Essay on Schizophrenia Disorders: Top 5 Essays | Disorders | Psychology

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Essay on Schizophrenia Disorders

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Essay Contents:

1. Essay on the Definition and History of Schizophrenia Disorders
2. Essay on the Epidemiology of Schizophrenia Disorders
3. Essay on the Clinical Presentation of Schizophrenia Disorders
4. Essay on the Clinical Features of Major Subtypes of Schizophrenia 
5. Essay on the Prognostic Features of Schizophrenia Disorders

Essay # 1. Definition and History of Schizophrenia Disorders:

This group of disorders is characterized by a disturbance of thinking, accompanied by disturbances in psychomotor activity, affect, perception and behaviour.

Morel coined the term ‘demence precoce’ to describe an adolescent patient, once bright and active, who slowly lapsed into a state of silent withdrawal. In 1868, K.L. Kahlbaum described the syndrome of Katatonie (the present Catatonia) and in 1871.

E. Hecker had described Hebephrenie. Emil Kraepelin (1856-1926), a German professor of psychiatry) first separated “manic depressive psychosis’ from ‘dementia praecox’ (the present chronic schizophrenia).

Eugen Bleuler (1857-1939), a Swiss psychiatrist coined the term ‘Schizophrenia’ meaning the “splitting of the mind” in his classic text, ‘Dementia Praecox or the Group of Schizophrenia’. In 1959, Kurt Schneider described the ‘symptoms of the first rank’ (in absence of organic disease).

Essay # 2. Epidemiology of Schizophrenia Disorders:

The exact incidence and prevalence is not known:

a) Incidence:

Incidence 10-20 per lac per year.

b) Prevalence:

Prevalence – 0.2-1% (in some parts of the world e.g., Northern Sweden) upto 2.8%

c) Age of onset:

Adolescence or early adulthood.

d) Sex ratio:

Equal in males and females.

e) Other variables:

Increased incidence in winter births, low birth order in a large family, left- handedness and in low social class.

Essay # 3. Clinical Presentation of Schizophrenia Disorders:

See Table 15.1.

Types and Symptomatology:

1. Catatonic

2. Paranoid

3. Hebephrenic

4. Simple

5. Schizoaffective

6. Residual and latent:

Residual schizophrenia is similar to latent schizophrenia and symptoms are similar to prodromal symptoms of schizophrenia. The only difference is that residual schizophrenia is diagnosed after at least one episode has occurred.

According to ICD-10 it is characterized by the following features, in addition to the general guidelines of schizophrenia described earlier:

a. Prominent:

Prominent ‘negative’ schizophrenia symptoms, i.e., psychomotor slowing, under activity, blunting of affect, passivity and lack of initiative, poverty of quantity or content of speech, poor nonverbal communication by facial expression, eye contact, voice modulation, and posture, poor self-care and social performance.

b. Evidence:

Evidence in the past of at least one clear- cut psychotic episode meeting the diagnostic criteria for schizophrenia.

c. A period:

A period of at least 1 year during which the intensity and frequency of florid symptoms such as delusions and hallucinations have been minimal or substantially reduced and the ‘negative’ schizophrenic syndrome has been present.

d. Absence:

Absence of dementia or other organic brain disease or disorder, and of chronic depression or institutionalism sufficient to explain the negative impairments.

7. Undifferentiated Schizophrenia:

This is a very common type of schizophrenia and is diagnosed either when features of no subtype are fully present or features of more than one subtype are exhibited, though the criteria for diagnosis of schizophrenia are met.

8. Post-schizophrenic Depression:

Some schizophrenic patients develop depressive features within 12 months of an acute episode of schizophrenia. The depressive features develop in the presence of residual or active feature of schizophrenia and are associated with an increased risk of suicide. It is important to distinguish the depressive features from negative symptoms of schizophrenia and extrapyramidal side-effects of antipsychotic medication.

9. Pseudoneurotic Schizophrenia (Hoch and Polatin):

In initial phases, there are predominant neurotic symptoms which last for years and show a poor response to treatment.

