Pemicu 3

Blok Saraf
Jessica Gracia
405140041
LI
• 1. MM gangguan psikosis (teori)
• 2. MM gangguan akut dan kronik
• 3. MM skizofrenia
• 4. MM psikotik
• 5. MM waham
• 6. MM skizoafektif
• 7. MM gg kepribadian
• 8. MM gg afek
• 9. MM diagnosis kerja (aksis)
LI 1 MM gangguan psikosis (teori)
• Early Greek physicians described
• delusions of grandeur, paranoia, and deterioration in cognitive functions and
personality.
• Two major figures in psychiatry and neurology
• Emil Kraepelin (1856-1926)
• Eugene Bleuler (1857-1939).
• Earlier, Benedict Morel (1809-1873),
• a French psychiatrist,
• term demence precoce to describe deteriorated patients whose illnesses began in
adolescence.
• Emil Kraepelin
• Morel’s demence precoce  dementia precox,
• a term that emphasized the change in cognition (dementia) and early onset (precox) of
the disorder.
• described as having a long-term deteriorating course and the clinical symptoms of
hallucinations and delusions
• manic-depressive psychosis
•  those who underwent distinct episodes of illness alternating with periods of normal
functioning
• paranoia
•  characterized by persistent persecutory delusions.
• These patients lacked the deteriorating course of dementia precox and the intermittent
symptoms of manic-depressive psychosis
• Eugene Bleuler
• replaced dementia precox in the literature .
•  term to express the presence of schisms among thought, emotion, and
behavior in patients with the disorder.
• unlike Kraepelin’s concept of dementia precox  schizophrenia need not
have a deteriorating course.
• often misconstrued, to mean split personality.
• Split personality, called dissociative identity disorder, differs completely from
schizophrenia
• identified specific fundamental (or primary) symptoms of schizophrenia:
• associational disturbances of thought, especially looseness, affective disturbances,
autism, and ambivalence,
• summarized as the four As: associations, affect, autism, and ambivalence.
 • Accessory (secondary) symptoms,
• which included the symptoms that Kraepelin saw as major indicators of dementia precox
• hallucinations and delusions.
• Other Theorists
• Ernst Kretschmer (1888-1926)
• 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.
• latter were more likely to incur bipolar disorders.
• Kurt Schneider (1887-1967)
• description of first-rank symptoms, were not specific for schizophrenia
• patients who showed no first-rank symptoms, the disorder could be diagnosed
exclusively on the basis of second-rank symptoms and an otherwise typical clinical
appearance.
• Karl Jaspers (1883-1969).
• played a major role in developing existential psychoanalysis.
• phenomenology of mental illness and the subjective feelings of patients with
mental illness.
• Adolf Meyer (1866-1950).
• saw schizophrenia as a reaction to life stresses.
• It was a maladaptation that was understandable in terms of the patient’s life
experiences.
•  which referred to the schizophrenic reaction.
• In later editions of DSM, the term reaction was dropped.
LI 3 MM Schizophrenia
• Schizophrenia  single disease, comprises a group of disorders with
heterogeneous etiologies.
• Signs and symptoms
• Changes in perception
• Emotion
• cognition
• thinking, and
• behavior.
•  effect of the illness is always severe and is usually long lasting.
• usually begins before age 25 years, persists throughout life, and affects persons of all social
classes.
• Diagnosis of schizophrenia is based entirely on the psychiatric history and mental
status examination.
• There is no laboratory test for schizophrenia..
Epidemiology
• In the United States,
• the lifetime prevalence of schizophrenia is about 1 percent

