Psychotic disorders-schizophrenia

SCHIZOPHRENIA

It is a mental disorder that usually starts at a young age, in which the person withdraws from relationships and reality, and in which serious deterioration in thoughts, behaviors and perception is observed. It may start with symptoms such as obsessions, difficulties, interest in metaphysical topics, weakness, fatigue, emotional depression or hyperactivity, decreased interest, distraction, and excessive concern with one’s own body and thoughts.

EPIDEMIOLOGY

The lifetime prevalence of schizophrenia is between 1% and 1.5%. Its frequency is reported as 0.85 per thousand by the World Health Organization. Although it is seen at the same time in men and women, there are differences in the onset and course of the disease. Although the mean age of onset of the disease varies between 15 and 40 years, 90% of the patients are in the 15-25 age group. The age of onset is around 15-25 for men and 25-35 for women. It is thought that men have more negative symptoms, women have better social functions and better outcomes.

ETIOLOGY:

Due to the diversity of symptoms and outcome forms of schizophrenia, it is not possible to say that a single cause causes schizophrenia. The most commonly used one is the stress-diathesis (strain-predisposition) model. In this model; It is suggested that patients have a biological predisposition to schizophrenia and cause schizophrenic symptoms after being triggered by stress. It has been reported that stresses may be hereditary, biological and psychosocial origin. We can examine the research and assumptions about the causes of schizophrenia under these headings.

1. Inheritance:

According to the results of studies on heredity, it is thought that there is a multifactorial transmission dependent on many genes (polygenic-multifactorial). Research in this direction is gathered in the fields of family, twin, adoption and molecular genetics research. According to these studies, it has been determined that identical twins carry a higher risk than fraternal twins, and that the risk of schizophrenia is higher in people whose natural parents are schizophrenic and who were raised by another family than those whose birth parents are not schizophrenic.

2.Biological:

A. Biochemical: Numerous studies have been conducted and are being conducted for a long time on whether there is a biochemical disorder specific to tyzophrenia in the brain. Very important findings were obtained from these studies, but most of the hypotheses put forward were not fully confirmed.

3. Psychosocial Causes:The suggestions put forward in this regard can be evaluated under two headings.

a) Psychodynamic views: According to the psychoanalytic view, the development of libido for psychological or biological reasons in schizophrenia remains stuck at a narcissistic level. Later in life, with various stresses, the ego regresses to this primitive level (regression) and the libido is withdrawn from objects and deposited in the ego itself (secondary narcissism). This situation reduces the person’s relations with the outside world. The state of object libido, in other words, the attention invested in external objects and the reorientation of the investment to the body (secondary narcissism) appears in schizophrenic patients’ excessive preoccupation with their own body and in symptoms such as autism. This regression may be due to the lack of basic trust, constant disappointments and impaired interpersonal relationships starting from childhood.

b) Familial reasons: Various suggestions have been put forward as a result of studies on the families of schizophrenics. Some researchers (Lidz) have suggested that there is a significant split and deterioration in schizophrenic families, and that special attention is given to schizophrenic children by their mothers. According to this suggestion, one of the parents is extremely dominant and aggressive, and the other is highly dependent and passive. It has also been emphasized that false love and togetherness are very common in the families of schizophrenics.

CLINICAL FEATURES:

1. Pre-illness personality and onset period:

There are no typical symptoms in the onset and course of schizophrenia. All kinds of psychological symptoms can be seen in schizophrenia. Symptoms can change over time. Before the disease, they usually show schizoid and schizotypal personality traits. These are children who are well-behaved, quiet, do not have many friends since childhood, and mostly play on their own with their lessons or toys. They are shy and cold towards communication attempts from the environment. They have low confidence in themselves and the environment, and they can easily lose this sense of trust.

2. Signs and Symptoms:

A. General view, outward behavior: Since schizophrenia is a very heterogeneous disorder, it is difficult to define a typical presentation. Most patients have a marked apathy, apathy, dullness, and a timid appearance. Those who have been ill for a long time are seen to be neglected, disorganized and not paying attention to their cleanliness. The most common and important symptoms are severe apathy, lack of action and withdrawal from society. They can vary in appearance, from a heavy stagnation and apathy to extreme exuberance. Strange face, eye movements (mannerism), stereotyped repetitive hand, arm, body movements (stereotype), movement reverberation (echopraxia), being frozen in a certain situation (freeze, catatonia) can be seen. Weird sexual behavior, self-fulfillment, walking around naked, spitting, nose picking can be seen. Some patients may have a severely negative attitude or ambivalence.

B. Speaking and relating : Disorder in speech, disorganization, acceleration, deceleration, impoverishment, stereotyped repetitions (stereotype), speech reverberation (echolalia), non-speech (mutism), making new words (neologism), gibberish (word salad), disorganized due to associative dissolution Many different symptoms such as gibberish, meaningless speech (encoheran speech) can be seen. May give side or inappropriate answers to questions.