Three classical features are:

1. Pan-anxiety (diffuse, free-floating anxiety which hardly ever subsides).

2. Pan-neurosis (almost all neurotic symptoms may be present).

3. Pan-sexuality (constant preoccupation with sexual problems).

Now –a –days, this subtype is subsumed under borderline personality disorder.

10. Schizophreniform Disorder:

This is a diagnostic category in DSM-IV with features of schizophrenia as diagnostic criteria. The only difference is that the duration is less than 6 months and prognosis is usually better than that of schizophrenia. A similar condition in ICD-10 is called acute schizophrenia like psychotic disorder.

11. Oneiroid Schizophrenia (Mayer-Gross):

This is a subtype of schizophrenia with an acute onset, clouding of consciousness, disorientation, dream-like states (Oneiroid means ‘dream’) and perceptual disturbances with rapid shifting.

12. Van Gogh Syndrome:

Dramatic self- mutilation occurring in schizophrenia has been also called as Van Gogh syndrome, after the name of the famous painter Van Gogh who had cut his ear during the active phase of illness.

13. Late Paraphrenia (Roth):

This is a disorder which occurs late in life, usually in the sixth decade. It is more common in women, especially unmarried or widowed. Delusions of persecution are common with bizarre and fantastic contents like being raped or gassed or strangers entering their rooms and interfering.

Hallucinations of all kinds (visual, auditory, tactile, gustatory and olfactory) are common. Intelligence and judgement outside the area of persecutory delusions are normal. 25% to 40% of patients have some defect of sight or hearing.

Presently, this syndrome is placed under paranoid schizophrenia, late onset type.

14. Negative Schizophrenia:

The main negative symptoms include ‘A’s (Affective blunting or flattening, Attentional impairment, Avolition, apathy, Anhedonia, Asociality, Alogia (lack of speech output) (See Table 15.3).

15. Pfropfschizophrenia:

This is a syndrome of schizophrenia occurring in the presence of mental retardation (IQ less than 70). It differs from schizophrenia in only that there is a poverty of ideation and delusions are not well systematized. The behavioural disturbances are more prominent than thought disorder.

Essay # 4. Clinical Features of Major Subtypes of Schizophrenia:

1. Thinking (Cognitive):

a. Catatonic:

Nonsensical, brief verbal ejaculations, Hyperamensia for certain events. Delusions difficult to evaluate

b. Paranoid:

Less disorga­nized thought process. Delusions of persution, reference, jealousy, innocence. grandiosity (delusions are systematized)

c. Hebephrenic:

Highly disorga­nized thought process (e.g., word salad, neologisms, rhyming, verbi­geration) Frag­ minted and unsystematized delusions with bizarre themes.

d. Simple:

Delusions are usually absent, if present they are short lasting and poorly systematized.

e. Undifferentiated:

Disorganized thought processes (e.g., word salad) Fragmented and unsystematized delusions with no Predominant themes.

f. Schizoaffective:

Features of flight of ideas and loose associations Depressive delusions with guilt, somatic or nihilistic themes or manic delusions of grandiosity or paranoid delusions.

2. Perception:

a. Catatonic:

Difficult to evaluate

b. Paranoid:

Persecutory or grandiose hallu­cinations with­ out coherent themes (auditory commonest)

c. Hebephrenic:

Unformed and Fragmented hallucinations (auditory commonest)

d. Simple:

Hallucinations are usually absent

e. Undifferentiated:

Unformed and fragmented,(auditory commonest)

f. Schizoaffective:

No characteristic hallucinations

3. Affect:

a. Catatonic:

Unpredictable excitements and agitation

b. Paranoid:

Angry, fearful, suspicious, accusatory, may be depression

c. Hebephrenic:

Silly, Incongruous Responses liability

d. Simple:

Shallow emotional response.

e. Undifferentiated:

Flat or inappropriate

f. Schizoaffective:

Mood state labile than stable. Elation, irrita­bility, anger, tearfulness, despair, Inappropriate behaviour consistent with depression

