Helpful definitions in understanding schizophrenia include the following:

Psychosis: Psychosis is defined as being out of touch with reality. During this phase, one can experience delusions or prominent hallucinations. People with psychoses are not aware that what they are experiencing or some of the things that they believe are not real. Psychosis is a prominent feature of schizophrenia but is not unique to this illness. Schizoid: This term is often used to describe a personality disorder characterized by almost complete lack of interest in social relationships and a restricted range of expression of emotions in interpersonal settings, making a person with this disorder appear cold and aloof. Schizotypal: This term defines a personality disorder characterized by acute discomfort with close relationships as well as disturbances of perception, odd beliefs, and bizarre behaviors. Often individuals with schizotypal personality disorder are seen as odd and eccentric because of unusual mannerisms and beliefs. Hallucinations: A person with schizophrenia may have strong sensations of objects or events that are real only to him or her. These may be in the form of things that they believe strongly that they see, hear, smell, taste, or touch. Hallucinations have no outside source, and are sometimes described as "the person's mind playing tricks" on him or her. Illusion: An illusion is a mistaken perception for which there is an actual external stimulus. For example, a visual illusion might be seeing a shadow and misinterpreting it as a person. The words "illusion" and "hallucination" are sometimes confused with each other. Delusion: A person with a delusion has a strong belief about something despite evidence that the belief is completely false. For instance, a person may listen to a radio and believe the radio is giving a coded message about an impending alien invasion. All of the other people who listen to the same radio program would hear, for example, a feature story about road repair work taking place in the area.

OBJECTIVES: 1. Schizophrenia. Cause, pathophysiology

People having a higher level of functioning before the start of their illness typically have a better outcome. In general, better outcomes are associated with brief episodes of symptoms worsening followed by a return to normal functioning. Women have a better prognosis for higher functioning than men, as do patients with no apparent structural abnormalities of the brain. Nearly one-third of those diagnosed with schizophrenia will attempt suicide. About 10 percent of those with the diagnosis will commit suicide within 20 years of the beginning of the disorder. Patients with schizophrenia are not likely to share their suicidal intentions with others, making life-saving interventions more difficult. The risk of depression needs special mention due to the high rate of suicide in these patients. The most significant risk of suicide in schizophrenia is among males under 30 who have some symptoms of depression and a relatively recent hospital discharge. Other risks

include imagined voices directing the patient toward self-harm (auditory command hallucinations) and intense false beliefs (delusions). The relationship of schizophrenia to substance abuse is significant. Due to impairments in insight and judgment, people with schizophrenia may be less able to judge and control the temptations and resulting difficulties associated with drug or alcohol abuse. In addition, it is not uncommon for people suffering from this disorder to try to "selfmedicate" their otherwise debilitating symptoms with mind-altering drugs. The abuse of such substances, most commonly nicotine, alcohol, cocaine and marijuana, impedes treatment and recovery. The onset of schizophrenia in most people is a gradual deterioration that occurs in early adulthood -- usually in a person's early 20s. Loved ones and friends may spot early warning signs long before the primary symptoms of schizophrenia occur. During this initial pre-onset phase, a person may seem without goals in their life, becoming increasingly eccentric and unmotivated. They may isolate themselves and remove themselves from family situations and friends. They may stop engaging in other activities that they also used to enjoy, such as hobbies or volunteering. Warning signs that may indicate someone is heading toward an episode of schizophrenia include:

Social isolation and withdrawal Irrational, bizarre or odd statements or beliefs Increased paranoia or questioning others' motivations Becoming more emotionless Hostility or suspiciousness Increasing reliance on drugs or alcohol (in an attempt to self-medicate) Lack of motivation Speaking in a strange manner unlike themselves Inappropriate laughter Insomnia or oversleeping Deterioration in their personal appearance and hygiene

Causes: It is likely, although not yet certain, that the disorder is associated with some imbalance of the complex, interrelated chemical systems of the brain, perhaps involving the neurotransmitters dopamine and glutamate. Many studies of people with schizophrenia have found abnormalities in brain structure. In some small but potentially important ways, the brains of people with schizophrenia look different than those of healthy people. For example, fluid-filled cavities at the

center of the brain, called ventricles, are larger in some people with schizophrenia. The brains of people with the illness also tend to have less gray matter, and some areas of the brain may have less or more activity. In fact, recent research has found that people with schizophrenia tend to have higher rates of rare genetic mutations. These genetic differences involve hundreds of different genes and probably disrupt brain development. Other recent studies suggest that schizophrenia may result in part when a certain gene that is key to making important brain chemicals malfunctions. This problem may affect the part of the brain involved in developing higher functioning skills.

