Psychoses Schizophrenia It is the most common psychiatric condition, very difficult to treat.

It is condition that unable the person and the family to live peacefully. About 60-70% of the mentally sick people suffer from schizophrenia. It is a severe condition. enerally affects the early adulthood. It is mostly a chronic illness- that causes permanent and irreversible disability. !chizophrenic patients are more seen in hospitals, "hereas depression patients in the community. Symptoms: #eatin$ others, a$$ressive % violent behaviour, bein$ abusive, assaultive, usin$ bad, vul$ar and filthy lan$ua$e, talkin$ to self, lau$hin$ to self, poor self care etc Definition: !chizophrenia is a $roup of mental disorder, characterized by disturbances in thou$hts, affect and behaviour, "hich results in disorientation of the personality of patients. &he patients may suffer from hallucinations and delusions. 'or ma(ority of the cases hospitalization is necessary. Etiology: ). Genetic factors- do play a ma(or role- in $eneral population occurrence is estimated to be 0.*%, the risk period bein$ bet"een the a$e of )+-,+ years of a$e. -isk factors- siblin$ "ith mental illness-7%, one parent-),%, both parents-.0%, t"ins- monozy$otic t"ins- 70%, dizy$otic t"ins- .0%/ the identical t"ins $ro"n to$ether and apart are prone to 70% risk factor- in addition to this, the environmental factors play a very important role in the manifestation of the illness0 1. Environmental Factors- !ocial 2lass and 'amily. &he symptoms start because of some psycho-social stress. !ocial class 3- illiterates, casual labourers, people #45 etc are prone to this stress factor- more schizophrenic patients are found here. &he stress of bein$ in class 3 and the driftin$ nature of the class are contributin$ factors. .. Bio-chemical factors- brain chemistry is affected- there is also anatomical disturbance in the brain. &he brain "ei$ht is less especially in &ype II patientst"o theories to e6plain this- i0 birth in(ury theory- stress- emotions that $o "ith birth ii0 slo" virus theory- various sickness like cold, fever etc e6perienced by the mother durin$ pre$nancy may affect the brain. Hereditary & Environment 7hen there is a serious hereditary factor involved in the manifestation of the illness-the environment also should be considered- the environment can be controlled and modified "hereas, the hereditary characters of an individual cannot be controlled or cured.

linical S!" #ypes of Schizophrenia). Simple Schizophrenia- usually belo" 10 years, mode of onset is sloe, insidious, $radual. !ymptoms- $radual loss of interest in people, ob(ects, situations. 5ack of motivation in education, appearance, lack of ambition /future (ob "ith $ood salary, marria$e0, slo"in$ do"n in academic performance. 8o interest in plannin$ for the future- they may drip into poverty "hen they reach adulthood. 9sually there are no hallucinations and delusions and do not disturb the family members and are not violent. !ince they are not problematic they are not brou$ht to the hospitals most of the time. :uration of the illness is too lon$. 1. He"ephrenic- usually in adolescence. !ymptoms- thou$ht disorder, irrelevant talk. 2han$es in association and affect can be seen, hallucinations and delusions are present, can be seen respondin$ to these symptoms, lau$hin$ and talkin$ to self, $rimaces are made, bizarre talkin$, behaviour is disor$anized, can become violent and cause dama$e to people and property. 4ersonal hy$iene is ne$lected to the e6tent of incontinence, there is rapid deterioration, the pro$nosis is very poor, they become disabled, it is a chronic and lon$ term life condition. &hey have normal se6ual ur$es- and "omen patients can be e6ploited se6ually. /pre-morbid personality is schizoid0 .. atatonic-starts at the a$e of 10. there is psychomotor disorder- e6citement; "ithdra"l. <6treme form of "ithdra"l is stupor. =utism-refusin$ to ans"er any >uestion. 8e$ativism, stereotypin$, purposeless repetitive movement. 2atatonic "ithdra"l- includes symptoms of decreased psychomotor activity, psycholo$ical pillo", "a6y fle6ibility / keepin$ the hand in the same position0 2atatonic <6citement- a$$ression, violent, the victim may be an innocent person. ?nset is sudden. =ain tmt- <2& ,. Paranoid $ onset is around .+ years, many above avera$e intelli$ence, >uite educated, may have a (ob, deterioration is not severe. !ymptoms include delusion /persecution; $randiose0, ideas of reference, can be seriously disturbed or a$$ressive, tend to be a$$ressive even in ordinary situations, thou$ht disorder is there. @allucination- especially auditory is found. History of Schizophrenia: &he odd today is that) % of the population is vulnerable to the illness. ),00 #.2.- Ayurvedha- mentions a condition, brou$ht do"n by the devils in "hich the patients are filthy, "alk naked, has lost memory, and moves about in an uneasy manner. !oramus- in 1nd century- described delusions of $randeur in patients. &hese patients "ere termed 5unatics and "ere simply isolated from the $eneral population, as it "as felt that they "ere not mana$eable- and "ere put a"ay in asylumsspecially built for the purpose. All inhumane treatment "as takin$ place in these asylums. 9ntil )Ath and )* th century- various forms of treatments took place. &o"ards the later part of the )Ath and early )*th century chan$es "ere slo"ly brou$ht in the "ay these patients "ere treated. =orel introduced the term B:emence 4recoceC in )A+6.

