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INTRODUCTION TO MED (PSYCHIATRY)

SCHIZOPHRENIA ANDSCHIZOPHRENIA ANDOTHER PSYCHOTIC DISORDERS OTHER PSYCHOTIC DISORDERS

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SCHIZOPHRENIASCHIZOPHRENIA

A 35 – YEAR-OLD WOMAN TELLS YOU THAT HER NEIGHBORS ARE SPYING ON HER BY LISTENING TO HER THROUGH HEATING VENTS. BECAUSE OF THIS, SHE HAS CHANGED RESIDENCES MANY TIMES OVER THE PAST 10 YEARS. SHE LOOKS PECULIAR AND SEEMS PREOCCUPIED BY “VOICES TALKING IN HER HEAD.”

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SCHIZOPHRENIASCHIZOPHRENIA

• Schizophrenia is a chronic mental disorder characterized by:– disturbed thoughts, speech, and behavior– Odd appearance– Social withdrawal– Poor grooming– Abnormal affect

• Flat

• Blunted or

• inappropriate

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• Usually the patient is well oriented to person, place, and time

• The patients has intact memory • In the residual phase the patient is in touch with reality• In the psychotic phase the patient is not in touch with

reality• According to the DSM-IV this diagnosis could only be

made if:– Symptoms have been around for six months

– At least one period of actual psychosis occur within those six months

– Impairment of occupational or social functioning must have occurred during this time period

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• Prodromal signs– Quiet– Passive or irritable– Few friendships– Avoids social activities– Daydreams– Somatic complaints– Interest in the occult, religion, or philosophy

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• During the acute psychotic episode the following thought disorders are present:– Disorders of perception (hallucinations)– Disorders of thought content (delusions, ideas

of reference, loss of ego boundaries)– Disorders of thought processes– Disorders of form of thought

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• Residual signs and symptoms– Flat affect– Peculiar thinking and behavior– Social withdrawal

• Hallucinations– Hearing voices when alone in a room– Smelling nonexistent odors

• Most commonly seen hallucinations:– Auditory– Visual– Tactile– Gustatory– Olfactory– Cenesthetic (visceral sensation) are also seen

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• Delusions – False belief not based on simple ignorance or

shared by a culture or subculture– Most commonly seen is delusions of

persecution

• Loss of ego boundaries– Patient does not know where his/her mind and

body end and those of others begin

• Have ideas of reference– Belief that others (including the media) are

referring to him/her when they are not

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• Disorder of thought processes– Abrupt halt in the train of thought, often due to

hallucinations– Deficiencies in thought or content of speech

[making up new words]

• Disorder of form of thought– Incoherence, word salad (unrelated

combinations of words or phases)– Loose associations (ideas shift from one subject

to another- in unrelated fashion)– Echolalia (repeating a word over and over)

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Five Types of Schizophrenia

1. Disorganized: • Disinhibited• Poor organization• Poor appearance and grooming• Inappropriate emotional responses• Age of onset is before 25

2. Catatonic:• Bizarre posturing (waxy flexibility) or extreme excitability• Rare since introduction of antipsychotic meds

3. Paranoid:• Delusions of persecution• Older age of onset• Better functioning than other types

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4. Undifferentiated:• Characteristics of more than one type

• This is the most common type

5. Residual:• Has one schizophrenic episode and subsequently

shows residual symptoms but no psychotic symptoms

• What are negative(deficit) symptoms and positive (productive symptoms?

