Schizophrenia and Other Psychotic Disorders

Dr. Rebwar G. HamaPsychiatrist

University of SulaimaniSchool of Medicine

Nature of Schizophrenia and Psychosis:

Schizophrenia vs. Psychosis Psychosis – Broad term (e.g., hallucinations,

delusions) Schizophrenia – A type of psychosis Psychosis and Schizophrenia are heterogeneous Disturbed thought, emotion, behavior

Definition

The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted.

Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time.

Nature of Schizophrenia and Psychosis

Historical Background Benedict Morel – Introduced dementia praecox

Demence (loss of mind) precoce (early, premature) Emil Kraepelin – Used the term dementia praecox

Focused on subtypes of schizophrenia Eugen Bleuler – Introduced the term “schizophrenia”

“Splitting of the mind” Kurt Schneider – He emphasized the role of psychotic

symptoms, as hallucinations, delusions and gave them the privilege of „the first rank symptoms” even in the concept of the diagnosis of schizophrenia

Schizophrenia: Some Facts and Statistics

Onset and Prevalence of Schizophrenia worldwide About 0.2% to 1.5% (or about 1% population) Often develops in early adulthood Can emerge at any time

Schizophrenia Is generally chronic Most suffer with moderate-to-severe lifetime impairment Life expectancy is slightly less than average

Schizophrenia affects males and females about equally Females tend to have a better long-term prognosis Onset differs between males and females

Schizophrenia has a strong genetic component

Schizophrenia: Some Facts and Statistics (cont.)

Schizophrenia: The “Positive” Symptom Cluster

The Positive Symptoms Active manifestations of abnormal behavior Distortions of normal behavior

Delusions: The basic feature of psychosis Gross misrepresentations of reality Include delusions of grandeur or persecution

Hallucinations: Auditory and/or Visual Experience of sensory events without

environmental input Can involve all senses Findings from SPECT studies

Schizophrenia: The “Negative” Symptom Cluster

The Negative Symptoms Absence or insufficiency of normal behavior

Spectrum of Negative Symptoms Avolition (or apathy) – Lack of initiation and

persistence Alogia – Relative absence of speech Anhedonia – Lack of pleasure, or indifference Affective flattening – Little expressed emotion Asociality – Isolation from public

Schizophrenia: The “Disorganized” Symptom Cluster

The Disorganized Symptoms Include severe and excess disruptions Speech, behavior, and emotion

Nature of Disorganized Speech Cognitive slippage – Illogical and incoherent speech Tangentiality – “Going off on a tangent” Loose associations – Conversation in unrelated directions

Nature of Disorganized Affect Inappropriate emotional behavior

Nature of Disorganized Behavior Includes a variety of unusual behaviors Catatonia – Spectrum

Wild agitation, waxy flexibility, immobility

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

Subtypes of Schizophrenia

Paranoid Type Intact cognitive skills and affect Do not show disorganized behavior Hallucinations and delusions – Grandeur or persecution The best prognosis of all types of schizophrenia

Disorganized Type (Hebephrenic) Marked disruptions in speech and behavior Flat or inappropriate affect Hallucinations and delusions – Tend to be fragmented Develops early, tends to be chronic, lacks remissions

Subtypes of Schizophrenia (cont.)

Catatonic Type Show unusual motor responses and odd mannerisms Examples include echolalia and echopraxia Tends to be severe and rare

Undifferentiated Type (Atypical Schizophrenia) Wastebasket category Major symptoms of schizophrenia Fail to meet criteria for another type

Residual Type One past episode of schizophrenia Continue to display less extreme residual symptoms

Schizophrenia Subtypes

DSM–IV diagnostic criteria for Schizophrenia

1. Two of the following for most of 1 month; Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms

2. Marked social or occupational dysfunction

3. Duration of at least 6 Months of persistent symptoms

4. Symptoms of Schizoaffective & mood disorder are ruled out

5. Substance abuse & medical conditions are ruled out as aetiological

Causes of Schizophrenia:Findings From Genetic Research

Family Studies Inherit a tendency for schizophrenia Do not inherit specific forms of schizophrenia Risk increases with genetic relatedness

Twin Studies Monozygotic twins – Risk for schizophrenia is 48% Fraternal (dizygotic) twins – Risk drops to 17% Adoption Studies -- Risk for schizophrenia remains high

Cases where a biological parent has schizophrenia Summary of Genetic Research

Risk for schizophrenia increases with genetic relatedness Risk is transmitted independently of diagnosis Strong genetic component does not explain everything

Causes of Schizophrenia: Neurotransmitter Influences

The Dopamine Hypothesis Drugs that increase dopamine (agonists)

Result in schizophrenic-like behavior Drugs that decrease dopamine (antagonists)

Reduce schizophrenic-like behavior Examples – Neuroleptics, L-Dopa for Parkinson’s disease Current theories – Emphasize many neurotransmitters

(Serotonin, GABA, & Glutamate) also have a role

Causes of Schizophrenia: Neurotransmitter Influences (cont.)

