Schizophrenia

Schizophrenia
Dr Nilima D Shah
Assistant professor
B.J. Medical College
Civil Hospital
Ahmedabad
E-mail: itisnilima@gmail.com

DEFINITION
PSYCHOSIS-
“psyche- mind”
“osis- abnormality”
“ A severe form of mental disorder in which an
individual’s contact with reality is highly distorted”

TYPES
•Brief psychotic disorder
•Schizophreniform disorder
•Schizophrenia
•Schizoaffective disorder
•Delusional disorder
•Shared psychotic disorder
•Post partum psychosis
•Culture bound psychosis
•Psychosis due to general medical condition
•Substance induced psychotic disorder

CASE HISTORY
A 35 year old married woman, teacher by profession , used to stay with her
husband and 10 year old child in a small town….. Around 6-7months back she
had a quarrel with her neighbor who complained that her son had broken her
window glass while playing cricket… She got the glass replaced at her own
expense and also reprimanded her son, asked him to be careful next
time………
But since that incident she remained worried that the neighbour would harass
her……and take revenge for the incident….. Once when someone called her
and the phone got cut…..she felt….. The missed call was a warning from the
neighbour…….When the milkman or the maid reached late, she felt that the
neighbour was asking them also to harass her…. Whenever she saw her
neighbour talking to someone she believed she was talking about her…..Her
neighbour once sent her some sweets on a festival.. She was sure that it had
poison in it…and threw it in the dustbin……
She started remaining alone ….lost in thoughts about how the neighbor would
possibly harm her and how she could save herself……..

CASE HISTORY
Gradually she started hearing voices when alone ……clear female voices
threatening to kill her…abusing her …and commanding her to behave in a
certain manner and laughing at her……..
Now she was convinced that the neighbor had conspired against her and that
she was definitely going to kill her……or her son…or she would do some black
magic on her husband….
She became fearful and started praying to God all the time begging him to
save her and her family… She could not concentrate on her job……Increasingly
she remained absent and finally she stopped going to work……She also did not
allow her son to go to school or go out to play and she also asked her husband
to stay at home for their safety…
Gradually her self care deteriorated ….her grooming and hygiene was
poor…she could not eat….she lost weight…….and would remain sleepless at
night ….She continued to hear the voices which she believed to be real

CASE HISTORY
Confused and worried about her extremely odd behavior, her husband tried to
explain the reality to her…..told her there were no voices and reassured her that
he would go and talk to the neighbor to apologize and sort out issues if any….
Few days later when she saw her husband talking to her neighbor she became
suspicious that her husband was involved with her in the plan to kill her …..when
her husband came home….. She fought with him telling him that he was cheating
on her…even he wanted to kill her and marry the neighbour…..Even on repeated
reassurance by him, she continued to believe he was unfaithful and that he was
now not interested in her because she did not earn anymore and could not do
even household work properly.
Few days later when her husband was cooking food for the family, and he took
the knife in his hand to cut vegetables, she felt he was going to kill her with the
knife!!!! She grabbed the knife, yelled at him – “I will kill myself before you can
kill me” and slashed her wrist…….. She was immediately brought to the
emergency department of the hospital…

CLINICAL FEATURES
In the present case-
Persecution
•DELUSIONS Reference
Infidelity
Other issues-
•Social, occupational Impairment
•Impairment in family functioning
•Poor self care,Sleep Appetite Problems
•Impulsive Suicidal behaviour
•HALLUCINATIONS- Auditory

DIAGNOSTIC CRITERIA
Any 2 out of 5 as per DSM IV TR
•Delusions
•Hallucinations
•Disorganized speech ( frequent derailment /incoherence)
•Grossly disorganized or catatonic behavior
•Negative symptoms – Alogia
Avolition
Anhedonia
Affect flattening
Attention deficits

DISORGANISED SPEECH
Question- what was the reason of quarrel between you and your
brother???
Answer- “It started with a two by two feet iron piece
without any conclusion or enquiring they have been
contacting the inspector of police without any authority
before they could give a boxful of medicines and the
flasks for use till noon”

