छिन्नमानस (SCHIZOPHRENIA)

या आजारामध्ये विनाकारण भीती वाटणे, चारित्र्याबद्दल संशय घेणे, शिवीगाळ करणे, मारहाण करणे, वेगवेगळे भास होणे, कानात आवाज ऐकू येणे, स्वतःशीच बडबड करणे, विनाकारण हसत राहणे किंवा रडणे, एकांतात बसून राहणे, कोणाशीही मिळून मिसळून न राहणे, अंघोळ न करणे, स्वतःची काळजी न घेणे , कचरा गोळा करणे इत्यादी लक्षणे दिसून येतात. 

In this condition patient gets unknown fear, Suspiciousness towards peoples as talking about him planning something in food to kill him or her. Patients becomes aggressive / abusive / assaultive / gets hearing of voices in absence of anyone, mattering to self, smiles / weeps without reason.

EUGEN BLEULER: Coined the term as “SCHIZOPHRENIA”  (Split Brain)ss

There is dispute of relation between Thought, Emotion and  Behavior (TEB)

Epidemiology:  Life time Prevalence is 1%

Age of onset : Men – 10 to 25 yrs.  Women- 25 to 35 yrs.  M:F-  1 :1

Those  who  born in winter and early spring having more risk as compare to summer and late spring.

Reproductive factors: First degree biological   relatives of Patient  have a 10 times risk.

ETIOLOGY 

Exact Etiology Is Not Known .

Theories:-

• Biological Theory.
• Genetic Theory.
• Psychosocial Theory.
• Neurobiology:  Dysfunction in.
• Limbic system
• Frontal cortex
• Cerebellum
• Basal ganglia  may involve in pathological process.

Neuropathology:   Decrease in size of brain including  Amygdala , Hippocampus and   Para hippocampal   gyrus .

Few studies showed increase number of D2 Receptors in Caudate , Putamen.

NEUROIMAGING:

• MRI Brain: Reduction in volume of  Hippocampus,   Amygdala ,  Para hippocampal   Gyrus.
• CT Scan : Lateral and Third Ventricular  Enlargement and Reduction in cortical volume
• MRS:    Lower levels of  Phosphomonoesters and Inorganic Phosphate.

                         Higher levels of   Phosphodiesters and ATP.

• NAA-N acetyl  aspartate-marker of neuron –low in  Hippocampus and Frontal lobes.

• PET(Glucose and Cerebral blood flow) :   Hypoactivity of  Frontal lobes and  Hyperactivity of Basal ganglia.

• EEG : Decreased alpha activity. Increased theta and delta activity.

• EYE MOVEMENT DYSFUNCTION : 50-85 % pts of  Schizophrenia has abnormal eye movement suggestive of Frontal lobe  pathology  (Hypothesis).

• Psychoneuroimmunology : Abnormal Cellular and  Humoral  reactivity of neurons.

• Psych neuroendocrinology:  Decreased concentration of  LH, FSH etc.

Change in Neurotransmitter levels like…

• Dopamine.
• Serotonin.
• Norepinephrine.
• GABA.
• Glutamate.
• Neuropeptides.
• (Cholecystokinin, Neurotensin Etc.)

Genetic Factors

Abnormality:

in long arm of  chromosomes  

i.e.5,6 ,8,11,18 & 22 and short arm of  9 and X chromosome

Prevalence :

• General population: 1 %.
• Monozygotic twin of Schizophrenia Patient : 47 %
• Dizygotic twin of Schizophrenia Patient : 12 %
• Nontwin sibling of Schizophrenia Patient : 8 %
• Child with one Schizophrenia Patient : 12%
• Child with both Schizophrenia Patient : 40 %

PSYCHOSOCIAL FACTORS

• Learning theories: Children learn irrational reactions and ways of thinking by imitating parents who have  their own emotional problems.
• Schism Family : If one parent is close to a child of opposite sex.
• Skewed Family : Power struggle between two parents and resulting dominance of one parent.
• Social theories: Industrialization and Urbanization have major effect on timing of onset  and  severity of illness

PHASES OF ILLNESS

• Prodromal phase: Back pain, neck pain, somatic complaints. No Active Psychotic symptoms.
• Acute Phase: Florid psychotic phase with active symptoms like delusions or hallucinations etc.
• Post Acute Phase: Phase begins once the acute symptoms reduce in severity or remit. It lasts for about 6 months.
• Stable or Maintenance Phase: Symptoms are stable.

