Schizophrenia and Other Psychoses

7/30/2019 Schizophrenia and Other Psychoses

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SCHIZOPHRENIA ANDOTHER PSYCHOSES

Petit Nacario


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DEFINITION: What is

Schizophrenia?O Schizophrenia is a chronic and disabling brain

disorder that has been recognized throughoutrecorded history.

O It affects about 1% of the population of the UnitedStates.

O Symptoms usually emerge for men in late teens toearly 20s. In females mid 20s to early 30s.

O Many people with this disorder have difficultyholding a job or caring for them. This creates agreat burden for their families and for society.

O a group of characteristic positive and negativesymptoms


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O deterioration in social, occupational, or interpersonalrelationships

O continuous signs of the disturbance for at least 6 months

O There is not one essential symptom that must be present

for a diagnosis. Instead, patients experience differentcombinations of the main symptoms of schizophrenia.

O Those with the disorder may hear voices that others donthear. They may believe that others are reading their minds,controlling their thoughts, or plotting to harm them.

O They may not make sense when they talk or they mayseem perfectly fine until they start talking about what they

are really thinking.


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3 inescapable facts about

Schizophrenia:O Age at onset: It is always late adolescent

or early adulthood.

O Role of stress: Onset and relapse almostalways related to stress.

O Efficacy of dopamine antagonists:

Drugs that block dopamine receptors are

therapeutic.


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HISTORYO Emil Kraepelin: This illness develops relatively

early in life, and its course is likely deterioratingand chronic; deterioration reminded dementia(Dementia praecox), but was not followed by any

organic changes of the brain, detectable at thattime.

O Eugen Bleuler: He renamed Kraepelins dementiapraecox as schizophrenia (1911); he recognizedthe cognitive impairment in this illness, which henamed as a splittingof mind.

O Kurt Schneider: He emphasized the role ofpsychotic symptoms, as hallucinations, delusionsand gave them the privilege of the first ranksymptoms even in the concept of the diagnosis ofschizophrenia.


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4 A (BLEULER)O Bleuler maintained, that for the diagnosis of schizophrenia

are most important the following four fundamentalsymptoms:

O affective blunting

O disturbance of association (fragmented thinking)O autism

O ambivalence (fragmented emotional response)

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

O The other known symptoms, hallucinations, delusions,which are appearing in schizophrenia very often also, he

used to call as a secondary symptoms, because theycould be seen in any other psychotic disease, which arecaused by quite different factors from intoxication toinfection or other disease entities.


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COURSE OF ILLNESSO Course of schizophrenia:

O continuous without temporary improvement

O episodic with progressive or stable deficit

O

episodic with complete or incomplete remission

O 3 overlapping phases of the disorder:

O Acute phase- the patient experiences severepsychotic symptoms.

O Stabilizing phase- the patient is getting better.

O Stable phase- in this phase, the patient might stillexperience hallucinations and delusions, but thehallucinations and delusions are not as severenor as disabling as they were during the acutephase.


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Positive SymptomsO The symptoms of schizophrenia fall into three broad

categories.

O Positive Symptoms are unusual thoughts or perceptions,including hallucinations, delusions, thought disorder and

disorder of movement. Auditory hallucinations are the mostcommon.

O Delusions

O False beliefs that are firmly and consistently held despitedisconfirming evidence,culture or logic.

O Individuals with mania or delusional depression may also

experience delusions. However, the delusions of patientswith schizophrenia are often more bizarre (highlyimplausible).


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Types of delusionsO Delusions of persecution: belief that one is the

target of others mistreatment, evil plots,and/or murderous intent (most common)

O Delusions of reference: belief that allhappenings revolve around oneself, and/orone is always the center of attention

O Delusions of grandeur: belief that one is afamous or powerful person from the past orpresent

O Delusions of control: belief that some externalforce is trying to take control of ones thoughts(thought insertion), body, or behavior


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O Example of delusions of control

Thought insertion = Believing that thoughtsthat are not your own have been placed in yourmind by an external source

A 29-year-old housewife said, I look out of thewindow and I think the garden looks nice and

the grass looks cool, but the thoughts ofEamonn Andrews come into my mind. Thereare no other thoughts there, only his Hetreats my mind like a screen and flashes histhoughts on it like you flash a picture.