Causes of Schizophrenia:Other Neurobiological Influences

Structural and Functional Abnormalities in the Brain Enlarged ventricles and reduced tissue volume Hypofrontality – Less active frontal lobes

A major dopamine pathway

Viral Infections during early prenatal development Findings are inconclusive

Structural and functional brain abnormalities Not unique to schizophrenia

Causes of Schizophrenia:Other Neurobiological Influences (cont.)

Causes of Schizophrenia:Psychological and Social Influences

The Role of Stress May activate underlying vulnerability May also increase risk of relapse

Family Interactions Families – Show ineffective communication

patterns High expressed emotion – Associated with relapse

The Role of Psychological Factors Exert only a minimal effect in producing

schizophrenia

Causes of Schizophrenia: Neurodevelopmental Model

Neurodevelopmental model supposes in schizophrenia the presence of “silent lesion” in the brain, mostly in the parts, important for the development of integration (frontal, parietal and temporal), which is caused by different factors (genetic, inborn, infection, trauma...) during very early development of the brain in prenatal or early postnatal period of life.

It does not interfere too much with the basic brain functioning in early years, but expresses itself in the time, when the subject is stressed by demands of growing needs for integration, during formative years in adolescence and young adulthood.

Treatment of Schizophrenia

The acute schizophrenic patients will respond usually to antipsychotic medication

Development of Antipsychotic (Neuroleptic) Medications Often the first line treatment for schizophrenia Began in the 1950s Most reduce or eliminate positive symptoms Acute and permanent side effects;

(Extrapyramidal and Parkinson-like side effects, Tardive dyskinesia)

Compliance with medication is often a problem According to current consensus we use in the first line

therapy the newer atypical antipsychotics, because their use is not complicated by appearance of extrapyramidal side-effects, or these are much lower than with classical antipsychotics.

Conventional antipsychotics - (classical neuroleptics);

Chlorpromazine, Clopenthixole, Levopromazine, Thioridazine, Droperidole, Flupentixol, Fluphenazine, Haloperidol, Perphenazine, Pimozide, Prochlorperazine, Trifluoperazine

Depot antipsychotics: (Fluphenazine deconate- Modecate), Flupenthixol, and Zuclopenthixole

Atypical antipsychotics - (new neuroleptics);

Amisulpiride, Clozapine, Olanzapine, Quetiapine, Risperidone, Sertindole, Sulpiride

Psychosocial Treatment of Schizophrenia

Psychosocial Approaches: Behavioral (i.e., token economies) on inpatient units Community care programs Social and living skills training Behavioral family therapy Vocational rehabilitation

Electroconvulsive therapy (E.C.T) is also used in the treatment of schizophrenia, but may be useful when catatonia or prominent affective symptoms are present

Treating Schizophrenia

Prognosis

Good prognosis Poor prognosis Old age of onset Young age of onset Female Male Married Unmarried No family history Family history Good premorbid personality Personality problems High IQ Low IQ Precipitants No obvious precipitants Positive symptoms Negative symptoms Treatment compliance Poor treatment compliance

Good support Low support Acute onset Insidious onset Presence of mood component No mood component

 

Summary of Schizophrenia

Schizophrenia – Spectrum of Dysfunctions Affecting cognitive, emotional, and behavioral

domains Positive, negative, and disorganized symptom

clusters DSM-IV and DSM-IV-TR

Five subtypes of schizophrenia Includes other disorders with psychotic features

Several Bio-Psycho-Social Variables are Involved Successful Treatment Rarely Includes Complete

Recovery

Other Psychotic Disorders

Schizophreniform Disorder

Schizophrenic symptoms for a few months (less than 6 months)

Associated with good premorbid functioning Most resume normal lives The same treatments recommended for

schizophrenia may also be utilized here

Brief Psychotic Disorder

One or more positive symptoms of schizophrenia Usually precipitated by extreme stress or trauma experience a psychosis which, while lasting at

least a day, undergoes a full, complete and spontaneous remission within one month

Tends to remit on its owns

Delusional Disorder

Delusions that are contrary to reality Lack other positive and negative symptoms Types of delusions include

Erotomanic, Grandiose, Jealouse, Persecutory, Somatic

appears to pursue a chronic, waxing and waning course

Patients with paranoia rarely seek treatment with a psychiatrist on their own initiative

Better prognosis than schizophrenia

Shared Psychotic Disorder (Folie à Deux)

Delusions from one person manifest in another person

The most common relationships are among parents and children, spouses, and siblings

Separation from the dominant person and immersion into normal social interaction

Schizoaffective Disorder

Symptoms of schizophrenia and a mood disorder Both disorders are independent of one another Such persons do not tend to get better on their

own long-term outcome of patients is not as good as

that for patients with a mood disorder, yet not as grave as that for patients with schizophrenia

Schizotypal disorder

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

May reflect a less severe form of schizophrenia

Postpartum Psychosis (puerperal psychosis)

rare disorder, occurring in perhaps less than 1 or 2 per 1000 deliveries

It is more common in primiparous than multiparous women

many of these patients never experience another psychotic illness unless they again become pregnant

Symptoms generally appear abruptly within about 3 days to several weeks after delivery

Hospitalization is generally indicated