DISORGANISED SPEECH
“Mental health is the blessed trinity, and as man cannot
be without god, it is futile to deny his son. For the
creation understand germ-any in voice new order, not lie
of chained reaction, spawning mark in temple Cain with
Babel’s grave’n image to wanton V day Israel”

CATATONIC BEHAVIOUR
Group of catatonic patients
This photograph appeared in the fifth edition of Emil Kraepelin's
Psychiatrie (Leipzig Johann Ambrosius Barth, 1896).

CLINICAL FEATURES
Other Symptoms-
•Impulsiveness
•Violence/ Homicide
•Suicide – leading cause of premature death
20 to 30 % attempt, 10- 13% complete
•Cognitive Impairment- attention
executive function
working memory
episodic memory

CLINICAL FEATURES
1) Neurological findings -soft neurological signs
• Tics, stereotypies, grimacing
• Impaired fine motor skills
• Abnormal motor tone
• Abnormal involuntary movements
2) Eye examination
• Disorder of smooth ocular pursuit
• Elevated blink rate
3) Speech disorders- forme fruste of aphasia

TYPES OF SCHIZOPHRENIA
•Paranoid
•Disorganized
•Catatonic
•Undifferentiated
•Residual
•Simple schizophrenia
•Post psychotic depressive disorder of schizophrenia
•Deficit schizophrenia

CASE HISTORY
In the emergency department, a medicolegal case was done, the patient
received primary management for her wrist wound and was subsequently
referred to the psychiatrist for self-injurious behavior with possible suicidal
intent….
The psychiatrist, after taking the history from her husband, interviewed her
and did a detailed mental status examination….. The patient was fearful and
reported that she was badly trapped, people were trying to kill her, and that
she continuously heard voices abusing her…..
Her husband was equally confused as to what had happened to his wife….The
doctor told him that this was a kind of mental illness for which she needed
treatment and advised admission because there was a threat of further self-
harm or violence………
The patient did not think she had any illness, but she was coaxed to get
admitted, saying that it would help in calming down her anxious thoughts, and
her wound could also be examined on a daily basis…..
Reluctantly…they agreed…

CASE HISTORY
An extensive history was subsequently taken including her birth history,
developmental history , education history, past medical and psychiatric history,
family history, personal history including menstrual history, obstetric history and
history of her married life and interpersonal relations with husband…history of
any substance use and premorbid personality traits ….
It was inquired whether she had any history of fever, convulsions or head injury
before the onset of symptoms….
Routine investigations were sent including…. Complete blood count, electrolytes,
liver function tests, renal function tests, fasting and postprandial blood sugar,
serum lipid profile ,X ray and ECG……..which were all normal..
Tab Risperidone 2 mg and tab diazepam 5 mg at bedtime were started for her ….
Risperidone was increased by 2 mg every 2 days… (upto 8 mg ) and an additional
haloperidol and phenargan injection was given to her when she became agitated,
and an additional lorazepam injection was given to her at night if her sleep was
disturbed……

DIFFERENTIAL DIAGNOSIS
1) Other Psychiatric conditions
2) Medical conditions with schizophrenia -like symptoms
• Temporal lobe epilepsy
• Neoplasm, cerebrovascular disease or trauma
•( especially frontal or limbic)

Others-
•Acute intermittent porphyria
•AIDS
•B12 Deficiency
•Carbon monoxide poisoning
•Cerebral lipoidosis
•Creutzfeldt jacob disease
•Fabry’s disease
•Fahr’s disease
•Hallervorden spatz disease
•Wilson’s disease
•Heavy metal poisoning
•Herpes encephalitis
•Homocystinuria
•Huntington’s disease
•Metachromatic leukodystrophy
•Neurosyphilis
•Normal pressure
Hydrocepha;lus
•Pellagra
•Systemic lupus erythematosus
•Wernicke korsakoff syndrome

