Schizophrenia basics for MBBS students.

1. Schizophrenia
Part-I
Dr Jilani AQ,
Associate Professor,
Department of Psychiatry,
DrRMLIMS, Lucknow
Email ID: imjilani@gmail.com

2. Topic Covered
1. Introduction
2. Diagnosis of Schizophrenia
3. Risk factors for Schizophrenia
4. Course of Schizophrenia
5. Clinical feature:
1. Positive symptoms
2. Negative symptoms
3. Cognitive symptoms
4. Mood Symptoms
5. Behavioural Symptoms

3. Introduction
• Psychosis:
• Psychiatric Disorders that affects the way brain processes information in such a way
which causes lose touch with reality i.e. loss of touch with reality with impaired
insight
• The person with the condition usually isn't aware of his or her behaviour
• Common symptoms of psychosis:
• Delusions
• Hallucinations
• Disorganized speech or
• Behavior and catatonia
• Neurosis:
• Psychiatric disorder where there is no loss of touch with reality and impairment of
insight
• The person with the condition usually is aware of his or her behaviour

4. Introduction
• Schizophrenia is a type of psychosis, others are:
1) Acute Transient Psychotic or Brief psychotic disorder
2) Delusional disorder
4) Psychotic depression
5) Psychoactive substance induced
6) Organic schizophrenia like disorder

5. Diagnosis of Schizophrenia
• How to diagnoses Schizophrenia:
• On the basis of set of clinical symptoms
• Which are present for at least one month
• In the absence of other psychiatric or medical conditions that would explain
the symptoms
• Hallmarks of Schizophrenia: Hallucinations & Delusions

6. Diagnosis of Schizophrenia: DSM-V Diagnostic
Criteria for Schizophrenia
• A. ≥2 of the following, each
present for a significant portion of
time during 1-month period (or
less if successfully treated):
I. Delusions
II. Hallucinations
III. Disorganized speech (e.g.,
frequent derailment or
incoherence)
IV. Grossly disorganized or Catatonic
behavior
V. Negative symptoms (i.e.,
diminished emotional expression
or avolition)
Criteria: There are 5 criteria from A to F
• B. Decline in the level of
functioning in ≥1 major areas
e.g. work, interpersonal
relations, or self-care achieved
prior to the onset of illness
(Premorbid state)

7. Diagnosis of Schizophrenia: DSM-V Diagnostic
Criteria for Schizophrenia
• C.
• 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 (i.e., 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 by two or more symptoms
listed in Criterion A present in an
attenuated form (e.g., odd beliefs,
unusual perceptual experiences).
Criteria: There are 5 criteria from A to F
• D.
• Other type of Psychotic
disorders or depressive/bipolar
disorder with psychotic features
have been ruled out.

8. Diagnosis of Schizophrenia: DSM-V Diagnostic
Criteria for Schizophrenia
• E.
• The disturbance is not
attributable to the physiological
effects of a substance (e.g., a
drug of abuse, a medication) or
another medical condition.
Criteria: There are 5 criteria from A to F
• F.
• If there is a history of autism
spectrum disorder or a
communication disorder of
childhood onset, the additional
diagnosis of schizophrenia is made
only if prominent delusions or
hallucinations, in addition to the
other required symptoms of
schizophrenia, are also present for
at least 1 month (or less if
successfully treated).

9. • Specify if:
• The following course specifiers are only to be used
after a 1-year duration of the disorder and if they are
not in contradiction to the diagnostic course criteria.
• First episode, currently in acute episode:
• First manifestation of the disorder meeting the
defining diagnostic symptom and time criteria. An
acute episode is a time period in which the symptom
criteria are fulfilled.
• First episode, currently in partial remission:
• Partial remission is a period of time during which an
improvement after a previous episode is maintained
and in which the defining criteria of the disorder are
only partially fulfilled.
• First episode, currently in full remission:
• Full remission is a period of time after a previous
episode during which no disorder-specific symptoms
are present.
Diagnosis of Schizophrenia: DSM-V Diagnostic
Criteria for Schizophrenia
Multiple episodes, currently in acute episode:
Multiple episodes may be determined after a
minimum of two episodes (i.e., after a first
episode, a remission and a minimum of one
relapse).
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous:
Symptoms fulfilling the diagnostic symptom criteria
of the disorder are remaining for the majority of
the illness course, with subthreshold symptom
periods being very brief relative to the overall
course.
Unspecified
Specify if:
With catatonia