Dahlbaum described a pattern characterized by chan$ed motor tension and named it as katatonia in )A6A. @ecker described that symptoms start early and labeled it as @ebephrenia. In )AA7, <mil Draepelin, first studied these patients and $ave a clinical classification. @e put them in t"o main cate$oriesE). 2ontinuous illness started from early part of life. 1. 4eople "ho "ere normal at a particular period and mentally ill for sometime. Draepelin found that dementia preco6 "as identical "ith hebephrenia. &he symptoms of paranoid schizophrenia "as identified by !anders. <u$ene #leuler- described the condition of schizophrenia as "e understand today. @e $ave the name !cizophrenia for dementia preco6. &ranslated it as splittin$ of the mind; personality- a central feature of this disease. &o #leuler, the primary function includes disturbances of Affect, Association, Ambivalence and Autism. ). Affect- inappropriate emotions. #luntin$ of affect- lack of emotions- this can been seen durin$ case history takin$- in =!<- mood can be found out. 1. Association- disorders of association- thou$h disorder- unable to reach a $oal in the thou$ht process. &hinkin$ is va$ue, over-inclusive and unable to hold conceptual boundaries <$.- =ary is a vir$in I am =ary I am a vir$in &hou$hts are not connected F amorphous thinkin$. .. Ambivalence- presence of contradictory /opposite0 feelin$s, emotions and attitude to"ards the same ob(ect, person and situations. :isturbance of volition"eakenin$ of volition /act or po"er of "illin$-voluntarily0 passin$ the day idle, doin$ nothin$- apathetic unable to make decisions. ,. Autism- loneliness. 5ives in a "orld of ima$ination and fantasy. &his is cut off from the "orld of reality /people and thin$s0, do not re>uire the company of others. &hey create a "orld of their o"n ima$ination. Adolf =eyer- father of modern psychiatry- started the concept of bio- psycho-social factors in causation. Acc, to him, !chizophrenia and other mental illness are not specific diseases but are particular reaction pattern of the or$anism ;the individual to his ;her environment.

Diagnostic Feat!res &his disorder, at some point in the illness, involves a psychotic phase /"ith delusions, hallucinations, or $rossly bizarre;disor$anized speech and behavior0. &his psychotic phase must last for at least one month /or less if successfully treated0. !chizophrenia also causes impairment in social or vocational functionin$ "hich must last for at least 6 months. &he psychotic phase is not due to a medical condition, medication, or ille$al dru$. omplications Individuals "ith this disorder may develop si$nificant loss of interest or pleasure. 5ike"ise, some may develop mood abnormalities /e.$., inappropriate smilin$, lau$hin$, or silly facial e6pressionsG depression, an6iety or an$er0. ?ften there is dayni$ht reversal /i.e., stayin$ up late at ni$ht and then sleepin$ late into the day0. &he individual may sho" a lack of interest in eatin$ or may refuse food as a conse>uence of delusional beliefs. ?ften movement is abnormal /e.$., pacin$, rockin$, or apathetic immobility0. 're>uently there are si$nificant co$nitive impairments /e.$., poor concentratiion, poor memory, and impaired problem-solvin$ ability0. &he ma(ority of individuals "ith !chizophrenia are una"are that they have a psychotic illness. &his poor insi$ht is neurolo$ically caused by illness, rather than simply bein$ a copin$ behavior. &his is comparable to the lack of a"areness of neurolo$ical deficits seen in stroke. &his poor insi$ht predisposes the individual to noncompliance "ith treatment and has been found to be predictive of hi$her relapse rates, increased number of involuntary hospitalizations, poorer functionin$, and a poorer course of illness. :epersonalization, derealization, and somatic concerns may occur and sometimes reach delusional proportions. =otor abnormalities /e.$., $rimacin$, posturin$, odd mannerisms, ritualistic or stereotyped behavior0 are sometimes present. &he life e6pectancy of individual "ith !chizophrenia is shorter than that of the $eneral population for a variety of reasons. !uicide is an important factor, because appro6imately )0% of individuals "ith !chizophrenia commit suicide - and bet"een 10% and ,0% make at least one suicide attempt. &here is an increased risk of assaultive and violent behavior. &he ma(or predictors of violent behavior are male $ender, youn$er a$e, past history of violence, noncompliance "ith antipsychotic medication, and e6cessive substance use. @o"ever, it should be noted that most individuals "ith !chizophrenia are not more dan$erous to others than those in the $eneral population. omor"idity Alcoholism and dru$ abuse "orsen the course of this illness, and are fre>uently associated "ith it. 'rom A0% to *0% of individuals "ith !chizophrenia are re$ular ci$arette smokers. An6iety and phobias are common in !chizophrenia, and there is an increased risk of ?bsessive-2ompulsive :isorder and 4anic :isorder. !chizotypal, !chizoid, or 4aranoid 4ersonality :isorder may sometimes precede the onset of !chizophrenia.

%hat is Schizophrenia& !chizophrenia is a chronic, severe, and disablin$ brain disorder that affects about ).) percent of the 9.!. population a$e )A and older in a $iven year. 4eople "ith schizophrenia sometimes hear voices others donHt hear, believe that others are broadcastin$ their thou$hts to the "orld, or become convinced that others are plottin$ to harm them. &hese e6periences can make them fearful and "ithdra"n and cause difficulties "hen they try to have relationships "ith others. Signs & Symptoms !ymptoms usually develop in men in their late teens or early t"enties and "omen in the t"enties and thirties, but in rare cases, can appear in childhood. &hey can include hallucinations, delusions, disordered thinkin$, movement disorders, flat affect, social "ithdra"al, and co$nitive deficits. #reatment &his is a time of hope for people "ith schizophrenia. Althou$h the causes of the disease have not yet been determined, current treatments can eliminate many of the symptoms and allo" people "ith schizophrenia to live independent and fulfillin$ lives in the community. Accordin$ to the 7orld @ealth ?r$anisation, one in every )00 persons suffers from schizophrenia, "hile psychiatrists estimate that ).+% to 1% of people in =umbai suffer from some psychiatric disorder. Diagnostic #ests 8o laboratory test has been found to be dia$nostic of this disorder. @o"ever, individuals "ith !chizophrenia often have a number of /non-dia$nostic0 neurolo$ical abnormalities. &hey have enlar$ement of the lateral ventricles, decreased brain tissue, decreased volume of the temporal lobe and thalamus, a lar$e cavum septum pellucidi, and hypofrontality /decreased blood flo" and metabolic functionin$ of the frontal lobes0. &hey also have a number of co$nitive deficits on psycholo$ical testin$ /e.$., poor attention, poor memory, difficulty in chan$in$ response set, impairment in sensory $atin$, abnormal smooth pursuit and saccadic eye movements, slo"ed reaction time, alterations in brain laterality, and abnormalities in evoked potential electrocephalo$rams0. Prevalence !chizophrenia is the fourth leadin$ cause of disability in the developed "orld /for a$es )+-,,0, and !chizophrenia is observed "orld"ide. 5ifetime prevalence varies from 0.+% to ).+%. &he incidence of !chizophrenia is sli$htly hi$her in men than "omen. 8e$ative symptoms /e.$., social "ithdra"al, lack of motivation, flat emotions0 tend to predominate

