The Clinical Presentation Schizophrenia
The clinical presentation and outcome of schizophrenia are so varied, the best way to understand this disorder is to deal with it in two major syndromes (the acute syndrome and chronic syndrome)In addition we have to remember that there are many intermediate forms of this disorder..
The Acute syndrome:Many psychiatrists concentrate on the personality of the patient before the obvious onset of schizophrenia .
The abnormal personality detected has been called (schizoid personality). In fact, this personality appears to contain the seeds of schizophrenia and is characterized by seductiveness , isolation , abnormal shyness ,ect..
These individuals with this type of personality may not necessarily become schizophrenic but it has been found that 25% of schizophrenic patient had such personality.
In addition, a high number of schizophrenic patient had a paranoid type of delusions , from this we conduct that the acute syndrome may begin insidiously (pre-morbid schizoid personality or called abnormal pre-morbid personality) .Or appear suddenly with normal pre-morbid personality (no schizoid personality)
Some of the clinical features of acute syndrome can be illustrated as the following:
A previously healthy 20 years old male student, had been behaving in an increasingly odd way. At times, he appeared angry and told his friends that he was being persecuted, at other times he was seen to be laughing to himself for no apparent reason. His academic work or study had deteriorated (bad marks in the exams)
The student is usually a clever one, and he say that he heard voices commenting on his actions (running commentary) . He may say that the police had conspired with his university teachers to harm his brain with poisonous gases and take away his thoughts …
The person begin to preoccupy in religion, praying ,internet and other subjects especially modern science .
The un expected behavior of the person make him perplexed by what is happening to him ,other patients may retire from job and spend much of time in their rooms apparently deep in thoughts .
Anyhow, we will deal with the psychopathological symptoms in more arranged patterns…
1-Abnormalities of mood:
a- Mood change: such as depression,anxiety , ect..
b-Blunting (or flattening) of mood which means :a reduction in normal variations of mood .
c-Incongruity of mood :an emotional response which is not suitable with situation ,ex: a patient may laugh when told about death of his father or somebody else.
2- Thoughts disorders:
a-Formal thought disorder like concrete thinking and loosening of associations.In fact , loosening of associations is also called (knight's move thinking (referring to the indirect move of knight in chess).
Note:terms like (words salad )or (neotogism) may also be used to refer to formal thought disorders.
b-Disorders of stream of thought such as flight of ideas ,thought blooking ,ect..
3- Auditory hallucination:
They are among the most common frequent symptoms of schizophrenia ,they are either simple noises ,voices or music.
The voices may be single words, brief phrases or whole conversation. The patient complains either from voices commenting on his behavior, or two or more voices seem to discuss the patient in the third person.
4- Visual hallucination:
These are less frequent than auditory hallucinations and seldom occur without other kind of hallucinations.**A few patients experience tactile, olfactory, gustatory and somatic hallucinations and are often interpreted in a delusional way.
Note:
1-in tactile hallucination here the patient complains from presence of spider or insect on his skin.
2- auditory hallucination are the most common in this disorder schizophrenia while visual hallucinations are usually seen in organic states .
5-Delusions:
A-Delusions occur commonly in schizophrenia and can be considered (as other important symptoms) valuable in the diagnosis of this disorder,
B-Persecutory delusions are common but not specific.
C-Delusions of reference may be observed (false beliefs that objects ,events or people have a special personal significance).
D-Delusions of control (the patient feel that he is a robot and being controlled by an outside agency)
E-Delusion of possession of thought (insertion, deprivation or broad casting)
Note: in everyday speech the word (paranoid ) is usually taken to mean (the feeling of being persecuted )but in psychology it is used to refer to morbid beliefs of grandeur ,love , jealousy ,ect….
6- Orientation: its normal in acute syndrome.
7- attention and concentration: they are commonly impaired and this leads to apparent difficulties in remembering , though the memory itself is not affected.
8-insight: it's usually impaired .They don’t accept that their symptoms result from an illness ,often ascribing them instead to the malevolent actions of other people. This will subsequently lead to avoidance of treatment.
Note:the combination of disturbed behavior ,hallucinations and delusions is often referred to (positive symptoms ). The clinical picture is variable as we said ,and the patient may not necessarily experience all these symptoms . In addition to that we must remember the symptoms may be non-specific at the beginning of the acute syndrome and this is called (the prodroma or prodromal symptoms) after which the patient enters a more obvious stage and the schizophrenia picture becomes clear.
-if the patient is not treated by specific lines(drugs, psychotherapy) he may show the symptoms of chronic syndrome later on. It is critical to support the patient at this stage because complete recovery can sometimes be expected.