• Gender and Age

• Equally prevalent in men and women.
• Onset is earlier in men than in women.
• The peak ages of onset  10 to 25 years for men and 25 to 35 years for women.
• 3 to 10% of women with schizophrenia present with disease onset after age 40 years.
• 90% of patients in treatment for schizophrenia  between 15 and 55 years old.
• Onset of schizophrenia before age 10 years or after age 60 years  extremely rare.
• Men are more likely to be impaired by negative symptoms than women
• women more likely to have better social functioning.
• In general, the outcome for female schizophrenia patients is better than that for male
schizophrenia patients.
• When onset occurs after age 45 years,  characterized as late-onset schizophrenia
• Reproductive Factors
• increase in the marriage and fertility rates among persons with schizophrenia.
 number of children born to parents with schizophrenia is continually
increasing.
• First-degree biological relatives of persons with schizophrenia have a ten
times greater risk for developing the disease than the general population
• Medical Illness
• Have higher mortality rate from accidents and natural causes than the general
population
• 80% of all schizophrenia patients have significant concurrent medical illnesses
• 50% of these conditions may be undiagnosed
• Infection and Birth Season
• More likely to have been born in the winter and early spring and less likely to
have been born in late spring and summer.
• Persons with a genetic predisposition for schizophrenia have a decreased
biological advantage to survive season-specific insults
• The etiology of schizophrenia
• Gestational and birth complications,
• exposure to influenza epidemics,
• maternal starvation during pregnancy,
• Rhesus factor incompatibility, and
• an excess of winter births
• Substance Abuse
• The lifetime prevalence of any drug abuse (other than tobacco) is often
greater than 50 percent.
• lifetime prevalence of alcohol within schizophrenia was 40 %.
• Alcohol abuse increases risk of hospitalization and, in some patients, may
increase psychotic symptoms.
• The use of amphetamines, cocaine, and similar drugs  marked ability to increase
psychotic symptoms.
• Nicotine.
• 90% of schizophrenia patients may be dependent on nicotine.
• Nicotine  improve some cognitive impairments and parkinsonism in schizophrenia,
• nicotine-dependent activation of dopamine neurons.
• Population Density
• correlated with city populations of more than 1 million people.
• social stressors in urban settings may affect the development of schizophrenia
in persons at risk.
• Socioeconomic and Cultural Factors
• Economics
• Patients with a diagnosis of schizophrenia are reported to account for 15 to 45 percent of
homeless Americans
• Hospitalization.
• Even with antipsychotic medication, however, the probability of readmission within 2
years after discharge from the first hospitalization  40 to 60%.
Etiology
• Genetic Factors
• There is a genetic contribution to some, perhaps all, forms of schizophrenia,
•  due to additive genetic effects.
• Person having schizophrenia is correlated with the closeness of the relationship to an
affected relative (e.g., first- or second-degree relative).
• In the case of monozygotic twins who have identical genetic endowment,  50 percent
concordance rate for schizophrenia.
• Born from fathers older than the age of 60
• Linkage genetic studies
• lq, 5q, 6p, 6q, 8p, lOp, 13q, 15q, and 22q.
• a-7 nicotinic receptor, DISC 1, GRM 3, COMT, NRG 1, RGS 4, and G 72.
• Mutations of the genes dystrobrevin (DTNBP1) and neureglin 1
•  negative features of schizophrenia
• Biochemical Factors
• Dopamine Hypothesis.
• schizophrenia results from too much dopaminergic activity.
• Efficacy antipsychotic drugs (i.e., the dopamine receptor antagonists [DRAs])  antagonists of the
dopamine type 2 (D 2 ) receptor.
• Drugs that increase dopaminergic activity, (cocaine and amphetamine) are psychotomimetic.
• Excessive dopamine release  severity of positive psychotic symptoms.
• Serotonin excess  positive and negative symptoms in schizophrenia.
• Patients with schizophrenia have a loss of GABAergic neurons in the hippocampus (inhibitory
amino acid neurotransmitter Y-aminobutyric acid)
•  hyperactivity of dopaminergic neurons
• Neuropeptides, such as substance P and neurotensin,
• are localized with the catecholamine and indolamine neurotransmitters
• Alteration in neuropeptide mechanisms  facilitate, inhibit, or otherwise alter the pattern of
firing these neuronal
• Ingestion of phencyclidine, a glutamate antagonist
•  acute syndrome similar to schizophrenia.
• The hypotheses  glutamate include those of hyperactivity, hypoactivity, and glutamate-
induced neurotoxicity
• Acetylcholine and Nicotine.
• schizophrenia  decreased muscarinic and nicotinic receptors in the caudate-putamen,
hippocampus, and selected regions of the prefrontal cortex.
• play a role in the regulation of neurotransmitter systems involved in cognition, which is
impaired in schizophrenia
Neuropathology
• Potential neuropathological basis for schizophrenia,
• Primarily in the limbic system and the basal ganglia,
• including abnormalities in the cerebral cortex, the thalamus, and the brainstem.
• The loss of brain volume result from
• reduced density of the axons, dendrites, and synapses that mediate associative functions of the
brain.
• Cerebral Ventricles.
• (CT) scans  lateral and third ventricular enlargement and some reduction in cortical volume.
• Earliest stages of the disease  reduced volumes of cortical gray matter
• Reduced Symmetry.
• including the temporal, frontal, and occipital lobes.
• Limbic System.
• role in controlling emotions,  pathophysiology of schizophrenia.
