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- Department of Psychiatry
- 1st Faculty of Medicine
- Charles University, Prague
- Head: Prof. MUDr. Jiří Raboch, DrSc.
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- The schizophrenic disorders are characterized in general by fundame=
ntal
and characteristic distortions of thinking and perception, and affe=
cts
that are inappropriate or blunted. Clear consciousness and intellec=
tual
capacity are usually maintained although certain cognitive deficits=
may
evolve in the course of time.
- The most important psychopathological phenomena include
- thought echo
- thought insertion or withdrawal
- thought broadcasting
- delusional perception and delusions of control
- influence or passivity
- hallucinatory voices commenting or discussing the patient in the t=
hird
person
- thought disorders and negative symptoms.
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- Schizophrenia occurs with regular frequency nearly everywhere in the
world in 1 % of population and begins mainly in young age (mostly a=
round
16 to 25 years).
- Schizophrenia is defined by
- a group of characteristic positive and negative symptoms
- deterioration in social, occupational, or interpersonal relationsh=
ips
- continuous signs of the disturbance for at least 6 months
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- Emil Kraepelin: This illness develops relatively early in life, and=
its
course is likely deteriorating and chronic; deterioration reminded
dementia („Dementia praecox“), but was not followed by =
any
organic changes of the brain, detectable at that time.
- Eugen Bleuler: He renamed Kraepelin’s dementia praecox as sch=
izophrenia
(1911); he recognized the cognitive impairment in this illness, whi=
ch he
named as a „splitting“ of mind.
- Kurt Schneider: He emphasized the role of psychotic symptoms, as
hallucinations, delusions and gave them the privilege of „the
first rank symptoms” even in the concept of the diagnosis of
schizophrenia.
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- Bleuler maintained, that for the diagnosis of schizophrenia are most
important the following four fundamental symptoms:
- affective blunting
- disturbance of association (fragmented thinking)
- autism
- ambivalence (fragmented emotional response)
- These groups of symptoms, are called „four A’ s” =
and
Bleuler thought, that they are „primary” for this diagn=
osis.
- The other known symptoms, hallucinations, delusions, which are appe=
aring
in schizophrenia very often also, he used to call as a “secon=
dary
symptoms”, because they could be seen in any other psychotic
disease, which are caused by quite different factors — from
intoxication to infection or other disease entities.
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- Course of schizophrenia:
- continuous without temporary improvement
- episodic with progressive or stable deficit
- episodic with complete or incomplete remission
- Typical stages of schizophrenia:
- prodromal phase
- active phase
- residual phase
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- Diagnostic manuals:
- lCD-10 („International Classification of Disease“, WHO=
)
- DSM-IV („Diagnostic and Statistical Manual“, APA)
- Clinical picture of schizophrenia is according to lCD-10, defined f=
rom
the point of view of the presence and expression of primary and/or
secondary symptoms (at present covered by the terms negative and
positive symptoms):
- the negative symptoms are represented by cognitive disorders, havi=
ng
its origin probably in the disorders of associations of thoughts,
combined with emotional blunting and small or missing production of
hallucinations and delusions
- the positive symptom are characterized by the presence of
hallucinations and delusions
- the division is not quite strict and lesser or greater mixture of
symptoms from these two groups are possible
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- For the diagnosis of schizophrenia is necessary
- presence of one very clear symptom - from point a) to d)
- or the presence of the
symptoms from at least two groups - from point e) to h)
- for one month or more:
- the hearing of own thoughts, the feelings of thought withdrawal, th=
ought
insertion, or thought broadcasting
- the delusions of control, outside manipulation and influence, or the
feelings of passivity, which are connected with the movements of the
body or extremities, specific thoughts, acting or feelings, delusio=
nal
perception
- hallucinated voices, which are commenting permanently the behavior =
of
the patient or they talk about him between themselves, or the other
types of hallucinatory voices, coming from different parts of body<=
/li>
- permanent delusions of different kind, which are inappropriate and
unacceptable in given culture
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- the lasting hallucination of every form
- blocks or intrusion of thoughts into the flow of thinking and resul=
ting
incoherence and irrelevance of speach, or neologisms
- catatonic behavior
- „the negative symptoms”, for instance the expressed apa=
thy,
poor speech, blunting and inappropriatness of emotional reactions=
li>
- expressed and conspicuous qualitative changes in patient’s
behavior, the loss of interests, hobbies, aimlesness, inactivity, t=
he
loss of relations to others and social withdrawal
- Diagnosis of acute schizophorm disorder (F23.2) – if the
conditions for diagnosis of schizophrenia are fulfilled, but lasting
