Schizophrenia is he severe psychotic disorder that affects thinking, emotions, cognition and behavior of an individual. It is majorly known as the perceptual disorder and recognized majorly due to most common illness which is diagnosed dual diagnosis. Psychotherapies, change in lifestyle and the pharmacological management is essentially followed up throughout the course of illness to reduce the symptoms and revert client back to normal. Schizophrenia is an broad spectrum having branched classification under the hood with various symptoms which are too narrowed for acute diagnosis and management.

1. BY,
AKASH R. GHORPADE
M.SC PSYCHIATRIC NURSE

2.  INTRODUCTION
 Emil Kraepelin, an Eminent Psychiatrist in 1896 formed the concept of “Dementia praecox” –
which means Mental Deterioration.
 In 1911 Eugen Bleuler coined the term “Schizophrenia”
 Where, Skhizo means ‘Split’ and Phren means ‘Mind’.

3.  DEFINITION
Schizophrenia is a psychotic condition characterized by a disturbance in
thinking, emotions, cognition and faculties in presence of clear
consciousness, which usually leads to social withdrawal.

4. ICD- 10 Classification of Schizophrenia
F20 – 29 Schizophrenia, Schizotypal and Delusional disorders
F20 Schizophrenia
F20.0 Paranoid Schizophrenia
F20.1 Hebephrenic Schizophrenia
F20.2 Catatonic Schizophrenia
F20.3 Undifferentiated Schizophrenia
F20.4 Post- Traumatic Schizophrenia
F20.5 Residual Schizophrenia
F20.6 Simple Schizophrenia
F21 Schizotypal Disorder

5.  CAUSES
• The exact cause of the disease is unknown, but studies has proven the fact that fluctuation of
neurotransmitters causes schizophrenia.
• Neuro Biological theory: shows the impact of Dopamine Hypothesis that Increase in
Neurotransmitters like Dopamine causes Schizophrenia.
• Genetic theory: shows that schizophrenia is more common in people born from consanguineous
marriage.
• Twin studies: shows that the rate of schizophrenia among monozygotic twins is four times than that
of dizygotic twins.
• Adoptation studies: shows that children who born to mother with schizophrenia were more likely to
develop the illness than comparison of those children born to mother without illness.

6. • Neurostructural theories: shows that prefrontal cortex and limbic cortex may never fully develop in
the brain of schizophrenia patient. Computed tomography and magnetic resonance imaging
Decrease in brain volume, Large lateral & 3rd ventricles, atrophy in frontal lobe, cerebellum &
structure.
• Perinatal risk factors: Maternal influenza, Complication in pregnancy specially during labor, birth
during late winter.
• Developmental theories: According to Sigmund Freud’s theory of psychosocial development, the
individual has poor ego boundaries, where superego is dominant constantly.
• Family theories: Mother child relationship, Double blind communication.
• Social theories: shows that stressful events precipitate the disease in the predisposed individuals.

7.  SYMPTOMS
 BLEULER’S FOUR A’s:
1) Affective disturbance: Inability to show appropriate emotional responses, shows blunted
flattened affect.
2) Autistic thinking: it is though process in which the individual is unable to relate to others
to the environment. Preoccupation with the self, and very little concern for external
3) Ambivalence: it refers to contradictory or opposing emotions, attitudes, ideas or desires
the same person, thing or situation simultaneous opposite feelings.
4) Associative looseness: Inability to think logically. The stringing together of unrelated
topics.

8. SCHNEIDER’S FIRST- RANK SYMPTOMS:
1. Thought Echo (Hearing one’s thought spoken aloud).
2. Hallucinatory Arguments (the patient hears the voices discussing about him by the third person).
3. Hallucinatory voices in the form of a running commentary (there are three types of audible
hallucinations).
4. Thought withdrawal (thoughts cease and subject experiences them as removed by external
forces).
5. Thought insertion (subject experiences thoughts imposed by some external force on his passive
mind).
6. Thought broadcasting (subject experiences that his thoughts are escaping from his control and
being experienced by the others around).

9. 7. Delusional perception (normal perception has a private and illogical meaning).
8. Somatic passivity (bodily sensation especially sensory symptoms experienced as imposed on
body by some external force).
9. Made volition or acts (subject acts like an robot, and experiences that he is being under control
of some external force).
10. Made impulses (the subject experiences impulses as being imposed by some external
force).
11. Made feelings or affect (the subject experiences feelings as being imposed by some external
force).