• decrease in the size of the region, including the amygdala, the hippocampus, and the
parahippocampal gyrus.
• Prefrontal Cortex.
• Functional deficits in the prefrontal brain imaging region
• Thalamus.
• show evidence of volume shrinkage or neuronal loss, in particular subnuclei.
• The total number of neurons, oligodendrocytes, and astrocytes is reduced by 30 to 45 percent
in schizophrenia
• Basal Ganglia and Cerebellum.
• involved in the control of movement, disease in these areas is implicated in the
pathophysiology of schizophrenia
• schizophrenia show odd movements  awkward gait, facial grimacing, and stereotypies.
• movement disorders involving the basal ganglia (e.g., Huntington’s disease, Parkinson’s disease) 
associated with psychosis.
• Neuropathological studies of the basal ganglia  cell loss or the reduction of volume of the globus
pallidus and the substantia nigra.
• increase in the number of D 2 receptors in the caudate, the putamen, and the accumbens
Neural Circuits
• Schizophrenia as a disorder of brain neural circuits.
•  disorder that involves discrete areas of the brain
• basal ganglia and cerebellum are reciprocally connected to the frontal lobes, and the
abnormalities in frontal lobe function seen in some brain imaging studies may be due to
disease in either area rather than in the frontal lobes themselves.
• Early developmental lesion of the dopaminergic tracts to the prefrontal cortex
• results in the disturbance of prefrontal and limbic system function
•  positive and negative symptoms and cognitive impairments observed in patients with
schizophrenia
Brain Metabolism
• Patients with schizophrenia had lower levels of phosphomonoester and
inorganic phosphate and higher levels of phosphodiester than a control
group.
• concentrations of N-acetyl aspartate, a marker of neurons,
• were lower in the hippocampus and frontal lobes of patients with schizophrenia
Applied Electrophysiology
• Schizophrenia patients have abnormal records,
• increased sensitivity to activation procedures
• frequent spike activity after sleep deprivation,
• decreased alpha activity,
• increased theta and delta activity,
• possibly more epileptiform activity than usual, and
• possibly more left-sided abnormalities than usual.
• exhibit an inability to filter out irrelevant sounds and are extremely sensitive to background noise.
• Complex partial epilepsy
• Schizophrenia-like psychoses have been reported to occur more frequently than expected in
patients with complex partial seizures, especially seizures involving the temporal lobes.
• Factors associated with the development of psychosis
• a left-sided seizure focus,
• medial temporal location of the lesion, and an
• early onset of seizures.
• The first-rank symptoms  symptoms of patients with complex partial epilepsy and may
reflect the presence of a temporal lobe disorder when seen in patients with schizophrenia
• Evoked Potentials.
• The P300 defined as a large, positive evoked-potential wave that occurs about
300 milliseconds after a sensory stimulus is detected.
• The major source  located in the limbic system structures of the medial temporal
lobes.
• Schizophrenia  smaller P300
• More common in children have affected parents,
• Other evoked potentials  N100 and the contingent negative variation.
• is a negative wave that occurs about 100 milliseconds after a stimulus
Eye Movement Dysfunction
• inability to follow a moving visual target accurately
• Eye movement dysfunction may be a trait marker for schizophrenia
• abnormal eye movements in 50 to 85 percent of patients with schizophrenia
Psychoneuroimmunology
• decreased T-cell interleukin-2 production,
• reduced number and responsiveness of peripheral lymphocytes,
• abnormal cellular and humoral reactivity to neurons, and
• the presence of brain-directed (antibrain) antibodies.
Diagnosis
• The DSM-5 diagnostic criteria
• presence of hallucinations or delusions is not necessary for a diagnosis of
schizophrenia
• the patient’s disorder is diagnosed as schizophrenia
• exhibits two of the symptoms listed in symptoms 1 through 5 of Criterion A in Table 7.1-1
(e.g., disorganized speech).
• Criterion B requires that impaired functioning, although not deteriorations, be present
during the active phase of the illness.
• Symptoms must persist for at least 6 months, and
• a diagnosis of schizoaffective disorder or mood disorder must be absent
Sub-types
• Paranoid Type.
• characterized by preoccupation with one or more delusions or frequent
auditory hallucinations.
• Classically, characterized mainly by the presence of delusions of persecution or grandeur
• first episode of illness at an older age than do patients with catatonic or
disorganized schizophrenia.
• ego resources of paranoid patients tend to be greater than those of patients
with catatonic and disorganized schizophrenia.
• show less regression of their mental faculties, emotional responses, and
behavior than do patients with other types of schizophrenia
• paranoid schizophrenia
• are typically tense, suspicious, guarded, reserved, and sometimes hostile or aggressive,
•  but they can conduct themselves in social situations.
• Their intelligence in areas not invaded
• Disorganized Type.
• characterized by a marked regression to primitive, disinhibited, and
unorganized behavior and by absence of symptoms that meet the criteria for
the catatonic type
• The onset generally early, occurring before age 25 years.
• Disorganized patients are usually active but in an aimless, non constructive
manner.
• appearance is disheveled, and their social behavior and the emotional responses
inappropriate.
• burst into laughter with out any apparent reason.