10. Risk factors
Non-Genetic (Environmental):
• Prenatal Factors:
• Viral infections e.g. rubella and influenza
• Starvation
• Obstetric complications:
• Rh incompatibility
• Preeclampsia
• Hypoxia
• Season of birth: winter birth
• Place of birth: urban
• Immigration
• Head injury
• Drug use: LSD, cannabis, and amphetamines
Genetic:
• Family history:
• First, second, third-degree relatives
• Paternal age: >35 year
• Genetic syndromes:
• Velocardifascial syndrome
• Klinefelter syndrome)
• Specific susceptibility genes:
• DTNBP1 (Dystrobrevin binding protein 1;
dysbindin-1) - most studied and promising
schizophrenia susceptibility genes

11. Schizophrenia –Genetic influence
• First degree relative (FDR) with schizophrenia: one of the greatest
risks for the disorder
• Risk in general population: 1 percent
• But the FDR such as a parent or sibling with schizophrenia increases the risk
to 10 percent
• If both parents with Schizophrenia: Risk is 50% in offspring's
• If an identical twin has Schizophrenia: Risk is 40 to 65% in sibling

12. • Incidence:
• A disorder with low incidence and a high
prevalence
• The annual incidence: 1 per 1000
population
• Prevalence:
• The prevalence of a disease is the
estimated the number of cases per 1,000
persons at risk present in a population at
a given time.
• DEVELOPED COUNTRIES- 2.4%- 6.7% per
1000 population at risk.
• DEVELOPING COUNTRIES- 1.4% TO 6.8%
per 1000 population at risk.
Schizophrenia: Epidemiology

13. • Gender & age
• Equally prevalent in both males and females.
• Onset in males is earlier than in females.
• Peak age of onset:
• Males : 10 – 25 YRS
• Females : 25 - 35 YRS
• Women display bimodal pattern of age distributions
• With second peak occurring in middle age.
• Mostly cases are seen in age group 15- 55yrs
Schizophrenia: Epidemiology

15. • Positive symptoms are those that reflect the
presence of abnormal mental process
• Predominate during acute phase of
schizophrenia
• Easier to Treat
• Tends to be transient while negative
symptoms tend to be chronic
Clinical feature of Schizophrenia: Positive
Symptoms
Delusions
Hallucinations
Disorganised speech
Disorganised behaviour
Catatonic behaviour

16. • Delusions:
• Delusions are defined as
“fixed beliefs that are not
amenable to change in light
of conflicting evidence”
• This means that despite
evidence contradicting one’s
thoughts, they are unable to
distinguish them from reality,
likely due to a lack of insight
• i.e. Hard to change even
when the person is presented
with conflicting information,
and
• There are many different
types or themes to delusions.
Clinical feature of Schizophrenia: Positive
Symptoms
• Delusions of grandeur: belief they have exceptional
abilities, wealth, or fame; belief they are God or other
religious saviors (e.g., I am the new Buddha, I am a rock
star);
• Delusions of control: belief that their
thoughts/feelings/actions are controlled by others
• Delusions of thought broadcasting: belief that one’s
thoughts are transparent and everyone knows what they
are thinking
• Delusions of persecution: belief they are going to be
harmed, harassed, plotted or discriminated against by
either an individual or an institution
• Delusions of reference: belief that specific gestures,
comments, or even larger environmental cues are directed
directly to them
• Delusions of thought withdrawal: belief that one’s
thoughts have been removed by another source

17. • Hallucinations:
• Perceptual experiences that occur even when there is no stimulus in the outside
world generating the experiences
• They can be auditory, visual, olfactory (smell), gustatory (taste), or somatic (touch)
• The most common hallucinations in psychosis (at least in adults) are auditory, and
can involve
• One or more voices talking about the person,
• One or more voices commenting on the person’s behavior,
• One or more voices giving orders to persons
• Content of the hallucinations:
• Usually negative (“you are a loser,” “that drawing is stupid,” “you should go kill yourself”) and
• Can be the voice of someone the person knows or a complete stranger
• Sometimes the voices sound as if they are coming from outside the person’s head
• Other times the voices seem to be coming from inside the person’s head, but are not
experienced the same as the person’s inner thoughts or inner speech.
Clinical feature of Schizophrenia: Positive
Symptoms

18. • Disorganized behavior:
• Odd dress, appearance, odd makeup (e.g., lipstick outlining a mouth for 1
inch), or unusual rituals (e.g., repetitive hand gestures)
• Aimless wandering, social withdrawal, self-neglect, or neglect of
environment
• Poor self care and hygiene
• Socially inappropriate, such as talking to oneself in public, obscene language,
or inappropriate exposure
• Substance abuse is another disorder of behavior; patients may abuse
cigarettes, alcohol, or other substances
Clinical feature of Schizophrenia: Disorganized
behaviour

