P610 - 14 - Schizophrenia and Psychotic Disorders

8/2/2019 P610 - 14 - Schizophrenia and Psychotic Disorders

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Schizophrenic Disorders


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Schizophrenic Disorders

Schizophrenia Catatonic Disorganized Paranoid Residual

Undifferentiated


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Definition

The schizophrenic disorders are characterized in general byfundamental and characteristic distortions of thinking andperception, and affects that are inappropriate or blunted. Clearconsciousness and intellectual capacity are usually maintainedalthough certain cognitive deficits may evolve in the course oftime.

The most important psychopathological phenomena include thought echo

thought insertion or withdrawal

thought broadcasting delusional perception and delusions of control

influence or passivity

hallucinatory voices commenting or discussing the patient in the thirdperson

thought disorders and negative symptoms.


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Schizophrenia

Essential features: a mixture of characteristic signs andsymptoms (both positive and negative) that have beenpresent for a significant portion of time during a 1-month period. Positive symptoms: appear to reflect an excess or distortion

of normal functions. Delusions, hallucinations, disorganized speech, grossly disorganized

behavior

Negative symptoms: restrictions in the range and intensityof emotional expression. Affective flattening, alogia (fluency and productivity of thought &

speech), avolition (initiation of goal-directed behavior)


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Positive and Negative Symptoms

Negative PositiveAlogia HallucinationsAffective flattening DelusionsAvolition-apath

y Bizarre behaviourAnhedonia-asociality Positive formal thought disorderAttentional impairment


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4 A (Bleuler)

Bleuler maintained, that for the diagnosis of schizophrenia aremost important the following four fundamental symptoms: affective blunting

disturbance of association (fragmented thinking)

autism ambivalence (fragmented emotional response)

These groups of symptoms, are called four A s and Bleulerthought, that they are primary for this diagnosis.

The other known symptoms, hallucinations, delusions, which

are appearing in schizophrenia very often also, he used to callas a secondary symptoms, because they could be seen in anyother psychotic disease, which are caused by quite differentfactorsfrom intoxication to infection or other diseaseentities.


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Schizophrenia

Research suggests that diagnoses of childhoodonset schizophrenia can be made with the adultcriteria

Early age of onset requires specialconsiderations for diagnoses, educational needs,as well as treatment.


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Course of Illness

Course of schizophrenia:

continuous without temporary improvement

episodic with progressive or stable deficit

episodic with complete or incomplete remission

Typical stages of schizophrenia:

prodromal phase active phase

residual phase


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Schizophrenia

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

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g., frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre orhallucinations consist of a voice keeping up a running commentary on the person'sbehavior or thoughts, or two or more voices conversing with each other.


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Schizophrenia

B. Social/occupational dysfunction:For a significant portion ofthe time since the onset of the disturbance, one ormore major areas of functioning such as work,interpersonal relations, or self-care are markedly below

the level achieved prior to the onset (or when the onsetis in childhood or adolescence, failure to achieveexpected level of interpersonal, academic, oroccupational achievement).


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Schizophrenia

C. Duration:Continuous signs of the disturbance persist for at least6 months. This 6-month period must include at least 1 month ofsymptoms (or less if successfully treated) that meet Criterion A(i.e., active-phase symptoms) and may include periods of

prodromal or residual symptoms. During these prodromal orresidual periods, the signs of the disturbance may be manifestedby only negative symptoms or two or more symptoms listed inCriterion A present in an attenuated form (e.g., odd beliefs,

unusual perceptual experiences).


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Schizophrenia

D. Schizoaffective and Mood Disorder exclusion:Schizoaffective Disorder and Mood Disorder With

Psychotic Features have been ruled out because either

(1) no Major Depressive, Manic, or Mixed Episodeshave occurred concurrently with the active-phasesymptoms; or (2) if mood episodes have occurredduring active-phase symptoms, their total duration has

been brief relative to the duration of the active andresidual periods.


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Schizophrenia

E. Substance/general medical condition exclusion:The disturbance is not due to the direct physiologicaleffects of a substance (e.g., a drug of abuse, a

medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder: Ifthere is a history of Autistic Disorder or anotherPervasive Developmental Disorder, the additionaldiagnosis of Schizophrenia is made only if prominentdelusions or hallucinations are also present for at least a

month (or less if successfully treated).


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SchizophreniaClassification of longitudinal course (can be applied only after at least 1 year has

elapsed since the initial onset of active-phase symptoms):

Episodic With Interepisode Residual Symptoms (episodes aredefined by the reemergence of prominent psychotic symptoms);

also specify if: With Prominent Negative Symptoms Episodic With No Interepisode Residual Symptoms

Continuous (prominent psychotic symptoms are presentthroughout the period of observation); also specify if: With

Prominent Negative Symptoms Single Episode In Partial Remission; also specify if: With

Prominent Negative Symptoms

Single Episode In Full Remission

Other or Unspecified Pattern


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Diagnostic Definitions

Delusions: erroneous beliefs that usually involve a misinterpretationof perceptions or experiences. Bizarreness is a characteristic of schizophrenic delusions; need to keep cultural

issues in mind when making the bizarre determination

Hallucinations: may occur in any sensory modality (e.g., auditory,

visual, olfactory, gustatory, tactile). May be a normal part of some religious experiences in some cultural contexts.