• Incongruous grinning and grimacing e common in these patients, whose behavior is best
described as silly or fatuous.
• Catatonic type.
• The classic feature of the catatonic type is a marked disturbance in motor
function;
• may involve stupor, negativism, rigidity, excitement, or posturing.
• Sometimes the patient shows a rapid alteration between extremes of
excitement and stupor.
• patients need careful supervision to prevent them om hurting themselves or
others.
• Medical care may be needed because of malnutrition, exhaustion, hyperpyrexia, or self-
in icted injury.
• Undifferentiated Type.
• cannot be easily fit into one type or another.
• Residual Type.
• continuing evidence of the schizophrenic disturbance in e absence of a
complete set of active symptoms or of sufficient symptoms to meet the
diagnosis of another type.
• Emotional blunting,
• social withdrawal,
• eccentric behavior,
• illogical thinking,
• When delusions or hallucinations occur,  neither prominent nor
accompanied by strong affect
Other sub-type
• Bouffee Delirante (Acute Delusional Psychosis)
• duration of less than 3 months.
• 40 percent of patients with a diagnosis of this progress  schizophrenia.
• Latent.
• was diagnosis used for what now called borderline, schizoid, and schizotypal
personality disorders.
• These patients may occasionally show peculiar behaviors or thought disorders
• but do not consistently manifest psychotic symptoms.
• the past, the syndrome was also termed borderline schizophrenia
• Oneiroid
• refers to a dream-like state in which patients may be deeply perplexed and
not fully oriented in time and place.
• engaged in their hallucinatory experiences to the exclusion of involvement in
the real world.
• Paraphrenia.
• synonym for paranoid schizophrenia or
• for either a progressively deteriorating course of illness or the presence of a
well systemized delusional system.
• Pseudoneurotic Schizophrenia.
• Occasionally, patients who initially have such symptoms as anxiety, phobias,
obsessions, and compulsions  later reveal thought disorder and psychosis. T
• characterized by symptoms of
• pananxiety, panphobia, panambivalence, and sometimes chaotic sexuality.
• This condition is currently diagnosed as borderline personality disorder.
• Simple Deteriorative Disorder (Simple Schizophrenia).
• characterized by a gradual, insidious loss of drive and ambition.
• Patients with the disorder are usually not overtly psychotic and do not
experience persistent hallucinations or delusions.
• Their primary symptom is withdrawal fom social and work-related situations.
• Postpsychotic Depressive Disorder of Schizophrenia.
• After an acute schizophrenia episode, some patients become depressed.
• closely resemble the symptoms of the residual phase of schizophrenia and
the adverse effects of commonly used antipsychotic medications.
• These depressive states occur in up to 25 % of patients with schizophrenia
and are associated with an increased risk of suicide.
• Early-Onset Schizophrenia.
• A small minority of patients manifest schizophrenia in childhood.
• diagnosis of childhood schizophrenia may be based on the same symptoms
used for adult.
• Its onset is usually insidious, its course tends to be chronic, and the prognosis
is mostly unfavorable.
• Late-Onset Schizophrenia.
• clinically indistinguishable from schizophrenia but has an onset a er age 45
years.
• more frequently in women and tends to be characterized by a pre dominance
of paranoid symptoms.
• The prognosis is favorable, and these patients usually do well on antipsychotic
medication.
• Deficit Schizophrenia.
• were said to exhibit the deficit syndrome.
• Deficit patients have a more severe course of illness than non deficit patients,
with a higher prevalence of abnormal involuntary movements before
administration of antipsychotic drugs
Clinical features
• no clinical sign or symptom is pathognomonic for schizophrenia
• a patient's symptoms change with time
• clinicians must take into account the patient's educational level, intellectual
ability, and cultural and subcultural membership
• Premorbid Signs and Symptoms
• Appear before the prodromal phase of the illness
• patients had schizoid or schizotypal personalities characterized as
• quiet, passive, and introverted;
• as children, they had few friends.
• Preschizo phrenic adolescents may have no close friends and no dates and may avoid team
sports.
• Some adolescent patients may show a sudden onset of obsessive-compulsive behavior as part
of the prodromal picture .
• signs and symptoms have been present for months or even years
• somatic symptoms, such as headache, back and muscle pain, weakness, and
digestive problems.
• The initial diagnosis may be malingering, chronic fatigue syndrome, or
somatization disorder.
• patient may begin to develop an interest in abstract ideas, philosophy, and
occult or religious questions
• Additional prodromal signs d symptoms can include markedly peculiar behavior,
abnormal affect, unusual speech, bizarre ideas, and strange perception
Schizophrenia [Clinical Features]
Mental Status Examination
• The appearace of a patient with schizophrenia can range from that of a
completely disheveled, screaming, agitated person to an obsessively
groomed, completely silent, and immobile person.
• Between these two poles, patients may be talkative and may exhibit bizarre
postures.
• Their behavior may become agitated or violent, apparently in an
unprovoked manner, but usually in response to hallucinations.
• In contrast, in catatonic stupor (catatonia) 
• seem completely lifeless
• exhibit muteness, negativism, & automatic obedience.
• sit immobile & speechless in their chairs
• respond to questions with only short answers
• move only when directed to move.