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• Negative symptoms is characterized by:– Loss of function

• flattened affect,

• thought blocking,

• poor grooming

• Lack of motivation

• Social withdrawal

• Poor speech content

– These respond better to clozapine than to traditional antipsychotics

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• Positive symptoms are characterized by excessive function:

• Hallucinations

• Agitation

• Strange behavior

• Delusions

• Talkativeness

– These respond better to anti-psychotics than negative symptoms do

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Physiologic Abnormalities• EEG

– Decreased alpha waves– Increased theta and delta waves– Epileptiform activity

• Eye movement– EOM are poor in 50 – 80 % of the patients

• Neuroendocrinology– Decrease in LH and FSH– Abnormal regulation of cortisol

• Laboratory findings– May find elevated levels of homovanillic acid (metabolite of

dopamine) in body fluids

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Mimics of Schizophrenia

• Medical illnesses– Temporal lobe epilepsy– Neurologic disease or trauma– Poisoning– Endocrine disorders

• Psychiatric illnesses– Brief psychotic disorder– Schizophreniform disorder– Schizoaffective disorder– Manic phase of bipolar – Schizoid and schizotypal personality disorders– Substance abuse (amphetamines and hallucinogens)

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Epidemiology

• 50% for monozygotic twins of schizophrenic persons

• 40% of children where both parents have the disease

• 12% for first degree relatives (child, sibling)• 1% of the general population• Peak age for men is 15 – 25• Peak age for women is 25 – 35• No gender difference

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Treatment

• Pharmacological treatment– Traditional antipsychotics

• Particularly effective against positive symptoms

• Significant improvement is seen in 70% of patients

– Atypical antipsychotics• Useful against negative symptoms

• Psychological treatment– Long term support is very useful and should consists of

individual, family, and group psychotherapy

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Classification Agent (Duration) Dose (mg/day)

Clinical use

Traditional

Low - potency

Thioridazine (Mellaril)

200 -600 Depression with intense anxiety or agitation

Chlorpromazine(Thorazine)

100 – 800 To treat nausea and vomiting

Hiccups

Traditional

High - potency

Haloperidol (Haldol)

2 – 15 Psychosis secondary to organic syndrome; Tourette disorder

Perphenazine (Trilafon)

8 – 40 To treat nausea and vomiting

Pimozide (Orap)

1 –10 Tourette disorder, body dysmorphic disorder

Trifluoperazine (Stelazine)

4 – 20 Non-psychotic anxiety (up to 12 weeks)

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Classification Agent (Duration) Dose (mg/day)

Clinical use

Atypical

Anti-psychotics

Clozapine (Clozaril)

300 – 900 Effective for negative, chronic, and refractory symptoms

Risperidone (Risperdal)

4 – 8 Useful for negative symptoms; has few side effects

Olanzapine (Zyprexa)

10 – 20 Useful for negative symptoms; has few side effects

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Side Effects of Anti-Psychotics

• Low – potency – Mainly anticholinergic side effects

• High – potency– Mainly neurologic side – effects

• Atypical (Clozapine)– More likely to cause agranulocytosis and

seizures

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• Anti-cholinergic side effects:– Dry mouth– Blurred vision– Constipation– Urinary retention– Severe agitation and confusion

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• Neurologic side effects– Parkinsonian effects : reduce dose and add

Cogentin (1 – 4 mg/day) or Benadryl (25 – 50 mg/day)

– Acute dystonia– Akathisia– Neuroleptic malignant syndrome: Medical

Emergency– Tardive dyskinesia : spontaneously remit in

50% of the cases. Otherwise give Bromocriptine 0.75 – 7.5 mg/day ( effective in @ 20% of cases); substitute Clozapine

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• Increasing agitation, depression and insomnia may indicate that the patient is going to have a psychotic episode

• Usual course of illness is – repeated psychotic episodes– Chronic downhill course– Often stabilizes in midlife

• 50% of patients have depression after an acute psychotic episode [watch for suicide attempts]

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Prognosis

• Chronic, lifelong impairment• Better prognosis if:

– Patient has mood symptoms

– Is older at onset

– Is married or has social relationships

– Is female

– Has good employment history

– Has positive symptoms

– Has had few relapse

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Other Psychotic Disorders

• There are five disorders other than schizophrenia that present with psychotic symptoms.