less than one month
- Diagnosis of schizoaffective disorder (F25) - if the schizophrenic =
and
affective symptoms are developing together at the same time
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- F20 Schizophre=
nia
- F20.0 Paranoid schizophrenia
- F20.1 Hebephrenic
schizophrenia
- F20.2 Catatonic
schizophrenia
- F20.3 Undifferentiated
schizophrenia
- F20.4 Post-schizophre=
nic
depression
- F20.5 Residual schizo=
phrenia
- F20.6 Simple schizoph=
renia
- F20.8 Other schizophr=
enia
- F20.9 Schizophrenia,
unspecified
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- F21 Schizotypal disorder
- F22 Persistent delusional disorders
- F22.0 Delusional disorder
- F22.8 Other persistent delusional disorders
- F22.9 Persistent delusional disorder, unspecified
- F23 Acute and
transient psychotic disorders
- F23.1 Acute polymorphic psychotic disorder with symptoms of
schizophrenia
- F23.2 Acute schizophrenia-like psychotic disorder
- F23.3 Other acute predominantly delusional psychotic disorders
- F23.8 Other acute and transient psychotic disorders
- F23.9 Acute and transient psychotic disorder, unspecified
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- F24 Induced
delusional disorder
- F25 Schizoaffe=
ctive
disorders
- F25.0 Schizoaffective disorder, manic type
- F25.1 Schizoaffective disorder, depressive type
- F25.2 Schizoaffective disorder, mixed type
- F25.8 Other schizoaffective disorders
- F25.9 Schizoaffective disorder, unspecified
- F28 Other nonorganic
psychotic disorders
- F29 Unspecified nono=
rganic
psychosis
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- Paranoid schizophrenia is characterized mainly by delusions of
persecution, feelings of passive or active control, feelings of
intrusion, and often by megalomanic tendencies also. The delusions =
are
not usually systemized too much, without tight logical connections =
and
are often combined with hallucinations of different senses, mostly =
with
hearing voices.
- Disturbances of affect, volition and speech, and catatonic symptoms=
, are
either absent or relatively inconspicuous.
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- Hebephrenic schizophrenia is characterized by disorganized thinking=
with
blunted and inappropriate emotions. It begins mostly in adolescent =
age,
the behavior is often bizarre. There could appear mannerisms, grima=
cing,
inappropriate laugh and joking, pseudophilosophical brooding and su=
dden
impulsive reactions without external stimulation. There is a tenden=
cy to
social isolation.
- Usually the prognosis is poor because of the rapid development of
"negative" symptoms, particularly flattening of affect and
loss of volition. Hebephrenia should normally be diagnosed only in
adolescents or young adults.
- Denoted also as disorganized schizophrenia
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- Catatonic schizophrenia is characterized mainly by motoric activity,
which might be strongly increased (hypekinesis) or decreased (stupo=
r),
or automatic obedience and negativism.
- We recognize two forms:
- productive form — which shows catatonic excitement, extreme =
and
often aggressive activity. Treatment by neuroleptics or by
electroconvulsive therapy.
- stuporose form — characterized by general inhibition of
patient’s behavior or at least by retardation and slowness,
followed often by mutism, negativism, fexibilitas cerea or by stup=
or.
The consciousness is not absent.
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- Psychotic conditions meeting the general diagnostic criteria for
schizophrenia but not conforming to any of the subtypes in F20.0-F2=
0.2,
or exhibiting the features of more than one of them without a clear
predominance of a particular set of diagnostic characteristics.
- This subgroup represents also the former diagnosis of atypical
schizophrenia.
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- A depressive episode, which may be prolonged, arising in the afterm=
ath
of a schizophrenic illness. Some schizophrenic symptoms, either =
222;positive“
or „negative“, must still be present but they no longer
dominate the clinical picture.
- These depressive states are associated with an increased risk of
suicide.
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- A chronic stage in the development of schizophrenia with clear
succession from the initial stage with one or more episodes
characterized by general criteria of schizophrenia to the late stage
with long-lasting negative symptoms and deterioration (not necessar=
ily
irreversible).
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- Simple schizophrenia is characterized by early and slowly developing
initial stage with growing social isolation, withdrawal, small acti=
vity,
passivity, avolition and dependence on the others.
- The patients are indifferent, without any initiative and volition. =
There
is not expressed the presence of hallucinations and delusions.
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- According to lCD-10 this disorder is characterized by eccentric beh=
avior
and by deviations of thinking and affectivity, which are similar to=
that
occurring in schizophrenia, but without psychotic features and expr=
essed
symptoms of schizophrenia of any type.
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- Includes a variety of disorders in which long-standing delusions
constitute the only, or the most conspicuous, clinical characterist=
ic
and which cannot be classified as organic, schizophrenic or affecti=
ve.
