Schizophrenia is one of the most debilitating mental illness which demands immediate attention by the family. There are certain types of schizophrenia based on its symptom presentation and its management mostly depends sxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

1. Schizophrenia & Other
psychotic illnesses
By
Kiranmayi Koni
Associate Professor
Apollo College of Nursing
AIMSR.

2. OVERVIEW
• INTRODUCTION
• DEFINITIONS
• BRIEF HISTORY
• EPIDEMIOLOGY
• ETIOLOGY
• PHASES OF SCHIZOPHRENIA
• PSYCHOPATHOLOGY
• TYPES
• CLINICAL MANIFESTATIONS
• INVESTIGATIONS & DIAGNOSIS
• COURSE & PROGNOSIS

3. PSYCHOSIS
A severe mental condition in which there is
disorganization of the personality, deterioration in
social functioning, and loss of contact with or
distortion of reality. There may be evidence of
hallucinations and delusional thinking.
• NO psychological disorder is more crippling
than schizophrenia.

4. PSYCHOTIC ILLNESSES

5. Schizophrenia can be classified into following
subtypes:
1. Paranoid
2. Hebephrenic (disorganized)
3. Catatonic
4. Residual
5. Undifferentiated
6. Simple
7. Post-schizophrenic depression
1: Schizophrenia

6. 2. Other psychotic illnesses:
–Schizoaffective disorder
–Brief psychotic disorder
–Schizophreniform disorder
–Delusional disorder
–Shared psychotic disorder
–Psychotic disorder due to a General Medical
Condition
–Substance induced psychotic disorder

7. SCHIZOPHRENIA

8. Definitions
• Schizophrenia is a psychotic condition
characterized by a disturbance in thinking,
emotions, volitions and faculties in the presence of
clear consciousness, which usually leads to social
withdrawal.
• Schizophrenia is a clinical syndrome of variable,
but profoundly disruptive psychopathology that
involves cognition, emotion, perception and other
aspects of behavior.
- Kaplan

9. Brief Introduction & History:
• Although schizophrenia is discussed as if it is a
single disease, it probably comprises a group of
disorders with heterogeneous etiologies, and it
includes patients whose clinical presentations,
treatment response, and courses of illness vary.
• Signs and symptoms are variable across patients,
over time (changes in perception, emotion, cognition,
thinking, and behavior).

10. Brief Introduction & History (Contd...):
• The effect of the illness is always severe and is usually
long lasting.
• Benedict Augustin Morel in 1850s used Demence
precoce to describe a young boy who suddenly had
symptoms of mental deterioration.
• Emil Kraepelin translated Morel’s demence precoce
into ‘Dementia precox’, a term that emphasized the
change in cognition (dementia) and early onset (precox) of
the disorder.

11. • Krapelin divided patients into 3 subtypes-
hebephrenic, catatonic and paranoid.
• Eugene Bleuler (1911) coined the term
schizophrenia, which replaced dementia precox
in the literature. Derived from the Greek words
skhizo (split) and phren (mind).
• Bleuler identified specific fundamental (or
primary) symptoms of schizophrenia to develop
his theory about the internal mental schisms of
patients which is now called as Bleuler’s 4 As.
Brief Introduction & History (Contd...):

12. Brief Introduction & History (Contd...):
• Bleuler also identified accessory (secondary)
symptoms.
• Kurt Schneider: Schneider described first-rank
symptoms of schizophrenia. He also stated
second rank symptoms.
• Adolf Meyer: Meyer, the founder of
psychobiology, saw schizophrenia as a reaction
to life stresses.

13. EPIDEMIOLOGY (Global scenario):
• The prevalence rate or schizophrenia is
approximately 1.1% of the population or at any one
time as many as 51 million globally, including:
– 6 to 12 million people in China ( a rough estimate based on
the population)
– 4.3 to 8.7 million people in India ( a rough estimate based
on the population)
– 2.2 million people in USA
– 285,000 people in Australia
– Over 280,000 people in Canada
Source: National Institute of Mental Health

14. INDIAN SCENARIO:
• Annual incidence rate per 1000 population in
India is 0.42
• Median prevalence rate of lifetime prevalence
was 4.0 per 1000 persons
• Incidence rates were higher for males,
migrants, urban settings and higher latitudes.