in menG "hereas depressive episodes, paranoid delusions, and hallucinations tend to predominate in "omen. o!rse !chizophrenia usually starts bet"een the late teens and the mid-.0s, "hereas onset prior to adolescence is rare /althou$h cases "ith a$e at onset of + or 6 years have been reported0. !chizophrenia can also be$in later in life /e.$., after a$e ,+ years0, but this is uncommon. 9sually the onset of !chizophrenia occurs a fe" years earlier in men than "omen. &he onset may be abrupt or insidious. 9sually !chizophrenia starts $radually "ith a prepsychotic phase of increasin$ ne$ative symptoms /e.$., social "ithdra"al, deterioration in hy$iene and $roomin$, unusual behavior, outbursts of an$er, and loss of interest in school or "ork0. A fe" months or years later, a psychotic phase develops /"ith delusions, hallucinations, or $rossly bizarre;disor$anized speech and behavior0. Individuals "ho have an onset of !chizophrenia later in their 10Is or .0Is are more often female, have less evidence of structural brain abnormalities or co$nitive impairment, and display a better outcome. !chizophrenia usually persists, continuously or episodically, for a life-time. 2omplete remission /i.e., a return to full premorbid functionin$0 is uncommon. !ome individuals appear to have a relatively stable course, "hereas others sho" a pro$ressive "orsenin$ associated "ith severe disability. &he psychotic symptoms usually respond to treatment "ith antipsychotic medication, "hereas the ne$ative symptoms are less responsive to antipsychotic medication. ?ften the ne$ative symptoms steadily become more prominent durin$ the course of !chizophrenia '!tcome &he best outcomes are associated "ith early and persistent treatment "ith antipsychotic medication soon after the onset of !chizophrenia. ?ther factors that are associated "ith a better pro$nosis include $ood premorbid ad(ustment, acute onset, later a$e at onset, $ood insi$ht, bein$ female, precipitatin$ events, associated mood disturbance, brief duration of psychotic symptoms, $ood interepisode functionin$, minimal residual symptoms, absence of structural brain abnormalities, normal neurolo$ical functionin$, a family history of =ood :isorder, and no family history of !chizophrenia Familial Pattern &he first-de$ree biolo$ical relatives of individuals "ith !chizophrenia have a risk for !chizophrenia that is about )0 times $reater than that of the $eneral population. 2oncordance rates for !chizophrenia are hi$her in monozy$otic /identical0 t"ins than in dizy$otic /fraternal0 t"ins. &he e6istence of a substantial discordance rate in monozy$otic t"ins also indicates the importance of environmental factors. #reatment Antipsychotic medication shortens the duration of psychosis in !chizophrenia, and prevents recurrences /but psychotic relapses can still occur under stress0. 9sually it takes years before individuals can accept that they have !chizophrenia and need medication. 7hen individuals stop their antipsychotic medication, it may take months

/or even years0 before they suffer a psychotic relapse. =ost, ho"ever, relapse "ithin "eeks. After each psychotic relapse there is increased intellectual impairment. Antipsychotic medication /J;- antidepressant medication J;- antian6iety medication0 usually prevents suicide, minimizes rehospitalization, and dramatically improves social functionin$. 9nfortunately, even on antipsychotic medication, most individuals "ith !chizophrenia canIt return to $ainful employment due to the intellectual impairments caused by this illness /e.$., poor concentration, poor memory, impaired problemsolvin$, inability to Kmulti-taskK, and apathy0. 5ife-lon$ treatment "ith antipsychotic medication is essential for recovery from !chizophrenia. Individuals also re>uire lon$-term emotional and financial support from their families. =ost individuals "ith !chizophrenia >ualify for $overnment /or insurance0 disability pensions. !ocial rehabilitation /e.$., club-houses, supervised social activities0 and sheltered;volunteer employment are also essential. 2ertain illicit dru$s, especially cannabis /KpotK0, have been sho"n to actually cause !chizophrenia.