Substance induced
•Alcohol hallucinosis
•Opium
•Barbiturate withdrawal
•Hallucinogens
•Amphetamine
•Cocaine
•phencyclidine

DELIRIUM
Definition
Acute onset of fluctuating cognitive impairment and a
disturbance of consciousness
Symptoms-
Inattention Thought disorganisation
Disorientation Perceptual disturbances
Impaired memory Altered sleep wake cycle
Hypoactivity/ hyperactivity Mood alterations
Urinary incontinence Myoclonic jerks
Fluctuating course Autonomic instablity

DELIRIUM
Pathophysiology
Reticular formation- dorsal tegmental pathway
Decreased acetylcholine
Treatment
Supportive
Underlying cause
Symptomatic
ECT- case reports in intractable cases

INVESTIGATIONS
•Routine Investigations in all cases- differential diagnosis
baseline
•Neuroimaging in selected cases
•Psychometric tests-
Thematic apperception test
Rorschach
Special batteries for neuropsychological assessment
Minnesota multiphasic personality inventory

ACUTE PHASE TREATMENT
•Decision of Indoor v/s Outdoor treatment
•Decision of treatment per se-
Three modalities of treatment available-
•Pharmacotherapy
•Electroconvulsive therapy
•Psychotherapy

PHARMACOTHERAPY
Antipsychotic drugs
Typical- Dopamine receptor antagonists
Haloperidol (2-30 mg)
Trifluoperazine (10- 30 mg)
Chlorpromazine (200- 1000)
Atypical – Serotonin dopamine receptor antagonists
Risperidone (2-8 mg)
Olanzapine (5-20 mg)
quetiapine (150- 800 mg)
ziprasidone (80-160 mg)
Aripiprazole (10-30 mg)

PHARMACOTHERAPY
Newer Antipsychotic drugs- Paliperidone (3-12 mg)
Amisulpiride (400- 1200 mg)
zotepine (75- 300 mg)
Asenapine (5- 10 mg)
Iloperidone (4-24 mg)
Drug for resistant Schizophrenia- Clozapine (25- 900 mg)
Depot preparations- fluphenazine decanoate (6.25-50 mg)
flupenthixol decanoate (12.5-400 mg)
zuclopenthixol decanoate (100-600 mg)
risperidone microspheres (12.5- 25mg)

ELECTROCONVULSIVE THERAPY
Indications -
•Severe agitation
•Patient not taking drugs orally
•Patient not tolerating oral medication
•Severe homicidal or suicidal ideation
•Catatonic symptoms
•pregnant woman with schizophrenia
Procedure- unlike the procedure depicted in movies…….

ELECTROCONVULSIVE THERAPY
Modified ECT-
Preanaesthetic medication- Atropine
Muscle Relaxant- Succinylcholine
Short acting general anaesthesia- Thiopentone sodium
propofol
Electrode placement- bifrontotemporal/ Rt unilateral
Electric current delivered - 1-5 seconds
Side effects-
Headache
Sore muscles
Neurocognitive

CASE HISTORY
Initially she refused to take medicines….especially when her husband would give
it to her…….got angry on him….and threw the medicines on his face ..shouting….
I know you want to kill me !!!! And then would start crying…….
But she took it when the on-duty doctor gently but firmly gave it to her, after
sending her husband away for a while.
She tolerated risperidone well…..in the first 2 days her sleep & appetite
improved… by the fifth day she felt like taking a good bath, dressed well and
even went out for a walk around the ward…
By the end of around 10 days, her aggressive outbursts almost stopped , the
voices she heard were also less frequent ….. She also told the doctor she felt
much better and that maybe her husband was not as bad as she thought…after
all he was taking good care of her since a week….. She also started talking to him
& taking medicines from him……

