schizophrenia and other psychotic do.ppt

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

Teresita L. Martinez, M.D.

Teresita L. Martinez, MD, FPNA, FCNSP

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

Historical Basis of the disorderEmil KraepelinEugen BleulerOther TheoristEpidemiologyEtiologyStress Diathesis ModelBiological factorsGeneticsPsychosocial Factors

Diagnostic ClassificationParanoidDisorganizedCatatonicUndifferentiatedSuicidalOther Psychotic DisordersSchizophreniformSchizoaffectiveDelusional DisorderBrief Psychotic Disorder


SCHIZOPHRENIAis a clinical syndrome of variable, but profoundly disruptive, psychopathology that involves: cognition emotion perceptionusually begins before age 25 persists throughout life affects persons of all social classes


SCHIZOPHRENIA EMIL KRAEPELIN

Dementia precox, a term that emphasized the change in cognition (dementia) and early onset (precox) of the disorder. Patients with dementia precox were described as having a long-term deteriorating course and the clinical symptoms of hallucinations and delusions. Kraepelin distinguished these patients from those who underwent distinct episodes of illness alternating with periods of normal functioning which he classified as having manic-depressive psychosis.


SCHIZOPHRENIAEUGENE BLEULER

coined the term schizophreniaHe chose the term to express the presence of schisms between thought, emotion, and behavior in patients with the disorder. schizophrenia need not have a deteriorating course.


THE FOUR AS

Bleuler identified specific fundamental (or primary) symptoms of schizophrenia toAssociationsAffectAutismAmbivalence


OTHER THEORISTS:Ernst Kretschmer - compiled data to support the idea that 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 - description of first-rank symptoms and second-rank symptomsKarl Jaspers - existential psychoanalysis, trying to understand the psychological meaning of schizophrenic signs and symptoms such as delusions and hallucinations. Adolf Meyer - the founder of psychobiology, saw schizophrenia as a reaction to life stresses


KURT SCHNEIDER CRITERIA FOR SCHIZOPHRENIAFirst-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 made affects, and made impulsesSecond-rank symptoms Other disorders of perception Sudden delusional ideas Perplexity Depressive and euphoric mood changes Feelings of emotional impoverishment


EPIDEMIOLOGY

In US -1 person in 100 will develop schizophrenia during their lifetimeAccording to DSM-IV-TR, the annual incidence of schizophrenia ranges from 0.5 to 5.0 per 10,000, Schizophrenia is found in all societies and geographical areas, and incidence and prevalence rates are roughly equal worldwide.


ETIOLOGYDIATHESISSTRESS MODELis apsychologicaltheory that explainsbehavioras both a result ofbiological andgenetic factors ("nature"), and life experiences ("nurture"). This model thus assumes that a disposition towards a certain disorder may result from a combination of one's genetics and early learning. The term "diathesis" is used to refer to a genetic predisposition toward an abnormal or diseased condition. Schizophrenia is produced by the interaction of a vulnerable hereditary predisposition, with precipitating events in the environment


ETIOLOGYGENETIC FACTORS

occur at an increased rate among the biological relatives of patients with schizophrenialikelihood of a person having schizophrenia is correlated with the closeness of the relationship to an affected relative


ETIOLOGY BIOCHEMICAL FACTORS

Dopamine Hypothesisschizophrenia results from too much dopaminergic activityDopanine tracts responsibleMesocortical - negative symptomsMesolimbic - positive symptomsNigrostriatal

Serotoninserotonin excess as a cause of both positive and negative symptoms in schizophreniaNorepinephrine selective neuronal degeneration within the norepinephrine reward neural system could account anhedoniaThe dopaminergic neurons in these tracts project from their cell bodies in the midbrain to dopaminoceptive neurons in the limbic system and the cerebral cortex.


ETIOLOGY BIOCHEMICAL FACTORS

GABAloss of GABAergic neurons in the hippocampus in patients with Schizophrenia GABA has a regulatory effect on dopamine activity, and the loss of inhibitory GABAergic neurons could lead to the hyperactivity of dopaminergic neuronsNeuropeptidessubstance P and neurotensin -alteration in mechanisms could facilitate, inhibit, or otherwise alter the pattern of firing these neuronal systems.Glutamateproduces an acute syndrome similar to schizophrenia. Acetylcholine and Nicotine. decreased muscarinic and nicotinic receptors in the caudate-putamen, hippocampus, and selected regions of the prefrontal cortex.


