Schizophrenia: History, Etiology, Symptoms For NEET PG

Schizophrenia is considered an important topic for the NEET PG exam as it is one of the most commonly encountered psychiatric disorders and is frequently tested in medical exams, including NEET PG. A good understanding of the signs, symptoms, diagnosis, and management of schizophrenia is crucial from the exam point of view.

Read this blog further to get a quick overview of this important topic from psychiatry. 

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    • A - Autistic thinking and behaviour (Fantasy thinking and Withdrawn Behaviour)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

Important information  Third person auditory hallucinations  Patient is the third person in the conversation referred to as “He”

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.

Important information  Positive symptoms are beyond the normal functioning of brain and these are due pathological cause generally.  Negative symptoms are usually the normal function of brain but because of the disease process they are being lost (Loss of functioning which is normal in other individuals).

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)

Important information  They respond poorly to medications and are usually the poor prognostic factors

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 

Important information  Commanding hallucination Person hear commands from the hallucinatory voices E.g.: Voice telling him to jump off the terrace/balcony

TREATMENT

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

	Typical or first-Generation Antipsychotic	Atypical or second-Generation Antipsychotic
Mechanism	D2 antagonism	D2 and 5 HT2 antagonism
Effective Against	Positive symptoms	Positive and negative symptoms (primarily active against positive symptoms)
EPS	More Extrapyramidal side effects	Less extrapyramidal side effects (Not as strong blockers of dopamine receptors)
Metabolic side Effect	Less metabolic side effects	More metabolic side effects (Weight gain, ↑blood sugar, Dyslipidemia)

Treatment of Catatonia

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

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