Psychiatry-Schizophrenia & Psychotic

disorders
Dr. Milan H Balakrishnan
Consultant Psychiatrist & Principal Consultant
MINDCARES
 History
Morel Demence Precoce..
Emil Kraeplins Dementia Praecox Long term deteriorating course
along with delusions and hallucinations
Schizm means break in thought,behaviour and emotion so
Schizophrenia-Eugene Bleuler
4 As-Autism
Ambivalence
Loosening of Associations
Blunting or Flattening of Affect
Bleuler considered Delusions & hallucinations 2ndary
Ernst Kretschmer divided: Asthenic(thin)
Athletic
Schizo-more common
Pyknic-short stocky-Bipolar
Adolf Meyer Bio-psycho-social
Kurt Schneider: First rank symptoms useful for making a
diagnosis but not specific
Diagnosis can also be made on 2nd rank symptoms
 Schizophrenia
Split Mind is It? NO
Clinical syndrome affects
Cognition
Emotion
Perception
Behaviour
Positive symptoms:
Delusions
Hallucinations
Disorganised Speech
Disorganised Behaviour
Agitated
Negative Symptoms:
Blunted Affect
Apathy
Avolition
Anhedonia
Alogia
Asociality
Attention impaired
Abstract thinking impaired
Passivity
Poor Rapport
 Schneiders First rank symptoms
( A) Hallucinations
First person Thought Echo(Gedankenlautwerden)
Second personVoices commenting on patients actions
Third personTwo or more voices discussing the patient among themselves
( B) Thought alienation phenomenon
Thought insertion (Patient thinks that someone is inserting thoughts into his
mind)
Thought withdrawal (Pt thinks that someone is taking out thoughts from his
mind)
Thought broadcast (Patient thinks that other come to know about his thoughts )
(C ) Passivity phenomenon
Made act ( Patient feels that is forced to do such act)
Made affect / feelings ( Patient feels that is forced to
experience such emotions)
Made Impulses (Patient feels that is forced to think is
such a manner)
Somatic passivity (Patient feels that these bodily
sensations are being inflicted upon him by some
external agency )
( D) Delusional perception Normal perception has a
private and illogical meaning.
 Second Rank Symptoms
Other disorders of perception
Sudden delusional ideas
Perplexity
Depressive & Euphoric mood changes
Feelings of emotional blunting
 Epidemiology
Prevalence-1/100
Incidence: 0.5 to 5 /10,000
Gender M: F equal
Males 10-25 yrs
Females 25-35 yrs 2nd peak -40s
Late > 45
V.late>60
 Various theories
More common in winter births
- Influenza viral change in genome,auto-immune
path
- Starvation
High association with substance abuse-Alcohol
Cannabis
Nicotine -90% Cognition and parkinsonism
improves; Reduces hall
Urban> Rural
 Genetics
Concordance rate for Monozygotic twins is 47%
If both parents have schizophrenia then chances in their
child - 40%
Concordance rate for Dizygotic twins is 12%
If one parent has schizophrenia then chances in their child --
12%
In one sibling has schizophrenia then 8%
Linkage with following genes 1, 5, 6,8,10,13,15,22
Genes alpha 7 nicotinic,DISC-1,GRM 3,COMT,NRG1,RGS4
DTNBP1,Neuregulin1-Negative features
 Neurotransmitter hypothesis
Dopamine- Most important theory
Positive symptoms-Meso-limbic Dopa over-activity
Negative symptoms,Cognitive,Affective symptoms-
Meso-cortical DOPA under-activity
Nigro-striatal-EPS
Tubero-infundibular-Prolactin elevation
 Serotonin theory : Serotonin excess especially in
meso-cortical sites
Norepinephrine theory: Low NE causes Anhedonia
GABA : Low GABA levels
Glutamate: Latest hypothesis- Overactivity, hypo-
activity or glutamate induced neuronal damage
Neuropeptides, acetylcholine and nicotine theory:
under study
 Large cerebral ventricles (Lateral and third ventricle
enlargement)
Decreased cerebral mass
Reduced symmetry in frontal, temporal and occipital lobe
is found
Hippocampus and prefrontal cortex(impairment of
executive functioning) are not only structurally smaller
but also functionally abnormal
Amygdala, thalamus, hippocampus and parahippocampal
gyrus are smaller in size
EEG shows:-
Decreased alpha activity,
Increased theta and delta activity,
More epileptiform activity
More left sided abnormalities
Study of evoked potentials: P300 smaller
N100 abnormal
Even in risk of schizo
Eye movement dysfunction is seen in
schizophrenics and a trait marker
 Psycho-analytical theories: State of regression to before Ego
formation
Family dynamics:
Double Bind: Bateson & Jackson-Conflicting messages lead to
psychotic withdrawl
Schizm-between parents
Skew-dominance of one parent-LIDZ
Pseudo-mutual and pseudo-hostile comm by parents child
cannot relate and communicate others
EE-caregiver Criticism,over-involvement and hostility increases
relapse rate
 Paranoid Schizophrenia
General criteria of schizophrenia is met
Patient has predominant delusions (persecution,
reference, control or infidelity) and auditory
hallucinations
No prominent disturbance of affect is noticed
Personality deterioration is much less than the other
types of schizophrenia
Most common type of schizophrenia
Good prognosis
 Disorganized/Hebephrenic
General criteria of schizophrenia is meet
Patient has formal thought disorder, poor self care,
disinhibited behaviour, multiple oddities of behaviour
Affect is inappropriate, blunted or sometime senseless
giggling is seen
Delusions and hallucinations are not pre-dominant
Onset is usually in early second decade.
(Early onset and poor prognosis)
Course is progressively deteriorating.
Worst prognosis after simple schizophrenia
 Catatonic Schizophrenia
General criteria of schizophrenia is meet
Marked disturbance of motor behaviour is seen
Patient can have prominent mannerism and grimacing
Catatonic signs like stupor, posturing, Rigidity, Waxy flexibility,
Negativism,
Gegenhalten, automatic obedience, Mitmachen, and Mitgehen
may be present
Onset is usually acute
I/V lorazepam or ECT is the treatment of choice
It has good prognosis
Undifferentiated Schizophrenia
General criteria of schizophrenia is meet
It is diagnosed when features of no subtype are fully
present or features of more than one subtype are exhibited

