(Core Course 8 – Unit 3a )

Historical Background:-
• Historically, the most ancient document on schizophrenia-like illness is one by
Charaka, in Ayurveda, written about 33 centuries ago.
• From the West, Morel is generally credited for his description in 1860 of
‘demence precoce’ akin to the present concept of schizophrenia though Haslam,
earlier in 1880, had described the syndrome clearly.
• Description of the illness as a deteriorating one did not correspond to what was
observed at follow-up patients. One outcome of this was the approach to
diagnosis based on symptoms, rather than outcome, adopted by Eugen Bleuler.
He coined the term schizophrenias in 1911.
• In the later half of this century, the psychopathological approach of Bleuler was
replaced by the phenomenological approach to clinical diagnosis based on inner
subjective experience of the patients. Kurt Schneider described 11 first rank
symptoms (FRS) whose presence in the absense of coarse brain disease was
diagnostic of schizophrenia.
• The clarity, which was attempted to be brought by FRS in defining
schizophrenia, was lost in the several other attempts which tended to widen the
concept, diffusing into other illnesses, especially the affective disorders.
Schematic Representation :-
Concept :-
Schizophrenia spectrum and other psychotic disorders include schizophrenia, other
psychotic disorders, and schizotypal (personality) disorder. They are defined by
abnormalities in one or more of the following five domains: delusions,
hallucinations, disorganized thinking (speech), grossly disorganized or abnormal
motor behavior (including catatonia), and negative symptoms.
(DSM-V p. 87)

Clinical Features :-
A discussion of the clinical signs and symptoms of schizophrenia raises three
key issues:-
• No clinical sign or symptom is pathognomonic for schizophrenia; every sign or
symptom seen in schizophrenia occurs in other psychiatric and neurological
disorders. This observation is contrary to the often-heard clinical opinion that
certain signs and symptoms are diagnostic of schizophrenia. Therefore, a
patient’s history is essential for the diagnosis of schizophrenia; clinicians cannot
diagnose schizophrenia simply by results of a mental status examination, which
may vary.
• Schizophrenia simply by results of a mental status examination, which may
vary. Second, a patient’s symptoms change with time. For example, a patient may
have intermittent hallucinations and a varying ability to perform adequately in
social situations, or signiϧcant symptoms of a mood disorder may come and go
during the course of schizophrenia.
• Clinicians must take into account the patient’s educational level, intellectual
ability, and cultural and subcultural membership. An impaired ability to
understand abstract concepts, for example, may reject either the patient’s
education or his or her intelligence. Religious organizations and cults may have
customs that seem strange to outsiders but are normal to those within the
cultural setting. (Kaplan and Sadock)

The following are some symptoms of schizophrenia, although none of them

appears in all cases. In an effort to categorize cases of schizophrenia so that they
can be studied and treated more effectively, it is common practice to consider
positive symptoms (symptoms that seem to represent an excess or distortion of
normal function) separately from negative symptoms (symptoms that seem to
represent a reduction or loss of normal function).
Positive Symptoms
•Delusions: Delusions of being controlled (e.g., Martians are making me steal ),
delusions of persecution (e.g., My mother is poisoning me ), or delusions of
grandeur (e.g., Tiger Woods admires my backswing ).
•Hallucinations: Imaginary voices making critical comments or telling patients what
to do.
•Inappropriate affect: Failure to react with the appropriate emotion to positive or
negative events.
• Incoherent speech or thought: Illogical thinking, echolalia, peculiar associations
among ideas, belief in supernatural forces.
•Odd behavior: Difficulty performing everyday tasks, lack of personal hygiene,
talking in rhymes, catatonia (remaining motionless, often in awkward positions for
long periods).

Negative Symptoms
•Affective flattening: Reduction or absence of emotional expression.
•Alogia: Reduction or absence of speech.
•Avolition: Reduction or absence of motivation.
•Anhedonia: Inability to experience pleasure.
The recurrence of any two of these symptoms for 1 month is sufficient for the
diagnosis of schizophrenia (Tamminga & Holcomb, 2005; Walker et al., 2004).
Only one symptom is necessary if the symptom is a delusion that is particularly
bizarre or an hallucination that includes voices.

