psychotic disorder

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SHIZOPHRENIA AND

OTHER PSYCHOTICDISORDERS

Hyacinth C. Manood, MD,DPBP



SCHIZOPHRENIA

Benedict Morel - dÃmence prÃcoce deteriorated patients whose illness began in

adolescence

Emil Kraepelin - dementia precox the change in cognition (dementia) and early onset

(precox) of the disorder. long-term deteriorating course and the clinical

symptoms of hallucinations and delusions

manic-depressive psychosis -distinct episodes of illness alternating with periods of normal functioning

paranoia - persistent persecutory delusions; lacked thedeteriorating course of dementia precox and theintermittent symptoms of manic-depressive psychosis.



Eugene Bleuler - schizophrenia ; the presence of schisms between thought, emotion, and

behavior in patients with the disorder. four As: associations, affect, autism, and ambivalence.

accessory (secondary) symptoms - hallucinations and delusions

Ernst Kretschmer - “schizophrenia occurred more

often among persons with asthenic (i.e., slender, lightly muscled physiques), athletic, or dysplastic body types

rather than among persons with pyknic (i.e., short,stocky physiques) body types. “

Kurt Schneider - first-rank symptoms



Kurt Schneider Criteria for

Schizophrenia First-rank symptoms

Audible thoughts Voices arguing or

discussing or both Voices commenting Somatic passivity

experiences Thought withdrawal and

other experiences of influenced thought

Thought broadcasting Delusional perceptions All other experiences

involving volition madeaffects, and madeimpulses

Second-rank symptoms

Other disorders of perception

Sudden delusional ideas Perplexity Depressive and euphoric

mood changes Feelings of emotional

impoverishment



Karl Jaspers - existential psychoanalysis trying to understand the psychological meaning

of schizophrenic signs and symptoms such as

delusions and hallucinations.

Adolf Meyer - founder of psychobiology reaction to life stresses ; schizophrenic reaction



EPIDEMIOLOGY

lifetime prevalence of schizophrenia isabout 1 percent

equally prevalent in men and women;Onset is earlier in men than in women ( M= 10 – 25; F= 25 – 35)

Onset of schizophrenia before age 10 orafter age 60 is extremely rare; When onsetoccurs after age 45, the disorder is

characterized as late-onset schizophrenia.



In general, the outcome for female schizophrenia patients

is better than that for male schizophrenia patients higher mortality rate from accidents and natural causes

than the general population

more likely to have been born in the winter and earlyspring - Season-specific risk factors, such as a virus or a seasonalchange in diet, may be operative .



gestational and birth complications,exposure to influenza epidemics, ormaternal starvation during pregnancy,Rhesus factor incompatibility, and an

excess of winter births. -neurodevelopmental pathological process

Substance abuse is common inschizophrenia



Etiology I. Genetic Factors:

Prevalence of Schizophrenia in Specific Populations

Population Prevalence (%)

General population1Non-twin sibling of a schizophrenia patient 8

Child with one parent with Schizophrenia 12

Dizygotic twin of a schizophrenia patient 12

Child of two parents with schizophrenia 40

Monozygotic twin of a schizophrenia patient47



II. Biochemical Factors:

1. Dopamine Hypothesis - schizophrenia results

from too much dopaminergic activity .

2. Serotonin - excess as a cause of both positive and

negative symptoms in schizophrenia.

3. Norepinephrine - selective neuronaldegeneration within the norepinephrine reward neuralsystem could account for the impaired capacity foremotional gratification and the decreased ability toexperience pleasure.



4. GABA - GABA has a regulatory effect ondopamine activity, and the loss of inhibitoryGABAergic neurons could lead to the

hyperactivity of dopaminergic neurons.

5. Neuropeptides -substance P and

neurotensin, are localized with thecatecholamine and indolamineneurotransmitters and influence the action of these neurotransmitters.



6. Glutamate - ingestion of phencyclidine, aglutamate antagonist, produces an acute syndromesimilar to schizophrenia. The hypotheses proposedabout glutamate include those of hyperactivity,

hypoactivity, and glutamate-induced neuro- toxicity.