Disorganized thinking: may be present in the speech of individualswith schizophrenia Derailment or loose associations, tangentiality, incoherent, word salad

Grossly disorganized behavior: dress in an unusual manner,inappropriate sexual behavior

Catatonic motor behaviors: waxy flexibility, catatonic agitation


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Schizophrenia: Catatonic Type

A type of Schizophrenia in which the clinical picture isdominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility)

or stupor(2) excessive motor activity (that is apparently purposeless and not

influenced by external stimuli)

(3) extreme negativism (an apparently motiveless resistance to all instructionsor maintenance of a rigid posture against attempts to be moved) ormutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntaryassumption of inappropriate or bizarre postures), stereotypedmovements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia


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Schizophrenia: Disorganized Type

A type of Schizophrenia in which the following criteriaare met:

A. All of the following are prominent:

(1) disorganized speech

(2) disorganized behavior

(3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.


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Schizophrenia: Paranoid Type

Paranoid schizophrenia is characterized mainly bydelusions of persecution, feelings of passive oractive control, feelings of intrusion, and often bymegalomanic tendencies also. The delusions are not

usually systemized too much, without tight logicalconnections and are often combined withhallucinations of different senses, mostly withhearing voices.

Disturbances of affect, volition and speech, andcatatonic symptoms, are either absent or relativelyinconspicuous.


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Schizophrenia: Paranoid Type

A type of Schizophrenia in which the followingcriteria are met:

A. Preoccupation with one or more delusions orfrequent auditory hallucinations.

B. None of the following is prominent: disorganizedspeech, disorganized or catatonic behavior, or flat orinappropriate affect.


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Schizophrenia: Residual Type

A type of Schizophrenia in which the following criteriaare met:

A. Absence of prominent delusions, hallucinations, disorganizedspeech, and grossly disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as indicatedby the presence of negative symptoms or two or moresymptoms listed in Criterion A for Schizophrenia, present inan attenuated form (e.g., odd beliefs, unusual perceptualexperiences).


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Schizophrenia: Undifferentiated

Type

A type of Schizophrenia in which symptomsthat meet Criterion A are present, but thecriteria are not met for the Paranoid,Disorganized, or Catatonic Type.


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Associated Features

Inappropriate affect Anhedonia Poor insightlikely due to a manifestation of the illness rather

than a coping strategy

Anxiety disorders Motor abnormalities (e.g., facial grimacing separate from Tardive

Dyskinesia) Suicide attempts (10% complete, 20% to 40% attempt) Some history of violent or assaultive behavior puts individual at

risk for violent behavior in active phase of schizophrenia Comorbid Substance-Related Disorders (80% to 90% of

individuals with SZ are regular cigarette smokers) OCD and Panic Disorder elevated


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Cultural Features

Ideas that may be delusional in one culture (e.g.,sorcery or witchcraft) may be commonly held inanother culture.

Visual or auditory hallucinations may be part ofa cultural belief as well.

Overdiagnosing common in African-American

and Asian-American ethnic groupsnot sure ifthis represents true differences or culturalinsensitivity and/or bias.


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Age Features

Onset typically between late teens and mid-30s

Onset prior to adolescence is rare

Essential features are same in children as theyare in adults; however, may be difficult to makethe diagnosis in children.

Hallucinations & delusions less elaborate

Visual hallucinations more common in children


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Early Warning Signs for Child-Onset

Schizophrenia

1. trouble telling dreams from reality,

2. seeing things and hearing voices which are not

real,

3. confused thinking,

4. vivid and bizarre thoughts and ideas,


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Schizophrenia

5. extreme moodiness,

6. odd behavior,

7. ideas that people are "out to get them,"

8. behaving like a younger child,

9. severe anxiety and fearfulness,


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Schizophrenia

10. confusing television with reality,

11. severe problems in making and keeping friends.


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Often children show their signs gradually, such a childmay become shy or withdrawn. These signs are oftenfirst noticed by teachers. Children may begin talking

about odd fears or ideas.

In children or adolescents there is a failure to achievewhat is expected of the individual, rather than a

deterioration in functioning. Comparing the child withunaffected siblings is helpful in making a decision.Their education is usually disrupted, and in adolescencemany individuals can't hold onto a job for long(American Academy of Child & Adolescent Psychiatry,

1995).


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Gender Features, Prevalence

Modal age of onset differs between males andfemales:

Males: 18-25yrs

Females: 25yrs to mid 30yrs; another peak later inlife

Adult prevalence: 0.5% to 1.5% Childhood prevalence: 1 in 40,000 before age 13


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Familial Pattern

10x greater risk among first-degree relatives ofSZ positive probands

Twin studies and adoption studies support agenetic link; however, substantial discordancerate among monozygotic twins strongly suggestsan environmental factor as well.


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Differential Diagnosis

Psychotic Disorder Due to a General MedicalCondition

Substance-Induced Psychotic Disorder Mood Disorder with Psychotic Features Schizophreniform Disorder

Duration: SZ 6+mos; Schizophreniform, 1-6mos

Brief Psychotic Disorder Delusional Disorder Psychotic Disorder NOS PDD

Documents

P610 - 14 - Schizophrenia and Psychotic Disorders