O Thought broadcasting: belief that ones thoughts

are being broadcast or transmitted to othersO Thought withdrawal: belief that ones thoughts are

being removed from ones mind


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HallucinationsO Sensory experiences in the absence of any

stimulation from the environment

O Any sensory modality may be involved:

auditory (hearing); visual (seeing); olfactory(smelling); tactile (feeling); gustatory (tasting)

O Auditory hallucinations are most common

Common auditory hallucinations inschizophrenia

O

Hearing own thoughts spoken by anothervoice

O Hearing voices that are arguing

O Hearing voices commenting on ones ownbehavior


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O Disorganized Speech / Thought Disturbances

O Problems in organizing ideas and speaking so thata listener can understand

O Loose Associations (cognitive slippage): continualshifting from topic to topic without any apparent orlogical connection between thoughts

O Neologisms: new, seemingly meaningless wordsthat are formed by combining words

O Disorganized Motor Disturbances

O Extreme activity levels (unusually high or low),

peculiar body movements or postures (e.g.,catatonic schizophrenia), strange gestures andgrimaces


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Negative SymptomsO Negative Symptoms refers to reductions in

normal emotional and behavioral states suchas:

O Flat affect with immobile facial expression,monotonous voice.

O Lack of pleasure in everyday life.

O Diminished ability to initiate and sustainplanned activity.

O

Speaking infrequently even when forced tointeract

O People with the disorder often neglect basichygiene and need help with ADL.


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Types of negative symptomsO Anhedonia: inability to feel pleasure; lack of interest or

enjoyment in activities or relationships

O Avolition: inability or lack of energy to engage in routine(e.g., personal hygiene) and/or goal-directed (e.g., work,

school) activitiesO Alogia: lack of meaningful speech, which may take several

forms, including poverty of speech (reduced amount ofspeech) or poverty of content of speech (little information isconveyed; vague, repetitive)

O Asociality: impairments in social relationships; few friends,poor social skills, little interest in being with other people

O

Flat affect: no stimulus can elicit an emotional response.Patient may stare vacantly, with lifeless eyes andexpressionless face. Voice may be toneless. Flat affectrefers only to outward expression, not necessarily internalexperience


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O Cognitive Symptoms are subtle and

often detected only whenneuropsychological test are performed.

O Poor executive functioning. (The ability to

absorb and interpret information and

make decisions based on thatinformation).

O Inability to sustain attention.

O Problems with working memory (the ability

to keep recently learned information inmind and use it right away).


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BEHAVIOR: OBJECTIVE

SIGNSO Alterations in personal relationships

O Decreased attention to appearance and socialamenities related to introspection and autism

O

Inadequate or inappropriate communicationO Hostility

O Withdrawal

O Alterations of activity

O Psychomotor agitation

O Catatonic rigidityO Echopraxia (repetitive movements)

O Stereotypy (repetitive acts or words)


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SUBJECTIVE SYMPTOMSO Altered perception

O Hallucination

O Illusions

O Paranoid thinking

O

O Alterations of thought

O Loose associations

O Retardation

O Blocking

O Autism

O Ambivalence

O

DelusionsO Poverty of speech

O Ideas of reference

O Mutism


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O Altered consciousness

O ConfusionO Incoherent speech

O Clouding

O Sense of going Crazy

O

O Alterations of affectO Inappropriate, blunted, flattened, or labile

affect

O Apathy

O Ambivalence

O OverreactionO Anhedonia


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ETIOLOGYO BIOLOGIC THEORIES: biochemical,

neurostructural, genetic, and perinatal

factors

O It is accepted, that schizophrenia is thegroup of schizophrenias which origin is

multifactorial:

O internal factors genetic, inborn,

biochemicalO external factors trauma, infection of

CNS, stress


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O Biochemical: The most influential and plausible arethe hypotheses, based on the supposed disorder of

neurotransmission in the brain, derived mainly fromO the effects of antipsychotic drugs that have in

common the ability to inhibit the dopaminergicsystem by blocking action of dopamine in thebrain

O dopamine-releasing drugs (amphetamine,

mescaline, diethyl amide of lysergic acid - LSD)that can induce state closely resembling paranoidschizophrenia

O Classical dopamine hypothesis of schizophrenia:Psychotic symptoms are related to dopaminergichyperactivity in the brain. Hyperactivity ofdopaminergic systems during schizophrenia is

result of increased sensitivity and density ofdopamine D2 receptors in the different parts ofthe brain.


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O Contemporary Models

O Dopamine hypothesis revisited: variousneurotransmitter systems probably takes place inthe etiology of schizophrenia (norepinephric,serotonergic, glutamatergic, some peptidergicsystems); based on effects of atypicalantipsychotics especially.

O Contemporary models of schizophreniaconceptualize it as a neurocognitive disorder, withthe various signs and symptoms reflecting thedownstream effects of a more fundamentalcognitive deficit:

O the symptoms of schizophrenia arise from

cognitive dysmetria (Nancy C.Andreasen)O concept of schizophrenia as a

neurodevelopmental disorder (Daniel R.Weinberger)


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O Neurodevelopmental Model

O Neurodevelopmental model supposes in

schizophrenia the presence of silent lesion in thebrain, mostly in the parts, important for thedevelopment of integration (frontal, parietal andtemporal), which is caused by different factors(genetic, inborn, infection, trauma...) during veryearly development of the brain in prenatal or earlypostnatal period of life.