15. National Mental Health Survey
2015-2016
• Prevalence of Schizophrenia and other Psychotic
disorders is 0.5% for current and 1.4% for lifetime
experience.
• The rate among males was slightly higher than females
(0.5% in males; 0.4% in females).
• 40-49 years of age group had higher prevalence for
current experience of schizophrenia and other
psychotic disorders.
• The rates for current experience were higher for urban
metro residents (0.7%) than of others.

16. National Mental Health Survey (Contd..)
• Schizophrenia before 10 years of age and after 60 yrs
of age is very rarely seen
• In younger age group, risk is higher for men
and in older groups risk is higher for women.
• Male and female client may differ in clinical
course.

17. EPIDEMIOLOGY(Contd..)
MARITAL STATUS & FERTILITY:
• People with schizophrenia, especially men, are less
likely to get married than the general population.
• Fertility rates usually lower (because of less
availability of sexual partner, anhedonia, loss of
libido, antipsychotic side effects).

18. EPIDEMIOLOGY(Contd..)
RACE & SOCIOECONOMIC STATUS:
• Role of race and ethnicity is controversial
• Increased incidence and prevalence in lower
socioeconomic status.
• Recent studies found lower economic status could be as
a result of schizophrenia.
SEASON OF BIRTH & ONSET:
• Those who born in winter and early spring have 5 to
15% increased risk.
• Summer is associated with a higher incidence of
symptom onset and negative symptoms are highly seen.

19. EPIDEMIOLOGY(Contd..)
MORBIDITY & MORTALITY:
– 40-60% of schizophrenia patients are likely to
suffer from life long impairment.
• Mortality rates are twice than that of general
population.
SUBSTANCE ABUSE:
• Lifetime prevalence of any drug abuse (other than
tobacco) is often greater than 50%
– Up to 90% may be dependent on nicotine.

20. ETIOLOGY

21. The cause of schizophrenia is still uncertain. Some of
the factors involved may be:
I. Genetic factors:
a. Family studies:
Increased risk among family members.
• First degree relatives-10 times
• Second degree – 6 times
• Third degree – 2 times
• Children with one schizophrenic parent :12%
• Children with two schizophrenic parents :40%
• Siblings of schizophrenic patient: 8%
Etiology

22. Etiology (Contd...)
b. Twin studies: Concordance rates among:
• Dizygotic twins – 6 to 10 %
• Monozygotic twins – 40 to 50 %
c. Adoption studies:
– Though adoption itself does not increase risk, at
least 10% risk of developing schizophrenia in
adopted away children of schizophrenia patients.

23. II. Stress diathesis model:
Genetic Diathesis Multiple life
Events
Biased
Circuit
Epigenetic
Environmental
Stressors
Disease
Manifestation
Decompensation

24. III. INFECTION HYPOTHESIS:
• Viral infections during pregnancy increases
risk
–Perinatal infection activates a subset of glial
cells; glial hyperactivity can cause neuronal
apoptosis
–Studies show mixed results.

25. IV. IMMUNE DYSFUNCTION:
– Persons with h/o autoimmune disease have
45% increased risk of developing schizophrenia
– Autoantibodies against transglutaminase,
gliadin common in schizophrenics
– Increased risk in: type 1 diabetes, multiple
sclerosis, iridocyclitis, psoriasis, sjogren
syndrome

26. V. BIRTH COMPLICATIONS
• Maternal diabetes, low birth weight, cesarean
section, Rh incompatibility, bleeding in
pregnancy, pre eclampsia; found statistically
significant.
• Hippocampus and neocortical areas more prone
to hypoxia.

27. VI. NEUROANATOMICAL
VENTRICLES:
• Increased size of lateral and third ventricular enlargement
• Reduced cortical gray volume
• Reduced symmetry in temporal, frontal and occipital lobes
LIMBIC SYSTEM:
• Decrease in the size of the region including amygdala,
hippocampus and parahippocampal gyrus.

28. BASAL GANGLIA & CEREBELLUM:
• Cell loss and shrinkage in volume and increase
in number of D2 receptors are seen
• Involvement of basal ganglia and cerebellum
causes odd movements, gait and grimacing
THALAMUS:
• Evidence of volume shrinkage or neuronal loss
may be reduced to 30-45%.