7. Acetylcholine and Nicotine - decreasedmuscarinic and nicotinic receptors ; dysregulation of

neurotransmitter systems involved in cognition



Neuropathology :

1. lateral and third ventricular enlargementand some reduction in cortical volume;

2. reduced symmetry in several brain areas

in schizophrenia, including the temporal,frontal, and occipital lobes ;

3. decrease in the size of the regionincluding the amygdala, thehippocampus, and the parahippocampalgyrus;



4. several symptoms of schizophrenia mimicthose found in persons with prefrontal

lobotomies or frontal lobe syndromes

5. The medial dorsal nucleus of the thalamus,which has reciprocal connections with the

prefrontal cortex, has been reported tocontain a reduced number of neurons

6. cell loss or the reduction of volume of the

globus pallidus and the substantia nigra.



III. Psychosocial and PsychoanalyticTheories

Sigmund Freud - postulated thatschizophrenia resulted from developmentalfixations that occurred earlier than thoseculminating in the development of neuroses.

Margaret Mahler - there are distortions in thereciprocal relationship between the infant and themother .

Paul Federn - the defect in ego functionspermits intense hostility and aggression to distortthe mother-infant relationship, which leads to

eventual personality disorganization and



Harry Stack Sullivan - schizophrenia is anadaptive method used to avoid panic, terror, and

disintegration of the sense of self .

All psychodynamic approaches are foundedon the premise that psychotic symptoms

have meaning in schizophrenia

Learning theory - the poor interpersonal

relationships of persons with schizophrenia developbecause of poor models for learning duringchildhood.



Family Dynamics Double Bind - children receive conflicting parental

messages about their behavior, attitudes, and feelings. InBateson's hypothesis, children withdraw into a psychoticstate to escape the unsolvable confusion of the double bind.

Schisms and Skewed Families - In one family type,with a prominent schism between the parents, one parent is

overly close to a child of the opposite gender. In the otherfamily type, a skewed relationship between a child and oneparent involves a power struggle between the parents andthe resulting dominance of one parent.

Pseudomutual and Pseudohostile Families

-suppress emotional expression by consistently usingpseudomutual or pseudohostile verbal communication.

Expressed Emotion - families with high levels of expressed emotion, the relapse rate for schizophrenia is high



DSM-IV-TR Diagnostic Criteria for

Schizophrenia A. Characteristic symptoms: Two (or more) of the following,each present for a significant portion of time during a 1-month period (or less if successfully treated):

delusions hallucinations disorganized speech (e.g., frequent derailment or

incoherence) grossly disorganized or catatonic behavior negative symptoms, i.e., affective flattening, alogia, or

avolition Note: Only one Criterion A symptom is required if delusions

are bizarre or hallucinations consist of a voice keeping up arunning commentary on the person's behavior or thoughts, or two or more voices conversing with each other.



B. Social/occupational dysfunction:

C Duration: > 6 monthsD. Schizoaffective and mood disorder exclusion:

Schizoaffective disorder and mood disorder with psychoticfeatures have been ruled out because either (1) no majordepressive, manic, or mixed episodes have occurredconcurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phasesymptoms, their total duration has been brief relative tothe duration of the active and residual periods.

E. Substance/general medical condition exclusion: Thedisturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or ageneral medical condition.

F. Relationship to a pervasive developmental disorder :



SUBTYPES:

Paranoid type

A type of schizophrenia in which the following criteria are met:A. Preoccupation with one or more delusions or frequent auditory

hallucinations.

B. None of the following is prominent: disorganized speech,disorganized or catatonic behavior, or flat or inappropriateaffect.

Disorganized typeA type of schizophrenia in which the following criteria are met:

A. All of the following are prominent:

disorganized speech disorganized behavior flat or inappropriate affect

A. The criteria are not met for catatonic type



Catatonic typeA type of schizophrenia in which the clinical picture isdominated by at least two of the following:

motoric immobility as evidenced by catalepsy (includingwaxy flexibility) or stupor

excessive motor activity (that is apparently purposelessand not influenced by external stimuli)

extreme negativism (an apparently motivelessresistance to all instructions or maintenance of a rigidposture against attempts to be moved) or mutism

peculiarities of voluntary movement as evidenced byposturing (voluntary assumption of inappropriate orbizarre postures), stereotyped movements, prominentmannerisms, or prominent grimacing

echolalia or echopraxia



Undifferentiated type

A type of schizophrenia in which symptoms that meet

Criterion A are present, but the criteria are not met forthe paranoid, disorganized, or catatonic type.

