Ans: a (Delusions and hallucinations) Ref: Ahuja, 6th ed,p. 59, 60Almost everything about schizophrenia is important, even the historical background.Schizophrenia is a clinical syndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behaviour.Bleuler'sfour AsAmbivalenceAutismAffect disturbancesAssociation disturbancesIn 1959 Schneider identified symptoms that he thought were pathognomonic for schizophrenia. He named these first-rank symptoms.First-Rank Symptoms of Kurt SchneiderA. HallucinationAudible thoughtsVoices heard arguingVoices heard commenting on one's actionsHearing one's own thoughts. These are actual hallucinations, but the source can be identified by the patient as his or her own thoughts.Hallucinations of more than one voice talking to each other; conference type auditory hallucinations. Subject can be of anything.Hallucinations of a voice or voices that continuously comment on the patient's behavior simultaneously with the action; running commentary type of auditory hallucinations.B. Thought alienation phenomenaThought insertionThought withdrawalThought diffusion or thought broadcastingThought insertion is a feeling that other people are intruding their thoughts on the patient.Thought withdrawal is a feeling that other people are taking the thoughts away.Thoughts are believed to be no longer private but shared (or perceived) by others.C. Passivity phenomenaMade feelings or affectMade impulsesMade volition or actsD. Delusional perceptionInfluences working on the patient's will. It is experienced by the patient as some alien control.Normal perception has a private and illogical meaningProbable etiology is:Trinucleotide repeat expression and birth traumaSchizophrenia can be classified into several sub types1. Paranoid schizophrenia2. Hebephrenic schizophrenia3. Catatonic schizophrenia4. Residual schizophrenia5. Undifferentiated schizophrenia6. Simple schizophrenia7. Post schizophrenic depression8. OthersHebephrenic schizophreniaThis form of schizophrenia usually starts early and has very bad prognosisClinical features-Highly disorganized thoughts and neologism, grimacing, mirror gazing, childish behaviour mannerismCatatonic schizophreniaIt is a common variety.Onset is in the 3rd or 4th decadeClinical featuresHyperamnesia, echolalia, echopraxia, negativism, mutism, waxy flexibility and verbigeration It has the best prognosisParanoid schizophreniaThis is the commonest type of schizophrenia in most parts of the world.It presents very late.Simple schizophreniaIt is the most difficult to diagnose and it has the worst prognosisIt presents early that is in the 2nd decade.Clinical featuresDelusions of persecution, reference, jealousy, grandiosityMuch less personality changes.Clinical featuresNegativism is present,Delusions and hallucinations are absentAmphetamine use will lead to paranoid schizophreniaManagement of Schizophrenia1. Somatic treatmenta) Pharmacological treatmentb) Electro convulsive therapyc) Others2. Psychosocial treatment and rehabilitation3. Psychosurgery - limbic leucotomyPharmacological treatment includes use of antipsychotics. The atypical antipsychotics are more commonly used nowadays.Clozapine is the drug used in treatment of refractory cases. It may cause agranulocytosis in up to 2% of patients; dose-related lowering of seizure threshold has also been seen.Fluphenazine decanoate and haloperidol decanoate are suitable for long-term parenteral maintenance therapy in patients who cannot or will not take oral medication and for use in non compliant patients.Good prognostic factorsPoor prognostic factors1. Acute or abrupt onset2. Onset > 35 yrs of ageflate onset)3. Presence of precipitating stressor4. Good premorbid adjustment5. Catatonic subtypefparanoid subtype has intermediate prognosis)6. Short duration7. Presence of depression8. Predominance of positive symptoms9. Family history of mood disorder10. First episode11. Pyknic physique(fat)12. Female sex13. Good social support14. Presence of confusion .perplexity, or disorientation in acute phase15. Proper treatment, good treatment compliance, and good response to treatment16. Outpatient treatment17. Normal cranial CT scan1. Insidious onset2. Onset < 20 yrs of agefearly onset)3. Absence of stressor4. Poor premorbid adjustment5. Disorganised, simple, undifferentiated, or chronic catatonic subtypes6. Chronic course (> 2 yrs)7. Absence of depression8. Predominance of negative symptoms9. Family history of schizophrenia10. Past history of schizophrenia11. Asthenic (thin) physique12. Male sex13. Poor social support or unamarried14. Flat or blunted affect15. Absence of proper treatment or poor response to treatment16. Institutionalized17. Evidence of ventricular enlargement on cranial CT scanBRIDGEPET scan* Flypoffontality and decreased glucose utilization ir dominant temporal lobe - schizophrenia* Increased glucose metabolism in amygdale - major depression* Increased frontal lobe metabolism and increased activity of caudate nucleus obsessive compulsive disorderNote:Oneroid schizophrenia - acute onset of schizophrenia with a dreamlike stateVongough syndrome - schizophrenia with self mutilationPfropt syndrome - schizophrenia with mental retardation