
schizophrenia are much more likely to
have a premorbid schizoid or
schizotypal personality traits
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8. Schizophrenia
Etiology
Psychological factors:
Psychological stress-high expressed emotions:
Families who have excessive critical comments and
hostility as well as emotional overinvlovement with the
patients are described as high expressed emotions
families. The chance of relapse for schizophrenic
patients living in those families is greater than in other
families.
Tim Crew and Mary Johnstone.
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9. Schizophrenia
Etiology
Social
Cannabis: the use of cannabis in
adolescence increases the risk of
schizophrenia in adulthood.
Life events: schizophrenic patients may
exposed to more life events than normals.
PSYCHIATRY 4:10 History
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10. Schizophrenia
epidemiology and risk factors
Age of onset: 15-35 years and it is 3-4
years earlier for males than females.
Sex: the incidence is the same for
both sexes but recent metanalysis
indicates more in men .
Socia class: more in lower
socioeconomic states ( drift
hypothesis)
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11. Schizophrenia
epidemiology and risk factors
Immigration it is more common in
immigrants than native population
but this could be a gene environment
interaction.
It is more common in urban than rural
populations.
PSYCHIATRY 4:10 Epid
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12. Schizophrenia
symptoms
DSM IV and ICD described some
types of schizophrenia as paranoid,
hebephrenic and catatonic types and
the symptoms are classified into
positive, acute or type I symptoms
and negative, chronic and type II
symptoms.
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13. Schizophrenia
symptoms
Positive symptoms include: delusions which
could be bizarre, persecutory, control or
somatic. Hallucinations which are mostly
auditory of the second or third person,
commanding and running commentary.
Visual hallucination are less common.
Other thought disorders include loosening of
association and thought block
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14. Schizophrenia
symptoms
Negative symptoms include:
Alogia
Affective flattening
Avolition-apathy
Anhedonia- asociality
Inattention
They are mostly a reflection of cognitive dysfunctions
due to prefrontal cortex atrophy.
Depression and extrapyramidal side effects of
antipsychotics could be misdiagnosed as negative
symptoms.
PSYCHIATRY 4:10
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15. Schizophrenia
diagnosis
There have been many descriptions of
the condition and many criteria for the
diagnosis including Bleuler’s 4 A s and
Schneider’s first rank and second rank
symptoms and more recently DSM and
ICD.
The main symptoms required for the
diagnosis includes delusions,
hallucinations, disorganised thoughts and
behaviour.
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16. Schizophrenia
cognition
Cognitive disorders are now considered
as the core symptoms of schizophrenia.
They impair individuals in areas of
vocation, social network and living
independently.
Typical antipsychotics cause cognitive
impairments and atypicals have no such
an effect.
Am J Psychiatry 166:6, June 2009
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17. Schizophrenia
outcome and prognosis
Most of the studies done on the
schizophrenic patients revealed that a
proportion of the patients will remain ill
from the first episode and will never
recover. Another proportion will have
only one episode with some residual
effect and will be able to function
normally in areas of social and
occupational life.
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18. Schizophrenia
outcome and prognosis
In the UK, a 5-year follow-up study of a first-admission
cohort of 49 schizophrenic patients found that in most
cases the illness followed one of four broad patterns:
• one episode only and no impairment (22%)
• several episodes with no or minimal impairment
(35%)
• repeated episodes with impairment after first
episode with subsequent exacerbation and no return
to normality (8%)
• impairment increasing with each of several episodes,
with increasingly severe residual symptoms and no
return to normality (35%
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19. Schizophrenia
outcome and prognosis
The outcome is generally better for
females. The prognosis is better for both
sexes in developing than industrialized
countries.
Factors indicating poor prognosis include
male sex, family history of schizophrenia,
structural brain abnormalities, absence of
life events, early onset, cognitive deficit,
substance abuse and poor premorbid
functioning
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20. Schizophrenia
outcome and prognosis
Good prognosis is predicted in good
premorbid social functioning, later
and sudden onset, presence of
depressive symptoms, good initial
response to medications and absence
of tension in the family.
PSYCHIATRY 4:10
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21. Schizophrenia
differential diagnosis
Mood disorders also called affective
disorders.
Delusional disorder
Organic psychosis
Substance induced psychosis
Delerium
Dementia 21

