SCHIZOPHRENIA EPIDEMIOLOGY & PATHOGENESIS

SCHIZOPHRENIA EPIDEMIOLOGY & PATHONGENESIS

Q. 1

Neurotransmitter related to schizophrenia pathology is

 A

NA

 B

Dopamine

 C

Serotonin

 D

All

Q. 1

Neurotransmitter related to schizophrenia pathology is

 A

NA

 B

Dopamine

 C

Serotonin

 D

All

Ans. D

Explanation:

All Correct : A,B & C

Neuro transmitters related to schizophrenia (in order of importance)

1.

Dopamine

tedQ

2.

Serotonin

Ded(2

3.

Nor epinephrine

l’edQ

4.

GABA

fed

5.

Glutamate

T/.I.

6.

Neuropeptide

altered

 

– CCK

 

 

– Neurostatin

 


Q. 2

Incidence of schizophrenia in India:

 A

1-5 per 1000

 B

0.15-0.5 per 1000

 C

5-10 per 1000

 D

10-15 per 1000

Q. 2

Incidence of schizophrenia in India:

 A

1-5 per 1000

 B

0.15-0.5 per 1000

 C

5-10 per 1000

 D

10-15 per 1000

Ans. A

Explanation:

A. i.e. 1 -5%


Q. 3

Schizophrenia is associated…………..personalities :

 A

Atheletic

 B

Psthesis

 C

Asthenic

 D

All

Q. 3

Schizophrenia is associated…………..personalities :

 A

Atheletic

 B

Psthesis

 C

Asthenic

 D

All

Ans. C

Explanation:

C. i.e. Asthenic

Quiz In Between


Q. 4

Schizophrenia mostly occurs in:

 A

Adolescents

 B

children

 C

Middle age

 D

Old age

Q. 4

Schizophrenia mostly occurs in:

 A

Adolescents

 B

children

 C

Middle age

 D

Old age

Ans. A

Explanation:

A. i.e. Adolescents


Q. 5

Which is more appropriate in a case of schizophrenia:

 A

Low socioeconomic group

 B

Seen in adolescents

 C

Common in primitive societies

 D

A & B

Q. 5

Which is more appropriate in a case of schizophrenia:

 A

Low socioeconomic group

 B

Seen in adolescents

 C

Common in primitive societies

 D

A & B

Ans. D

Explanation:

B i.e. Seen in adolescent > A i.e. Low socioeconomic status Though all the factors are risks associated with schizophrenia. The onset in adolescent is better choice as answer, as schizophrenia commonly begins in late adolescenceQ.


Q. 6

True about late onset schizophrenia:

 A

Onset after 45 yrs

 B

Onset between 25-30 yrs

 C

Prognosis is poor

 D

Olfactory hallucinations are common

Q. 6

True about late onset schizophrenia:

 A

Onset after 45 yrs

 B

Onset between 25-30 yrs

 C

Prognosis is poor

 D

Olfactory hallucinations are common

Ans. A

Explanation:

A i.e. Onset after 45 yrs

Late onset schizophrenia is characterized by onset after age 45 years, more frequent female involvement, predominance of paranoid symptoms, favourable prognosis and patients usually do well on antipsychotic medicationQ.

Early Onset Schizophrenia (EOS)

– Early onset schizophrenia (EOS) is defined as schizophrenia with onset of clear positive symptoms prior to 18 years of age. Schizophrenia with onset between 13 and 18 years age is k/a adolescent onset, whereas onset of schizohrenia prior to age 13 is referred to as childhood onset or very early onset.

Childhood onset schizophrenia (COS) has high rates of association with heritable etiology, premorbid developmental abnormalities (eg decreased anterior cigulate gyms = ACG volume) and cormorbid psychiatric disorders (eg ADHD, depression, seperation anxiety). COS have more significant deficits in measure of IQ, memory and tests of perceptumotor skills (reflecting most severe neuropsychological deficits). The diagnostic criteria for schizophrenia in children are identical to criteria for adult, except that instead of showing deteriorating functioning, children may fail to achieve their expected levels of social and academic functioning.

– EOS are more likely to have a premorbid h/o social rejection, poor peer relationships, clingy withdrawn behavior & academic trouble than those with adult onset schizophrenia. They may have h/o delayed motor & verbal miles stones and do poorly in school despite normal intelligence. Although COS and autism may be similar in their early histories, children with schizophrenia have normal intelligence and do not meet the criteria for a pervasive developmental disorder. Children with autism are impaired in multiple areas of adaptive functioning from early life onwards (onset almost always before 3 years age). COS is more often onset in adolescence or young adulthood and practically not reported before 5 years age.

