Anatomical Changes in Schizophrenia:
• Cortical atrophy, enlargement of the lateral and third ventricles
Neurotransmitter Changes in Schizophrenia:
• There is a significant increase in dopamine activity.
• The hypofunction theory of glutamate in NMDA receptors has been strengthened in recent years.
• NMDA blockers such as phencyclidine and ketamine may cause schizophrenia-like symptoms.
Positive Symptoms of Schzophrenia
Disorganization (in thought, affect, behavior)
Delusion (delusion)
Presence (hallucination)
Catatonia
Delusions: False beliefs that are incompatible with the patient's cultural, social structure and education, and do not conform to reality. They cannot be replaced by logical explanations. Delusion is a thought content disorder.
Assumption: It is the perception of a stimulus that does not exist or the belief that it is perceived. There may be hallucinations of hearing, sight, smell, touch, taste. Hallucinations are perceptual disorders.
Negative Symptoms of Schzophrenia
• Anhedonia (not enjoying)
• Avolition (reluctance)
• Apathy
• Anergy
• Affective blunting
• Impoverishment of thought
• Decreased speech duration and content
• Reduction in self-care
• Withdrawal from society
Diagnostic criteria of Schzophrenia
Exact Criteria for Schizophrenia in the DSM-S
A- Characteristic symptoms
1) Delusions
2) Hallucinations
3) Disorganized (incoherent) speech
4) Highly disorganized or catatonic behavior
5) Negative symptoms, affective dullness
B- Social occupational dysfunction
C- Duration: at least 6 months
D- Exclusion of schizoaffective disorder and mood disorder
E- Exclusion of psychotic conditions related to substance use and general medical condition disorder
F- Relationship with a pervasive developmental disorder: If there is a history of autism spectrum disorder, a diagnosis of schizophrenia is made with the presence of prominent delusions and hallucinations for at least one month.
Signs and Findings in Schizophrenia
Symptoms of Bleuler 4A
Association disorder
Affective bluntness
ambivalence (coexistence of positive and negative emotions)
Autism (introversion)
Schneider's first-line symptoms
Arguing voices
Voices commenting
Thought stealing
Thought publication
Thought insertion
Bodily passivity (somatic passivity)
Delusional perception
Thought echo
Influence of emotions and impulses
Cognitive abilities
Consciousness is clear, memory and orientation are normal.
However, learning ability decreased due to lack of interest.
His ability to assess reality is impaired (psychosis).
Perception
Significant impairments occur in perception (illusions).
There are hallucinations (illusion) and illusions (illusion).
Auditory hallucinations are typically present in schizophrenia.
In illusions, the person perceives external stimuli incorrectly.
Idea
Disturbances in thought flow:
Block
Clang connotation (speech based on harmony)
Neologism (word-making)
Encoherence (mixed, disorganized speech)
word salad
regressive (childlike) thinking
Dereistic-autistic thinking
Disorders in thought content:
Delusions are the most important thought content disorder.
Persecution delusions: Delusions of harm. The patient thinks that other people want to harm him.
Reference delusions: The patient thinks that others are trying to give him a message, watching him or talking about him.
Grandiose delusions: They are delusions of grandiosity. The patient sees himself as a big, important person who is inconsistent with reality.
Somatic passivity delusions: The patient thinks his body is being influenced or controlled by others.
In Capgras Syndrome, patients believe that people they know have been replaced by others.
Movement
Stereotype (stereotyped movements)
Catatonia (freezing)
Catalepsy (wax elasticity)
lack of action
Ecopraxia (imitation)
Types of Schizophrenia
• Schizophrenia includes subtypes that differ from each other clinically and prognostically.
• These subtypes are no longer separate diagnoses in the DSM S. According to DSM S, no subtype is specified when schizophrenia is diagnosed.
paranoid type
It is characterized by persecution (harm), delusions of reference and grandiose (magnitude) delusions.
Delusions are systematic in themselves.
It is the most common type.
There is no incoherence, catatonia, disorganized behavior.
disorganized type
Also known as the diffuse type. Delusions are not systematic as in the paranoid type, they are scattered.
It is seen at a young age.
It has a worse prognosis than the paranoid type.
Reality relations have weakened.
Emotional reactions may be inappropriate, causeless laughing and crying.
There is encoherent speech.
It can be meaningless grimaces, meaningless behaviors.
Childishness and non-systematized delusions are in the foreground.
catatonic type
It has a wax solidity. (catalepsy)
Mutism is the most common finding.
There may be stupor, negativism, rigidity, excitation, posturing, stereotypies.
Movement disorders are prominent. Auditory hallucinations are not typical symptoms.
It is the type of schizophrenia that most benefits from ECT (electroconvulsive therapy).
residual type
It progresses with residual symptoms from previous episodes of schizophrenia.