10.  CORE SYMPTOMS:
Positive symptoms Negative symptoms Cognitive Symptoms Affective Symptoms
Delusions
Affective flattening or
blunting
Poor memory Depression
Hallucinations
Avolition (Apathy or
lack of initiative)
Attention deficit Elation
Excitement or
agitation
Attentional
impairment
Executive dysfunction Suicidal ideation
Hostility or aggressive
behavior
Anhedonia (inability to
experience pleasure)
Suspiciousness, ideas
of reference
Alogia (lack of speech
output)
Possible Suicidal
tendency
Asociality (social
withdrawal)

11.  OBJECTIVE & SUBJECTIVE SYMPTOMS OF SCHIZOPHRENIA:
Objective symptoms Subjective symptoms
Withdrawal behavior Hallucinations
Hostility Illusions
Inadequate or inappropriate
communication
Paranoid thinking
Psychomotor agitation Anhedonia
Catatonic rigidity Confusion
Stereotype behavior Ideas of reference
Apathy Thought blocking
Ambivalence Retarded thinking
Mutism Insomnia
Inability to trust others

12.  CLINICAL TYPES OF SCHIZOPHRENIA:
1. Paranoid schizophrenia:
2. Hebephrenic/ disorganized schizophrenia
3. Catatonic schizophrenia
4. Residual schizophrenia
5. Undifferentiated schizophrenia
6. Simple schizophrenia
7. Post schizophrenic depression

13. 1) Paranoid schizophrenia:
 The word paranoid means ‘delusional’.
 It is characterized by following features:
a) Delusion of persecution: in persecutory delusions, individual believes that he is being involuntarily treated in
some way. (frequent theme includes being conspired against, cheated, followed, harassed or obstructed, in
the pursuit of long term goal).
b) Delusion of reference: in this delusion, the individual falsely believes that others are taking about him.
c) Delusion of jealously: the content of jealous delusions centers around the theme that the persons sexual
partner is unfaithful.
d) Delusion of grandiosity: individual with grandiose delusion, may believe that they have special relationship
with famous personalities like actors or religious persons.
e) Audible hallucinations: that threatens and commands the patient or auditory hallucinations without verbal
form, such as whistling, laughing, or crying.

14. 2) Hebephrenic Schizophrenia: (Disorganized schizophrenia)
 It has an early and insidious onset and is often associated with poor premorbid personality.
 The essential symptoms includes: Thought disorder, Incoherence, severe loosening of association,
extreme social impairment.
 Emotional disturbance: inappropriate, blunt and flat affect, mirror-gazing, disinhibited behaviour
and extreme social withdrawal.
 Delusion and Hallucinations are fragmentary and changeable.
 The course is chronic and progressively fast without significant remission.
 Recovery is classically poor.

15. 3) Catatonic Schizophrenia:
 Catatonic schizophrenia is characterized by marked disturbance in motor behaviour.
 This may take the form of catatonic stupor or catatonic excitement.
 Clinical features of exited catatonia:
a) Increase in psychomotor activity (ranging from restlessness- agitation- excitement- aggressiveness).
b) Increase in speech production.
c) Loosening of association and frank incoherent.
 This excitement has no apparent relationship with external environment.
 Sometimes this excitement becomes very severe and is accompanied by rigidity (stupor), hyperthermia, dehydration
and can result in death. It is then known as acute catatonia or pernicious catatonia.
 Clinical features of stuporous catatonia (retarded catatonia):
 This is characterized by extreme retardation of psychomotor function.
 Delusion of hallucination is present but usually not prominent. Not all features are present at a time.

16. Other features of stuporous catatonia includes:
• Mutism- (complete absence of speech).
• Extreme rigidity
• Negativism
• Stupor Posturing (often creates the bizarre posture for long period of time).
• Echolalia (repetition of phrases or words)
• Echopraxia (repetition of one’s observed action).
• Waxy flexibility- (one or many parts of the body is placed in the position that will be maintained for long
period of time, even if very uncomfortable and awkward posture is attained).
• Ambitendency (a conflict between to do or not to do)
• Automatic Obedience (obeys every commands irrespectively).

17. 4) Residual or latent Schizophrenia:
 Residual schizophrenia is the submerged illness due to medical and psychopharmacological management with
possible reverse of symptoms, if the medications and controlled environment and gets disturbed.
 Residual schizophrenia is similar to the latent schizophrenia.
 The only difference is residual schizophrenia is diagnosed after at least one episode has occurred.
 The symptoms includes: emotional blunting, eccentric behaviour, illogical thinking, loosening of associations.
5) Undifferentiated Schizophrenia:
 This is very common type of schizophrenia and is diagnosed;
a) When features of no other subtype of schizophrenia is present.
b) When features of more than one subtype are exhibited and the general criteria for diagnosis of
schizophrenia is met.

18. 6) Simple Schizophrenia:
 It is one of the type of subtypes which is the most difficult to diagnose.
 Presence of characteristics like negative symptoms of residual schizophrenia such as marked
social withdrawal, shallow emotional responses with loss of initiative and drive.
 Delusional and hallucination are usually absent.
 Wandering tendency
 Self- absorbed idleness
 Aimless activity
 Prognosis is very poor.