O It does not interfere too much with the basic brainfunctioning in early years, but expresses itself inthe time, when the subject is stressed by demandsof growing needs for integration, during formativeyears in adolescence and young adulthood.

O ventricular brain ratios

O brain atrophyO cerebral blood flow


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O Psychodynamic theories

O developmental theories of SchizophreniaO family theories

O Special issues related to Schizophrenia

O

Depression & SuicideO People with schizophrenia attempt suicide

much more often than people in the generalpopulation. About 10% (especially young adultmales) succeed. It is hard to predict whichpatients with the disorder are prone to suicide.Listen when they talk about harmingthemselves.


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Psychotherapeutic nurse-patient

relationshipGeneral principles:O Be calm when talking to patients.

O Accept patients as they are but do notaccept all behaviors.

O Keep promises.

O Be consistent.

O Be honest.

O Orient patients to time, person, and place,if indicated.

O Do not touch patients without warningthem.


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O Avoid whispering or laughing whenpatients are unable to hear all of a

conversation.

O Reinforce positive behaviors.

O Avoid competitive activities with somepatients.

O Do not embarrass patients.

O For withdrawn patients, start with one-to-

one interactions.

O Allow and encourage verbalization of

feelings.


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PSYCHOPHARMACOLOGYO Antipsychotic medications have been available since the

mid 1950s. These drugs have greatly improved the lives ofpatients with schizophrenia since their first development,but these medications do not cure the disease.

O The older antipsychotic medications effectively alleviate thepositive symptoms of schizophrenia. These which areconsidered conventional or typical medications producedside effects which made compliance difficult.

O Most of these older "conventional" antipsychotics differed inthe side effects they produced. Side effects such asorthostatic hypotension, sedation, anticholinergic effect andextrapyramidal effects.

O These conventional antipsychotics include chlorpromazine(Thorazine), fluphenazine (Prolixin), haloperidol (Haldol),thiothixene (Navane), trifluoperazine (Stelazine),perphenazine (Trilafon), and thioridazine (Mellaril).


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Mechanism of Action of

AntipsychoticsO While the precise mechanism of action that

accounts for the effects of antipsychoticmedications is still unknown, the dopaminehypothesis is the predominate theory used toexplain the action of these drugs.

O Schizophrenia is caused by an excess indopamine activity in the brain, which is inhibited byblockade of the receptors

O There are two core components to the dopamine

theory: (1) psychosis is induced by increasedlevels of dopamine activity and (2) mostantipsychotic drugs block postsynaptic dopaminereceptors


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Extrapyramidal EffectsO Extrapyramidal Side Effects are a group

of symptoms that can occur in personstaking antipsychotic medications. They

are more commonly caused by the typicalantipsychotics but can and do occur withall of them.

O Extrapyramidal side effects include:

O tremor, akathisia, slurred speech,dystonia, bradykinesia, and muscularrigidity


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O

Akathisia is a movement disordercharacterized by inner restlessness and

the inability to sit or stand still. Akathisia

may appear as a side effect of long-term

use of antipsychotic medications, Lithium,

and some other psychiatric drugs.

O Persons with akathisia typically have

restless movements of the arms and legs

such as tapping, marching in place,

rocking, crossing and uncrossing the legs.They may feel anxious at the thought of

sitting down.


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O Dystonia is a neurological movement

disorder characterized by involuntarymuscle contractions, which force certain

parts of the body into abnormal,

sometimes painful, movements or

postures.O Acute dystonic reactions are

characteristically sustained contraction of

the muscles of neck (torticollis), eyes

(oculogyric crisis), tongue, jaw and othermuscle groups typically occurring within

10-14 days after initiation of the

neuroleptic.


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O Bradykinesia means "slow movement."

Bradykinesia essentially refers to a

component of parkinsonism. The full spectrum

of parkinsonism is derived from the features of

Parkinson's disease, which include

bradykinesia, tremor, and rigidity.O Rigidity is defined as hypertonia in which the

following are true:

O The resistance to externally imposed joint

movement is present at very low speeds of

movement, does not depend on imposedspeed, and does not exhibit a speed or angle

threshold;


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Atypical antipsychoticsO In the 1990s, new drugs, called atypical

antipychotics, were developed.

O These medications appear to be equally effective

for helping reduce the positive symptoms likehallucinations and delusions - but may be betterthan the older medications at relieving the negativesymptoms of the illness, such as withdrawal,thinking problems, and lack of energy.

O The atypical antipsychotics include aripiprazole

(Abilify), risperidone (Risperdal), clozapine(Clozaril), olanzapine (Zyprexa), quetiapine(Seroquel), and ziprasidone (Geodon).