-Blunted or inappropriate affects appear almost universally in children with schizophrenia (eg giggle or cry inappropriately without being able to explain why). Formal thought disorders including loosening of associations & thought blocking are common in COS. Illogical thinking & poverty of thoughts are often present. But unlike adults with schizophrenia, children with schizophrenia do not have poverty of speech content, but they speak less than other children of the same intelligence and are ambiguous in the way they refer to person, objects and events. The communication deficits in COS include unpredictably changing the topic of conversation without introducing the new topic to the listner (loose associations). COS also exhibit illogical thinking & speaking and tend to under use self initiated repair strategies (such as repetitions, revision & detailing) to aid in their communication. When an utterance is unclear or vague, normal children attempt to clearify it with revisions, repetitions and more detail but COS, on the other hand, fail to add communication with repietitions, fillers or starting overs. These communication deficits are negative symptoms of COS. Poor motor functioning, visuospatial impairments & attention deficits are other feature seem to occur frequently in COS.

Late Onset Schizophrenia (LOS) & Very

Late Onset Schizophrenia (VLOS) – According to International Late onset schizophrenia Group, LOS with onset in middle age (45 to 60 years) is a neuro developmental disorder and that its difference with early onset schizophrenia are more of degree than of kind. It also postulated that very late onset schizophrenia like psychosis (with onset over 60 year age) is a neurodegenerative disorder with more brain abnormalities & neuropsychological deficits. But a potential problem of this tripartite classification system is its reliance on age rather than clinical presentation.

Late onset schizophrenia (LOS) is clinically indistinguishable from schizophrenia but has an onset after age 45 yearsQ. It affects women 2 to 10 times more often than menQ. This finding coupled with the higher incidence rates of early onset schizophrenia in men have lead to the hypothesis that estrogen mediated dopaminergic inhibition protects younger women from schizophrenia; whereas the estrogen deficiency a/w menopause may he related to increased incidence of late onset schizophrenia in women. However, the incidence of schizophrenia is still much higher in younger versus older women and treatment based on estrogen neuroprotective hypothesis are largely unsuccessful giving rise to an alternative hypothesis that older men may be protected in some way.

Late onset schizophrenia is characterized by onset after age 45 years, more frequent female involvement, predominance of paranoid symptoms, favourable prognosis and patients usually do well on antipsychotic medicationQ

-Familial association (h/o schizophrenia) is more common in early onset & late onset than in very late onset schizophrenia

– Late onset patients function somewhat better during adolescence & adulthood and have similar pattern but lower severity of cognitive imapairments when compared to early onset schizophrenia; however, they perform significently worse than healthy subjects on measures of executive functioning, learning, motor skills and verbal memory.

– Development & persistence of delusions may result from broad range of cognitive biases in early onset & late onset schizophrenia, where as it is d/t mentalization (i.e. errors in person’s ability to be aware of one’s own and others mental status) in very late onset schizophrenia (i.e. thought intentions & afects).

– Although there is no difference between early & late onset schizophrenia in positive symptoms, family history, brain abnormalities (i.e. non specific structural brain changes i.e. larger 3,d ventricle & right temporal horn on MRI), memory retention, or minor physical abnormalities, the late onset diseae is more likely to be female versus no gender differences in early onset; have the paranoid subtype of 

schizophrenia; have lower levels of negative symptoms; have less impairment in learning , abstraction, and flexibility; have better premorbid functioning with respect to work & marriage; and require lower daily dose of antipsychotic medications.

– Very late onset schizophrenia like psychosis is distinguished from the other two types (early & late) by more brain abnormalities & neuropsychological deficits; more females; greater prevalence of persecutory and partition delusions (belief that someone /something can pass through a structure that would normally constitute a barrier to such passage); higher rates of visual, tactile and olfactory hallucinationsQ; lower genetic load; more sensory abnormalities; and absence of negative symptoms or formal thought disorder. Very old age at onset is related to a lower prevalence of thought disorder & affective blunting and a higher prevalence of visual hallucintions.