Negative symptoms often correlated with reduced blood flow and other abnormalities in the frontal cortex. Reduced connections between different brain areas can often be deduced from EEGs.

Schizophrenia is a mental disorder that is characterized by at least 2of the following symptoms, for at least one month: Delusions

Hallucinations Disorganized speech (e.g., frequent derailment or incoherence) Grossly disorganized or catatonic behavior A set of three negative symptoms (a "flattening" of one's emotions, alogia, avolition; see below)

Positive Symptoms Delusions

Hallucinations Disorganized thinking Agitation

Negative Symptoms Affective flattening - The person's range of emotional expression is clearly diminished; poor eye contract; reduced body language

Alogia - A poverty of speech, such as brief, empty replies Avolition - Inability to initiate and persist in goal-directed activities (such as school or work)

Thus, people with schizophrenia can experience symptoms that may be grouped under the following categories:

Positive symptoms: Hearing voices, suspiciousness, feeling as though they are under constant surveillance, delusions, or making up words without a meaning (neologisms). Negative (or deficit) symptoms: Social withdrawal, difficulty in expressing emotions (in extreme cases called blunted affect), difficulty in taking care of themselves, inability to feel pleasure. These symptoms cause severe impairment and are often mistaken for laziness.

Cognitive symptoms: Difficulties attending to and processing of information, understanding the environment, and remembering simple tasks. Affective (or mood) symptoms: Most notably depression, accounting for a very high rate of attempted suicide in people suffering from schizophrenia. Anxiety can also be present and may be a direct result of the psychosis or come and go during a psychotic episode.

Types:
Different subtypes of schizophrenia are defined according to the most significant and predominant characteristics present in each person at each point in time. The result is that one person may be diagnosed with different subtypes over the course of his illness. Schizophrenia: Paranoid Subtype The defining feature of the paranoid subtype (also known as paranoid schizophrenia) is the presence of auditory hallucinations or prominent delusional thoughts about persecution or conspiracy. However, people with this subtype may be more functional in their ability to work and engage in relationships than people with other subtypes of schizophrenia. The reasons are not entirely clear, but may partly reflect that people suffering from this subtype often do not exhibit symptoms until later in life and have achieved a higher level of functioning before the onset of their illness. People with the paranoid subtype may appear to lead fairly normal lives by successful management of their disorder. People diagnosed with the paranoid subtype may not appear odd or unusual and may not readily discuss the symptoms of their illness. Typically, the hallucinations and delusions revolve around some characteristic theme, and this theme often remains fairly consistent over time. A persons temperaments and general behaviors often are related to the content of the disturbance of thought. For example, people who believe that they are being persecuted unjustly may be easily angered and become hostile. Often, paranoid schizophrenics will come to the attention of mental health professionals only when there has been some major stress in their life that has caused an increase in their symptoms. Schizophrenia: Disorganized Subtype As the name implies, this subtypes predominant feature is disorganization of the thought processes. As a rule, hallucinations and delusions are less pronounced, although there may be some evidence of these symptoms. These people may have significant impairments in their ability to maintain the activities of daily living. Often, there is impairment in the emotional processes of the individual. For example, these people may appear emotionally unstable, or their emotions may not seem appropriate to the context of the situation. They may fail to show ordinary emotional responses in situations that evoke such responses in healthy people.