29. VII. NEUROCHEMICAL THEORIES
Neurotransmitters implicated are:
–Dopamine
–Glutamate
–GABA
–Serotonin
–Acetylcholine
–Norepinephrine

30. DOPAMINE PATHWAY
1- Nigrostriatal
2- Mesolimbic
3- Mesocortical
4- Tuberoinfundibualr
5- Thalamic Dopamine pathway

31. DOPAMINE PATHWAY (Contd...)
a. Mesolimbic pathway is associated with
functions of memory, emotion, arousal and
pleasure.
• Excess activity implicated in the positive symptoms
of schizophrenia.
b. Mesocortical pathway is concerned with cognition,
social behavior, planning, problem solving,
motivation and reinforcement in learning.
• Diminished activity in mesocortical pathway
implicated in negative symptoms of schizophrenia.

32. DOPAMINE PATHWAY (Contd...)
c. Nigrostriatal pathway associated with function of
motor control.
• Degeneration in this pathway is associated with
Parkinson’s disease and involuntary psychomotor
symptoms of schizophrenia
d. Tuberoinfundibular pathway is associated with
endocrine function (digestion, metabolism, hunger,
thirst, temperature control and sexual arousal)
implicated in certain endocrine abnormalities
associated with schizophrenia.
e. Thalamic-dopamine pathway is associated with sleep
and arousal mechanisms

33. VIII. NEUROIMAGING
a. MRI BRAIN CHANGES:
• Most common enlargement of lateral and third
ventricles
• Medial temporal volume reduction of amygdala,
hippocampus, parahippocampal and neocortical
temporal regions.
• Reduction in parietal lobe volume and thalamus
volume

34. Brain ventricles in MRI

35. Enlarged ventricles in Schizophrenia

36. b. fMRI:
• Abnormal information processing in brain areas
linked to cognition and emotion
• Inadequate recruitment of hippocampus during
recall
• Lack of emotional processing.
https://link.springer.com/article/10.3758/s13415-016-0493-5

37. Motor neuronal activation in schizophrenia

38. Neuronal activation in hallucinating brain

39. IX. PSYCHODYNAMIC EXPLANATION OF
SCHIZOPHRENIA
FREUDIAN THEORY
Tripartite personality structure
• Psychodynamic psychologists see behavior as
the result of a compromise between three parts
of the psyche.

40. Psychodynamic theory
• In 1924 Freud suggested that schizophrenia is due to
conflict between different parts of the personality.
• If the upbringing of an individual has been extremely
harsh or traumatic, an individual may regress to this early
stage in their development.
• Schizophrenia was thus seen by Freud as an infantile
state
• As a result of regression, client develops delusions of self
importance, unsocialized behavior.
• Fantasies become confused with reality, as the ego tries to
gain control
• Hallucinations and delusions then emerge as the ego
struggles to regain a sense of reality.

41. Schizophrenogenic mother
• Fromm-Reichman (1948) identified the
schizophrenogenic mother as a contributory
factor in the development of schizophrenia.
• This is someone who is cold, dominant and
creates conflict.
• These mothers are rejecting, overprotective, self-
sacrificing, moralisitc and fearful of intimacy.

42. X. Social factors:
• Prevalent in areas of high social mobility and
disorganization
• Members of very low social class
• Stressful life events can precipitate in predisposed
individuals

43. PHASES OF SCHIZOPHRENIA
PREMORBID PERSONALITY

44. PRE-MORBID PERSONALITY:
Often indicates social maladjustment or schizoid or
other personality disturbances.
• Pre-morbid behavior is often a predictor in the
pattern of development of schizophrenia, which
can be viewed in four phases:
• Phase I: The schizoid personality
• Phase II: The prodromal phase
• Phase III: Schizophenia
• Phase IV: Residual phase

45. Phase I: The schizoid personality:
• DSM-IV-TR describes these individuals as
indifferent to social relationships and having a
very limited range of emotional experience and
expression.
• These people do not enjoy close relationships and
prefer to be “loners”
• They appear cold and aloof.
“Not all individuals with characteristics of schizoid
personality will progress to schizophrenia”.