Residual type

A type of schizophrenia in which the following criteriaare met:

A. Absence of prominent delusions, hallucinations,disorganized speech, and grossly disorganized orcatatonic behavior.

B. There is continuing evidence of the disturbance, asindicated by the presence of negative symptoms or twoor more symptoms listed in Criterion A for schizophrenia,present in an attenuated form (e.g., odd beliefs, unusualperceptual experiences).



Clinical Features

no clinical sign or symptom ispathognomonic for schizophrenia

patient's symptoms change with time.

clinicians must take into account the

patient's educational level, intellectualability, and cultural and subculturalmembership



Premorbid Signs and Symptoms: patients had schizoid or schizotypal personalities

characterized as quiet, passive, and introverted;as children, they had few friends; sudden onset of obsessive-compulsive behavior as part of theprodromal picture. The signs may have startedwith complaints about somatic symptoms, suchas headache, back and muscle pain, weakness,

and digestive problems; develop an interest inabstract ideas, philosophy, and the occult orreligious questions ;



Mental Status Examination appearance of a patient with

schizophrenia can range from that of acompletely disheveled, screaming,

agitated person to an obsessivelygroomed, completely silent, and immobileperson ;

Precox Feeling - an intuitive experienceof their inability to establish an emotionalrapport with a patient



reduced emotional responsiveness, sometimes

severe enough to warrant the label of anhedonia,and overly active and inappropriate emotions suchas extremes of rage, happiness, and anxiety.

flat or blunted affect can be a symptom of the illnessitself, of the parkinsonian adverse effects of antipsychotic medications, or of depression



most common hallucinations are auditory,with voices that are often threatening,obscene, accusatory, or insulting;

Cenesthetic hallucinations - are unfounded

sensations of altered states in bodily organs;

may believe that an outside entity controlstheir thoughts or behavior or, conversely,that they control outside events in anextraordinary fashion ;



loss of ego boundaries describes the lack of a clearsense of where the patient's own body, mind, andinfluence end and where those of other animateand inanimate objects begin: ideas of reference,

cosmic identity

looseness of associations, derailment, incoherence,tangentiality, circumstantiality, neologisms,

echolalia, verbigeration, word salad, and mutism



Thought control, in which outside forcesare controlling what the patient thinks orfeels;

Thought broadcasting - in whichpatients think others can read their mindsor that their thoughts are broadcastthrough television sets or radios.

decreased social sensitivity and appear tobe impulsive



Violence - Delusions of a persecutory nature,

previous episodes of violence, and neurologicaldeficits are risk factors for violent or impulsivebehavior

Suicide is the single leading cause of prematuredeath among people with schizophrenia.

usually oriented to person, time, and place; minor

cognitive deficiencies



cognitive impairment is a better predictor of level of function than is the severity of psychotic symptoms;

poor insight - poor compliance with treatment

Nonlocalizing signs ( soft signs) includedysdiadochokinesia, astereognosis, primitive reflexes,and diminished dexterity



COURSE / PROGNOSIS

The classic course of schizophrenia is oneof exacerbations and remissions

Further deterioration in the patient'sbaseline functioning follows each relapseof the psychosis

Sometimes, a clinically observablepostpsychotic depression follows apsychotic episode



vulnerability to stress is usually lifelong

10 to 20 % - good outcome; >50 % - poor

outcome



SCHIZOPHRENIFORM DISORDER

acute psychotic disorder that has a rapidonset and lacks a long prodromal phase

similar to schizophrenia, except that itssymptoms last at least 1 month butless than 6 months.

return to their baseline level of functioningonce the disorder has resolved.



lifetime prevalence rate = 0.2 percent

1-year prevalence rate of 0.1 percent

have more affective symptoms (especially mania) and abetter outcome

increased occurrence of mood disorders in the relatives

progression to schizophrenia range between 60 and 80percent



DSM-IV-TR Diagnostic Criteria forSchizophreniform Disorder

A. Criteria A, D, and E of schizophrenia aremet.

B. An episode of the disorder (includingprodromal, active, and residual phases)lasts at least 1 month but less than 6

months. (When the diagnosis must bemade without waiting for recovery, itshould be qualified as provisional)