%hat is Schizophrenia& (By Dr. R. V. Shirvaikar, M.B.B.S. (BOM), DPM (ENG)) =ost of the educated people "ho read ne"spapers, ma$azines and "atch scientific pro$rammes on &.3. are a"are of schizophrenia as a ma(or mental disorder, formerly kno"n as insanity, because of the unusual, >ueer and eccentric behaviour of the patient and because it appears out of this "orld. !uch patients are branded as ImadI and are rebuked and ridiculed by uncultured people. &his pushes such unfortunate victims of severe mental disorder deeper into the process of desocialisation, "hich later affects the patientIs social rehabilitation after treatment. It is therefore absolutely necessary for the $uardians of psychiatric patients and responsible people in $eneral to kno" "hat really is meant by schizophrenia. Is it incurableL !hould such patients be treated as outcasts, like IlepersI "ho "ere ostracized in the last century or like AI:! patients "ho are condemned these daysM 'amily members of such mental patients suffer not only from the patientIs behaviour and the uphill task of $ivin$ him re$ular treatment but also from the pre(udiced community by "ay of a near boycott. !chizophrenia, thou$h a difficult mental disorder to cure, is >uite treatable by easily available modern treatment methods. =ost of such patients improve sufficiently enou$h to return to their ori$inal position in the society. &he concept of schizophrenia is still not definite even in scientific circles. Its definition differs from country to country and has therefore become a very controversial issueG thou$h there is some a$reement about its causes, symptoms, course and treatment.

Historical 'vervie( of the oncept &he very first reference to a severe mental disorder "as made in Ayurveda as early as in ),00 #.2. @o"ever, in modern times the earliest description of schizophrenia as illness "as made in late )Ath century. &he first scientific description of such an illness "as made by =orel in )A+6. @e called it K:emenca 4recocieK. @e mentioned ne$ative symptoms /social "ithdra"al and inactivity0 and ultimate deterioration of personality in adolescents. Dahlbaum /)A6A0 described IkatatonieI, e>uivalent to IcatatoniaI /"ith ri$id postures, mutism and impulsivity0. !oon after"ards @ecker /)A7)0 described I@ebephreneI e>uivalent to @ebephrenia of today, "ith oddities in speech and conduct. &he first valid description of schizophrenia, as it is understood today, "as made by <Draepelin in ermany in )A*6 callin$ it I:ementia 4raeco6, meanin$ premature intellectual deterioration. @e classified ma(or mental disorders into t"o main $roups, viz, =anic :epressive Insanity and :ementia 4raeco6. @e incorporated the diseases described by Dahlbaum /Datatonie0 and @ecker /@ebephrenie0 as the types of :ementia 4raeco6. @e also added another type of his o"n, viz. :ementia 4aranoidies /e>uivalent to 4aranoid !chizophrenia0. @e speculated that this "as a brain disorder of unkno"n patholo$y, causin$ intellectual deterioration after some years. &his "as earlier su$$ested by riesin$er in )A,+. =ost of the psychiatrists in <urope, 9D and 9!A could not accept this classification because of its poorly kno"n etiolo$y and patholo$y. #leuler, a !"iss psychiatrist, developed DraepelinIs concept of :ementia 4raeco6 and called it IschizophreniaI in )*)) for the first time. @e emphasized its psycho$enic ori$in. @ence the 5atin term for Ksplit mindK. @e "as influenced by the theories of !i$mund 'reud, the father of psychoanalysis and stated that the disease meant Iloosenin$ of associationsI bet"een the different mechanisms of the mind. @e named the main symptoms of schizophrenia as I'undamental symptomsI "hich "ere later described as K'our AIsK. &hey "ereE ). 5oosenin$ of Associations, 1. #luntin$ and Incon$ruity of the emotional apparatus of KAffectK, .. Autism /shuttin$ off from the social environment and blockin$ of communication0, ,. Ambivalence /love and hate relationship "ith parents0. ?ther symptoms of hallucinations /perception in the absence of sensation0, delusions /false and firm beliefs0 "ere called accessory phenomena of lesser importance. @e also added Isimple schizophreniaI to the three types viz. @ebephrenic 2atatonic and 4aranoid, as described by Draepelin, to constitute one disease entity of schizophrenia. &hese ideas "ere "idely accepted in the 9!A because of the 4sychoanalytical bias there. As the boundaries of #leulerIs schizophrenia "ere loose, many other syndromes havin$ such symptoms "ere dia$nosed as schizophrenia in the 9!A, "hereas DraepelinIs concept "as accepted and follo"ed more in 9.D. and <urope, "ith the result that the number of cases dia$nosed as schizophrenia "ere much lesser in 9D than in 9!A. In )*60 5an$feldt differentiated !chizophrenia from !chizophrenieform psychosis to e6plain the variability and inconsistency of these disorders. @e found that, <2& and Insulin &herapy /prevailin$ thenG no" out of vo$ue0 "ere ineffective in true schizophrenia. &he latter "as called 4rocess !chizophrenia.