19. 7) Post- Schizophrenic Depression:
 Some schizophrenic patients develops depressive features within 12 month of an acute
episode of schizophrenia.
 The depressive features develops in the presence of residual schizophrenia and are
associated with an increase risk of suicide.
 Depressive features can occur due to side effects of anti-psychotics.

20.  PHASES OF SCHIZOPHRENIA:
PRODROMAL
 Decline in functioning
that precedes 1st
psychotic episode.
 Socially withdrawn,
irritable.
 Physical complaints.
 Newfound interest in
religion/ the occult.
PSYCHOTIC
(Acute Phase)
 Positive symptoms
 Perceptual
disturbances (e.g.
auditory
hallucinations)
 Delusions (usually
secondary, delusion of
reference is common).
 Disordered thought
process/ content.
RESIDUAL
(Chronic Phase)
 Occurs between
episodes of psychosis.
 Marked by negative
symptoms (flat affect,
social withdrawal).
 Odd thinking and
behaviour.

21.  DIAGNOSIS
(According to DSM-4)
 At least 2 or more symptoms must be present out of following 5 symptoms for a period
of 1 month
 (Symptoms can be for the portion of time and not as constant)
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized/ Catatonic behavior
5. Negative symptoms such as flat affect/ Alogia/ Avolition.

22. (According to DSM-5)
 At least 2 or more symptoms must be present out of following 5 symptoms for a period of
1 month.
 Where at least 1 symptom must be (1),(2) or (3).
 (Symptoms can be for the portion of time and not as constant)
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized/ Catatonic behavior
5. Negative symptoms such as flat affect/ Alogia/ Avolition.

23.  INVESTIGATIONS:
1. History collection
2. Physical examination
3. Neurological examination
4. Mental status examination
5. Blood investigations (Vitamin deficiency, Uremia, Thyrotoxicosis, Electrolyte
imbalances, Agranulocytosis).
6. CT scan and/or MRI.

24.  TREATMENT MODALITIES:
Psycho-pharmacology:
 Anti-Psychotics:
Typical Anti-psychotics/ Conventional
(before 1970)
1st Generation
Blocks only D2 receptors
Atypical Anti-psychotics
(after 1970)
2nd Generation
Blocks D1, D2, D4 and 5-HT2 receptors.
Chlorpromazine
(300-1500 mg/ day orally) OR (50-100 mg/ day IM)
Clozapine
(25- 450 mg/ day orally)
Triflupromazine
(15 -60 mg/ day orally) OR (1-5 mg/ day IM)
Olanzapine
(10- 20 mg/day orally)
Thioridazine
(15- 60 mg/ day orally) OR (1- 5 mg/day IM)
Risperidone
(2- 10 mg/ day orally)
Fluphenazine
25- 50 mg/day IM (every 1-3 weeks)
Quetiapine
(150- 750 mg/ day orally)
Haloperidol
(5- 100 mg/ day orally) OR (5- 20 mg/day IM)
Aripiprazole
(5- 30 mg/ day orally)

25.  ELECTRO CONVULSIVE THERAPY (ECT):
 Indications for ECT in schizophrenia:
a. Catatonic Stupor
b. Uncontrolled catatonic Excitement
c. Severe side effects with drugs
d. Schizophrenia refractory to all other forms of treatment
 (Usually 8-10 ECT’S are needed).

26.  Psychological therapies:
a. Psychotherapy
b. Group therapy
c. Behavior therapy
d. Social skill training
e. Cognitive therapy
f. Family therapy
 Psychosocial rehabilitation:
a. Activity therapy to develop work habit
b. Vocational guidance
c. Independent Job placement (Shelter homes)

27.  PROGNOSIS:
Good prognostic factors Poor prognostic factors
Abrupt or acute onset Insidious onset
Later onset Younger onset
Presence of precipitating factor Absence of precipitating factor
Paranoid and catatonic subtypes Simple and undifferentiated subtypes
Short duration (<6 months) Long duration (>2 years)
Predominance of positive symptoms Predominance of negative symptoms
Family history of mood disorders Family history of Schizophrenia
Good social support Poor social support
Female sex Male sex
Married Single, Divorced or Widowed
Out- patient treatment Institutionalization

28.  Questions to work on:
1. Define Schizophrenia.
2. Write Bleuler’s 4 A’s Symptoms.
3. Enlist the types of Schizophrenia.
4. How Schizophrenia is diagnosed according to DSM-4?
5. Elaborate the role of Physiotherapist in the management of client with Schizophrenia?

29. THANK
YOU