Specify if:

Without good prognostic features

With good prognostic features: as evidenced bytwo (or more) of the following:

onset of prominent psychotic symptoms within 4weeks of the first noticeable change in usual behavioror functioning

confusion or perplexity at the height of the psychotic

episode good premorbid social and occupational functioning absence of blunted or flat affect



Schizoaffective Disorder symptoms of both schizophrenia and

mood disorders

onset of symptoms was sudden and often

occurred in adolescence.

good premorbid level of functioning, and

often a specific stressor preceded theonset of symptoms.

0.5 to 0.8 percent lifetime prevalence



depressive type of schizoaffective disorder maybe more common in older persons; bipolar typemay be more common in young adults;

age of onset for women is later than that for men

better prognosis than patients with schizophreniaand a worse prognosis than patients with mooddisorders



DSM-IV-TR Diagnostic Criteria for Schizoaffective Disorder

A. An uninterrupted period of illness during which, at some time, there iseither a major depressive episode, a manic episode, or a mixed episodeconcurrent with symptoms that meet Criterion A for schizophrenia.

Note: The major depressive episode must include Criterion A1:depressed mood.B. During the same period of illness, there have been delusions or

hallucinations for at least 2 weeks in the absence of prominent moodsymptoms.

C. Symptoms that meet criteria for a mood episode are present for asubstantial portion of the total duration of the active and residualperiods of the illness.

D. The disturbance is not due to the direct physiological effects of asubstance (e.g., a drug of abuse, a medication) or a general medicalcondition.

Specify type:

Bipolar type: if the disturbance includes a manic or a mixed episode(or a manic or a mixed episode and major depressive episodes)

Depressive type: if the disturbance only includes major depressiveepisodes



Delusional Disorder and SharedPsychotic Disorder

nonbizarre delusions of at least 1 month'sduration that cannot be attributed to otherpsychiatric disorders

.025 to 0.03 percent

mean age of onset is about 40 years

slight preponderance of female



Men are more likely to develop paranoiddelusions

women are more likely to developdelusions of erotomania.

defense mechanisms of reactionformation, denial, and projection



Mental Status may seem eccentric, odd, suspicious, or hostile.

quite normal except for a markedly abnormal delusionalsystem

moods are consistent with the content of their delusions

do not have prominent or sustained hallucinations



delusions are usually systematized and arecharacterized as being possible

no insight into their condition and arealmost always brought to the hospital by

the police, family members, or employers. Judgment can best be assessed byevaluating the patient's past, present, andplanned behavior.

Men are more likely to develop paranoiddelusions



Types :

Persecutory Type

Jealous Type

Erotomanic Type

Somatic Type

Grandiose Type



DSM-IV-TR Diagnostic Criteria for Delusional Disorder

A. Nonbizarre delusions (i.e., involving situations that occur in real life, such asbeing followed, poisoned, infected, loved at a distance, or deceived byspouse or lover, or having a disease) of at least 1 month's duration.

B. Criterion A for schizophrenia has never been met. Note: Tactile and olfactoryhallucinations may be present in delusional disorder if they are related to thedelusional theme.

C. Apart from the impact of the delusion(s) or its ramifications, functioning is

not markedly impaired and behavior is not obviously odd or bizarre.

D. If mood episodes have occurred concurrently with delusions, their totalduration has been brief relative to the duration of the delusional periods.

E. The disturbance is not due to the direct physiological effects of a substance(e.g., a drug of abuse, a medication) or a general medical condition.



Shared Psychotic Disorder - shared paranoiddisorder, induced psychotic disorder, folieÃ¡ deux, folie impose, and double insanity)

characterized by the transfer of delusionsfrom one person to another.



DSM-IV-TR Diagnostic Criteria for SharedPsychotic Disorder

A. A delusion develops in an individual in the context of a closerelationship with another person(s), who has an already-established delusion.