<l$in, 4hillips and Dantor devised ratin$ scales to differentiate bet"een 4rocess /&rue0 and 8on-4rocess !chizophrenia on the basis of premorbid personality and psychosocial ad(ustment. 4oor pro$nosis "as stated as the feature distin$uishin$ 4rocess schizophrenia from 8on-4rocess !chizophrenia. &he former "as hereditary and endo$enous, "hereas the latter "as psycho$enic and e6o$enous. Draepelin believed that schizophrenia "as endo$enous and hereditary "ith prevalence of hallucinations and delusions, poor pro$nosis. &hey ultimately became chronic and true symptoms of dementia follo"ed later. &his "as found to be the result of herdin$ to$ether of chronic patients "ith patients of $ood pro$nosis in mental hospitals. D. !chneider /)*+*0 propounded a ne" concept of schizophrenia and described first rank symptoms viz, auditory hallucinations and insertion of undesirable thou$hts by other persons /due to loss of <$o #oundaries0, thou$ht broadcastin$ /thou$hts shared by others0, and delusional misinterpretation of real perception. @is second rank symptoms "ere perple6ity, emotional bluntin$, other kinds of /nonauditory0 hallucination and delusions. In the si6ties and early seventies, there "ere different concepts of schizophrenia all over the "orld, thus lackin$ in a standard definition of schizophrenia. !o in )*7., 7@? or$anised a pro(ect of KInternationalK study of schizophrenia in 2olombia, 2zechoslovakia, :enmark, India, 8i$eria, &ai"an, 9D, 9!A and 9!!-. &he last t"o countries had a broader concept of schizophrenia resultin$ in itIs over dia$nosis. !ubse>uently, tendency to dia$nose on the basis of symptoms and its course became rudimentary because etiolo$y "as neither clear nor confirmed. :ifferent countries follo"ed different definitions of schizophrenia, and duration and mode of onset "ere considered to be better. :ia$nostic aids than the symptoms of acute illness. 8o" it is almost a$reed by various definin$ institutions that duration of symptoms must be at least for one month. At present, the most "idely used definitions of schizophrenia, at least for research purposes, are the !t. 5ouis 2riteria /'ei$hner eta))*710, the -esearch :ia$nostic 2riteria /-:20 /!pitzev etal )*7+0 and the American 4sychiatric AssociationIs :!= I3 /)**,0 2riteria as "ell as 7.@.?Is l2: )0 2riteria /)**10. &hey all re>uire clear evidence of psychosis at present or in the past and all but the 'ei$hner 2riteria specify particular kinds of hallucinatory e6periences or delusional ideation. All the four stipulated that affective symptoms must not be prominent and all re>uire a minimum duration of illness. /?nly 1 "eeks for -:2 definition0, ) month for l2: and 6 months for 'ei$hner. All definitions are arbitrary, (ustified only by their usefulness. &hey are liable to be altered or supplemented. &hou$h schizophrenia and its types are discussed as a sin$le disease, it probably comprises a $roup of disorders "ith hetero$eneous causes, and definitely includes

patients "hose clinical picture, treatment responses and defined causes of illness are varied. =ayer$rom defined schizophrenia as a $roup of mental illnesses characterised by specific psycholo$ical symptoms and, in the ma(ority of cases, leadin$ to a disor$anisation of the patientIs personality. Some of the recent etiological themes are )0 :opamine hypofunction in mesofrontal areas of the brain are associated "ith manifestations of ne$ative symptoms. 10 &here is 2omputer &omo$raphic evidence of cerebral atrophy, enlar$ed ventricles causin$ e6tensive co$nitive impairment in schizophrenia "ith ne$ative symptoms "hich are often unresponsive to neuroleptic treatment. %hat schizophrenia sho!ld mean to ordinary fol)s& After this e6planation of the scientific concepts and definition of schizophrenia I have to "rite about "hat schizophrenia should mean to ordinary people especially parents and close relatives or friends of persons dia$nosed to be afflicted "ith schizophrenia. 9nfortunately, even today schizophrenia is re$arded "ith $reat pre(udice, abhorrence and apprehension (ust like leprosy in the last century and AI:! in recent years. 7hereas "e all must understand the implications of such a dia$nosis in adolescents and youn$ adults and take prompt therapeutic measures, it is e>ually important that "e sho" a realistic and healthy attitude of sympathy, coura$e as "ell as determination to do everythin$ possible to help doctors to brin$ the patient out of the snake pit as early as possible. &he patient as "ell as his $uardians should remember that there is a possibility that the dia$nosis is incorrect. 'ears of incurability are e6a$$erated by rumors and hearsay. Indian research has identified a disorder named Acute 4sychotic :isorder "hich is often mistaken for acute schizophrenia /7i$ % !in$h, I2=-0. &he l2: classification also contains another disorder named Acute and &ransient psychotic disorder "hich also could be mistaken for schizophrenia. #oth the above stated disorders have much better pro$nosis than schizophrenia. =y o"n e6periences of over a lon$ period of +0 years are more encoura$in$. About 1+% of the patients treated for schizophrenia recover and stay "ell for lon$ periods after recovery. Another .0% $et short attacks at lon$er intervals but recover enou$h to return to their occupation and family life. ?nly about 10% do not recover ade>uately and have to be kept under psychiatric observation and treatment over a lon$ period. &hey may not be fit to return to their family or society. About )0% of patients become chronically ill. -ecent addition of atypical antipsychotic dru$s to psychiatristIs repertoire has raised the hope of continuous and prolon$ed medication even for chronic patients "ithout si$nificant side effects. &he demented schizophrenia patients seen by Draepelin "ere dissocialized, re(ected or untreated patients of old style mental hospitals, "hen there "ere

no antipsychotic at all. @o"ever he later did admit that )+% of all his patients recovered fully. I have treated scores of chronic patients "ho later continued in their (obs till retirement, of course "ith the sympathetic help of collea$ues and superiors. !ome have helped their close relative to run small shops or trades over a lon$ period. ?ne could compare schizophrenia patients "ith those of diabetes, hypertension, bronchial asthma, "hich also run a very lon$ course in spite of re$ular treatment perhaps even for a lifetime. &hey are also not IcurableI. ?ften such chronic physically ill persons are a burden to the family and perhaps to the society. Net they are not re(ected like the persons afflicted "ith schizophrenia. &he pre(udice of the people is often based on superstitious beliefs that the person is possessed by evil spirits and should be avoided. 'e" of such pre(udiced people realise that they can also act almost like the patients they re(ect "hen they lose control due to the influence of e6treme (oy or an$er or under the effect of alcohol or a reli$ious trance. In short, persons afflicted "ith schizophrenia under treatment are in no "ay much different from those "ho are physically ill over a lon$ period. &heir relatives must have hope of cure and sho" coura$e and determination to $ive their unfortunate relatives best chance for recovery and for returnin$ to family life. Diagnosis of Schizophrenia (By Dr. Vidyadhar Watve, MD, D PM FIRS) &he term psychosis is used "hen a patient has delusions /false beliefs not shared by others0, hallucinations /perceptions in absence of stimuli0, disor$anized speech, disor$anized or catatonic behaviour /maintainin$ posture or sudden severe e6citement0. !chizophrenia is one type of psychosisG but every psychosis is not schizophrenia. Diagnosis !chizophrenia has four $roups of symptoms. ). Positive symptoms* "hich consist of delusions, hallucinations and disor$anized behaviour. 1. +egative symptoms* "hich consist of emotional bluntin$, poor initiative, and poor communication. .. ognitive symptoms* "hich consist of poor attention, memory impairment, and poor plannin$. ,. ,ffective or emotional symptoms* "hich consist of an$er, hostility, a$$ression, and depressive symptoms includin$ suicidal ideation. !chizophrenia consists of the presence of characteristic positive or ne$ative symptoms of at least one month durationG deterioration in "ork, interpersonal relations, or self-care. &hese symptoms should not be due to $eneral medical conditions, like brain tumor, encephalitis, mali$nancy or metabolic disorder. !imilarly, the above-mentioned clinical picture should not be due to substance dependence. 2hronic alcohol dependence or cannabis dependence can produce a