4. Behaviour:

a. Catatonic:

Stupor and mutism. Command automatism, echolalia, echopraxia. Catalepsy, posturing, rigidity, stereotypy Negativism and Oppositional Excitement, Mannerisms, verbigeration, Physiolo­gical pillow

b. Paranoid:

Wary, suspicious or uncooperative. May or may not act on delusions.

c. Hebephrenic:

Grimacing, mannerisms, bizarre behaviour. Incomprehen­sible acts. Socially regressive acts. e.g., urinating or masturbating in presence of others)

d. Simple:

Early and insidious onset with progressive course. Presence (suicidal etc.) of characteristic negative features of residual schizophrone, vague hypochondrical features, social decline, living standby, wandering aimlessly, very poor prognosis

e. Undifferentiated:

Mixed features of other subtypes

f. Schizoaffective:

Ideation, crying Elation (social intrusiveness) or irritability violent out bursts).

Etiology:

(i) Biochemical theories:

Evidence of the role of dopamine is from the effect of neuroleptics i.e., increased dopamine brain levels especially in limbic system (most believed hypothesis).

i. Norepinephrine theories:

Individual theories report increase (in paranoid type), decrease (in chronic) or defective levels of norephinephrine.

ii. Serotonin theories:

Increased 5-HT in chronic patients; decreased in paranoid and acute patients; correlate with agitation; affected by neuroleptics (especially atypical ones).

(ii) Genetic theories:

Prevalence in Different Genetic Studies Prevalence of Schizophrenia

(a) Family:

Parent: 5%

Sibling: 10%

Child of a Schizophrenic: 14%

Child of 2 Schizophrenics: 46%

(b) Twins:

Monozygotic (Mz): 42% (30-60%)

Dizygotic (Dz): 9% (6-20%)

(iii) Viral etiologies:

i. Post-viral encephalitis conditions resembling schizophrenia have been reported e.g., with influenza, Epstein-Barr virus, infectious mononucleosis and currently HIV infection.

(iv) Immunologic:

i. An autoimmune illness might have some role in the pathogenesis of schizophrenia.

ii. Schizophrenia affects immune system and thus causing immunologic compromise.

(v) Neurophysiologic theories:

(a) Electrodermal activity:

i. Increased skin conductance recovery in response to a standard stimulus may be a trait marker for high risk.

(b) Cardiovascular activity:

i. Tonic heart rate. Increase in schizophrenics (not in controls) and not affected by neurolepties.

ii. Phasic heart response. Increased response in schizophrenics.

(c) Smooth pursuit eye movements:

These are slow-tracking lateral eye move­ments seen when an individual watches a swinging pendulum. Normally eyes move on a smooth back and forth sinusoidal pattern but in some schizophrenics and other psychotics, this smooth pursuit is interrupted by multiple arrests in which the eye comes to a complete stop resulting in an irregular pattern.

(d) Electroencephalogram (EEG):

Chronic schizophrenics have less power in fast alpha range (11-13Hz), more power in fast beta range (20-40 Hz) and more power in slow theta and delta bands (0.5-8 Hz) than normals.

(e) Evoked potentials:

i. Shortened latencies.

ii. Reduced amplitude.

iii. Augmenting (increasing) response with increase in stimulus intensity in schizophrenics.

(f) Cerebral Blow Flow (using Xenon-133) and Brain Metabolism (using PET techniques):

i. Decreased blood flow in frontal areas.

ii. Increased blood flow in left hemispheres (Neuroleptics increase blood flow in right hemispheres)

(vi) Neurologic and postmortem studies:

(a) Neurologic studies:

Minor non localizing neurological abnormalities in 60-70% of schizophrenic patients. These neurological “soft signs” include defects in stereo- gnosis, graphesthesia, coordination, balance, gait and tremors.

(b) Neuroradiologic studies:

(i) Increased ventricular size:

Increased ventricular size (especially lateral ventricles). It is the most frequently reported finding on CT Scans.