46. Phase II: The prodromal phase:
• This phase is characterized by social withdrawal,
impairment of role functioning, eccentric, neglect of
personal hygiene and grooming, blunt affect,
disturbed communication, bizzare ideas, lack of
initiation, interests or energy.
• May last for many years before deteriorating to
schizophrenic state.

47. Phase III: Schizophrenia
• In this phase, psychotic symptoms are prominent
such as delusions, hallucinations, disorganized
speech, catatonic behavior, negative symptoms such
as affective flattening, alogia or avolition.
• Social or occupational dysfunction
• Continuous signs of disturbance persist for at least
6 months.
• 6 month period must include at least 1 month of
symptoms that meet criterion and may include
periods of prodromal or residual symptoms.

48. Phase IV: Residual phase:
• Schizophrenia is characterized by periods of
remission and exacerbation.
• Usually residual phase follows active phase
and symptoms are similar to prodromal
phase.

49. Psychopathology
i. Intrapsychic influences:
• Certain characteristics of individual (eg: hypersensitivity,
increased anxiety and social detachment) may, under extensive
stress, escalate into suspicion, intolerable fears, withdrawal,
and isolation from others.
• The child who later become schizophrenic may be extremely
sensitized to certain negative characteristics of parents (eg:
hostility), may incorporate these feelings into his own
distorted self image.
• His view of himself is worthless, guilty, helpless individual
• Triggering life events such as death of a loved one, may
exacerbate a crisis and emotional collapse for the person
who predisposed.

50. ii. Interpersonal influences:
• An interpersonal view of schizophrenia is based on the
premise that a person learnt values, attitudes and
communication pattern through his family and
culture.
• Indirect, unclear, incongruent and growth impending
communication
• No freedom to comment
• Lack of adequate feedback mechanisms

51. Clinical features

52. The S/S commonly encountered in schizophrenics:
• Autistic thinking
• Loosening of associations
• Thought blocking
• Neologism
• Poverty of speech
• Poverty of ideation
• Echolalia
• Perseveration
• Verbigeration
• Delusions of various kinds: delusions of persecution, delusions
of grandeur, delusions of reference, delusions of control, somatic
delusions.
• Other thought disorders are over inclusion, impaired
abstraction, concreteness and ambivalence.

53. Positive & Negative symptoms
i. Positive symptoms:
• Features in acute schizophrenia are delusions,
Hallucinations and interference with thinking.
ii. Negative symptoms:
• Affective flattening or blunting
• Avolition- apathy (lack of initiative)
• Attentional impairment, anhedonia,
asociality, alogia.

54. https://study.com/academy/lesson/blunted-affect-
definition-lesson-quiz.html

56. Schneider’s first rank symptoms of schizophrenia
(SFRS)
• Kurt schneider proposed first rank symptoms in
1959.
• Presence of any 1 strongly suggests schizophrenia
• Audible thoughts or thought echo
• Hallucinatory voices in the form of statement and
replay(hears voices discussing him in third person)
• Hallucinatory voices commenting on one’s action
• Thought withdrawal

57. Contd..
• Thought insertion
• Thought broadcasting
• Delusional perception
• Somatic passivity
• Made volition
• Made impulses
• Made feelings or affect

58. • Loss of ego boundaries
• Loss of insight
• Poor judgment
• Suicide due to presence of command
hallucinations, associated depression,
impulsive behavior, or return of insight
Other features

59. Types of schizophrenia & other
psychotic disorders

60. Types of schizophrenia
• Five subtypes of schizophrenia have been
described based predominantly on clinical
presentation: paranoid, disorganized, catatonic,
undifferentiated, and residual.
Note: DSM-5 no longer uses these subtypes but they are
listed in the 10th revision of the International Statistical
Classification of Diseases and Related Health Problems
(ICD-10).