schizophrenia-like picture but such a case is dia$nosed as substance-induced psychosis rather than schizophrenia. If an illness other"ise meets the criteria but has a duration of at least one month but less than si6 months, it is termed as schizophreniform disorder. If it has lasted less than four "eeks, it may be classified as brief psychotic disorder. !chizophrenia can be dia$nosed at any a$e if the criteria are met. &herefore the a$e-atonset criterion is deleted from older classification of mental disorders. Differential diagnosis: !chizophrenia remains a clinical dia$nosis that is based on history and mental status e6amination /=!<0. &here are no patholo$ical laboratory tests to dia$nose schizophrenia. After takin$ careful history from the relative, a compete physical e6amination is done to e6clude psychoses "ith kno"n medical causes. !imilarly, substance-abuse as a cause of psychosis is also ruled out. 4sychotic symptoms have been found to result from substance - abuse /e.$. alcohol, cocaine, amphetamines, hallucino$ens0G into6ication due to commonly prescribed medications /e.$. steroids, anticholiner$ics, levodopa0G infectious, metabolic and endocrine disordersG tumors and mass lesionsG and temporal lobe epilepsy. Acute onset, cloudin$ of the sensorium, or onset occurrin$ after the a$e of .0 years re>uires careful investi$ation. -outine lab tests are useful to rule out medical causes. &hey include 2#2, urinalysis, 5.'&s, #98, &'& and serolo$ical tests for syphilis and @I3. In selected patients '< , 2& or =-I of brain "ill be useful. &he ma(or task in differential dia$nosis involves separatin$ schizophrenia from schizoaffective disorder, mood disorder "ith psychotic features /mania or depression "ith psychotic features0, delusional disorder, or a personality disorder. &o rule out schizoaffective disorder and psychotic mood disorders, depressive or manic episodes should have been absent durin$ the active phase and the mood episode should have been relatively brief as compared to the total duration of the psychotic episode. :elusional disorder has non-bizarre delusion "hich can be a delusion of infidelity or paranoid delusion or somatic delusion. &he functionin$ in other areas is normal in delusional disorder. !chizophrenia is characterized by bizarre delusions and hallucinations. 4atients "ith personality disorders, particularly those in the eccentricI cluster /e.$. !chizoid, schizotypal and paranoid personality0, may be indifferent to sociail relationship, may have bizarre ideation and odd speech, or may be suspiciousG but they do not have delusions, hallucinations, or $rossly disor$anized behaviour.

4atients "ith schizophrenia may develop other symptoms like thou$ht disorders, behavioural disturbances and personality deterioration. &hese symptoms are uncharacteristic of the mood disorders, delusional disorder or the personality disorders. !ometimes panic disorder is accompanied by feelin$s of unreality but insi$ht is "ell preserved and there are no delusions or hallucinations. &he rituals of behaviour occurrin$ in a patient "ith obsessive-compulsive disorder may result in bizarre behaviour, but they are performed to relieve an6iety and not in response to delusional beliefs. &hus dia$nosis of schizophrenia needs careful history-takin$, detailed clinical evaluation, and routine investi$ations to rule out other medical and psychiatric disorders "hich can mimic clinical picture of schizophrenia. #reatment of Schizophrenia #ypical ,ntipsychotics Dr!gs: &he typical 8euroleptic /8540 is still the dru$ of choice in schizophrenia even in the era of a typical 854 in certain cases "ith prominent positive symptoms. &hey are cheap as compared to atypical 854. ,typical ,ntipsychotic Dr!gs: Antipsychotic dru$s have revolutionised the therapies for people "ith schizophrenia. &hey have fe"er side effects profileG they even remit many of the ne$ative symptoms of schizophreniaG they also control many of the emotional and co$nitive symptoms of this ma(or psychiatric ; brain disorder. !ome of the ma(or lon$-term side effects like tardive dyskinesia also appear to be less. 4ro$ressive research in this field is e6pected to further refine and sophisticate the therapeutic profile of these dru$s. Electro onv!lsive #herapy -E# . /By Dr. Shailesh ha!"!le, M.D.0: <2& stands for <lectro-2onvulsive &herapy. It is one of the most effective, rapidly actin$, safe treatment modality in psychiatry. 9nfortunately, it is unpopular, unacceptable amon$ the $eneral population, as it is also surrounded by various misconceptions. It is the "ron$ pro(ection and unscientific presentation of electroconvulsive therapy i.e. shockI treatment in @indi movies that has led to a variety of misconceptions amon$ people at lar$e. &he lack of efforts by psychiatrists to put forth the true scientific nature of treatment in various health a"areness pro$rammes has contributed to this persistent misunderstandin$ about <&2. History/origin of E # It has ori$inated from observations that patients sufferin$ from epilepsy and psychosis become symptomatically better after occurrence of $eneralised - tonic - clonic seizure. !cientist thou$ht that $eneralised seizure could be of therapeutic value in treatin$ psychosis. In the period bet"een )*., and )*.A efforts to induce seizure usin$ electrical stimulus "ere successful. %hat is done d!ring E #& In <2& the purpose is to induce $eneralised - tonic - clonic seizure in a patient. It is done