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O Side Effects When patients first start to take

the atypical antipsychotics, they may becomedrowsy or experience dizziness when theychange positions (orthostatic hypotension).

O They may have blurred vision, or develop arapid heartbeat, menstrual problems, asensitivity to the sun, or skin rashes.

O Many of these symptoms will go away afterthe first few days but could last for up to oneto two weeks. Advise your patients that if thesymptoms do not go away after two to threeweeks to notify the practitioner who

prescribed the medication.O Also advise them that they should not bedriving until they adjust to their newmedication.


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MonitoringO On monthly visits monitor for things such

as over eating, weight gain, polyuria(increase urination), polydipsia (increased

thirst).O When each of you see your clients, if they

have recently been put on anantipsychotic, discuss the abovesymptoms with them.

O Have them notify the practitioner if theyare having problems with any of thesesymptoms.

O


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MILIEU MANAGEMENT:O For disru pt ive pat ients:

O Set limits on disruptive behavior

O Decrease environmental stimuli.

O Frequently observe escalating patients to intervene.

Intervention before acting out occurs protects patients andothers physically and prevents embarrassment forescalating patients.

O Modify environment to minimize objects that can be used asweapons.

O Be careful in stating what the staff will do if patient acts out;however follow through once a violation occurs.

O When using restraints, provide for safety by evaluating thepatients status of hydration, nutrition, elimination, andcirculation.


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O For withdrawn patients :O Arrange non-threatening activities that involve

these patients in doing something.

O Arrange furniture in a semicircle or around a

table, w/c forces patients to sit with someone.

O Help patients to participate in decision

making, as appropriate.

O Reinforce appropriate grooming and hygiene.

O Provide psychosocial rehabilitationthat is ,

training in community living, social skills, andhealth care skills.


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O For suspic iou s pat ients:

O Be matter-of-fact when interacting withthese patients.

O Staff members should not laugh or

whisper around patients unless patients

can hear what is being said.O Do not touch suspicious patients without

warning. Avoid close physical contact.

O Be consistent in activities.

O Maintain eye contact


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O For pat ients wi th h al lucinat ions :

O Attempt to provide distracting activities.

O Discourage situations in which patients talk to othersabout their disordered perceptions.

O Monitor television selections.

O Monitor for command hallucinations that mightincrease the potential for patients to becomedangerous.

O

Have staff members available in the dayroom so thatpatients can talk to real people about real people orreal events.

O For diso rganized pat ients:

O Remove disorganized patients to a less stimulating

environment.O Provide a calm environment; the staff should appear

calm.

O Provide safe and relatively simple activities to thesepatients.


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OTHER PSYCHOTIC

DISORDERS:O Schizoaffective disorder

O There will be symptoms of schizophrenia as wellas mood disorder (depression, bipolar, mixed

mania).O Episodic disorders in which both affective and

schizophrenic symptoms are prominent (during thesame episode of the illness or at least during fewdays) but which do not justify a diagnosis of eitherschizophrenia or depressive or manic episodes.

O Patients suffering from periodic schizoaffectivedisorders, especially with manic symptoms, haveusually good prognosis with full remissions withoutany remaining defects.


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O

They are divided in different subgroups:O F25.0 Schizoaffective disorder, manic

type

O F25.1 Schizoaffective disorder,

depressive typeO F25.2 Schizoaffective disorder, mixed

type

O F25.8 Other schizoaffective disorders

O F25.9 Schizoaffective disorder,unspecified


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Induced Delusional

DisorderO A disorder characterized by the development of one

delusion or of the group of similar related delusions, whichare persisting unusually long, very often for the whole life.

O Other psychopathological symptoms hallucinations,intrusion of thoughts etc. are not present and are excludingthis diagnosis.

O It begins usually in the middle age.

O A delusional disorder shared by two or more people withclose emotional links. Only one of the people suffers from agenuine psychotic disorder; the delusions are induced inthe other(s) and usually disappear when the people areseparated.

O The psychotic disorder of the dominant member of thisdyad is mainly, but not necessarily, of schizophrenic type.The original delusions of dominant member and his partnerare usually chronic, either persecutory or megalomanic.


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Schizotypal disorder

O According to lCD-10 this disorder is

characterized by eccentric behavior and

by deviations of thinking and affectivity,

which are similar to that occurring in

schizophrenia, but without psychotic

features and expressed symptoms of

schizophrenia of any type.


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referencesO Department of Psychiatry

O 1st Faculty of Medicine

O Charles University, Prague

O Head: Prof. MUDr. Ji Raboch, DrSc.O Schizophrenia Symptoms, by NARSAD, the

Mental Health Research Association.

O Schizophrenia Treatment, by John Grohol,PsychCentral, 08/07/08

O Psychiatric Study Guide by Central RegionalHospital

O Scott Stroup, MD, MPH

2004

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Schizophrenia and Other Psychoses