It is the chronic type in which mostly negative symptoms are dominant.
undifferentiated type
Contains properties of all types
|
Schizophrenia
Prognosis Criteria |
||
|
|
good
prognosis |
poor
prognosis |
|
age of onset |
late |
early |
|
Gender |
woman |
early |
|
marital status |
married |
single |
|
Residential area |
rural |
urban |
|
pre-illness condition |
good |
bad |
|
eliciting factor |
there is |
none |
|
Beginning |
acute |
sly |
|
Family history of schizophrenia |
none |
there is |
|
psychosocial support |
there is |
none |
|
Expression of emotion in the family |
low |
high |
|
Birth complications |
none |
there is |
|
history of violence |
none |
there is |
|
Clinical manifestations |
positive
symptoms |
negative
symptoms |
|
clinical types |
paranoid
and catatonic |
disorganized |
|
mood symptoms |
there is |
none |
|
Obsessions/Compulsions |
none |
there is |
|
Neurological findings |
none |
there is |
|
Structural brain anomaly |
none |
there is |
|
active period |
short |
long |
|
Departure |
episodic |
chronic |
Treatment of Schizophrenia
• Antipsychotics are used.
• Clozapine is the most effective antipsychotic drug. Extrapyramidal side effects are very few. It can improve negative symptoms.
• Clozapine is not the first-choice drug because it can cause agranulocytosis. It is used in resistant cases.
• Supportive psychotherapy, behavior modification, family psychotherapy may be helpful.
Antipsychotic Drugs (Neuroleptics)
Mechanism of action and areas of use
The main goal of antipsychotic drugs is to reduce dopaminergic activity.
Drugs of first choice in psychotic disorders.
It has indications in many different diseases such as mood disorders, tic disorders (risperidone, haloperidol).
Antipsychotic drugs are divided into first generation (classical) and second generation (atypical) antipsychotics.
First-generation drugs often act as patent dopamine blockers.
Second-generation antipsychotics cause less dopaminergic antagonism than first-generation antipsychotics.
Many second-generation antipsychotics show serotonin antagonism.
Therefore, second-generation antipsychotics cause fewer extrapyramidal side effects than first-generation antipsychotics.
Side effects of antipsychotic drugs
The side effects of antipsychotic drugs are related to the receptors they block. (Dopamine, serotonin, acetylcholine, histamine, alpha adrenergic receptors)
1) Central Boundary System Side Effects
A - extrapyramidal syndromes
It is associated with dopaminergic blockade.
It is more common with first generation (classical) antipsychotics (such as haloperidol, zuclopenthixol).
Second generation antipsychotics such as risperidone, paliperidone and amisulprid may also cause extrapyramidal side effects.
acute dystonia
- They are painful irregular spasms, usually in the neck muscles.
- It is usually seen in young people and in the first week.
- No recurrence except oculogic crisis.
- Treated with Biperiden (Akineton).
akathisia
It is the most common of the extrapyramidal side effects.
It is characterized by increased psychomotor agitation.
There is an inability to stand still, a constant desire to wander and walk.
It can occur between 6 hours and 2 weeks.
Propranolol, biperiden and benzodiazepines can be given in the treatment.
Parkinson-like syndrome:
- It usually starts after 1 week.
- There are tremor, bradykinesia, rigidity and other parkinsonism findings.
- Controlled with biperiden or antiparkinsonian drugs.
Tardive (late) dyskinesia
- It is characterized by oro-facial-lingual movements, it can also occur in the body.
- Occurs with dopamine hypersensitivity in basal ganglia.
- It is seen in long-term (6 months) and high-dose users.
- Drugs other than clozapine can do.
- Clozapine has the least extrapyramidal side effects.
- The only effective method is to discontinue the drug and continue the treatment with clozapine.
- 50% of patients recover in 1 year.
Late dystonia
- It is common in young people.
- It is irreversible.
- Botulinum toxin is used in its treatment.
B) Neuroleptic malignant syndrome
It is characterized by autonomic dysfunction (sweating, tachycardia, blood pressure changes), hyperthermia, rigidity, confusion and myoglobinemia.
CPK increases. It occurs in 1% of patients.
Systemic findings such as leukocytosis, oliguria / anuria may develop.
10% fatal.
In treatment, antipsychotics are discontinued and dantrolene is used.
Dopamine agonists such as bromocriptine may be helpful.
C) Sedation
It is dependent on H1 receptor blockade.
Drugs such as chlorpromazine, quetiapine, clozapine cause more sedation.
Tolerance to the sedation effect may develop.
D) Seizures
It is common with chlorpromazine and clozapine, which have high anticholinergic effects because they lower the seizure threshold.
E) Confusion and memory impairment:
It is related to muscarinic receptor blockade and is common in low potency.
2) Anticholinergic side effects
Central: Memory impairment, confusion, delirium, falling on seizure threshold
Peripheral: Dry mouth, mydriasis, blurred vision, tachycardia, constipation, difficulty urinating
3) Cardiovascular side effects
Orthostatic hypotension (alpha adrenergic blockade)
Tachycardia (anticholinergic effect)
QTc prolongation (sertindole, ziprasidone, IV haloperidol)
hyperlipidemia
4) Metabolic
Prolactin elevation (due to dopamine blockade), sexual dysfunction
Prolactin elevation is also more common with first generation drugs and second generation antipsychotics that block potent dopamine such as risperidone, paliperidone, amisulprid.
Metabolic syndrome findings such as obesity, dyslipidemia and diabetes develop especially due to second generation antipsychotics.
Among the second generation antipsychotics, clozarun, olanzapine, olanzapine and quetiapine; It causes more metabolic syndrome than other drugs.
5) Hematological side effects
Clozapine may cause agranulocytosis. Regular hemogram follow-up should be performed in patients using clozapine.