61. Schizophrenia can be classified into following
subtypes:
1. Paranoid
2. Hebephrenic (disorganized)
3. Catatonic
4. Residual
5. Undifferentiated
6. Simple
7. Post-schizophrenic depression

62. Paranoid schizophrenia
• Word paranoid means ‘delusional’, the most common
form of schizophrenia.
• Delusion of persecution: Individual believe that they are
being malevolently treated in some way.
• Frequent themes include: being cheated, spied upon,
followed, poisoned or drugged, harassed or
obstructed in the pursuit of long term goals.
• Delusion of jealousy: eg: person’s sexual partner is
unfaithful.
• Idea is held on inadequate grounds and is unaffected
by rational judgment

63. Contd….
• Delusion of grandiosity: irrational ideas
regarding their own worth, talent, knowledge
or power.
• Hallucinatory voices that threaten or command
the patient
• Other features include disturbances of affect,
volition, speech and motor behavior.
https://www.youtube.com/watch?v=xIrA6iCke2M&p
bjreload=10

64. Catatonic schizophrenia
• Catatonic schizophrenia is characterized by
marked disturbances of motor behavior.
• May be catatonic stupor, catatonic excitement and
catatonia altering between excitement and stupor.

65. Clinical features of excited catatonia:
• Increase in psychomotor activity ranging from
restlessness, agitation, excitement, aggressiveness to
at times violent behavior.
• Increase in speech production
• Loosening of associations and frank incoherence
• If it is very severe, it is accompanied by rigidity,
hyperthermia and dehydration can result in death.
It is known as acute lethal catatonia or pernicious
catatonia.
https://www.youtube.com/watch?v=_s1lzxHRO4U

66. S/S of retarded catatonia (c.stupor):
• Mutism
• Rigidity
• Negativism
• Posturing
• Stupor
• Echolalia
• Echopraxia
• Waxy flexibility
• Ambitendency
• Automatic obedience

67. Hebephrenic schizophrenia
Other name: Disorganized schizophrenia.
Common features includes:
• Thought disorder
• Incoherence
• Severe loosening of association
• Extreme social impairment
• Delusions and hallucinations are fragmentary and
changeable
• Other oddities like mirror gazing, senseless gigling,
mannerisms, grimacing etc.
• Course is chronic, worse in prognosis

68. Residual schizophrenia
• Emotional blunting
• Eccentric behavior
• Illogical thinking
• Social withdrawal
• Loosening of association
• This should be used when there is at least one
episode of schizophrenia in the past but without
prominent symptoms at present.

69. Undifferentiated schizophrenia
• This is diagnosed when either features of no
subtype are fully present or features of more than
one subtype are exhibited.

70. Post schizophrenic depression
• Depressive features develop in the presence of
residual or active features of schizophrenia and are
associated with an ↑ risk of suicide.

71. Simple schizophrenia
• Early, insidious onset, progressive course,
presence of characteristic negative symptoms.
• Vague hypochondriacal features, wandering
tendency
• Self absorbed idleness and aimless activity.
• No episode with all typical psychotic symptoms.
• Prognosis is very poor

72. TYPES OF OTHER PSYCHOTIC
DISORDERS

73. Other psychotic illnesses are:
• Schizoaffective disorder
• Brief psychotic disorder
• Schizophreniform disorder
• Delusional disorder
• Shared psychotic disorder
• Psychotic disorder due to a General Medical
Condition
• Substance induced psychotic disorder

74. Schizoaffective disorder
• Client may manifest schizophrenic behaviors, with
a strong element of symptomatology associated
with mood disorders (depression or mania).
• Client may appear depressed with psychomotor
retardation and suicidal ideation, or symptoms may
include euphoria, grandiosity and hyperactivity.

75. BRIEF PSYCHOTIC DISORDER
• Sudden onset of psychotic symptoms may or may
not be preceded by a severe psychosocial stressor.
• These symptoms last at least 1 day but less than
one month and there is an eventual full return to
the premorbid level of functioning.

76. SCHIZOPHRENIFORM DISORDER
• The essential features of this disorder are identical to
those of schizophrenia, with the exception that the
duration, including prodromal, active and residual
phases, is at least 1 month but less than 6 months.
• The diagnosis is changed to schizophrenia If the
clinical picture persists beyond 6 months.