ETIOLOGYPSYCHOANALYTIC THEORIESSigmund Freud postulated that schizophrenia resulted from developmental fixations that occurred earlier than those culminating in the development of neuroses. These fixations produce defects in ego development.Ego disintegration in schizophrenia represents a return to the time when the ego was not yet, or had just begun, to be established.Intrapsychic conflict arising from the early fixations and the ego defect, which may have resulted from poor early object relations, fuel the psychotic symptoms.Psychoanalytic theory also postulates that the various symptoms of schizophrenia have symbolic meaning for individual patients


ETIOLOGYLEARNING THEORIES

Children who later have schizophrenia learn irrational reactions and ways of thinking by imitating parents who have their own significant emotional problems. In learning theory, the poor interpersonal relationships of persons with schizophrenia develop because of poor models for learning during childhood.


ETIOLOGYFAMILY DYNAMICSpoor mother-child relationship had a sixfold increase in the risk of developing schizophrenia, and offspring from schizophrenic mothers who were adopted away at birth were more likely to develop the illness if they were reared in adverse circumstances compared to those raised in loving homes by stable adoptive parents


ETIOLOGYFAMILY DYNAMICSDouble BindThe double-bind concept was formulated by Gregory Bateson and Donald Jackson to describe a hypothetical family in which children receive conflicting parental messages about their behavior, attitudes, and feelingschildren withdraw into a psychotic state to escape the unsolvable confusion of the double bindSchisms and Skewed FamiliesTheodore schism - one parent is overly close to a child of the opposite genderskewed - power struggle between the parents and the resulting dominance of one parent.


ETIOLOGYFAMILY DYNAMICSPseudomutual and Pseudohostile FamiliesLyman Wynnesome families suppress emotional expression by consistently using pseudomutual or pseudohostile verbal communication. In such families, a unique verbal communication develops, and when a child leaves home and must relate to other persons, problems may arise. Expressed EmotionParents or other caregivers may behave with overt criticism, hostility, and overinvolvement toward a person with schizophrenia.


DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA

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 speechgrossly disorganized or catatonic behavior negative symptoms

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other. C. Social/occupational dysfunction:Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A


DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA

Schizoaffective and mood disorder exclusionSubstance/general medical condition exclusionRelationship to a pervasive developmental disorder: If there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).


DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA SUBTYPES

Paranoid typePreoccupation with one or more delusions or frequent auditory hallucinations. Disorganized typeA type of schizophrenia in which the following criteria are met: All of the following are prominent: disorganized speech disorganized behavior flat or inappropriate affect


DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA SUBTYPESCatatonic type A type of schizophrenia in which the clinical picture is dominated by at least two of the following motoric immobility as evidenced by catalepsyexcessive motor activityextreme negativism or mutism peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, 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 for the paranoid, disorganized, or catatonic type.Residual typeAbsence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for schizophrenia, present in an attenuated form

DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA SUBTYPES


COURSE OF THE DISEASEthe symptoms begin in adolescence followed by the development of prodromal symptomsthe prodromal syndrome may last a year or more Exacerbations and remissionsAfter the first psychotic episode, a patient gradually recovers and may then function relatively normally for a long time. Patients usually relapseFurther deterioration in the patient's baseline functioning follows each relapse of the psychosis. Sometimes, a clinically observable postpsychotic depression follows a psychotic episode


PROGNOSISOver 5-10 years, only 10-20% will have a good outcomeMore than 50 percent have poor outcome - with repeated hospitalizationsReported remission rates range from 10 to 60 percent, and a reasonable estimate is that 20 to 30 percent of all schizophrenia patients are able to lead somewhat normal lives.


TREATMENTantipsychotic medications psychosocial interventions- psychotherapyPsychosocial modalities should be integrated into the drug treatment regimen and should support it.


PHASES OF TREATMENT IN SCHIZOPHRENIA

lasts from 4 to 8 weeksHospitalizationMedicationsAtypicalTypical


PHASES OF STABILIZATION AND MAINTENANCE PHASEto prevent psychotic relapse and to assist patients in improving their level of functioningMEDICATIONSTypicalAtypicalDepot preparations


OTHER PSYCHOTIC DISORDERS


SCHIZOPHRENIFORMGabriel Langfeldt 1939describe a condition with sudden onset and benign course associated with mood symptoms and clouding of consciousness.


DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIFORM DISORDERCriteria A, D, and E of schizophrenia are met. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as provisional)Specify if:Without good prognostic featuresWith good prognostic features: as evidenced by two (or more) of the following: onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or 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

has features of both schizophrenia and affective disorders In current diagnostic systems, patients can receive the diagnosis of schizoaffective disorder if they fit into one of the following six categories: patients with schizophrenia who have mood symptoms patients with mood disorder who have symptoms of schizophreniapatients with both mood disorder and schizophreniapatients with a third psychosis unrelated to schizophrenia and mood disorderpatients whose disorder is on a continuum between schizophrenia and mood disorderpatients with some combination of the above


DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOAFFECTIVE DISORDERAn uninterrupted period of illness during which, at some time, there is either a major depressive episode, a manic episode, or a mixed episode concurrent with symptoms that meet Criterion A for schizophrenia. Note: The major depressive episode must include Criterion A1: depressed mood. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. 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.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 depressive episodes


DELUSIONAL DISORDER AND SHARED PSYCHOTIC DISDelusions are false fixed beliefs not in keeping with the cultureDelusions are Non bizarre

Nonbizarre means that the delusions must be about situations that can occur in real life, such as being followed, infected, loved at a distance, and so on; that is, they usually have to do with phenomena that, although not real, are nonetheless possibleAdvanced age Sensory impairment or isolation Family history Social isolation Personality features (e.g., unusual interpersonal sensitivity) Recent immigration

Risk Factors:


DSM-IV-TR DIAGNOSTIC CRITERIA FOR DELUSIONAL DISORDERNonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration. Criterion A for schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. 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.


TYPES OF DELUSIONSErotomanic type: delusions that another person, usually of higher status, is in love with the individual. Grandiose type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous personJealous type: delusions that the individual's sexual partner is unfaithful Persecutory type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way Somatic type: delusions that the person has some physical defect or general medical condition Mixed type: delusions characteristic of more than one of the above types but no one theme predominates Unspecified type


DSM-IV-TR DIAGNOSTIC CRITERIA FOR SHARED PSYCHOTIC DISORDERA delusion develops in an individual in the context of a close relationship with another person(s), who has an already-established delusion. The delusion is similar in content to that of the person who already has the established delusion. The disturbance is not better accounted for by another psychotic disorder (e.g., schizophrenia) or a mood disorder with psychotic features and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general


BRIEF PSYCHOTIC DISORDERpsychotic condition that involves the sudden onset of psychotic symptoms, which lasts 1 day or more but less than 1 month. Remission is full, and the individual returns to the premorbid level of functioning. Brief psychotic disorder is an acute and transient psychotic syndrome


DSM-IV-TR DIAGNOSTIC CRITERIA FOR BRIEF PSYCHOTIC DISORDERPresence of one (or more) of the following symptoms: delusions hallucinations disorganized speech (e.g., frequent derailment or incoherence) grossly disorganized or catatonic behavior Note: Do not include a symptom if it is a culturally sanctioned response pattern. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. The disturbance is not better accounted for by a mood 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 medical condition.Specify if: With marked stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture Without marked stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture With postpartum onset: if onset within 4 weeks postpartum


CULTURE-BOUND SYNDROMES denotes specific arrays of behavioral and experiential phenomena that tend to present themselves preferentially in particular sociocultural contexts and that are readily recognized as illness behavior by most participants in that culture


AMOK

A dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at persons and objects. The episode tends to be precipitated by a perceived slight or insult and seems to be prevalent only among men. The episode is often accompanied by persecutory idea; automatism, amnesia, exhaustion, and a return to premorbid state following the episode.


GHOST SICKNESS A preoccupation with death and the deceased (sometimes associated with witchcraft), frequently observed among members of many American Indian tribes. Various symptoms can be attributed to ghost sickness, including bad dreams, weakness, feeling of danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of consciousness, confusion, feelings of futility, and a sense of suffocation.


KORO A term probably of Malaysian origin, that refers to an episode of sudden and intense anxiety that the penis (or, in women, the vulva and nipples) will recede into the body and possibly cause death. The syndrome is reported in South and East Asia, where it is known by a variety of local terms, such as shuk yang, shook yong, and suo yang (Chinese); jinjinia bemar (Assam); or rok-joo (Thailand).


PIBLOKTOAn abrupt dissociative episode accompanied by extreme excitement of up to 30 minutes' duration and frequently followed by convulsive seizures and coma lasting up to 12 hours. It is observed primarily in Arctic and subarctic Eskimo communities, although regional variations in name exist.


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schizophrenia and other psychotic do.ppt