Schizophrenia

Schizophrenia is a serious mental illness that significantly impairs the patient's ability to understandably behave, act and apply himself in life. It is a protracted psychotic illness tending to become chronic. It disrupts a person's relationship to reality, it causes personality changes, and affects the ability to work. Striking psychopathological changes occur - thought disorder (delusions, loosening of the connection of thoughts), perception disorder (hallucinations), behavior disorder (strange and incomprehensible).

Self-portrait of a schizophrenic


 * Risk factors: male gender, depression, high IQ.


 * Diagnostics: Patient observation

History
The term was first used in 1911, until then the term dementia praecox (Kraepelin) was used - at that time similar entities - catatonia (strange motor behavior), paranoia, hebephrenia (derangement), etc.

Schizophrenia means "splitting" of the mind, describing patients' ability to experience and behave according to disparate scenarios (described as "double accounting"). The patient behaves according to a morbidly distorted reality and at the same time respects reality in many respects and is able to adapt. In the 1960s, the WHO launched a study International Pilot Study of Schizophrenia.

Epidemiology, etiology and pathogenesis
This disease is "relatively common" (approx. 1%), it usually starts between the ages of 15 and 35, affects men and women equally, and tends to be hereditary.

The etiology is unknown and probably multifactorial. Theories describe the formation:


 * Theory of load and disposition
 * inherited or acquired disposition of maladaptive thought structures that eventually result in clinical manifestation.
 * disposition can be a defect in a protein, a receptor, a broken structure.


 * Dopamine hypothesis
 * They explain the effect of neuroleptics - they block the effect of dopamine,
 * dopamine agonists (amphetamine) cause psychoses,
 * a greater amount of D receptors was found in the brains of untreated schizophrenics,
 * mainly D2 receptors (but e.g. clozapine blocks D2 minimally),
 * the influence of serotonin is also assumed,
 * for identical twins, concordance is 35 to 58%.


 * Neurodevelopmental Model

An alternative hypothesis that states that the clinical disease is only the culmination of a process that begins very early in the development of the individual as a disorder of migration, selection and functional involvement of neurons.

Progress
Due to advances in treatment, the course changes, with attacks alternating with periods of relative calm.


 * Premorbid stage - does not manifest itself clinically, there may be latent disorders of cognition, character traits.
 * Prodromal stage - suitable for prevention, attacks alternate with retreat, later psychopathology stabilizes.

The curability is approximately the same as, for example, hypertension, we can control the symptoms, with mutual cooperation, schizophrenia can practically be cured.

Simplex schizophrenia
This form is infrequent, but prognostically significant. In the foreground are changes in behavior, decline of will, loss of interests, flattening of emotions.

Paranoid Schizophrenia
This form is common. It is accompanied by hallucinations and delusions, which are mostly persecutory, but also grandiose, and often affect the thinking and experience of the patient. Its urgency varies according to the stage of the disease.

Hebephrenic Schizophrenia
It is characterized by fickleness, aimless or erratic activity. There is fragmentation of behavior due to inappropriately naughty, erratic displays. He speaks mechanically, philosophizes wildly, and his clothes are striking.

Catatonic schizophrenia
In the foreground are psychomotor disorders, excessive excitement, aimless restlessness. The body and limbs remain in the set positions. There is increased tone (catalepsy, flexibilitas cerea), stupor, command automatism, imitation, negativism.

Other forms of schizophrenia
This includes all undifferentiated schizophrenias, i.e. those that can't be classified anywhere. Residual schizophrenia or post-schizophrenic depression often follow after the acute symptoms of schizophrenia subside.

A new typology of schizophrenia
According to the presence of the so-called positive and negative symptoms:


 * negative symptoms - the result of the reduction or disappearance of some characteristic, slowing down of motor skills, hypobulia, apathy, flat emotionality;
 * positive symptoms – delusions, hallucinations, bizarre, restless behavior.

Negative often given by a disorder, positive a kind of reaction to the reduction of other abilities.

Accordingly, we divide into:


 * type I,
 * type II,

or


 * positive schizophrenia (they respond well to pharmacotherapy),
 * negative schizophrenia,
 * mixed schizophrenia.

Diagnosis
There is 'no test or method that is specific for this disease. The diagnosis is based on the observation of the patient and the analysis of the information obtained from him. In the prodromal stage, behavioral changes appear, a tendency to anxiety, despondency, reduced self-care. Typical symptoms follow, such as hearing and voicing one's own thoughts, taking away or inserting thoughts, delusions of control, hallucinated voices that comment on the patient's behavior or come from some part of his body, bizarre, culturally alien delusions.

They are accompanied by inactivity, loss of interests, social withdrawal, flatulence, inappropriateness of emotional reactions, catatonia, halt in thinking, incoherence, neologisms. Relational thinking often appears - a strong delusional belief that everything around is staged, everything has a different meaning.

These symptoms must last at least a month. Determining the beginning is difficult, but important - the sooner it is caught, the better.

Differential diagnosis and auxiliary examinations
Diagnosing this disease takes time. The main thing is to distinguish an acute attack from intoxication hallucinogens or toxic psychosis after stimulants. It is also important to differentiate the manic component of bipolar disorder at the beginning. Other diseases in the differential diagnosis include dementia, Wilson's disease, porphyria, SLE, Huntington's disease, tumors and [ [neuroinfection]].

Ancillary examinations can help in the differential diagnosis. Organic disorders are seen on CT or MRI. On SPECTu (Tc-HMPAO) we see a lower perfusion frontally and temporally on the left.

Treatment



 * Relies on pharmacotherapy antipsychotic (formerly neuroleptic);
 * the term neuroleptics was associated with their main adverse effect – extrapyramidal muscle stiffness';
 * with the introduction of antipsychotics II. generation of (atypical) side effects decline;
 * for a good prognosis, it is important to make a correct diagnosis and draw up a treatment plan;
 * it is good to start treatment as soon as possible, the earlier, the better the prognosis and fewer relapses;
 * in general, it is good to stick to one drug, not to combine drugs from the same group.

Side effects


 * tremor, dystonia (torticollis, torsion spasms of the trunk) and akathisia, dyskinesia (chewing, chewing);
 * early 90s – antipsychotics II. generation' - risperidone, olanzapine, clozapine (clozapine carries the risk of neutropenia and agranulocytosis;
 * sometimes it is necessary to give in depot preparations - they release slowly;
 * for patients with acute restlessness, a good combination with benzodiazepines';
 * for non-responders – electroconvulsions;
 * psychoeducation - an effort to teach about the nature of the disease, the patient should understand what is happening to him;
 * care for a schizophrenic is highly individualized;
 * psychotherapy - occupational therapy, assertiveness training, cognitive-behavioral module, family therapy.

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