(ii) Cortical surface abnormalities:

Increases in the sylvian tissues, prefrontal cortex and frontal areas suggesting temporal and frontal pathology.

(iii) Cerebellar abnormalities:

Cerebellar abnormalities especially atrophy of the vermis.

(iv) Magnetic Resonance Imaging (MRI):

One study mentions frontal atrophy in schizophrenics.

(c) Postmortem findings:

Decreased brain volume and width especially parahippocampal gyri, substantia nigra, amygdala, hippocampus and medial pallidum (indicating cell loss).

i. increased ventricular size

ii. loss of cells in prefrontal association areas.

(vii) Psychological theories:

(a) Routine psychological testing.

(b) Projective tests

(i) Rorschach test.

a) Abnormal responses to the overall form of inkblot which normals tend to see in consistent ways.

b) Responses crudely formed (poor form responses)

c) A lack of imagination and creativity.

d) Confabulatory answers and human content.

e) Lack of movement

f) Mixing of form perception in “contami­nation” responses

g) Inability to integrate colour into the percepts.

h) Popular responses are absent.

(a) Thematic Apperception Test (TAT):

Interpretation of drawings by schizo­phrenics and tend to be distorted and demonstrate a lack of creativity.

(b) Attention:

I. Inability to filter out the important sensory input.

II. A Sensory input dysfunction causing a stimulus overload and hyperarousal states.

(c) Cognition and Information Processing:

i. Problems in registration, integration and retrieval of information.

(d) Over Inclusive Thought Processes:

Over inclusive thought processes (Cameron) In schizophrenia, normal boundaries of concepts cannot be maintained.

(e) Construct Theory (Kelly):

Repeated invalidation of personal constructs may lead to loose and inconsistent construct systems.

(f) Over-arousal (Venables):

Psychophysio­logical over-arousal at resting state and as reaction to stress.

(viii) Family theories:

(a) Double-Bind theory:

i. Parent conveys two or more conflicting and incompatible messages at the same time.

ii. Child cannot comment on inconsistency; if he does respond to the inconsistency, he meets with disapproval.

(b) Marital Skew and Schism:

Skew—Overprotective, intrusive and dominant mother and over compliant, submissive father said to lead to schizo­phrenic son.

Schism—Hostility between parents lead to schizophrenic daughter.

(c) Familial homeostasis (Jackson):

The identified patient’s illness is necessary for the maintenance of family equilibrium.

(d) Abnormal family communications:

Disrupted, non-sequential communications from and between parents said to lead to schizophrenia.

(e) Expressed Emotions (EE):

Relapse rates raised if:

I. Patient’s family shows high expressed emotions (EE) (critical comments, hostility or over involvement) at assessment interview.

II. More than 35 hours per week is spent in high EE environment (That is why there is role of Mid Way Homes in rehabilitating schizophrenics).

(ix) Social theories:

(i) Breeder hypothesis:

Low social class leads to schizophrenia caused by social conditions.

(ii) Social isolation:

Hare said that schizophrenia is associated with social isolation rather than social class.

(iii) Social drift hypothesis:

Schizophrenics drift down to the social scale (to low social class).

(x) Psychodynamic theories

(a) Classified theories:

(i) Freud:

Regression of the libidinal forces into a narcissistic focus is felt to promote primary process thinking (primitive, pleasure seeking thinking) which involves the use of primitive symptoms such as hallu­cinations and delusions, to compensate for lack of interpersonal relations.

(ii) Paul Federn:

He believed schizophrenia to be result of “loss of ego boundaries”.

(iii) Heinz Hartmann:

Schizophrenic symptoms can result from conflicts secondary to intolerable realities or amplified drive pressures.

(b) Interpersonal theories:

If a person lacked sufficient exposure to positive interpersonal relationships, a personality deficit or schizophrenia might result.

(c) Object relations theories:

i. Melanie Klein:

She regarded the potential schizophrenia patient is endowed with strong sadistic and envious impulses that rendered the infant prone to intense paranoid anxiety.