CASE HISTORY
However she still stongly believed that her neighbour was actively conspiring
against her and that she was safe only because she was in the hospital…she was
afraid of going home……
the doctor spoke to her husband, told him that she was responding well to
medicines and that he would have to wait a little more for her to be even
better……
But 2 days later… her husband noticed that her body was very stiff….. Her speech
became slurred ….saliva dribbled from her mouth and her hands were
tremulous………
The doctor examined her, there were signs of parkinsonism! the patient had
developed extrapyramidal side effects of antipsychotic medications………
The doctor gave her one injection phenargan and started trihexiphenidyl 2 mg
orally once daily……within 2 days the side effect resolved…………

SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS
Extrapyramidal side effects –
More with typical, but also seen with atypicals rarely
•Acute muscular dystonia-
oculogyric crisis, opisthotonus,
Torticollis, limb and trunk dystonia
•Parkinsonian side effects- tremors, rigidity, salivation,
bradykinesia
•Akathisia
•Tardive dyskinesia
•Neuroleptic malignant syndrome

ACUTE MUSCULAR DYSTONIA
TORTICOLLIS
TONGUE DYSTONIA
TRUNK DYSTONIA LIMB DYSTONIA

Other side effects –
•Cardiac- QT interval prolongation- ventricular arrhythmia
•Postural hypotension
•Sexual dysfunction
•Anticholinergic side effects- dry mouth, constipation,
urinary retention
•Elevated prolactin levels
•Lowering of seizure threshold
•Transient abnormalities in the liver function tests
•Skin and eye reactions

Atypical antipsychotics
•Hyperlipidemia & Weight gain
•Increased risk of type 2 Diabetes Mellitus
•Hyperprolactinemia- galactorrhoea, amenorrhoea,
infertility
•QT interval prolongation
•Obsessive compulsive symptoms- risperidone, olanzapine,
clozapine

Side effects of clozapine
•Agranulocytosis
•Seizures
•Acute myocarditis
•Constipation
•sialorrhea
•Sedation
•Weight gain (average 4.45 kg in 10 weeks)
•Increased risk of type 2 Diabetes Mellitus

FURTHER HOSPITAL
STAY……….

CASE HISTORY
After around 3 weeks… the patient was almost completely alright…..did not hear
any voices, did not suspect her husband… also reconsidering her doubts on her
neighbor…….
She was now also worried about her son who was staying with her parents in law
…and about her job in which she had remained absent for so long………..She was
asking for discharge……
When the doctor asked her what was wrong with her for so many days…….she
replied…. “I don’t know anything…..may be I was a little upset and stressed out
with too much work…but I am completely ok now !!” the doctor explained to her
that she has had a mental illness, and she was better now because of
medicines…and that she must take her medicines regularly … she nodded.
The husband also told the doctor that his boss had been calling him and now he
could no longer get leaves. The doctor decided to discharge the patient after a
detailed conversation with her husband…..

CASE HISTORY
Husband: Doctor, thank you very much, we never knew that this was mental
illness and that it could be treated….. My wife is much better now…..but doctor I
am wondering…why this happened to my wife???? She is so kind hearted and well
educated… so perfect in her work and family life as well……
Doctor- I understand this is a very upsetting illness, but just like any other illness it
could happen to anyone…..
Husband: yes but what are the reasons??? Just like if some insect bites there is
malaria….or smoking can cause lung cancer…what causes this kind of illness???
Doctor: there are various biological, psychological and social reasons…..heredity
also plays a role….you told me her grandmother had some psychological
problems.. Also there are some chemicals in the brain that go topsy turvy to
cause such odd symptoms, which can be corrected by administering medicines

CASE HISTORY
Husband: But doctor …it all started after that small quarrel with the
neighbour……Does it mean that now onwards we should take extra care not to
give her any stress……
Doctor: well, it is true that stress can activate the biological vulnerability to cause
symptoms…. But life and stress go hand in hand…..do you think it is possible to
avoid any kind of stress…???? It would be better if we support her at the times of
stress to help her cope very well…..
Husband: you mentioned it is hereditary…. Does it mean my son will also have
this illness when he grows up???
Doctor: It is a matter of probability…. He has more chance of developing this
illness than the general population….. But he is not sure to have it. He may
develop, he may not develop…… god forbid if he does, early treatment can make
him alright soon…..

