SchizophreniaSchizophreniaOther Psychotic Other Psychotic

DisordersDisorders

Three Criteria Sets for all Three Criteria Sets for all Psychotic DisordersPsychotic Disorders

• 1st – applies to all disorders in group; defines requirements for psychosis

• 2nd – defines attributes common to all schizophrenic disorders

• 3rd – requirements about etiology, social impairment, & diagnostic precedence applying to many but not all disorders

• All 3 sets tend to overlap

Schizophrenia:Schizophrenia:Splitting of the MindSplitting of the Mind

Most debilitating & baffling mental illness• Distorted perception of reality• Impaired capacity to reason, speak, &

behave rationally or spontaneously• Impaired capacity to respond

spontaneously with appropriate affect & motivation– Incongruity between different mental functions

• As betw thought content & feeling• As betw feeling & overt activity

– Someone who laughs at a funeral

Clinical PresentationClinical Presentation• Criticism of DSM-IV is that system

becomes diagnosis by exclusion• Criteria as a whole does not characterize• Examples include:

– Hypervigilant accountant suspicious others are plotting against him/her

– Housewife believes she is controlled by dead mother’s voice

– Withdrawn & apathetic college student brooding incessantly about reality of existence

Important factorsImportant factors• Specific set of symptoms, yet variety in

severity from person to person• Also variety with one person from one

period of time to another• Generally controlled with treatment

– More than 59% with continuous treatment recover

– Medication for entire life– Treatment allows most people to work, live

with families, & enjoy friends

CausesCauses• Much speculation• Appears to run in families; heredity link• “Schizophrenogenic” Mother

– Previous discredited theory of bad parenting; inadequate care

• Susceptibility/vulnerability to illness triggered by:– Environmental events; viral infection changing

body chemistry– Highly stressful situation in adult life– Combination of things

HeredityHeredity• With 1 parent with diagnosis

– 8-18% even if adopted by mentally healthy parents• Both parents

– Risk 15-50%• Mentally healthy biological parents, but adoptive parents with

diagnosis• 1% chance of developing disorder• Same chance as in general population• One identical twin with disorder• 50-60% sibling with identical genetics will also have disorder• Do not inherit directly

– Appears when body is undergoing hormonal & physical changes of adolescence

– Some researchers believe “dormant” during childhood• Emerges as body & brain undergo changes in puberty

Key PointsKey Points• Age at onset

– Generally late adolescence, early adulthood; rare later in life unless onset before 45 yrs

• Duration– 6 months or more– Unless Schizophreniform

• Loss of prior level of functioning• Tendency toward chronicity• Symptoms usually appear gradually

– Preparatory or prodromal period• Symptoms include:

– Tenseness, lack of concentration, sleep, withdraws from society

– Personality changes– Work performance, appearance & social relationships

deteriorate

Positive & Negative Positive & Negative SymptomsSymptoms

• Diagnose when positive symptoms for minimum of 2 weeks (other symptoms 6 mos.)– Added features– Excesses or

distortions• Hallucinations• Delusions

Negative Symptoms– Lack of something

• Disorganized speech• Diminution or loss of

normal functioning

Relapse & Remission PhasesRelapse & Remission Phases• Common• Symptoms worsen or become better in

cycles• May suffer:

– Delusions, hallucinations, or disordered thinking & speech

• Appearance normal at times until psychotic phase– Cannot think logically– May lose all sense of identity– May lose sense of significant others

Delusions & HallucinationsDelusions & Hallucinations• Delusions

– Thoughts that are fragmented with no basis in reality

– Also differ in degree of conviction

– Someone may be spying or planning to harm

• Strong belief– May be wrong but has some

basis in reality• If bizarre delusions

– no other Criteria “A” needed– Someone can insert thoughts

into brain

• Hallucinations– Sensory perception with

compelling sense of reality of true perception but occurs W/O external stimulation of relevant sensory organ

– May or may not have insight into having hallucinations

• Distinguish from illusion– actual stimulus misperceived /misinterpreted

• If voices are commenting or conversing – no other Criteria “A” needed

• Ask if “voices” client hearing are own voice?

• Most common are voices– Visual, tactile next

Distortions of AbilityDistortions of Ability• Loss of knowing whether an event or

situation perceived is real– Waiting at a crosswalk, a voice says “you smell

really bad”• Real voice• Jogger passing by• In my head?

• Normal behaviors much of time:– Not so out of touch of realization that:

• we eat 3 meals a day• sleep at night• drive on street etc.