People diagnosed with this subtype also may have significant impairment in their ability to communicate effectively. At times, their speech can become virtually incomprehensible, due to disorganized thinking. In such cases, speech is characterized by problems with the utilization and ordering of words in conversational sentences, rather than with difficulties of enunciation or articulation. Schizophrenia: Catatonic Subtype The predominant clinical features seen in the catatonic subtype involve disturbances in movement. Affected people may exhibit a dramatic reduction in activity, to the point that voluntary movement stops, as in catatonic stupor. Alternatively, activity can dramatically increase, a state known as catatonic excitement. Other disturbances of movement can be present with this subtype. Actions that appear relatively purposeless but are repetitively performed, also known as stereotypic behavior, may occur, often to the exclusion of involvement in any productive activity. Schizophrenia: Undifferentiated Subtype The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are not sufficiently formed or specific enough to permit classification of the illness into one of the other subtypes. Schizophrenia: Residual Subtype This subtype is diagnosed when the patient no longer displays prominent symptoms. In such cases, the schizophrenic symptoms generally have lessened in severity. Hallucinations, delusions or idiosyncratic behaviors may still be present, but their manifestations are significantly diminished in comparison to the acute phase of the illness. Treatment: Group therapy, combined with drugs, produces somewhat better results than drug treatment alone, particularly with schizophrenic outpatients. Positive results are more likely to be obtained when group therapy focuses on real-life plans, problems, and relationships; on social and work roles and interaction; on cooperation with drug therapy and discussion of its side effects; or on some practical recreational or work activity. This supportive group therapy can be especially helpful in decreasing social isolation and increasing reality testing (Long, 1996). Family therapy can significantly decrease relapse rates for the schizophrenic family member. In high-stress families, schizophrenic patients given standard aftercare relapse 50-60% of the time in the first year out of hospital. Supportive family therapy can reduce this relapse rate to below 10 percent. This therapy encourages the family to convene a family meeting whenever an issue arises, in order to discuss and specify the exact nature of the problem, to list and consider alternative solutions, and to select and implement the consensual best solution. (Long, 1996).

2.

History taking, important questions to be asked

During a medical history for schizophrenia, the health professional asks many different questions. The health professional will ask some general questions, such as: How are you feeling? Have you recently noticed changes in the amount of energy you have or in your appetite or sleep? Have you recently had changes in daily habits, such as changing from the day shift to the night shift? Does your work require that you travel frequently? Have you had unusually high stress lately (for example, due to events such as the death of a loved one, a change in job, getting married or divorced, or having a baby)? Have you had any recent exposure to irritating chemicals or toxins? Have you recently changed the amount of medicine you take or started a new medicine? Have you had any periods of time when you have lost track of time, such as you "woke up" and didn't know what had happened? Have you had any times when you were in a stupor? The health professional will ask some questions specifically about unusual experiences, such as: Do you ever hear voices (or see things) that other people do not hear (or see)? Do you ever think that you are being given a special message, are supposed to do a special project, or have been selected to be someone special? Are you having confusing thoughts that are hard for you to understand or follow? Do you get frustrated easily? Do you think that you are in danger? Do you think about hurting yourself or someone else? Do you think that you are being followed, that someone is controlling your thoughts, or that someone else knows what you are about to do or say? The health professional may also ask other questions to see whether a person has symptoms of other conditions, such as depression, anxiety, or heavy alcohol or illegal drug use. The health professional will also ask questions about family history, including any history of schizophrenia or other mental illnesses. The health professional may also ask to interview one or more family members. During these interviews, the health professional may ask the family member(s) to describe the actions and behaviors of the person who has symptoms that may be caused by schizophrenia.

3.

Common psychiatric emergencies

Depression is the cause of about 50% of the suicide cases so it is very important to ask a patient about them having suicidal thoughts. There is a 16% chance that someone with schizophrenia will turn violent. While dealing with such emergencies, speak clamly and reassuringly and maintain eye contact throughout. Dont make any quick movements.
Psychiatric Disorders Associated with Increased Risk of Suicide or Other Forms of Violence Major depressive disorder Bipolar disorder (especially depressive or mixed states) Schizophrenia

Anorexia nervosa Alcohol use disorder (acute intoxication or withdrawal) Other substance use disorders (cocaine, amphetamines, phencyclidine) Substance withdrawal (opiates, cocaine, amphetamines) Personality disorders (especially borderline and antisocial)

4. 5.

Depression induced schizophrenia How do you assess mental status based on speech?