C. Thought:

a) Associations (thought and trend): The logical chain between the words and symbols that make up the thought has been broken. Pauses (blocks) in the flow of thought, shifts from one thought to another unrelated, deviations, intense concentration of thoughts in the mind, thought compression, disintegration and dissolution of the thought flow (association dissolution) are observed. In thought, the patient is immersed in the flow, harmony and rhyme of words rather than meaning (klang connotation). Sometimes parts of several words or a few concepts are combined (condensation) to produce new words and concepts (neologism). Gradually, thought emerges from abstraction and becomes concrete. In other words, a way of thinking that represents concrete experiences rather than conceptual thinking develops. Thought becomes infantile (regressive thinking). Logical ties originate from the inner world of the individual, fears, impulses, and primitive associations as in the child (dereistic thinking). Identifications are made from similarities or details, a single feature of a whole can represent the whole (paleological thought).

b) Thought content: The most important thought disorder is delusions (delusions). A delusion is a thought that does not fit the truth in a certain age or society and cannot be changed by rational discussion. Delusions in schizophrenia are often disorganized, disorganized, inconsistent, and bizarre (bizar delusion). The main types of delusions observed are as follows; Erotomania is delusions of grandeur, persecution, mystical, somatic, nihilistic (annihilation), being taken (reference), being influenced, inserting thoughts, reading thoughts, broadcasting thoughts, stealing thoughts. Apart from these delusions, hypochondriac, mystical, metaphysical pursuits, various obsessions, and strange memories of childhood are also common.

D. Affect: In general, it is mentioned that a decrease in emotion, its shallowness. Bluntness and monotony in affect are evident. They show an unchanging, monotonous and diminished emotional response to events. It is often seen that patients are cold and difficult to relate to. However, in the initial period, extreme anxiety and panic-like situations are seen. Anxiety may be very intense (prepsychotic anxiety) in the patient who has thoughts as if his world is collapsing and his ego is falling apart. Over time, blunting, shallowness and superficialization become evident in the emotions. It is characterized by gesturing and monotonous speech, not making eye contact. In some cases, inappropriateness is seen in the affect that goes with unwarranted crying and laughter. A depressed mood can be observed in postpsychotic depression.

E. Cognitive abilities: Consciousness is clear, memory and orientation are in place. However, in chronic cases with severe destruction, it is assumed that there are disorientation and memory disorders. However, these findings are usually due to the patient’s lack of interest and distraction. In some acute, exaggerated, disorganized types of schizophrenia, there may be a clinical presentation that can be confused with delirium. Again, with careful observation, it is understood that these symptoms are not true consciousness and disorientation, but are related to the severe disorder in the patient’s perception and thinking. However, neuropsychological tests may be impaired in schizophrenic patients with negative symptoms. Judgment, insight, and abstract thinking abilities are impaired.

F- Physical and physiological symptoms: If there is no other disease, physical examination findings are normal. Some patients may experience overeating, weight gain, while others may not eat and lose weight. Sleep and sleep-wake patterns can be very disrupted. Excessive sleep, no sleep, disruption of the day-night cycle can be seen. In addition, faint neurological findings may be detected.

G- Impulsivity and suicide: Impulse control is extremely difficult in schizophrenics. Suicide attempts may occur suddenly. The suicide risk is around 50%, 20 times higher than the general population. 15% of those who attempt it result in death. Conditions that increase the risk of suicide; young, male, high education level, lack of social support, frequent exacerbations, awareness of the disease, and presence of depressive symptoms.

DIAGNOSTIC CRITERIA:

A. DSM-IV, Characteristic symptoms: Two or more of the following during a one-month period (or shorter if successfully treated):

1. Delusions

2. Hallucinations

3. Disorganized speech (disorganization or incoherence in associations)

4. Highly disorganized or catatonic behavior

5. Negative symptoms (affective blunting, alogia, or avolition)

D. Exclusion of schizoaffective disorder and mood disorder

E. Exclusion of substance use/general medical condition

F. If there is a history of pervasive developmental disorder, a diagnosis can be made if criteria for A are met for at least one month.

Departure and Ending:

Schizophrenia is a chronic disease with very different prognosis and outcome. While it starts insidiously and slowly and lasts for years, there may be periods of exacerbation. After that, it can turn into a type of residual schizophrenia, which progresses very slowly and mostly negative symptoms are dominant. In some cases, there may be a better adjustment period after the exacerbation period. As the disease progresses, the dominance of positive findings decreases and negative findings come to the fore. The probability of recurrence is around 60% in the first 2 years. 50% of patients attempt suicide and 10% succeed. violence is normal

SOURCE:

-Ozturk MO:[1997] Mental Health and Disorders, 7th Edition, Hek.Birl. Arrow. Ankara

-FREQUENTLY ENCOUNTERED PSYCHIATRIC DISEASES IN TURKEY Symposium Series No:62 •March 2008 P:49-58 Prof.Dr.Ruhi Yavuz

-Yavuz R. Schizophrenia and Neurotransmitters; New Symposium, Issue 3, July 1992

-ETIOLOGY OF SCHIZOPHRENIA

Aygun ERTUGRULA
aPsychiatry Department, Hacettepe University Faculty of Medicine, ANKARAV

-Akvardar Y, Çalak E, Etaner U et al. (1997) Psychoanalytic

Introduction to Theory, MEPEV Seminars, Istanbul, TEAM

Publishing, pp.56-103.

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