Residual Schizophrenia
General criteria of schizophrenia is meet
Patient should have at least one clear cut episode of
psychosis
Subsequently negative symptoms persist for years
Simple Schizophrenia
Onset is early
Diagnosis is difficult
Delusion/hallucination are usually absent.
Negative symptoms are seen without being preceded
by overt psychotic episode
Simple deteriorative-loss of drive & ambition(Research
Criteria)
It has the worst prognosis
Post Schizophrenic depression
Depression usually develop within 12
months of an acute episode of
schizophrenia
Some features of schizophrenia are still
present
Increased risk of suicide during this
period
 Other
Latent
Oneroid
Paraphrenia
Van-Goghs
Propf
Pseudo-neurotic-pan anxiety,pan-ambivalence,pan-phobia
and chaotic sexuality
Simple schizophrenia(Simple deteriorative)-loss of drive &
ambition
 MSE
General appearance:
Precox feeling
Hallucinations: mainly auditory followed by visual
Tactile, olfactory, gustatory-Suspicion
1st person
2nd person
3rd person
Illusions:maybe
Disorders of Thought :
Content:delusions-
persecutory,religious,grandiose,somatic
Reference
Loss of ego boundaries: may feel one with objects
Form of thought: Loosening of
association,tangentiality,derailment,circumstantiality,ver
bigeration,neologism,word salad,neologism
Thought process: Flight of ideas
Thought blocking
Poor abstraction
Thought control
Thought withdrawal
Thought Broadcast
 Orientation is not impaired but Delusions of
misorientation
Attention and Executive function may be
impaired
Impaired Insight and Judgement
Neurological abnormalities: soft signs
Increased Blink rate
 Co-morbidities
Obesity
Diabetes type II
Cardiovascular Risk
HIV:
COPD
RA :Inverse relationship ?
 Diff Diagnosis
Delusional
Malingering
OCD
Brief psychotic
Personality
Mood disorders
Schizophreniform
Schizo-affective
Personality
Schizoid
Schizotypal
Paranoid NPH
Suicide in schizophrenia:
Commonest cause of early death
10% suicide rate
Risk factors:
Young male
Positive symptoms
Affective symptoms
High pre-morbid functioning
Drug abuse
Commanding hall
 Homicide: rare contrary to popular belief
History of dangerous
Delusions & hall with violence
 Good Prognosis Bad Prognosis
Late onset (>35 yrs) Early onset (<20 yrs)
Female sex Male sex
Good social support Poor social support
Good premorbid adjustment Poor premorbid adjustment
Presence of stressor Absence of stressor
First episode Recurrent Episode
Acute onset Insidious onset
Short duration Chronic duration
Catatonic subtype Disorganized/Hebephrenic
Presence of affective symptoms subtype
Predominant positive symptoms Absence of affective symptoms
Good compliance Predominant negative symptoms
Normal CT scan Poor compliance
Ventricular enlargement on CT
Family history of schizophrenia
 Course of illness
Variable
Approx 45 % will have good outcome
30% will have intermediate outcome
Approx 25 % will have a poor outcome
 Treatment
Acute

Maintenance Depots

Problems of compliance

Non-pharmacological- Group psychotherapy,

Psychoeducation,
Individual psychotherapy
Psychosocial rehabilitation.
Family therapy is aimed at reduction of expressed emotions (Critical comments, over
involvement, hostility).
 Delusional disorder
Delusions without schizophrenic or mood disorder
Low prevalence -0.025-0.03
Female preponderance

Types
Persecutory
Jealous ,infidelity,othello conjugal paranoia
Erotomanic-de Clerembault,psychose passionelle-Paradoxical conduct
Somatic type (Mono-symptomatic hypochondrial psychosis)-
infestation,Dysmorbhophobia,halitosis
Grandiose
Mixed
Unspecified-Capgras, fregoli, intermetamorphosis, Cotards
 Rule out medical illness
Preceded by stressor
Good prog
female
<30
Good premorbid
Stressor
Sudden onset

Difficult to treat
 Schizophreniform
Gabriel Langdfelt
Retrospective diagnosis
Between mood disorders & schizophrenia
Good prognosis
acute onset
confusion
no blunting
no negative features
good pre-morbid functioning
 Schizo-affective
Jacob Kasanin
Prevalence less than schizophrenia
Mood symptoms and schizophrenic symptoms together
Delusions and hallucinations for 2 weeks without mood
symptoms
Type-bipolar,depressive
Treatment Mood stabilizers
 Brief psychotic Disorder or Acute and
Transient psychotic disorder
Preceded by Stress
Sudden
Labile, confusion, restlessness, emotionally volatile,
aggressive
Good prognostic
APDs bzds