22. Schizophrenia
differential diagnosis
Schizoaffective disorder
Personality disorder
malingering
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23. Schizophrenia
Management
The management of first episode schizophrenia
should include diagnosis and differential diagnosis.
Proper history, physical and neurological examination
is mandatory.
Investigations are needed to exclude other disorders
and they include:
Urine screening for drugs
Blood tests including full blood count, liver function
tests, thyroid function tests, urea and electrolytes
and calcium.
EEG and Neuroimaging including CT and MRI 23

24. Schizophrenia
Management
Antipsychotics: it is better to start with an atypical
antipsychotic if the patient is not already on
antipsychotics.
Benzodiazepines may be needed as adjuvants for a
short time to control agitation and insomnia.
Control drug and alcohol intake.
Family support in the form of psycho education and
groups . Try to identify high expressed emotions to
avoid future relapses.
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25. Schizophrenia
Management
Encourage drug compliance.
Minimise the duration of untreated psychosis DUP.
Cognitive behaviour therapy to improve residual
psychopathology.
Try to avoid stigma of mental illness.
Hospitalisation
Risk assessment. Especially possibility of suicide and
homicide.
Psychiatry 4/11 25

26. Schizophrenia
Management
Pharmacological treatment of schizophrenia:
Chlorpromazine was introduced in 1952. it is one of a
group of antipsychotics called classical, typical,
dopamine blocking or first generation antipsychotics.
The other members include trifluperazine,
fluphenazine, thioridazine, haloperidone etc..
In the year 1990 another generation of antipsychotics
was introduced called nonclassical, second generation,
serotonin and dopamine blocking or atypical
antipsychotics. They include resperidone, olanzepine,
quetiapine, sertindole, zotepine, amisulpride,
ziprasidone and colzapine 26