CASE HISTORY
Husband: Ok doctor .. How long should my wife take these medicines….???
Doctor: For a long time….3 years, may be even more…..but we will see to it that
she is well on the least possible dose of the least number of medicines…..one of
the medicines (diazepam) we will stop in a few days……the other ones will be
continued …
Husband: In between my wife had become rigid like a robot and her speech was
slurring and hands were trembling…. You said it was some side effect and it
improved after the other medicine….. But does it mean she can develop paralysis
anytime if on these medicines??????
Doctor: No, that was not paralysis, and these medicines will not cause paralysis.
However there is a risk of some side effects, both short term and long term..a list
of which will be given to you with your discharge card. But overall the medicine is
safe and effective, and many patients tolerate it very well without any side
effects…. And clearly, at present the benefit is more than the risk….. We will keep
monitoring her and take prompt action in case anything goes wrong..

CASE HISTORY
Husband: What should I do if she becomes violent or suicidal again???
Doctor: If she keeps taking her medicines well… it is least likely to happen….
However, if you feel that something is going wrong in her mind, you bring her to
us right away….
Husband: After we complete the full course, will she be cured completely???
Doctor: This is a very tricky illness … the chances of relapse are drastically reduced
by taking medicines for a long time, but it can still occur, if it does, she may have
to start medicines again…….dont worry, we will be following her up regularly and
together we will do what is best for her as and when required…..
Husband: Ok doctor…. One more thing….Can she join her job or she needs to
rest???
Doctor: oh..She is already worried about her job….. Further absenteeism may
make matters worse…. I think she should join in a day or two after settling down
at home…

CASE HISTORY
Husband: We have conveyed at the workplace she was not coming as she was not
well….. The principal of the school is as such very supportive…doctor if needed will
you give a certificate that she was unwell??
Doctor: yes sure, you can put an application with the case papers and discharge
card, and if they ask for, we will also give an official certificate.
Husband: Ok doctor , thanks for your support…when should we come next???
Doctor: Next Monday , 4 pm……………….

PSYCHOTHERAPY
Acute Phase- Initial 4 to 8 weeks
•Crisis intervention
•Psycho education
•Supportive Psychotherapy
Later- Stabilization phase- any one or combination of :
•Psychodynamic psychotherapy
•Supportive psychotherapy
•Cognitive behavior psychotherapy
•Interpersonal psychotherapy
•Personal psychotherapy
•Individual /Gruoup therapy
•Social skills training
•Vocational rehabilitation

CASE HISTORY
Monday 4 pm….
Patient was doing well, had restarted her job…..
Her husband also had joined his job…
son was also happy as his mother now allowed her to go out and play…
Patient’s mother in law had come to stay with them for a few months to help her
in household work and to take care of her…….
Diazepam was omitted and rest of the medicines were continued…..
Subsequent follow ups were uneventful…the patient continued to do well…did
not develop any side effects…. All her symptoms were under control , she could
resume her responsibility both at home and workplace……


COURSE AND PROGNOSIS
•20 to 30 % - able to live normal lives
•20 to 30 % - continue to experience moderate symptoms
•40 to 60 % - significantly impaired for their entire lives
•Classic course is of exacerbations and remissions
•Pattern of illness during the first five years is indicative
•20 to 25% may develop post psychotic depressive
symptoms
•Upto10 % may commit suicide

Good prognosis Poor prognosis
Late onset Young onset
Precipitating factor No precipitating factor
Acute onset Insidious onset
Good premorbid functioning Poor premorbid functioning
Mood disorder symptoms Withdrawn autistic behaviour
Family history of mood disorder Family history of schizophrenia
Married Single, divorced, widowed
Good support systems Poor support system
Positive symptoms Negative symptoms
Neurological signs and symptoms
History of perinatal trauma
History of assaultiveness
Many relapses
No remission in 3 years

