Schizophrenia: History, Etiology, Symptoms For NEET PG

HISTORY 

Here’s a brief history of schizophrenia -

• Emil Kraepelin
  • One of the first person to classify the Psychotic disorder
  • Used the term ‘Dementia Praecox’ for Schizophrenia

• Eugene Bleuler: Coined the term ‘Schizophrenia’   
  • Proposed fundamental (primary) symptoms of schizophrenia (4 A’s of bleuler)
    • A - Autistic thinking and behaviour (Fantasy thinking and Withdrawn Behaviour)
    • A – Ambivalence (Inability to decide) 
    • A - Affect disturbances (Disturbances of affect are there)
    • A - Association disturbances (Disturbances of association of thought is seen in Schizophrenia)

• Kurt Schneider 
  • Gave 11 Schneiderian first rank symptoms (SFRS)
  • If any of these symptoms are present diagnosis of schizophrenia is made
    •  Three Thought phenomenon  
      • Thought insertion
      • Thought withdrawal 
      • Thought broadcast
    • Three made phenomenon (Something is imposed)
      • Made volition (someone is controlling the actions) 
      • Made affect (someone is controlling the emotions)
      • Made impulse (someone is controlling the impulses)
      • Concept of ‘passivity’: Passivity experiences are those in which patient experiences that thought, emotions, actions or sensations are controlled/influenced by others (thought insertion and thought withdrawal are passivity phenomena)
    • Three Auditory Hallucinations 
      • Voices Arguing or Discussing about the patient (Third person auditory hallucinations)
      • Voices giving running commentary 
      • Voices saying thought aloud (thought echo)
    • Delusional perception: A delusion is attached to a normal perception in an un-understandable manner.
      • E.g.: I have a black pen in my hand. I am the poorest human being in the entire country.
    • Somatic passivity: Patient experiences somatic sensations and blames an external agency for the same 
      • I am feeling a strange burning sensation in my elbow because some intelligence agency from other city is throwing radio-waves to my elbow

ETIOLOGY OF SCHIZOPHRENIA

Neurotransmitter hypothesis: Most acceptable

• It says schizophrenia is caused by abnormality in the neurotransmitter 

1. Dopamine hypothesis 
   • Excessive levels of dopamine cause schizophrenia
   • In this case Dopamine antagonists must be useful in the treatment of schizophrenia
2. Dopamine and serotonin hypothesis
   • Excessive levels of Dopamine and Serotonin 
   • New antipsychotics block dopamine and serotonin receptor (Atypical antipsychotics)

Genetic factor

• This plays an important role in the development of schizophrenia 
• Linkage studies have been done
• Many candidate genes have been identify 
• Most important: DiGeorge syndrome (22q11.2 deletion, Velocardiofacial syndrome): 30% them have schizophrenia

Schizophrenia Symptoms

Here are the positive and negative symptoms of schizophrenia - 

1. Positive symptoms of schizophrenia (or psychotic symptoms)

• Delusions
• Hallucinations
• First symptom that respond to medical management
• Both of them respond well to medications and are good prognostic factors.

2. Negative symptoms of schizophrenia 

• Avolition
  • Loss of drive for meaningful activities
  • E.g.: Student stays at home, stops taking bath, sleeps all day
  • Along with it another symptoms called “Apathy” is seen which means lack of concern
  • E.g.: Same student misses exams but does not care about it.
• Anhedonia
  • Lack of pleasure 
  • Inability to pleasure something that were pleasure in the past 
• Affective flattening (or emotional blunting)

3. Disorganisation symptoms 

• Disorganised behaviour (socially inappropriate behaviour)
• Disorganised speech and thinking (formal thought disorder)

4. Motor symptoms (Catatonic symptoms/Symptoms of conation)

• Stupor (Stage just before coma)
  • Mutism and Achinesis is a feature of stupor 
  • Immobility and minimal responsiveness
• Posturing/Catalepsy
  • Maintenance of a posture for a prolonged period of time 
• Waxy flexibility 
  • Flexible as wax
  • Initially some resistance is present, then movement starts to happen, feels like wax 
• Automatic obedience
  • Excessive cooperation (even though the consequences are not that pleasant)
• Negativism
  • Opposite to automatic obedience refusal to accept examiners instructions
• Echolalia: Repetition of examiner’s speech
• Echopraxia: Mimicry of examiner’s behaviour 
• Grimacing: Maintenance of odd facial expressions
• Stereotypy: Spontaneous, repetition of odd purposeless movements
• Mannerisms
  • Spontaneous, repetition of semi- purposeful movements done in an exaggerated manner
  • E.g. Fixing/Combing hairs
• Perseveration
  • Induced movement repeated beyond point of relevance
  • Patient will persist with the same response

SUICIDE IN SCHIZOPHRENIA

• 10% (in DSM-5 it is 5-6%)
• 20 – 40% patients with Schizophrenia attempt suicide
• Suicide most common cause of premature & unnatural death in Schizophrenia
• Suicide became higher 
  • Immediately after admission
  • Immediately after discharge 

TREATMENT

• Antipsychotics are the first line treatment in the management of schizophrenia  

Treatment of Catatonia

• Intravenous lorazepam
• If doesn’t work, then ECT (Electroconvulsive therapy)

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