DSM-V Diagnostic Criteria:-

A. Two (or more) of the following, each present for a significant portion of time
during a 1 -month period (or less if successfully treated). At least one of these
must be (1 ), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition)

B. For a significant portion of the time since the onset of the disturbance, level of
functioning in one or more major areas, such as work, interpersonal relations,
or self-care, is markedly below the level achieved prior to the onset (or when
the onset is in childhood or adolescence, there is failure to achieve expected
level of interpersonal, academic, or occupational functioning).
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).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic
features have been ruled out because either 1 ) no major depressive or manic
episodes have occurred concurrently with the active-phase symptoms, or 2)
if mood episodes have occurred during active-phase symptoms, they have
been present for a minority of the total duration of the active and residual
periods of the illness.
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.
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).
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.
•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

Specify current severity:

Severity is rated by a quantitative assessment of the primary symptoms of
psychosis, including delusions, hallucinations, disorganized speech,
abnormal psychomotor behavior, and negative symptoms. Each of these
symptoms may be rated for its current severity (most severe in the last 7 days)
on a 5-point scale ranging from 0 (not present) to 4 (present and severe).

Note: Diagnosis of schizophrenia can be made without using this severity

specifier
ICD 10 Diagnostic Criteria:-
Although no strictly pathognomonic symptoms can be identified, for practical
purposes it is useful to divide the symptoms into groups that have special
importance for the diagnosis and often occur together, such as:
• thought echo, thought insertion or withdrawal, and thought broadcasting;
• delusions of control, influence, or passivity, clearly referred to body or limb
movements or specific thoughts, actions, or sensations; delusional perception;
•hallucinatory voices 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;
• persistent delusions of other kinds that are culturally inappropriate and
completely impossible, such as religious or political identity, or superhuman
powers and - 79 - abilities (e.g. being able to control the weather, or being in
communication with aliens from another world);
• persistent hallucinations in any modality, when accompanied either by fleeting
or half-formed delusions without clear affective content, or by persistent over-
valued ideas, or when occurring every day for weeks or months on end;
• breaks or interpolations in the train of thought, resulting in incoherence or
irrelevant speech, or neologisms;
• Catatonic behaviour, such as excitement, posturing, or waxy flexibility,
negativism, mutism, and stupor;
•"negative" symptoms such as marked apathy, paucity of speech, and blunting or
incongruity of emotional responses, usually resulting in social withdrawal and
lowering of social performance; it must be clear that these are not due to
depression or to neuroleptic medication;
• significant and consistent change in the overall quality of some aspects of
personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-
absorbed attitude, and social withdrawal.

Diagnostic Criteria as per DSM-V:-

• The characteristic symptoms of schizophrenia involve a range of cognitive,
behavioral, and emotional dysfunctions, but no single symptom is
pathognomonic of the disorder. The diagnosis involves the recognition of a
constellation of signs and symptoms associated with impaired occupational or
social functioning. Individuals with the disorder will vary substantially on most
features, as schizophrenia is a heterogeneous clinical syndrome.
• At least two Criterion A symptoms must be present for a significant portion of
time during a 1-month period or longer.
• Schizophrenia involves impairment in one or more major areas of functioning
(Criterion B). If the disturbance begins in childhood or adolescence, the
expected level of function is not attained. Comparing the individual with
unaffected siblings may be helpful.
• Some signs of the disturbance must persist for a continuous period of at least
6 months (Criterion C). Prodromal symptoms often precede the active phase,
and residual symptoms may follow it, characterized by mild or subthreshold
forms of hallucinations or delusions.
• Mood symptoms and full mood episodes are common in schizophrenia and
may be concurrent with active-phase symptomatology. However, as distinct
from a psychotic mood disorder, a schizophrenia diagnosis requires the
presence of delusions or hallucinations in the absence of mood episodes. In
addition, mood episodes, taken in total, should be present for only a minority
of the total duration of the active and residual periods of the illness.