Resistant cases-
•Change antipsychotic
•Another antipsychotic
•Clozapine
•Ect
•psychotherapies
•Psychiatric rehabilitation
•Institutionalization- social skills and vocational training
•De institutionalization- community integration

CASE HISTORY
7 months later…….
She was once again brought to the emergency psychiatry department by her
husband…this time in a worse condition…. She was shabbilly dressed, having
unkempt appearance, uncombed hair and was laughing and crying inappropriately
and talking to herself…
She was self absorbed and not interested in talking to the doctor even……
Her husband explained the situation to the doctor…..actually 2 months back there
was a vacation in the school and as she was feeling alright, she went to her village
with her son to stay with her parents…… She forgot to take her medicines with
her…......Neither a psychiatrist nor the medicines were available in the village…..
She was feeling alright and she was tempted to decide to do without her
medicines only………..

CASE HISTORY
After around one month … she started having symptoms of suspiciousness and
hearing of female voices abusing her, same as before…
Her mother got worried and started taking extra care of her…. She would
continuously instruct her “get up, take bath, go for a walk, take rest, eat, watch tv,
sleep etc….”
If she would be a little upset, she would go and probe her asking what happened
and give her advice that she should keep smiling, behave normally, and not think
too much……
She further worsened … started laughing and crying without reason and shouting
and using abusive language…..answering back to the voices she heard…….
Her parents felt that she had started behaving like her grandmother who also had
history of such abnormal behaviour…… or may be it was the evil eye…they took
her to the nearby temple to do some ritual…..and various faithhealers…..
She did not improve………

CASE HISTORY
Her parents were ashamed of telling her husband that her condition had
worsened while she was at their place…… hence they were trying their own ways
to make her alright……
Ultimately one day during a telephonic conversation……….her son told him- Papa,
mummy has fallen ill again, she is not alright….
And immediately she was brought back …..and the doctor was consulted….
Another hospitalization…… vehemently refused medicines, hence injectables were
to be given forcefully for 4-5 days ,2 ECTs were to be given, following which she
was put on oral medicines again.. And she again improved, but this time taking a
little longer………….
Again at the time of discharge, she and her husband were explained, in greater
detail, the importance of continued medicines……………

DIFFICULT ISSUES IN
MANAGEMENT

DIFFICULT ISSUES
In this case
•Compliance
•Faithhealers & cultural beliefs
•Expressed emotion- criticism, hostility, Overinvolvement
•Stigma
•Caregiver’s burden

DIFFICULT ISSUES
Other tricky issues- ( due to lack of insight into illness )
•Patient just not ready to come for consultation
•Patient just not taking medicines/ taking on sos basis (Role
of depot preparations or covert administration)
•Patient selectively taking only some drug …
eg only BZD or AP drug without trihexiphenidyl or vice versa
•Suddenly stopping all drugs

Other tricky issues (due to symptoms of illness per se)
•Patient suspicious on all family members and staying alone
•Patient getting lost
•Patient wandering on streets
•Concurrent substance use
•Suicide or self injurious behaviour
•Legal issues- crime- homicide
•Patient on antipsychotic becoming pregnant
•concurrent medical illness remaining undiagnosed
DIFFICULT ISSUES

•Other tricky issues (family / society related)
•Patient neglected and disowned, thought to be malingering
•Family sharing some of the psychotic beliefs of the patient
•Unattended patient, no-one to give history and care for
•Little children or old parents caring for youthful patients
•Inconsistent history given by parents and in laws…
•Illness becoming ground for divorce
DIFFICULT ISSUES

TO CONCLUDE….
Very intriguing, very challenging…..each patient
unfolding a different story………for us to do the
best for them !!!!!!!!!!

“They say when you talk to God
it's prayer, but when God talks to
you, it's schizophrenia!!!!!!!!
THANKYOU !!!!!!!!

Schizophrenia

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