B. The delusion is similar in content to that of the person whoalready has the established delusion.

C. The disturbance is not better accounted for by anotherpsychotic disorder (e.g., schizophrenia) or a mood disorderwith psychotic features and is not due to the direct

physiological effects of a substance (e.g., a drug of abuse, amedication) or a general medical condition.



Brief Psychotic Disorder sudden onset of psychotic symptoms, which lasts 1

day or more but less than 1 month

Remission is full, and the individual returns to thepremorbid level of functioning

occurs more often among younger patients (20sand 30s)

with personality disorders (most commonly,

histrionic, narcissistic, paranoid, schizotypal, andborderline personality disorders).

precipitating stressors - major life events



DSM-IV-TR Diagnostic Criteria for Brief PsychoticDisorder

A. Presence of one (or more) of the following

symptoms:1.delusions2.hallucinations3.disorganized speech (e.g., frequent derailmentor incoherence)4.grossly disorganized or catatonic behavior

Note: Do not include a symptom if it is a culturally sanctioned response pattern.

B. Duration of an episode of the disturbance is atleast 1 day but less than 1 month, with eventual full

return to premorbid level of functioning.

C. The disturbance is not better accounted for by amood disorder with psychotic features,schizoaffective disorder, or schizophrenia and is not

due to the direct physiological effects of a substance(e.g., a drug of abuse, a medication) or a general



•With marked stressor(s) (brief reactivepsychosis): if symptoms occur shortly after andapparently in response to events that, singly or

together, would be markedly stressful to almostanyone in similar circumstances in the person'sculture

• Without marked stressor(s): if psychoticsymptoms do not occur shortly after, or are notapparently in response to events that, singly ortogether, would be markedly stressful to almostanyone in similar circumstances in the person'sculture

• With postpartum onset: if onset within 4weeks postpartum

DSM-IV-TR Diagnostic Criteria for Psychotic Disorder Not Otherwise



DSM IV TR Diagnostic Criteria for Psychotic Disorder Not OtherwiseSpecified

This category includes psychotic symptomatology (i.e.,delusions, hallucinations, disorganized speech, grossly

disorganized or catatonic behavior) about which there isinadequate information to make a specific diagnosis or aboutwhich there is contradictory information, or disorders withpsychotic symptoms that do not meet the criteria for anyspecific psychotic disorder.

Examples include1.Postpartum psychosis that does not meet criteria for mooddisorder with psychotic features, brief psychotic disorder,psychotic disorder due to a general medical condition, orsubstance-induced psychotic disorder2.Psychotic symptoms that have lasted for less than 1 month

but that have not yet remitted, so that the criteria for brief psychotic disorder are not met3.Persistent auditory hallucinations in the absence of any otherfeatures4.Persistent nonbizarre delusions with periods of overlapping

mood episodes that have been present for a substantial portionof the delusional disturbance



Culture-bound Syndromes

amok - A dissociative episode characterized by aperiod of brooding followed by an outburst of violent, aggressive, or homicidal behavior directedat persons and objects. The episode tends to be

precipitated by a perceived slight or insult andseems to be prevalent only among men. Theepisode is often accompanied by persecutory idea;automatism, amnesia, exhaustion, and a return to

premorbid state following the episode.



ataque de nervios - uncontrollableshouting, attacks of crying, trembling, heat in thechest rising into the head, and verbal or physicalaggression. Dissociative experiences, seizurelike

or fainting episodes, and suicidal gestures sense of being out of control association of most ataques with a precipitating

event and the frequent absence of the hallmark

symptoms of acute fear or apprehensiondistinguish them from panic disorder.



bouffÃ©e dÃ©lirante - a sudden outburstof agitated and aggressive behavior, markedconfusion, and psychomotor excitement.

brain fag -initially used in West Africa to referto a condition experienced by high school oruniversity students in response to the challengesof schooling ; difficulties in concentrating,remembering, and thinking.



koro - an episode of sudden and intense anxiety that thepenis (or, in women, the vulva and nipples) will recede intothe body and possibly cause death

piblokto - An abrupt dissociative episode accompaniedby extreme excitement of up to 30 minutes' duration andfrequently followed by convulsive seizures and coma lastingup to 12 hours.

spell - A trance state in which persons communicatedwith deceased relatives or spirits.

psychotic disorder

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