CLINICAL FEATURES

No Any Sign Or Symptom Is Path gnomic Of Schizophrenia

PREMORBID SIGNS AND SYMPTOMS

1. Premorbid signs and symptoms appear before the   prodromal  phase of illness.
2. Prodromal  signs and symptoms are parts of evolving disorder.
3. In Premorbid history- Patient has usually Schizoid or   Schizotypal  personalities. They may enjoy watching movies or television or listening to music instead of attending social activities.
4. Illness can start with symptoms like Headache, Back and muscle pain, weakness or digestive problems. Later can get positive or negative symptoms.
5. Eugen Bleuler :- Described symptoms as
6. Fundamental (Primary ):- 4 A’s

                                                 Association (Looseness)

                                                 Affect

                                                 Autism

                                                 Ambivalence

       7. Secondary( Accessory):- Delusion and Hallucination

Kurt Schneider Criteria for Schizophrenia

First Rank Symptoms:

• Audible Thoughts.
• Voices Commenting.
• Voices arguing or discussing or both.
• Thought control.
• Delusional Perceptions.

Second Rank Symptoms:

• Other disorder of Perceptions.
• Sudden delusional Ideas.
• Perplexity.
• Dysphoric and Euphoric mood changes.

Sir T. J. Crow — Positive Symptoms

• Hallucinations:- Auditory, Visual, Tactile, Olfactory,  Gustatory.
• Delusions:- Persecution/ Reference, Delusion of being controlled, Thought Broadcasting/ Thought Withdrawal, Thought Insertion/  Thought Reading
• Bizarre  behavior :- Aggressive/agitated  behavior, Repeated / Stereotyped  behavior 
• Positive formal thought disorder :-  Tangentiality, Circumstantiality, Pressure of speech, Clanging, Derailment Etc..         

 

Negative Symptoms

• Affective flattening:- Unchanging facial expression, Decreased spontaneous movements, Poor eye contact, Inappropriate affect.
• Alogia :-  Poverty of speech, blocking.
• Avolition /Apathy:- Poor grooming and hygiene, Impersistance at work or school.
• Anhedonia/A sociality:- Recreational interests, activities, Sexual interest,, Closeness, Relationship with friends &  peers.
• Attention:- Social Inattentiveness, Inattentiveness during testing

TYPES OF SCHIZOPHRENIA

• Paranoid Type:- Preoccupied with one or more delusion and frequent Auditory hallucinations. Classically Delusion of persecution.
• Disorganized (Hebephrenic):- Disinhibited or Disorganized behavior.
• Catatonic Schizophrenia:- Marked disturbance in motor function.

                                                                   Characterized by, Negativism, Catatonic excitement, Waxy  flexibility, Mutism. Echolalia, Echopraxia.

• Undifferentiated type: Can not differentiate. May get mixed presentation.
• Residual Schizophrenia:- Absence of active symptoms but evidence of some disturbances or symptom.

OTHER SUBTYPES OF SCHIZOPHRENIA

• Simple Schizophrenia :- Progressive development for a least one year of all of the following-
• Marked decline in occupational or academic functioning.
• Gradual appearance and deepening of negative symptoms such as affective  flattening, alogia or avolition.
• Poor interpersonal Support, social isolation or social withdrawal.
• Oneroid Schizophrenia :- Dreamlike state in which Patients is deeply perplexed and not fully oriented to time and place.
• Pseudo neurotic Schizophrenia :- Pan anxiety ,  Panphobia , Pan ambivalence, Obsessions and Compulsions
• Early onset Schizophrenia :-  Children
• Late onset Schizophrenia :-    >45 yrs.

Differential Diagnosis Of Schizophrenia

Psychiatric Illness – 

• Brief psychotic disorder
• Schizophreniform Disorder
• Schizoaffective disorder
• Delusional disorder
• Personality Disorders-Schizoid, Schizotypal Etc.
• Mood Disorder
• Psychosis NOS

Medical or Neurological Conditions –

• Substance Induced
• Neoplasm, CVA, Trauma
• Epilepsy
• AIDS
• Vit B 12 Deficiency, Pellagra
• Poisoning Example: CO or heavy metal
• SLE, Neurosyphilis, Wilson disease, Huntington disease
• Normal Press Hydrocephalus
• Metabolic disorder.

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