27. Schizophrenia
Management
Antipsychotics have parenteral preparations for
patients who have low compliance.
Antipsycotics are absorbed in the jejunum and
metabolized in the liver. They also induce liver
enzymes and are protein bound. The antipsychotic
action of these drugs is thought to be postsynaptic
blockade of dopamine (D2)receptors in the mesolimbic
area of the brain. Modification of dopamine
transmission in the frontal cortex may be relevant too.
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28. Schizophrenia
Management
They act on other receptors too leading to some side
effects and they include other dopamine receptor
subtypes, serotonin, muscarinic, adrenergic and
histaminergic receptors.
It is recommecded by NICE that a first onset of
schizophrenia be treated with oral atypical
antipsychotic. Parentral antipsychotics are left for
noncompliant patients. These drugs are used to treat
the acute episode and mentainence treatment
afterwards which could be for months or years.
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29. Schizophrenia
Management
If the patient did not respond to atypical
antipsychotics or could not tolerate them he will be
switched to typical antipsychotics. Patients who did
respond or could not tolerate those drugs too will be
given clozapine under close monitering because of the
serious side effects.
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30. Schizophrenia
Management
Atypical antipsychotics are thought to have a wider
antipsychotic effect because they on both serotonin
and dopamine receptors. They produce less side
effects therefore they are more tolerable by patients
and there will be shorter DUP duration of untreated
psychosis. However they much more expensive.
However the new side effect profile of those drugs
has changed a lot of those beliefs.
It is always preferable to discus the choice of the
treatment with the patients, family doctor and his
carers .
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31. Schizophrenia
Management
Contraindications for typical antipsychotics include
bone marrow suppression and coma produced by CNS
depressants. Caution should be taken when given to
psychotic patients with cardiovascular, liver, renal and
neurological disorders as well as glaucoma.
Atypical drugs should be used with caution in
pregnancy and breast feeding mothers.
Clozapine is contraindicated in neutropenia,
agranylocytosis and myeloproliferative disorders.
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32. Schizophrenia
Management
Unwanted effects
Typical antipsychotics
Extrapyramidal side effects include acute dystonia,
akathisia and parkinsinism. They could be controlled by
reducing the dose, changing the drug or adding an
anticholinergic drug like procyclidine or benzhexol
either orally or parenterally. Akithisia is controlled by
adding a beta blocker.
Tardive dyskinesia after prolonged use of
antipsychotics could be helped by changing to an
atypical antipsychotic or if no response clozapine.
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33. Schizophrenia
Management
Unwanted effects
Anticholinergic side effects including constipation,
urinary hesitancy or retention, blurred vision,
precipitaton of glaucoma, failure of ejaculation and
cutaneous flushling.
Antiadrenergic effects as hypotension and inhibition
of ejaculation too.
Sedation due to D2, H1 and alpa receptor antagonism.
Cardiovascular effects as tachycardia, prolonged QT
interval, flat T wave, cardiac arrythmias and
myocarditis.
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34. Schizophrenia
Management
Unwanted effects
Hyperprolactinemia due to hypothalamopituitary D2
receptor blockade in the form ammenorrhea,
galactorrhea, and breast enlargement in females.
Impotence and gynecomastia in males.
Other side effects include photosensivity, skin
pigmentation, allergic rash, corneal and lense deposits,
cholestatic jaundice, leucopenia and agranulocytosis,
and lowering seizure threshold.
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35. Schizophrenia
Management
Unwanted effects
Neuroleptic malignant syndrome it is fatal in 20% of
the cases and is characterised by hyperthermia,
autonomic instability, alteration of consciousness and
elevated serum CPK.
They might also produce weight gain, hypothermia,
nausia and agitation and anxiety.
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36. Schizophrenia
Management
Unwanted effects
Atypical antipsychotics were thought to have a very
safe profile of side effects, however they were found
to cause somnolence with metabolic syndrome in the
form of type 2 diabetes, obesity and dyslipidemia.
Amisulpride: insomnia and agitation.
Aripiprazole: nausia, vomiting, anxiety and
restlessness.
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37. Schizophrenia
Management
Clozapine: sedation, fatigue, hypersalivation,
anticholinergic effects, weight gain, postural
hypotension, tachycardia and nausia. Agranulocytosis,
lowering seizure threshold and hyperglycemia.
Olanzepine: obesity, somnolence, dizziness,
anticholinergic effects and hyperglycemia.
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38. Schizophrenia
Management
Quetiapine: postural hypotension, somnolence,
dizziness, constipation and dry mouth and prolonged
QT interval.
Resperidone: extrapyramidal side effects, insomnia,
anxiety, agitation, headache and weight gain.
Psychiatry 4/11
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Schizophrenia related disorders
• Schizophreniform psychosis or
acute schizophrenia like psychosis
This is a condition were the symptoms are similar to
schizophrenia but the duration of the symptoms is
more than one month and less than six months.
Patients return to their baseline level of functioning
once the disorder has resolved.
(60-80)% of patients progress to schizophrenia.

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Schizophrenia related disorders
• Schizophreniform psychosis or
acute schizophrenia like psychosis
• It has a rapid onset without a prodrome.
Hallucinations, delusions and negative
symptoms of alogia and avolition may be
present. Speech may be confused or
disorganized and behaviour may be
disorganized or catatonic.

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Schizophrenia related disorders
• Schizoaffective disorder
• They are a heterogenous group of disorders. Some
may have a mood disorder with prominent
schizophrenic symptoms, schizophrenia with
prominent affective symptoms and others have a
distinct clinical picture.
• Men with disorder are more likely to have antisocial
behaviour with flat or inappropriate affect.

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Schizophrenia related disorders
• Delusional disorder
• Occurs when a patient exhibit nonbizarre
delusions of at least one month’s duration
that cannot be attributed to other psychotic
disorders.
• Nonbizarre means that the delusions must be
about situations that can occur in real life,
such as being followed, infected, loved at a
distance and so on

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Delusional disorder
• It is much rarer than schizophrenia. Slightly more common in
females. Men are more likely to develop paranoid delusions
than women, who are more likely to develop delusions of
erotomania.
• There is some association with recent immigration and low
socioeconomic status.
• Types:
• persecutory type.
• jealous type.
• erotomanic type.
• somatic type. MHP : Parasitosis, Foul body odour or
Halithosis, and dysmorphophobia.
• grandiose type.

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Brief psychotic disorder
• Is an acute and transient psychotic syndrome.
It lasts from one day to one month and the
symptoms may resemble those of SZ. It may
develop in response to a severe psychosocial
stressor or group of stressors.

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Thank you for
listening