19. • Motor disturbances:
• Stereotypy: repeated, non-goal directed movement such as rocking,
• Mannerisms: normal, goal-directed activities that appear to have social
significance, but are either odd in appearance or out of context, such as
repeatedly running one’s hand through one’s hair or grimacing,
• Mitgehen: moving a limb in response to slight pressure, despite being told to
resist the pressure,
• Echopraxia: the imitation of the movements of another person
• Automatic obedience: carrying out simple commands in a robot-like fashion
• Posturing: Holding the same posture for longer time
• Negativism: opposing the action
Clinical feature of Schizophrenia: Positive
Symptoms

20. • Decrease or loss of
normal functions due to
Schizophrenia
• Predominate during the
chronic Phase of
Schizophrenia
• Most Difficult to treat
Clinical feature of Schizophrenia: Negative
Symptoms
• Affective flattening
• Alogia
• Anhedonia
• Avolition
• Asociality
• Inattention

21. • Reduction in the range
and intensity of
emotional expression,
• Including facial
expression,
• voice tone,
• eye contact and
• body language
Affective flattening
• Decrease in speech
fluency and
productivity
• Due to slowing or
blocked thoughts
• Often manifested as
short, empty replies to
questions
Alogia (poverty of speech) Anhedonia
• Loss of capacity to feel
joy & Pleasure
• Reduced interest in
previously pleasurable
activities e.g.
• Diminished social/ sexual/
recreational interests and
activities
• Deterioration of
relationships with friends
and colleagues
• Difficulty in achieving
intimacy or closeness
Clinical feature of Schizophrenia: Negative
Symptoms

22. • The reduction, difficulty, inability to or
restriction in the initiation of goal
directed behavior.
• Reduced desire, motivation or
persistence;
• No longer interested in
activities that the person
used to show enthusiasm e.g.
No longer interested in going
out with friends
• No longer interested in anything
• Sitting in the house for hours or
days doing nothing
Avolition Inattention
• Inability to focus on
tasks or to maintain
sustained interest
and effort in
completing them
Clinical feature of Schizophrenia: Negative
Symptoms
• Reduced social drive &
interaction
Asociality

23. • Difficulties in concentration and memory:
– Disorganized thinking
– Slow thinking
– Difficulty understanding
– Poor concentration
– Poor memory
– Difficulty expressing thoughts
– Difficulty integrating thoughts, feelings, behaviors
Clinical feature of Schizophrenia: Cognitive
Symptoms

24. Clinical feature of Schizophrenia
Positive symptoms Negative symptoms Cognitive symptoms
Affective/Mood
Symptoms
Behavioural
Symptoms
Hallucinations Asociality and Social withdrawal Poor executive control Depressed mood
Aggression/Agitatio
n
Delusions
Flat affect, Emotional Withdrawal and
Anhedonia ( lack of pleasure in
everyday life)
Inattention, Trouble focusing Anxiety Hostility
Disorganized
thoughts and
speech
Avolition (a lack
of motivation/initiation) and apathy
Working memory/audiovisual
learning problems
Guilt
Impulsiveness
Grossly
disorganized
behavior
Alogia (a poverty of speech), Lack of
spontaneity, Stereotyped thinking
Poor reasoning/problem-solving
abilities
Tension Sexual acting out
Catatonic
excitement
Lack of goal-oriented activity, Poor
abstract
Slow processing speed
Suicidal
Ideas/Acts
Fearfulness/
suspiciousness
Catatonic stupor Social cognition impairment Wandering
Poor hygiene and grooming and
Distorted sense of time
IQ is reduced & deviates 1-2 SD
from expected performance
Mannerism/
Stereotypy/
Hallucinatory
Behaviour

25. • loss of interest
• Avoiding company of others
• Staying away from work
• Being irritable oversensitive
• Develop abstract ideas,
philosophy and religious
questions
• Bizarre ideas
• Abnormal affect
• Strange perception
Course of Schizophrenia
Prodromal Phase
• Significant ‘positive’ symptoms,
• prominent persecutory delusions, hallucinations & odd ideas
• Gradually social withdrawal, impaired performance at
work
• Preoccupied with vague pseudo-scientific / mystical
ideas
• Person’s vocabulary may become vague making it
difficult to grasp
• Smile or laugh without reason
• Constantly perplexed , show signs of restlessness,
sudden unexpected variability in behavior
• Thought alienation, ideas of reference, suspiciousness,
lack of insight
Acute Phase

26. • Significant Negative symptoms:
• Most striking feature – “Diminished Volition” i.e. lack of drive
• Under activity, leading to self & social withdrawn behavior; poor self care
• Lack of conversation, shouting, hurling abuses in public
• Odd behavior, dressing style inappropriate
• Engage in aimless & repeated activity
• Odd postures and movements, stereotypes, mannerisms & dyskinesias
• Few Leisure Activities; Odd ideas; Depression
• Incontinence
Course of Schizophrenia

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