Dr Z Tsolekile Dewet
2023
Introduction
▪ Chronic, severe, debilitating mental illness
▪ Syndrome: collection of signs and symptoms of largely unknown aetiology.
▪ Predominantly defined by observed signs of psychosis, abnormalities in thought, behaviour,
social problems & functional impairment
▪ Condition characterized by relapses and remissions
▪ Disabling condition
▪ Distress to patients and families
History
▪ Early Greek physicians described delusions of grandeur, paranoia and deterioration in
cognitive functions and personality
▪ Emil Kraepelin (1856 -1926) - “dementia praecox”-change in cognition with early onset of the
disorder. Described patients as having a long-term deteriorating course with clinical symptoms
of delusions and hallucinations
▪ Eugene Bleuler (1857 -1939) - “Schizophrenia”-schisms among thought , behaviour and
emotion.
▪ Four A’s
• Associations
• Affect
• Ambivalence
• Autistic isolation
Epidemiology
▪ Lifetime prevalence of 1% ( 0,12%-1.6%)
▪ Prevalence
▪ Male=Female, but course and onset differs
▪ Males 10-25 years
▪ Females 25-35 years, 2nd peak in middle age
▪ Males > negative symptoms
▪ Onset after 45 years- late onset schizophrenia
▪ According to WHO amongst 10 most debilitating conditions
Epidemiology contd.
▪ Found in all societies
▪ Associated with ↑d mortality rate
▪ 1,5-2,5 x
▪ Medical illnesses
▪ Co-morbid conditions
▪ Up to 50% may be undiagnosed
▪ Cardiovascular complications common (d/t sedentary lifestyle & med SE’s)
▪ Suicide
▪ 10-38%,(1yryear post-dx)
Etiology
G E
• Genetic factors
▪ 10x d risk in persons with 1st degree relatives for developing the disease.
▪ Heritability is high (60-80%), but no specific genetic risk factor.
• Environmental factors
• Stressful life events/Sociocultural factors
▪ Prenatal (maternal malnutrition/infections: influenza, toxoplasmosis, herpes simplex 2,
rubella)
▪ Early life adversity
▪ Urbanization
▪ Migration/Minority group
▪ Cannabis use (esp in adolescents)
Etiology contd.
• Biochemical Factors
• DA hypothesis- symptoms of schizophrenia
• (+) symptoms are produced by hyperactivity of DA pathways in limbic and
mesolimbic areas,
• (–)symptoms, hypoactivity in prefrontal and neocortical pathways(meso-cortical
areas)
• Involvement of other neurotransmitters e.g. Glutamate, NA, 5HT
• Structural Brain Abnormalities
• Mild to moderate atrophy on MRI
• Structural differences quite prominent in patients who have negative symptom patterns
Stages of Schizophrenia
▪ Insel described 4 stages of illness
▪ Neurodevelopmental: Trajectory of illness
Stage I: Risk Stage II: Prodrome of Schizophrenia
Genetic vulnerability Changes in thoughts
Environmental exposure Social isolation
Subtle behavioural changes Impaired functioning
Stage III: Onset of Psychosis Stage IV: Chronic disability stage
Positive symptoms Psychiatric deficits
Negative symptoms Unemployment
Cognitive symptoms Homelessness
Incarceration
7% suicide rate(50% of all deaths by
39 years)
Obesity and smoking
Clinical Presentation
https://youtu.be/ZB28gfSmz1Y
• No symptom or sign is definitive for schizophrenia
• Careful history important as symptoms change with time
• Premorbid symptoms and signs appear before the prodromal phase
• Patients may have schizoid or schizotypal personalities
• May be quiet, passive and introverted children
• Few friends, solitary activities
• May present with somatic complaints
• Family and friends may notice changes in social, occupational, personal activities
• May then present with peculiar behaviour, abnormal affect, unusual speech, bizarre ideas,
perceptual disturbances
Affective
Symptoms
Aggressive
Symptoms
Other
Diagnosis
▪ Approach to classification
▪ Categorical vs Dimensional
▪ DSM 5
▪ Categorical with Dimensional scale
▪ Spectrum Disorder
▪ Multiple Diagnostic Overlaps
▪ Schizophrenia
▪ Personality Disorders
▪ Other psychiatric conditions
▪ Exclusion Criteria
▪ Substance abuse
▪ Autistic or Pervasive Developmental Disorder
Mental State Examination
▪ GENERAL APPEARANCE AND BEHAVIOUR
▪ May be unkempt, poor self-care
▪ Psychomotor activity
▪ SPEECH
▪ Monotonous, poverty of speech
▪ Disorganised speech
▪ MOOD AND AFFECT
▪ Reduced emotional responsiveness
▪ Inappropriate emotions
▪ PERCEPTUAL DISTURBANCES
▪ Hallucinations
Mental State Examination contd.
▪ THOUGHT FORM DISTURBANCES
▪ Loosening of associations
▪ Tangentiality
▪ THOUGHT CONTENT DISTURBANCE
Delusions
▪ IMPULSIVENESS,VIOLENCE,SUICIDE, HOMICIDE
▪ SENSORIUM AND COGNITION
▪ Memory,
▪ JUDGEMENT AND INSIGHT
Comorbid conditions
▪ Obesity
▪ DM
▪ CVS
▪ HIV
▪ Substances (up to 90%)
Differential diagnosis
▪ Delirium
▪ Substance Intoxication
▪ Medical conditions
▪ Other psychiatric disorders
Treatment
Biopsychosocial
▪ Biological
▪ Hospitalisation
▪ Pharmacotherapy
▪ Managing side effects
▪ Psychological
▪ Psychoeducation
▪ Social skills training
▪ Family oriented psychotherapies
▪ Social
Course of Illness
▪ Chronic illness
▪ Premorbid symptoms
▪ Relapsing and remitting course
▪ Deterioration in functioning over time
▪ During active phase, full blown symptoms
▪ Residual phase
▪ No symptoms
▪ Remaining symptoms with impaiments
“Rule of Thirds” – (recover, improved, none)
Prognosis
Conclusion
▪ Psychotic disorders cause extreme distress and diability over periods of time
▪ Disorder is treatable and relapses can be limited
▪ Primary health care worker has an important role to play.
▪ Acknowledgements: Prof N Khamker
References
▪ Roos L, Burns JK (2016) Textbook of psychiatry for Southern Africa(2 nd ed). Cape Town.
Oxford University Press
▪ Sadock BJ, Sadock VA, Ruiz P (2015) Kaplan and Sadock’s Synopsis of Psychiatry, 11 th
edition. New York. Wolters Kluwer
▪ https://youtu.be/ZB28gfSmz1Y
Thank You