• Brief Psychotic disorder

• Schizophreniform disorder

• Schizoaffective disorder

• Delusional disorder

• Shared Psychotic disorder [Folie a duex]

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Brief Psychotic Disorder• At least one psychotic symptom lasting 1 day but

less than 1 month• More common in patients with concomitant

borderline and histrionic personality disorders• Duration of symptoms is shorter than in

schizophrenia• Symptoms often follow exposure to a

psychosocial stressor [unlike in schizophrenia]

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• Patients are relatively normal in the pre-morbid period [schizophrenia see withdrawal, strange behavioral and odd beliefs]

• No family history of schizophrenia

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Typical Patient Presentation

• 27 year-old woman whose brother died recently of HIV disease is brought by relatives to the hospital. They claim that over the past week she has begun to show bizarre, dramatic behavior and claims that she hears her brother “talking to her inside her head.”

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Treatment

• Short hospital stay• Antipsychotics• Benzodiazepines• Psychotherapy for dealing with the stressful

precipitating eventPrognosis

• 50 – 80 % recover completely• The others may ultimately be diagnosis

with schizophrenia or a mood disorder

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Schizophreniform Disorder

• Two or more psychotic symptoms lasting at least 1 month but not more than 6 months

• Duration of symptoms is shorter than schizophrenia

• Patient relatively normal in the pre-morbid period• Symptoms come on more suddenly and terminate

more abruptly than in schizophrenia

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Typical Patient Presentation

26 year-old man with no previous history of psychiatric illness is brought to the emergency room by his girlfriend. She tells you that about 3 months ago, he suddenly began to show bizarre behavior, often seemed preoccupied as though he was listening to something and showed abrupt mood changes.

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Treatment

• Hospitalization• Anti-psychotics• Psychotherapy to deal with the experience

of having had a psychotic episodePrognosis

• 33% recover completely• 66% progress to schizoaffective disorder or

schizophrenia

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Schizoaffective Disorder

• Fits the criteria for both mood disorder and schizophrenia

• Chronic impairment in functioning between episodes

• Meets the criteria for mania or depression as well as for schizophrenia

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Typical Patient Presentation

35 year-old man with a history of psychotic symptoms and severe depression has never held a job for more than 3 months. He is brought to the emergency room by his sister, with whom he lives, when he begins to show increasingly strange behavior

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Treatment•Hospitalization

•Antidepressants,

•Anti-manic, and

•Electro-convulsive therapy

•Anti-psychotic agents are used for psychotic episodes and when other medications fail

Prognosis

•Better than for schizophrenia, worse than for mood disorder

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Delusional Disorder

• A rare disorder• Fixed non- bizarre delusional symptom (often

paranoid)• Few if any other thought disorders• More common in:

• Immigrants

• Hearing impaired

• Patients older than 40 years of age

• Most commonly has a sudden onset

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• Though delusion is of the paranoid type it is unlikely bizarre

• Patients functions relatively normally socially [unlike schizophrenia]

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Typical Patient Presentation

• 55 year –old patient tells you that his neighbor has been plotting for years to get him arrested by listening in on all of his phone conversations. The patient is married and has been in the same job for 25 years

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Treatment• Psychotherapy is important – to gain patient’s trust• Pimozide (Orap) can be given especially for somatic

delusions• Haldol can also be given

Prognosis• 50% recover• 30% remain the same• 20% show decreased symptoms• Good prognosis if:

• Younger age onset• Sudden onset• Presence of precipitant

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Shared Psychotic Disorder

• Also called Folie A Deux• Development of psychotic symptoms in a

person in a close relationship with another person

• More common in women and in people from low socio-economic groups

• Psychotic symptoms occur only after exposure to the inducer

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Typical Patient Presentation

• 20 year-old woman whose psychotic mother believes that the landlord is trying to poison her now begins to believe the same thing

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Treatment

• REMOVE THE PATIENT FROM THE INFLUENCE OF THE INDUCER

• Social support and psychotherapy

• Anti-psychotic medications

Prognosis

• 10 – 40 % resolve with separation

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