In addition to the five symptom domain areas identified in the diagnostic

criteria, the assessment of cognition, depression, and mania symptom domains
is vital for making critically important distinctions between the various
schizophrenia spectrum and other psychotic disorders.
Subtypes of Schizophrenia :-
1. Paranoid Type : The paranoid type of schizophrenia is characterized by
preoccupation with one or more delusions or frequent auditory
hallucinations. Classically, the paranoid type of schizophrenia is
characterized mainly by the presence of delusions of persecution or
grandeur.
2. Dirorganized Type : The disorganized type of schizophrenia is
characterized by a marked regression to primitive, disinhibited, and
unorganized behavior and by the absence of symptoms that meet the
criteria for the catatonic type.
3. Catatonic Type : a. The classic feature of the catatonic type is a marked
disturbance in motor function; this disturbance may involve stupor,
negativism, rigidity, excitement, or posturing. Sometimes the patient
shows a rapid alteration between extremes of excitement and stupor.
4. Undifferentiated Type : Frequently, patients who clearly have
schizophrenia cannot be easily fit into one type or another. These
patients are classified as having schizophrenia of the undifferentiated
type.
5. Residual Type : The residual type of schizophrenia is characterized by
continuing evidence of the schizophrenic disturbance in the absence of a
complete set of active symptoms or of sufficient symptoms to meet the
diagnosis of another type of schizophrenia.
Etiology
Biological Theories:-
• Genetic Factors: There is a genetic contribution to some, perhaps all,
forms of schizophrenia, and a high proportion of the variance in liability to
schizophrenia is due to additive genetic effects. schizophrenia-related
disorders (e.g., schizotypal personality disorder) occur at an increased rate
among the biological relatives of patients with schizophrenia. The
likelihood of a person having schizophrenia is correlated with the closeness
of the relationship to an affected relative (e.g., first- or second-degree
relative). In the case of monozygotic twins who have identical genetic
endowment, there is an approximately 50 percent concordance rate for
schizophrenia. This rate is four to five times the concordance rate in
dizygotic twins or the rate of occurrence found in other 1st-degree relatives.
Some data indicate that the age of the father has a correlation with the
development of schizophrenia. In studies of schizophrenia patients with no
history of illness in either the maternal or paternal line, it was found that
those born from fathers older than the age of 60 years were vulnerable to
developing the disorder. Presumably, spermatogenesis in older men is
subject to greater epigenetic damage than in younger men.
• Biochemical Factors:-
Dopamine Hypothesis : The simplest formulation of the dopamine
hypothesis of schizophrenia posits that schizophrenia results from too
much dopaminergic activity. The theory evolved from two observations.
First, the efficacy and the potency of many antipsychotic drugs are
correlated with their ability to act as antagonists of the dopamine type 2
receptor. Second, drugs that increase dopaminergic activity, notably cocaine
and amphetamine, are psychotomimetic.

Serotonin : Current hypotheses posit serotonin excess as a cause of both

positive and negative symptoms in schizophrenia.

Norepinephrine : A selective neuronal degeneration within the

norepinephrine reward neural system could account for this aspect of
schizophrenic symptomatology of Anhedonia. However, proposal are
inconclusive.

GABA : The inhibitory amino acid neurotransmitter γ-aminobutyric acid

(GABA) has been implicated in the pathophysiology of schizophrenia based
on the finding that some patients with schizophrenia have a loss of
GABAergic neurons in the hippocampus.
Neuropeptides : Neuropeptides, such as substance P and neurotensin, are
localized with the catecholamine and indolamine neurotransmitters and
influence the action of these neurotransmitters. Alteration in neuropeptide
mechanisms could facilitate, inhibit, or otherwise alter the pattern of firing
these neuronal systems.

Glutamate : Glutamate has been implicated because ingestion of

phencyclidine, a glutamate antagonist, produces an acute syndrome similar
to schizophrenia.

Acetylcholine and Nicotine : Postmortem studies in schizophrenia have

demonstrated decreased muscarinic and nicotinic receptors in the caudate-
putamen, hippocampus, and selected regions of the prefrontal cortex.
These receptors play a role in the regulation of neurotransmitter systems
involved in cognition, which is impaired in schizophrenia.
Psychoanalytic Theories:-
• Sigmund Freud postulated that schizophrenia resulted from developmental
fixations early in life. These fixations produce defects in ego development,
and he postulated that such defects contributed to the symptoms of
schizophrenia. Ego disintegration in schizophrenia represents a return to
the time when the ego was not yet developed or had just begun to be
established. Because the ego affects the interpretation of reality and the
control of inner drives, such as sex and aggression, these ego functions are
impaired. Thus, intrapsychic conflict arising from the early fixations and
the ego defect, which may have resulted from poor early object relations,
fuel the psychotic symptoms

Behavioral Theories:-
• According to learning theorists, children who later have schizophrenia learn
irrational reactions and ways of thinking by imitating parents who have
their own significant emotional problems. In learning theory, the poor
interpersonal relationships of persons with schizophrenia develop because of
poor models for learning during childhood.
• A Diathesis-Stress Model of Schizophrenia