Appearance:
Presenting Appearance including sex, chronological and apparent age, ethnicity, apparent height and weight, any physical deformities Basic Grooming and Hygiene, dress and whether it was appropriate attire for the weather, for a doctor's interview, accessories like glasses or a cane Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), work speed, any noteworthy mannerisms or gestures

Manner:
Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness) Behavioral Approach (distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing) Speech (normal rate and volume, pressured, slow, accent, enunciation quality, loud, quiet, impoverished) Eye Contact (makes, avoids, seems hesitant to make eye contact) Expressive Language (no problems expressing self, circumstantial and tangential responses, difficulties finding words, misuse of words in a bizarre-thinking-processes way, mumbling) Receptive Language (normal, able to comprehend questions, difficulty understanding questions) Recall and Memory *could explain recent and past events in their personal history, recalls three words (e.g., Cadillac, zebra, and purple) immediately after two rehearsals, and then again five minutes later (five minutes is how long it takes for information to move from short-term to long term memory). If they can't, you can prompt them. Make them recall your name after 30 minutes

Orientation, Alertness
Orientation (person, place, time, presidents, your name) Alertness (sleepy, alert, tired for working late, dull and uninterested, highly distractible) Coherence (responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow) Concentration and Attention (attention to your questions, naming the days of the week or months of the year in reverse order, spelling words, or the ABC's backwards) Thought Processes ( difficult to understand line of reasoning, showed loose associations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization) Hallucinations and Delusions (presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications) Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong) Intellectual Ability (roughly average, above average, or below average based on answers to questions like "name last four presidents," "who is the governor of the state," "what is the capitol of the state," "what direction does the sun set," etc)

Mood:
Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry). Rapport (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset) Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful when discussing such and such) Suicidal and Homicidal Ideation (ideation but no plan or intent, clear/unclear plan but no intent, ideation coupled with clear plan and intent to carry it out) Risk for Violence (fair, low, high, uncertain, effected by substance use) Impulsivity (low medium, high, effected by substance use) Anxiety (note level of anxiety, any behaviors that indicated anxiety, ways they handled it)
TOW SPECIFIC THINGS ARE NOTED DURING THE SPEECH PART OF THE MENTAL STATUS EXAMINATION: Echolalia- speech repetition Palilalia- Multiple echolalia

6. Drugs

Haloperidol: It is used primarily to treat schizophrenia and other psychoses, delusional disorder, Huntingdons disease. Potent anti emetic and given in case of intractable hiccups. Also used for the treatment of severe behavioural problems in children with disrubtive behaviour disorder or ADHD (attention-deficit hyperactivity disorder). Haloperidol has been used in the prevention and control of severe nausea and vomiting. . Haloperidol has strong antiadrenergic and weaker peripheral anticholinergic activity; It also possesses slight antihistaminic and antiserotonin activity. The precise mechanism whereby the therapeutic effects of haloperidol are produced is not known, but the drug appears to depress the CNS at the subcortical level of the brain, midbrain, and brain stem reticular formation. Haloperidol seems to inhibit the ascending reticular activating system of the brain stem (possibly through the caudate nucleus), thereby interrupting the impulse between the diencephalon and the cortex. Haloperidol may also inhibit the reuptake of various neurotransmitters in the midbrain, and appears to have a strong central antidopaminergic and weak central anticholinergic activity. The drug produces catalepsy and inhibits spontaneous motor activity and conditioned avoidance behaviours in animals. The exact mechanism of antiemetic action of haloperidol has also not been fully determined, but the drug has been shown to directly affect the chemoreceptor trigger zone (CTZ) through the blocking of dopamine receptors in the CTZ. Common side effects of Haldol are nausea, vomiting, diarrhea, dry mouth, nervousness, spontaneous eye movements, mood changes, breast enlargement, difficulty urinating, and occasional movement disorders. Severe side effects of Haldol may include death in the elderly, prolongation of the QT heartbeat interval, tardive dyskinesia (involuntary movements), prolonged erection (hours), a symptom complex sometimes referred to as neuroleptic malignant syndrome (NMS) with fever, irregular heartbeats, mental status changes, renal failure, and other symptoms. Lorazepam: A benzodiazepine used as an anti-anxiety agent with few side effects. It also has hypnotic, anticonvulsant, and considerable sedative properties and has been proposed as a preanesthetic agent. Lorazepam, a benzodiazepine not transformed to active metabolites, is used to treat anxiety, status epilepticus, and for sedation induction and anterograde amnesia. Lorazepam binds to an allosteric site on GABA-A receptors, which are pentameric ionotropic receptors in the CNS. Binding potentiates the effects of the inhibitory neurotransmitter GABA, which upon binding opens the chloride