SubtypesSubtypes• Priority of patterns

– Catatonic, if signs prominent • rigidity, lack of response or acute agitation

– Disorganized• Disorganized speech, disorganized behavior, flat or inappropriate

affect– Paranoid

• Preoccupation with delusions or auditory hallucinations• No flat or inappropriate affect, catatonic behavior, disorganized

speech, or disorganized behavior– Undifferentiated

• Symptoms meet criteria A but not for paranoid, catatonic, or disorganized types

– Residual • does not require fulfillment of common criteria set for

schizophrenia• Attenuated form of criteria

Continuum Continuum of Schizophreniaof Schizophrenia

Based on duration of episodeBrief Psychoticschizophreniformschizophrenia

• Brief Psychotic Disorder– Duration 1 day – 1 month– Eventual complete recovery

• Schizophreniform– Duration 1 month – 6 months– Impaired social or occupational functioning not required

buy may occur

• Schizophrenia– Duration more than 6 months

DataData• Affects men/women equally• Estimates of developing disorder = 1%• Onset in women typically 5 years later• 150 of 100,00 persons develop • Approximately ¼ hospital beds & ½ psychiatric

beds in US– More than any other illness

• Relatively rare• Most catastrophic mental illness

– Early age of onset, lifelong disability, emotional & financial devastation

– Federal figures reflect $30 - $48 billion in direct medical costs, loss of productivity, & social security pensions

TreatmentTreatment• No single “correct” treatment useful since

syndrome consisting of a number of disorders

• Most effective – Psychopharmacology & psychosocial therapies– Antipsychotic medications treatment of choice since 50’s– Brings biochemical imbalances closer to norm– Reduces hallucinations, delusions– Helps maintain coherent thoughts– Compliance necessary– 60-80% not taking medication relapse in 1st yr– Relapse rates fall to 10% if medication continued

Schizoaffective Disorder: Schizoaffective Disorder: Bipolar or Depressive TypeBipolar or Depressive Type

• Continuously meet Criterion A• Also major depressive episode,

manic episode, or mixed episodes• Includes delusions, hallucinations of

2 weeks time in absence of mood symptoms

Delusional DisorderDelusional Disorder• Persistent nonbizarre delusions

– 1 or more systematic & circumscribed delusions often of persecutory nature

• 1 month time• Never met Criterion “A” for Schizophrenia• Function reasonable well

– aside from impact/ramifications of delusions

• If mood episodes, total duration brief• Relatively uncommon with .05-.1% lifetime risk • Usually mid-life disorder noticed by friends/family

– Hypersensitive, argumentative, & litigious types

• Usually no voluntary help sought

Types of Types of Delusional DisordersDelusional Disorders

• Erotomania– Another person, usually of higher status, is in love with person

• Grandiose– Inflated worth, power, knowledge, identity, or special

relationship to deity or famous person• Jealous

– Individual’s sexual partner is unfaithful• Persecutory

– Being persecuted for no apparent reason• Somatic

– Having some physical defect or general medical condition• Mixed Type

– More than 1 type with no predominant theme• Unspecified Type

Shared Psychotic DisorderShared Psychotic Disorder• Person develops delusion(s)

– similar in content to already established delusion

– of another person with whom close relationship

Psychotic Disorder Due to Psychotic Disorder Due to General Medical ConditionGeneral Medical Condition

• Prominent delusions or hallucinations• Judged caused by general medical

condition• Do not occur exclusively during

course of Dementia or Delirium

Substance-Induced Substance-Induced Psychotic DisorderPsychotic Disorder

• Prominent delusions or hallucinations associated with evidence symptoms developed within 1 month of significant substance intoxication or withdrawal, or is etiologically related to medications use or toxin exposure

• Specific codes determined by specific substance

Psychotic Disorder NOSPsychotic Disorder NOS• Syndromes with prominent psychotic

symptomatology • Symptomatology not meeting criteria

for any specific Psychotic Disorder

Necessary Clinical Necessary Clinical InformationInformation

• History of:– documented

psychiatric illness

– socially unusual, odd, or isolative behavior

– substance abuse– medical illnesses

• Current experience– hallucinations or odd

perceptual experiences

• Disorganized thought or speech

• Delusions• Negative symptoms

– (e.g., flat affect, avolition (no goal directed activity)

• Depression or mania• Duration of symptoms

Treatment of Treatment of Delusional DisordersDelusional Disorders

• Extraordinarily difficult to treat• Longer symptoms present, more oppositional to

simple treatments• Some culturally-induced syndromes may respond

to relocation – return to country of origin

• Emphasis on trusting relationship• Systematic desensitization effective• Antipsychotic medication takes “edge” off

delusions– Psychosocial treatment more possible

• Antidepressants also proved helpful

Side Effects of MedicationSide Effects of Medication• Most side effects disappear after few weeks

– Dry mouth– Blurred vision, constipation– Drowsiness– Dizziness due to drop in blood pressure

• Some irreversible & serious side effects– Tardive Dyskinesia (TD)

• 20-30% develop• Small tongue tremors, facial tics, abnormal jaw movements• May progress into thrusting & rolling tongue, lip smacking,

pouting, grimacing, chewing or sucking motions• Also spasmodic movements • Usually do not progressively worse

– Severe in less than 5% • Can fade if medication discontinued• Effectiveness of ending psychoses, validates risk