77. Delusional disorder
• Essential feature is presence of one or more nonbizarre
delusions that persist for at least 1 month.
• If present at all, hallucinations are not prominent and
behavior may not be bizarre.
Subtypes: based on the predominant delusional theme.
• Erotomanic type
• Grandiose type
• Jealous type
• Persecutory type
• Somatic type

78. Shared psychotic disorder
• Essential feature is folie a deux, a delusional system
develops in a second person as a result of a close
relationship with another person who already has
a psychotic disorder with prominent delusions.
• Course is chronic, and is more common in
women than in men.

79. PSYCHOTIC DISORDER DUE TO GENERAL
MEDICAL CONDITION
• Essential features are prominent hallucinations
and delusions which can be directly attributed
to a general medical condition.

80. SUBSTANCE INDUCED PSYCHOTIC
DISORDER
• Presence of prominent hallucinations and
delusions that are judged to be directly
attributable to the physiological effects of a
substance (i.e a drug abuse, a medication or toxin
exposure).

81. INVESTIGATIONS &
DIAGNOSIS

82. Investigations
• Diagnosis of schizophrenia is based entirely on
the psychiatric history and mental status
examination. There is no laboratory test for
schizophrenia.
CT:
• Enlargement of third and lateral ventricles
• Reduced temporal lobe size with abnormalities of
medial temporal lobe structures
MRI:
• Inconsistent array of findings in basal ganglia
• Cerebellar atrophy and thickening of the corpus

83. Enlarged ventricles in Schizophrenia

84. Microscopic histopathology:
• In brain cyto architectural changes like
neuronal degeneration in the cortical layers
especially pre-frontal and cortical pyramidal
cells.
• The most striking changes reported in
hippocampus, parahippocampal gyrus

85. DIAGNOSIS As per ICD 10 guidelines
• Minimum of one very clear symptom (2 or more if less clear
cut) from a to d or
• At least two of the groups referred from e to h, should have
been clearly present for most of the time during a period of 1
month or more.
• a. Thought echo, thought insertion or withdrawal and
thought broadcasting
• b. Delusions of control, influence, or passivity or delusional
perception
• C. Hallucinatory voices of any form (giving a running
commentary on the patient's behaviour, or discussing the
patient among themselves, or other types of hallucinatory
voices coming from some part of the body)

86. DIAGNOSIS as per ICD 10 guidelines (Contd..)
d. Persistent delusions of other kinds that are
culturally inappropriate and completely impossible
e. Persistent hallucinations in any modality with
delusions
f. Interpolations in train of thought, resulting in
incoherence or irrelevant speech or neologisms
g. Catatonic behavior
h. Symptoms of negativism
i. Significant and consistent change in the overall
quality of some aspects of personal behavior

87. DSM-V classification
1. Two or more of the following for at least a one-month
(or longer) period of time, and at least one of them must
be 1, 2, or 3:
– Delusions
– Hallucinations
– Disorganized speech
– Grossly disorganized or catatonic behavior
– Negative symptoms
2. Impairment in one of the major areas of functioning for
a significant period of time since the onset of the
disturbance: Work, interpersonal relations, or self-care.

88. DSM-V classification (Contd...)
3. Some signs of the disorder must last for a continuous
period of at least 6 months ( 1 month of symptoms
that meet criterion A (active phase symptoms) and
periods of residual symptoms (negative symptoms).
4. Schizoaffective disorder and bipolar or depressive
disorder with psychotic features have been ruled out.

89. DSM-V classification (Contd...)
5. The disturbance is not caused by the effects of a
substance or another medical condition
6. If there is a history of autism spectrum disorder or a
communication disorder (childhood onset), the
diagnosis of schizophrenia is only made if prominent
delusions or hallucinations, along with other
symptoms, are present for at least one month.

90. Course and prognosis
• Schizophrenia has been described as most crippling
and devastating of all psychiatric illnesses
• The classic course is one of exacerbations and
remissions
• Over the 5-10 years period after first psychiatric
hospitalization for schizophrenia, only 10-20%
described as having good outcome.
• More than 50% have a poor outcome, with repeated
hospitalization.

91. Course and prognosis (Contd..)
• The prognosis of schizophrenia is often reported in
the paradigm of thirds.
• One third: achieve significant and lasting
improvement.
• One third: achieve some improvement with
intermittent relapses and residual disability.
• One third: Severe and permanent incapacity.