-Schizophrenia, regardless of onset is a heterogenous mixture of positive & negative symptoms a/w cognitive impairment and marked social-occupational dysfunction. The most common features of LOS are persecutory delusions (mostly bizarre) and auditory hallucinations. There is no difference between early & late onset in the prevalence of delusions of reference, bizarre delusions, lack of insight or severity of positive symptoms. However, LOS tended to have more persecutory delusions with or without hallucinations, organized delusions, and abusive auditory hallucinations or hallucinations with a running commentary. and less severe negative symptoms, less frequently observed loose associations & inappropriate affect and lower dialy doses of antipsychotics needed for treatment (in comparison to early onset). LOS patients typically meet criteria for the paranoid or undifferentiated subtype of schizophrenia.

Features

Early onset

Late Onset

Verylate Onset

 

Schizophrenia

Schizophrenia

Schizephrenia

 

(EOS)/

(LOS)

(VLOS)

 

Childood Onset

 

 

 

Schizophrenia

 

 

 

(COS)

 

 

Age

 

45-60 yearsQ

>60 years

 

13 and 18 is Ad

 

 

 

OS,

or VEOS

 

 

Sex predominance

No gender

difference

Female

Female

Heritable etiology,

Highest

Present (lesser)

Absent

Family h/o

schizophrenia,

 

 

 

premorbid

developmental

abnormalities/ childho

od maladjustment,

premorbid h/o social

rejection/poor peer

relationship / clingy

withdrawn

behavior/academic

trouble/ delayed

motor & verbal mile

stones

 

 

 

Negative symptoms,

blunted or

Highest

Present

(lesser);

Absent (least);

on the other

inappropriate affect,

formal thought

 

whereas LOS

have more

hand have

higher rates of

disorder, loosening of

 

prevalence of

visual, tactile

association, thought

 

organized

& olfactory

blocking, deficits in

IQ, memory,

perceptumotor skills

 

delusions,

abusive or

running

hallucinations

Q and greater

prevalence of

(i.e.

 

commentary

persecutory &

neuropsychological

 

auditory

partition

deficits) & cognitive

impairment ,

impairment in

learning abstraction &

flexibility

 

hallucinations

and

persecutory

delusions with

or without

hallucinations

delusions

Development &

persistence of

delusion

Cognitive biases

Cognitive

biases

Mentalization

Structural brain

abnormalities (On

Nonspecific

Non specific

Tumor, stroke

etc

MRI)

 

 

 

Prognosis

Worst

Worse

(Favourable)

Bad (more

favourable)

Neuroleptic dose

(daily)

High

Lower

Lowest

Risk of tardive

dyskinesia

Present

Present

Highest

Quiz In Between


Q. 7

Schizophrenia is more common in which socio­economic strata ‑

 A

Middle

 B

Upper

 C

Low

 D

Upper middle

Q. 7

Schizophrenia is more common in which socio­economic strata ‑

 A

Middle

 B

Upper

 C

Low

 D

Upper middle

Ans. C

Explanation:

Ans. is ‘c’ i.e., Low

  • ‘Schizophrenia is more prevalent in patients having a lower socioeconomic status”.          – Namboodiri

Etiology of Schizophrenia

  • The exact etiology is not clear. Experts think schizophrenia is caused by several factors.

1. Heredity (Genetic factors)

  • Schizophrenia runs in families. The illness occur in 0.5-1% of general population. However, First degree relative of schizophrenic patients have a 10 times more lifetime risk of having illness. The risk is 3-6 times and 2 times more in second and third degree relatives, respectively

2. Environmental factors

  • Environmental factors and stress are important in precipitating schizophrenia in many individuals. These factors are : ‑
  1. Socioeconomic : – Low socio-economic status, Industrialization; Immigration; familes with high expressed emotions; Nuclear families; Schisms & skewed families; and pseudomutul & pseudohostile families.
  2. Drugs : – Drugs causing schizophrenia like state are amphetamine (most common causative drug), LSD, Phencyclidine, ketamine, Mescaline, Cocaine, Cannabis.
  3. Metabolic & Neurological disorders : – Schizophrenia like symptoms may occur in Huntington’s chorea (early stage), homocystinuria, acute intermittent porphyria, Wilson’s disease and hemochromatosis.

3. Biochemical factors

  • Dopamine hypothesis is the most accepted hypothesis for schizophrenia. There is hyperactivity of dopaminergic system. This hypothesis is supported by: 1) Amphetamine and cocaine which release dopamine in central synapses induce schizophrenia like symptoms; and 2) Antipsychotic drugs control the schizophrenic symptoms by blocking dopamine (D,) receptors. However, the dipamine hypothesis has been questioned also as Homo vanillic acid (HVA the principal metabolite of dopamine) is not elevated and prolactin level is not decreased (Dopamine has inihibitory action on prolactin release).
  • Other neurotransmitters involved are : – Increased serotonin, Decreased GABA, variable change (Increased or decreased) glutamate, and increased norepinephrine.