Genetic factors and acquired constitutional factors (such as

prenatal events and birth complications) combine to result in
brain vulnerability. Normal maturational processes, combined
with stress factors (family stress, cannabis use, urban living,
immigration, etc.), may push the vulnerable person across the
threshold and into schizophrenia.
Differential Diagnosis :-
1. Secondary Psychotic Disorders (psychotic disorder due to a general
medical condition, catatonic disorder due to a general medical condition,
or substance-induced psychotic disorder.)
2. Other Psychotic Disorders (schizophreniform disorder, brief psychotic
disorder, schizoaffective disorder, and delusional disorders)
3. Mood Disorders (major depressive episode with delusions or
hallucinations, unipolar or bipolar mood disorders, full-blown manic
episode often presents with delusions and sometimes hallucinations.)
4. Personality Disorders (Schizotypal, schizoid, and borderline personality
disorders )
5. Malingering and Factitious Disorders
 Comorbidity with other disorders:-

Rates of comorbidity with substance-related disorders are high in schizophrenia.

Over half of individuals with schizophrenia have tobacco use disorder and smoke
cigarettes regularly. Comorbidity with anxiety disorders is increasingly
recognized in schizophrenia. Rates of obsessive-compulsive disorder and panic
disorder are elevated in individuals with schizophrenia compared with the
general population. Schizotypal or paranoid personality disorder may sometimes
precede the onset of schizophrenia. Life expectancy is reduced in individuals
with schizophrenia because of associated medical conditions. Weight gain,
diabetes, metabolic syndrome, and cardiovascular and pulmonary disease are
more common in schizophrenia than in the general population. Poor
engagement in health maintenance behaviors (e.g., cancer screening, exercise)
increases the risk of chronic disease, but other disorder factors, including
medications, lifestyle, cigarette smoking, and diet, may also play a role. A shared
vulnerability for psychosis and medical disorders may explain some of the
medical comorbidity of schizophrenia
Course and Prognosis :-
Course : The classic course of schizophrenia is one of exacerbations and
remissions. After the ϧrst psychotic episode, a patient gradually recovers and
may then function relatively normally for a long time. Patients usually
relapse, however, and the pattern of illness during the ϧrst 5 years after the
diagnosis generally indicates the patient’s course. Further deterioration in the
patient’s baseline functioning follows each relapse of the psychosis. This
failure to return to baseline functioning after each relapse is the major
distinction between schizophrenia and the mood disorders. Sometimes a
clinically observable postpsychotic depression follows a psychotic episode,
and the schizophrenia patient’s vulnerability to stress is usually lifelong.
Positive symptoms tend to become less severe with time, but the socially
debilitating negative or deϧcit symptoms may increase in severity. Although
about one-third of all schizophrenia patients have some marginal or
integrated social existence, most have lives characterized by aimlessness;
inactivity; frequent hospitalizations; and, in urban settings, homelessness
and poverty.
Prognosis: Several studies have shown that over the 5- to 10-year period after
the ϧrst psychiatric hospitalization for schizophrenia, only about 10 to 20
percent of patients can be described as having a good outcome. More than 50
percent of patients can be described as having a poor outcome, with repeated
hospitalizations, exacerbations of symptoms, episodes of major mood
disorders, and suicide attempts. Despite these glum ϧgures, schizophrenia
does not always run a deteriorating course, and several factors have been
associated with a good prognosis

Treatment : Although antipsychotic medications are the mainstay of the

treatment for schizophrenia, research has found that psychosocial
interventions, including psychotherapy, can augment the clinical
improvement. Just as pharmacological agents are used to treat presumed
chemical imbalances, nonpharmacological strategies must treat
nonbiological issues. The complexity of schizophrenia usually renders any
single therapeutic approach inadequate to deal with the multifaceted
disorder. Psychosocial modalities should be integrated into the drug
treatment regimen and should support it. Patients with schizophrenia
beneϧt more from the combined use of antipsychotic drugs and psychosocial
treatment than from either treatment used alone.
Therapeutic Approaches:-
1. Pharmacotherapy
2. Other Biological Therapies like Electro Convulsive Therapy (ECT)
3. Psychosocial Therapy
a) Social skills training
b) Family oriented therapies
c) Case management
d) Assertive community therapy
e) Group therapy
f) Cognitive Behavioral Therapy (CBT)
g) Individual Psychotherapy
h) Personal Therapy
i) Dialectical Behavior Therapy
j) Vocational Therapy
k) Art Therapy
l) Cognitive Training
Conclusion:-
References:-

1. Carson, R.C, Butcher, J.N, Mineka , S & Hooley,

J.M ; Abnormal Psychology.
2. Kaplan and Sadock’s Synopsis of Psychiatry.
3. Textbook of Postgraduate Psychiatry by Vyas and
Ahuja.
4. Diagnostic and Statistical Manual 5th edition.