in a very systematic and scientific "ay. )0 'itness of the patient for $eneral anesthesia is evaluated. 10 &he patient is 8il #y =o9th /8#=0 for at least 6 hrs. .0 &he patient is on a bed /and not in a chair as sho"n in the media0. ,0 !hort actin$ $eneral anaesthetic / A0 /&hiopentone - sodium0 I3 is $iven follo"ed by muscle rela6ant succinylcholine. +0 7hen the patient is under anesthesia and muscles are rela6ed, electric current is passed throu$h electrodes to induce a seizure. <2& machine is used to monitor duration and intensity of the current. 60 &he patient $ets the seizure but the (erky movements are very mildE muscle rela6ant. 70 &he patient sleeps for a variable period up to ) hr. !ince the patient is under anaesthesia, he does not have any memory of the procedure e6cept for the prick of the needle.

0echanism of action of E # <6act mechanism of action is not kno"n. 3arious hypotheses have been put forth. 1ndications for E # )0 !evere depression, suicidal depression 10 2atatonic states .0 <6cited a$$ressive psychotic patients ,0 4atients "ho have not sho"n satisfactory response to various anti psychotics and anti depressants ,dverse effects of E # )0 8o permanent adverse effect of <2& is reported. 10 !hort term memory lapses till the course of <2& is $oin$ on is common but memory lapses are short term and self-limitin$. 0yths a"o!t E # )0 It causes brain dama$e. In reality, no structural dama$e is reported so far. 10 ?nce <2& is $iven, it has to be $iven repeatedly throu$hout life. In reality, the course of <2& varies from , to )0 <2&s. ?nce recovery is achieved, there is no need for continuation of <2&. .0 After <2&, the patient becomes dull, listless, lethar$ic and slu$$ish. In reality, no such chan$e is seen. 9sually after <2& in 4ostictal state effect of concurrently administered medicine, the patient may feel dro"sy for a "hile up to .0 minutes or so. #ut he;she never becomes dull and lethar$ic permanently. Psychological #reatment of Schizophrenia (By Dr. Shirisha Sathe, B.#.M.S., M.#. ( li.Psy)) 2ounsellin$ - the popular name for psychotherapy - has a pivotal role to play in the recovery process of any kind of mental illness. And "hen the mental illness amounts to

!chizophrenia, the recovery process turns out to be denser, primarily because of the multifold demands of the situation. And this in turn demands the role of psychotherapy to be more accommodatin$, cooperative and effective. #he role of psychotherapy in schizophrenia as compared to its role in other mental illnesses is: )0 =ore e6pansive - as it has to transact "ith an array of issues ran$in$ from personal to social. 10 =ore intensive - as the dama$e caused by the illness is severe in terms of physical and mental fitness, intra-personal and interpersonal relationships, and social and "ithin family inte$ration. .0 =ore subtle - as it is e6pected to deal "ith several delicate, sensitive and yet specific issues in the life of the sufferer "hich are closer to his heart and "hich may have an everlastin$ impact on the life of the sufferer and his;her closer circle. #he psychotherapist or the co!nsellor has to consider three o"2ectives )0 Illness related ob(ectives 10 Identifyin$ and mana$in$ stressors. .0 ?ther ob(ectives. 3. 1llness related o"2ectives: a. 0anaging symptoms and impairment - &hou$h symptom mana$ement is primarily a domain of pharmacotherapy, "hen a patient e6periences them, understandin$ those symptoms and copin$ "ith them to attain a $ood functional level is counsellorsH area. #ein$ an6ious about O"hat is happenin$ to meLH, fearful about OAm I $oin$ crazyLH depressed about O:o I have any future no"LH are some e6amples "here the counsellor helps the person to mana$e the OproblemH out of the OproblemH. !ymptoms like disor$anised thinkin$, hallucinations and delusions, cause considerable amount of problems in the day-to-day life of a patient. ?nly an e6pert psychotherapist is able to teach the patient to live "ith these symptoms by usin$ psychotherapeutic tools and techni>ues and try to lead a normal life. ". Preventing ac!te episodes and relapse - &o achieve this ob(ective the counsellor has to be an educator not only to the patient but also to his;her care$iver. Illness, its causes, its nature, likelihood of relapse, role of medicine are various issues about "hich the patient and the family are normally i$norant. Alon$ "ith early dia$nosis, Brelapse preventionC is a key factor in recovery process. c. 4ong term management and planning - -ecovery is an indefinite process in schizophrenia. !o the patient and the care$ivers need a lon$ term plannin$ about mana$ement of their internal and e6ternal resources. /=an, money, material, time, ener$y, etc.0 &he counsellor has also to discuss issues like the patientHs career, (ob, marria$e in the conte6t of the nature of illness. 5. 1dentifying and managing stressors:

a. Fostering social and interpersonal reintegration - 7ith the onset of the illness the bizarre behaviour dama$es the personal, interpersonal and social life of a patient and his family. #ecause of the sti$ma, the patient "ithdra"s from the e6ternal "orld and the family "ithdra"s socially. @ere the counsellorHs (ob is to impart the skills like communication, self-disclosure etc. and help them rebuild the social support. ". 0anaging family and carer symptomatology - !chizophrenia is an illness "hich places lots of demands on the family members. -i$ht from understandin$ the illness, empathizin$ "ith the patient, bein$ at the receivin$ end of his bizarre behavior and emotional outbursts, constantly "orryin$ about the future, providin$ financial support and this too may be for an endless period of time. &his affects the mental health and family dynamics on a lar$e scale. 4arent-child relation, siblin$ relation all are stressed and strained. &o maintain the physical and mental health of the family members by facilitatin$ healthy family interaction is the counsellorHs (ob. c. 6ed!cing the handicap - !ocial sti$ma, lack of self-acceptance, lack of acceptance of reality are the ma(or blocks in reducin$ a handicap. 2ounsellor has to help the patient and the family to overcome his block so that the person can re$ain a $rip on his career and meanin$ful productive life in spite of the limitations put by the illness. 7. 'ther o"2ectives: a. Enhancing self help - &akin$ Bcontinuous effortsC for $ettin$ "ell is a prime re>uirement and responsibility of a sufferer but maintainin$ his or her motivational level is a bi$ task for the counsellor as the process of recovery is tou$h, e6haustive and many a times frustratin$ for the patient. ". Generalisation of s)ills - =any ac>uired skills, e.$., social skills like communication, emotional skills like e6pressiveness, assertiveness, thinkin$ skills like $oal settin$, problem solvin$ etc. are lost "ith the pro$ressin$ illness. !ometimes even the self-care skills are lost. &he patient has not only to relearn these skills but he also needs a special trainin$ in usin$ these skills in a variety of situations and conditions. c. 0o"ilising e8tra-familial support, liaison and cooperation amon$st other helpin$ a$encies, influencin$ social policy to"ards preventive "ays - are some of the various issues "hich a counsellor has to tackle "ith the help of other support systems from selfhelp support $roups to even the professionals from the field of la". &hus the counsellor, as an e6pert, empo"ers the patient and the care$ivers and, as a responsible human bein$, creates a"areness in the society so that non-threatenin$, acceptin$ and accommodative surroundin$, conducive to recovery of the patient afflicted "ith schizophrenia, prevails. 4egal ,spects in Schizophrenia 0anagement (By Dr. B. D.P.M.) . Mhasa$ade, M. D.

:-. =@A!A7A:< @API- @?C, the bailiff of sessions court !atara announced and I entered the courtroom and then in the "itness bo6 in )*76 for the first time after I passed my post-$raduation in psychiatry. It "as the case of a murder. I think sometime or the other almost every psychiatrist has to enter the "itness bo6 of a court. &hat means psychiatric dia$nosis is not as simple as any other illness like enteric fever, myocardial infection or cancer. It al"ays has a le$al baseG thou$h it may not be applicable in each and every case. ivil 6esponsi"ility Q =arria$e - It is a type of contract. &herefore, if it is proved beyond doubt that a person "as mentally ill to such an e6tent as not to kno" the responsibility of the act at the time of marria$e, the marria$e is null and void. Q :ivorce - If it is proved beyond doubt that a person is mentally ill after marria$e and is not able to shoulder the responsibility of the marria$e, then the other person can ask for a divorce. Q 2ontract - /-e$ardin$ property etc.0 If it is proved beyond doubt that the person "as sufferin$ from severe mental illness at the time of si$nin$ the contract, then the contract is null and void. ,dmissions and the discharges in mental hospitals &ill recently, the Indian 5unacy Act )*)1 "as in force. #ut no" the =ental @ealth Act )*A7 prevails. Accordin$ to this act, the follo"in$ procedures are to be follo"ed for admission to and dischar$e from a mental hospital. ,dmissions o!rt ommitted 'rders - )0 -eception order 10 :etention order. &he patientHs relatives should take certificates from t"o doctors, "ho are licensed to practise, private practitioners or those "ho are in the $overnment service and file a petition in the court. &he court then passes either the reception order allo"in$ the superintendent of the mental hospital to receive the patient and keep him there until further order or detention order orderin$ the superintendent to detain the patient for observation or dia$nosis for a total period of .0 days. 7ithin this period, the superintendent certifies him to be mentally ill or if he does not find him mentally ill, then dischar$es the patient as uncertifiable. 9ol!ntary Boarder ,dmission -9B. - As the name su$$ests the patient $oes to the mental hospital and volunteers himself for admissions by si$nin$ a prescribed form. In the case of a minor, a relative can si$n for the patient for 3# admission. In special circumstances, if the mentally ill person refuses to e6press his "illin$ness for admission he may be admitted on an application made on his behalf by a relative or a friend. @o"ever, in this procedure, the patient has to be dischar$ed "ithin *0 days. Discharge from 0ental Hospital In the case of admission by reception order or detention order a patient can be dischar$ed after recovery byE

)0 5eave of absence for 1 months "hich may be e6tended every 1 months, so that, if necessary, the patient can be readmitted on the ori$inal reception order. 10 :ischar$e throu$h visitors committee - the patient after recovery from his illness is put before the visitors committee /3.2.0 &his committee can dischar$e the patient but the patient cannot be readmitted on the basis of the ori$inal reception order. In the case of a 3.#.. admission the patient is dischar$ed on an application by the patient or his;her relative /in the case of a minor0. As per the =ental @ealth Act )*A7 all the patients have to pay maintenance char$es, treatment char$es, etc. dependin$ upon the income slab. 'pening and 6!nning of Psychiatric +!rsing Home Any person can open and run a psychiatric nursin$ home after obtainin$ license from :irector eneral of @ealth, ovt. of =aharashtra. &he director $ives license after a committee inspects the nursin$ home and $ives its opinion. &he nursin$ home has to be maintained and run as per the $uidelines of the =ental @ealth Act )*A7, failin$ "hich the committee can report to the :irector eneral and ask him to cancel the license.