Q. 8

Schizophrenia results with ?

 A

Increased GABA

 B

Decreased norepinephrine

 C

Increased dopaminergic activity

 D

Decreased dopaminergic activity

Q. 8

Schizophrenia results with ?

 A

Increased GABA

 B

Decreased norepinephrine

 C

Increased dopaminergic activity

 D

Decreased dopaminergic activity

Ans. C

Explanation:

Ans. is ‘c’ i.e., Increased dopaminergic activity

  • Dopamine hypothesis is the most accepted hypothesis for schizophrenia. There is hyperactivity of dopaminergic system. This hypothesis is supported by: 1) Amphetamine and cocaine which release dopamine in central synapses induce schizophrenia like symptoms; and 2) Antipsychotic drugs control the schizophrenic symptoms by blocking dopamine (D,) receptors. However, the dipamine hypothesis has been questioned also as Homo vanillic acid (HVA the principal metabolite of dopamine) is not elevated and prolactin level is not decreased (Dopamine has inhibitory action on prolactin release).
  • Other neurotransmitters involved are : – Increased serotonin, Decreased GABA, variable change (Increased or decreased) glutamate, and increased norepinephrine.

Q. 9

Which is true about age and sex distribution of Schizophrenia?

 A

Most common age is >50 years

 B

Early onset is a good prognostic factor

 C

Male sex is a poor prognostic factor

 D

Males are prone for the disease

Q. 9

Which is true about age and sex distribution of Schizophrenia?

 A

Most common age is >50 years

 B

Early onset is a good prognostic factor

 C

Male sex is a poor prognostic factor

 D

Males are prone for the disease

Ans. C

Explanation:

Ans. is ‘c’ i.e., Male sex is a poor prognostic factor

(Ref: Kaplan Sadock Synopsis lfr/e p.480)

  • The schizophrenia starts in late adolescent and early adult (15-25 years).
  • Men and women have an equal lifetime risk for schizophrenia.
  • However’ schizophrenia tends to strike women 3-4 years later than men.
  • Most men develop schizophrenia between 75 and 25 years of age.
  • For women the period of maximum onset is between 15 and 30 with a smaller peak between 45 and 50 (after menopause).

Quiz In Between


Q. 10

Schizophrenia word means

 A

Split mind

 B

Split mind

 C

Split thoughts

 D

Split associations

Q. 10

Schizophrenia word means

 A

Split mind

 B

Split mind

 C

Split thoughts

 D

Split associations

Ans. A

Explanation:

Ans. is’a’i.e., Split mind [Ref. Niraj Ahuje’s Psychiatry)
“Schizophrenia” word means mental splitting.


Q. 11

Feature (s) of Schizophrenia is/are:

 A

1st rank symptom is helpful in making diagnosis

 B

Depression may be present

 C

Brain ventricle enlargement may be present

 D

Onset occur only after age of 40 yr

Q. 11

Feature (s) of Schizophrenia is/are:

 A

1st rank symptom is helpful in making diagnosis

 B

Depression may be present

 C

Brain ventricle enlargement may be present

 D

Onset occur only after age of 40 yr

Ans. A:B:C:E

Explanation:

Ans. (A) 1st rank symptom is helpful in making diagnosis (B) Depression may be present (C) Brain ventricle enlargement may be present (E) Usually onset occur later in women as compared to men

Schizophrenia:

Two common affective symptom:

  • Reduced emotional responsiveness (warrant the label of anhedonia, and overly active and inappropriate emotions such as extremes of rage, happiness, and anxiety).
  • Other feeling tones include perplexity, a sense of isolation, overwhelming ambivalence & depression.

Onset:

  • Usually later in women & often runs a more benign course. (Compared to men).

CNS involvement:

  • Computed tomography (CT) scans of patients with schizophrenia have consistently shown lateral and thiril ventricular enlargement and,some reduction in cortical volume.

Diagnosis:

  • Schneider’s first rank symptoms of schizophrenia though not specific but of geat help in making diagnosis & have significantly influenced the diagnostic criteria & classification of schizophrenia.

Quiz In Between



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