(d) Developmental theories:

(i) Margaret Mahler:

Schizophrenia is regarded as corresponding to Mahler’s autistic phase of development. The patient fails to develop an adequate and stable symbiosis.

(ii) Sylvano Arieti and Peter Giovacchini:

Arieti perceives that schizophrenic patients have lost their ability to empathize with others, and therefore, to respond emotionally.

Complications:

Violent acts, increased suicide rate and death, impairment in routine daily functioning such as work, social relations and self-care, sexual problems, homicide.

Diagnosis:

A reliable detailed history (from reliable informants e.g., spouses, parents, other relatives, friends or office colleagues) and mental state examination is the backbone of diagnosis.

Differential Diagnosis (See Table 15.4):

Management:

There are many therapies which have been used for the management of schizophrenia:

(1) Drugs:

(a) Neuroleptics (Antipsychotic drugs):

These drugs have revolutionized the treatment of schizophrenia.

Uses:

(i) Acute attack:

Classical Neuroleptics are effective in alleviating the positive symptoms (delusions, hallucinations and agitation etc.) Newer atypical neuroleptics are useful in alleviating negative symptoms (Apathy, Anhedonia, Alogia, Asociality, Affective blunting).

(ii) Maintenance:

Neuroleptics have well established role in preventing relapse in schizophrenia (oral and injectable depot preparations are useful). Maintenance may not be required in patients who have

i. Acute psychotic episode

ii. Postpartum schizophrenic attack

iii. Very deteriorated chronic patients who may be refractory to treatment.

iv. Postictal or interictal psychosis (schizophrenia type).

(iii) Resistant cases:

i. Adjust the dosage according to plasma levels.

ii. Shifting one class of medication to other

iii. Other therapies e.g., Electroconvulsive Therapy (ECT)

iv. Addition of lithium carbonate or carbamazepine may be helpful if there is suspicion of Schizo­affective illness.

v. There is little rationale in giving multiple neuroleptics

vi. Newer agents e.g., Clozapine, Olanzapine Risperidone and Rimoxipride may be effective.

(b) Benzodiazepines:

These may be helpful in reducing anxiety and agitation associated with acute psychotic episodes.

(c) Lithium:

It is effective where the patient has schizo-affective illness or when there is uncertainty about diagnosis.

(d) Propranolol and other Beta blockers:

They increase serum levels of neuroleptics and are sometimes used in treating akathisia.

(e) Anticonvulsants:

Especially carbamazepine has been reported to be effective in treating schizo­affective illness.

(f) Antidepressants:

If there is superimposed secondary depression, then low doses of antidepressants may be used for brief period.

(2) Electroconvulsive therapy (ECT):

ECT has a special role in treating:

i. Acute psychotic episodes

ii. Schizophrenic with catatonic and affective symptoms

iii. Schizophrenics with suicidal or homicidal tendencies

iv. Refractory or intolerant to drugs

v. Those requiring massive doses of neuroleptics

Hospitalization and Milieu therapy:

It is especially required in:

a. risk of suicidal or homicidal ideation

b. significant confusion/extreme fear

c. inability of patients to plan and care for themselves (lack of appropriate resources)

d. problems in follow up

e. patients with some associated physical illness

(3) Group therapy:

It is the mainstay of the treatment for both inpatients and outpatients.

(4) Individual psychotherapy:

It is mainly supportive and oriented to helping the patient adapt to the details of daily life.

(5) Psychosocial rehabilitation:

The main goal of this is to ameliorate symptoms, remediate disabilities and overcome handicaps and the return of patients to productive lives. The main focus is on

i. Social skills training:

To communicate with strangers and familiar people and to reduce socially inappropriate behaviour, is cornerstone of this training.

(6) Family therapy:

a. Reduction of contact

b. Psych educational interventions.

c. Half way homes.

d. Crisis intervention.

Essay # 5. Prognostic Features of Schizophrenia Disorders:

The factors which may influence the outcome of schizophrenia are given in Table 15.4.