-The acute syndrome is variable in time period .it may be short or long.
The chronic syndrome:
In contrast with the positive symptoms of acute syndrome, the chronic syndrome is characterized by (negative symptoms) of under activity, lack of drive, social withdrawal, emotional apathy, catatonic symptoms, and also by thought disorders.
The symptoms can be illustrated as follow:
A middle aged man lives in a group for psychiatric patients and attends a sheltered workshop .In both places he withdraws from company, he is usually disheveled and unshaven ,and cares for himself only when encouraged to do so by others. His social behavior is odd and awkward .his speech is slow and its content is vague and incoherent. When questioned, he says that he is a victim if persecution by extra-terrestrial beings who beam rays upon him, he shows few signs of emotions about any aspect of life.
This clinical picture changes minimally over the years except for episodes of acute symptoms that may occur due to over stimulation.
Clinical picture of chronic syndrome
1-Diminshed volition:
It’s the most striking feature and means the lack of drive and initiative.
2-social behavior:
The behavior of patient deteriorate, they may neglect personal hygiene and their appearance is bad and dirty dressing, unshaved beard.
In addition he may withdraw from social encounters. Some behave in a way that embarrass other people by breaking social conventions, for example talking intimately to strangers, shouting obscenities in public or may put off his clothes to demonstrate his genitalia for people in the street.
3-Motor disturbance: it includes the following:
-catatonic symptoms: the most striking features are stupor and excitement .
-stereotypes :repeated non-goal directed movement.
Mannerisms :repeated goal directed movement.
Waxy flexibility: this refers to (When patient is put in a awkward posture ,he can maintain this posture for longer time than do healthy people.
4-Speech: its abnormal and reflects underlying thought disorder of the same kind found in acute syndrome (formal thought disorder and disorder of stream of thoughts).
5-Affect (mood): its generally blunted (flattened) and when emotions are shown it may be incongruous.
6-Hallucination: these are common and the forms observed are similar to those seen in the acute syndromes.
The hallucinations in this stage are usually not clear and they lose their brightness.
7-Delusions :these are common and often systematized ,they may be held with convinced that they are being persecuted but show neither fear or anger.
Delusions may be encapsulated from the rest of the patients beliefs:
Note: systemized and encapsulated delusions are different.
8-Orientaion: is normal.
9- Attention and concentration: they are often impaired .
10-Memory: it is not generally abnormal except that some patients have difficulty in giving their age correctly .
11-Insight: is impaired as in the acute syndrome.
Notes: patients with chronic cases feel that mind is shallow.
-chronic cases may have self-talked accompanied by signals and certain movement.
-the chronic case have poverty in thoughts (limited thoughts and ideas)
-the chronic case of schizophrenia have decreased in number because of effective treatment that had been provided to prevent the patient (in the acute syndrome) from entering the chronic phase, on the other hand, neglecting the patient (without being treated by drugs or psychotherapy ) leads to establishment of the disorder and this makes the number of chronic cases to be increased.
Diagnosis of schizophrenia ةخفهrive , social withdrawal ,enk of drive , social withdrawal ,enpy) he may show the symptoms of chronic syndrome later on.صوا
1-History: history is taken to detect social, hereditary or other causal factors that have a relationship with the development of this disorder.
2-Physical examination:
This is done to exclude the presence of physical disorders that caused this altered mental state like hypothyroidism..ect..
3- Mental state assessment.
4-Investagations:
These are done either to confirm our suspicion or exclude it.
After carrying out the lines needed to diagnose schizophrenia, we can decide whether patient has the disorder or not depending on the diagnostic criteria of schizophrenia.
Primary delusions:
These delusions occur suddenly and with complete convention, and without any identifiable mental event leading up to it , they are usually are of diagnostic if schizophrenia ,although similar delusions can occur in epileptic psychosis,
Here the delusions arises by the arising of new meaning in connection with some other psychological event,
-the delusional mood becomes obvious in its meaning when followed either by sudden delusional idea or delusional perception
ملاحظه:ان ال mood delusion لا يعتبر delusion بحد ذاته فيما يخص محتواه
Secondary delusions:
These arise from a preceding abnormal experience
The experience may be of various kinds :
-hallucination : ex: a person hears a voice and believes that he is being followed
- mood experience : ex: patient with deep depression think that the other people considered him worthless
-another delusions : a person with delusion that he has no money and believes he enter the prison for unpaid dept. .
Note: In this way some patients develop a series of secondary delusions related to one another called (systematized delusions )