- Their origin is probably heterogeneous, but it seems, that there is=
some
relation to schizophrenia.
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- A disorder characterized by the development of one delusion or of t=
he
group of similar related delusions, which are persisting unusually =
long,
very often for the whole life.
- Other psychopathological symptoms — hallucinations, intrusion=
of
thoughts etc. are not present and are excluding this diagnosis.
- It begins usually in the middle age.
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- The criteria should be the following features:
- acute beginning (to two weeks)
- presence of typical symptoms (quickly changing “polymorphic
symptoms”)
- presence of typical schizophrenic symptoms.
- Complete recovery usually occurs within a few months, often within =
a few
weeks or even days.
- The disorder may or may not be associated with acute stress, define=
d as
usually stressful events preceding the onset by one to two weeks.=
li>
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- A delusional disorder shared by two or more people with close emoti=
onal
links. Only one of the people suffers from a genuine psychotic diso=
rder;
the delusions are induced in the other(s) and usually disappear whe=
n the
people are separated.
- The psychotic disorder of the dominant member of this dyad is mainl=
y,
but not necessarily, of schizophrenic type. The original delusions =
of
dominant member and his partner are usually chronic, either persecu=
tory
or megalomanic.
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- Episodic disorders in which both affective and schizophrenic sympto=
ms
are prominent (during the same episode of the illness or at least d=
uring
few days) but which do not justify a diagnosis of either schizophre=
nia
or depressive or manic episodes.
- Patients suffering from periodic schizoaffective disorders, especia=
lly
with manic symptoms, have usually good prognosis with full remissio=
ns
without any remaining defects.
- They are divided in different subgroups:
- F25.0 Schizoaf=
fective
disorder, manic type
- F25.1 Schizoaf=
fective
disorder, depressive type
- F25.2 Schizoaf=
fective
disorder, mixed type
- F25.8 Other
schizoaffective disorders
- F25.9 Schizoaf=
fective
disorder, unspecified
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- Many psychiatric disorders are multifactorial (caused by the intera=
ction
of external and genetic factors) and from the genetic point of view=
very
often polygenically determined.
- Relative risk for schizophrenia is around:
- 1% for normal population
- 5.6% for parents
- 10.1% for siblings
- 12.8% for children
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- The etiology and pathogenesis of schizophrenia is not known
- It is accepted, that schizophrenia is „the group of
schizophrenias“ which origin is multifactorial:
- internal factors – genetic, inborn, biochemical
- external factors – trauma, infection of CNS, stress
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- The most influential and plausible are the hypotheses, based on the
supposed disorder of neurotransmission in the brain, derived mainly=
from
- the effects of antipsychotic drugs that have in common the ability=
to
inhibit the dopaminergic system by blocking action of dopamine in =
the
brain
- dopamine-releasing drugs (amphetamine, mescaline, diethyl amide of
lysergic acid - LSD) that can induce state closely resembling para=
noid
schizophrenia
- Classical dopamine hypothesis of schizophrenia: Psychotic symptoms =
are
related to dopaminergic hyperactivity in the brain. Hyperactivity of
dopaminergic systems during schizophrenia is result of increased
sensitivity and density of dopamine D2 receptors in the different p=
arts
of the brain.
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- Dopamine hypothesis revisited: various neurotransmitter systems pro=
bably
takes place in the etiology of schizophrenia (norepinephric,
serotonergic, glutamatergic, some peptidergic systems); based on ef=
fects
of atypical antipsychotics especially.
- Contemporary models of schizophrenia conceptualize it as a
neurocognitive disorder, with the various signs and symptoms reflec=
ting
the downstream effects of a more fundamental cognitive deficit:
- the symptoms of schizophrenia arise from “cognitive
dysmetria” (Nancy C. Andreasen)
- concept of schizophrenia as a neurodevelopmental disorder (Daniel =
R.
Weinberger)
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- Neurodevelopmental model supposes in schizophrenia the presence of
“silent lesion” in the brain, mostly in the parts, impo=
rtant
for the development of integration (frontal, parietal and temporal),
which is caused by different factors (genetic, inborn, infection, t=
rauma...)
during very early development of the brain in prenatal or early
postnatal period of life.
- It does not interfere too much with the basic brain functioning in =
early
years, but expresses itself in the time, when the subject is stress=
ed by
demands of growing needs for integration, during formative years in
adolescence and young adulthood.
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- The acute psychotic schizophrenic patients will respond usually to
antipsychotic medication.
- According to current consensus we use in the first line therapy the
newer atypical antipsychotics, because their use is not complicated=
by
appearance of extrapyramidal side-effects, or these are much lower =
than
with classical antipsychotics.
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