channel in the receptor, allowing chloride influx and causing hyperpolerization of the neuron. The most important clinical adverse event caused by lorazepam is respiratory depression. Risperidone: atypical antipsychotic drug with high affinity for 5-hydrotryptamine (5-HT) and dopamine D2 receptors. It is used primarily in the management of schizophrenia, inappropriate behavior in severe dementia and manic episodes associated with bipolar I disorder. Risperidone is effective for treating the positive and negative symptoms of schizophrenia owing to its affinity for its loose binding affinity for dopamine D2 receptors and additional 5-HT antagonism compared to first generation antipsychotics, which are strong, non-specific dopamine D2 receptor antagonists. For the treatment of schizophrenia in adults and in adolescents, ages 13 to 17, and for the short-term treatment of manic or mixed episodes of bipolar I disorder in children and adolescents ages 10 to 17. Blockade of dopaminergic D2 receptors in the limbic system alleviates positive symptoms of schizophrenia such as hallucinations, delusions, and erratic behavior and speech. Blockade of serotonergic 5-HT2 receptors in the mesocortical tract, causes an excess of dopamine and an increase in dopamine transmission, resulting in an increase in dopamine transmission and an elimination of core negative symptoms. Dopamine receptors in the nigrostriatal pathway are not affected by risperidone and extrapyramidal effects are avoided. Like other 5-HT2 antagonists, risperidone also binds at alpha(1)-adrenergic receptors and, to a lesser extent, at histamine H1 and alpha(2)-adrenergic receptors Symptoms of overdose include drowsiness, sedation, tachycardia, hypotension, and extrapyramidal symptoms.
http://www.sciencedaily.com/releases/2013/08/130825171525.htm

7.

What is paracusia? Causes, DDx

Auditory hallucinations feature prominently in many psychiatric disorders. It has been estimated that approximately 75% of people with schizophrenia experience auditory hallucinations. These hallucinations are also relatively common in bipolar disorder (20% to 50%), in major depression with psychotic features (10%), and in posttraumatic stress disorder (40%).2

Not all auditory hallucinations are associated with mental illness, and studies show that 10% to 40% of people without a psychiatric illness report hallucinatory experiences in the auditory modality. 3,4 A range of organic brain disorders is also associated with hallucinations, including temporal lobe epilepsy; delirium; dementia; focal brain lesions; neuroinfections, such as viral encephalitis; and cerebral tumors.5 Intoxication or withdrawal from substances such as alcohol, cocaine, and amphetamines is also associated with auditory hallucinations.

Hypnagogic and hypnopompic hallucinations are especially common in healthy individuals and occur during the period of falling asleep or waking up. The frequency of these experiences in the general population may be evidence of the existence of a symptomatic continuum, which ranges from subclinical experiences of psychosis to full-blown psychotic episodes with severe, unwanted, and intrusive symptoms. 6 The phenomenological characteristics of auditory hallucinations differ on the basis of their etiology, and this can have diagnostic implications. People without mental illness tend to report a greater proportion of positive voices, a higher level of control over the voices, less frequent hallucinatory experiences, and less interference with activities than people who have a psychiatric illness.7,8 There is also evidence that delusion formation may distinguish psychotic disorders from nonclinical hallucinatory experiences.9 In other words, the development of delusions in people with auditory hallucinations significantly increases the risk of psychosis when compared with individuals who have hallucinations but not delusions. By contrast, characteristics of auditory hallucinations that are thought to be more indicative of psychosis include8,10: Higher frequency of hallucinatory experiences Localization of voices outside the head Greater linguistic complexity Greater emotional response The extent to which patients believe that other people share this experience

Potential causes]
Associated diseases
The premier cause of auditory hallucinations in the case of psychotic patients is schizophrenia. In those cases, patients show a consistent increase in activity of the thalamic and strietal subcortical [11][12] nuclei, hypothalamus, and paralimbic regions; confirmed via PET scan and fMRI. Other research shows an enlargement of temporal white matter, frontal gray matter, and temporal gray matter volumes (those areas crucial to both inner and outer speech) when compared to control [13][14] patients. This implies both functional and structural abnormalities in the brain can induce auditory [15][16][17] hallucinations, both of which may have a genetic component. Mood disorders have also been known to cause auditory hallucinations, but tend to be milder than their psychosis induced counterpart.

Non-disease associated causes

Auditory hallucinations have been known to manifest as a result of intense stress, sleep deprivation, drug use, and errors in development of proper psychological processes.