Source: Kaplan and Sadocks Synopsis of Psychiatry 15.

Schizophrenia [Clinical Features]
Mental Status Examination
• MENTAL STATUS EXAMINATION
• Less extreme subtype of catatonia 
• show marked social withdrawal & egocentricity
• a lack of spontaneous speech or movement
• absence of goal-directed behavior.
• Other obvious behavior  odd clumsiness or stiffness in body movements, signs 
indicating a disease process in the basal ganglia.
• Patients with schizophrenia 
• poorly groomed
• fail to bathe
• dress much too warmly for the prevailing temperatures.
• Other odd behaviors include 
• Tics
• Stereotypies
• Mannerism
• Echopraxia

Source: Kaplan and Sadocks Synopsis of Psychiatry 15.

Schizophrenia [Clinical Features]
Mood, Feelings, and Affect
• Perceptual Disturbance
• Hallucinations
• Any of the 5 senses  may be affected by hallucinatory experiences in patients with
schizophrenia.
• The most common hallucinations  auditory
• often threatening, obscene, accusatory, or insulting
• 2/> voices  converse among themselves, or a voice may comment on the patient's life or
behavior.
• Visual hallucinations  common
• Tactile, olfactory, & gustatory hallucinations  unusual  if (+)  possibility of an underlying
medical or neurological disorder that is causing the entire syndrome.
• Cenesthetic Hallucinations  unfounded sensations of altered states in bodily organs.
• Burning sensation in the brain
• A pushing sensation in the blood vessels
• A cutting sensation in the bone marrow.
• Bodily distortions may also occur.

Source: Kaplan and Sadocks Synopsis of Psychiatry 15.

Schizophrenia [Clinical Features]
Mood, Feelings, and Affect
• Thought
• Disorders of thought  the most difficult symptoms  may be the core
symptoms of schizophrenia.
• Dividing the disorders of thought
• Disorders of thought content
• Form of thought
• Thought process

Source: Kaplan and Sadocks Synopsis of Psychiatry 15.

Schizophrenia [Clinical Features]
Mood, Feelings, and Affect
• Thought
1. Disorders of thought content
• Reflect  patient's ideas, beliefs, & interpretations of stimuli.
• Delusions (most obviously)  are varied in schizophrenia  may assume persecutory, grandiose,
religious, or somatic forms.
• Patients may believe that  outside entity controls their thoughts or behavior or, conversely, that they
control outside events in an extraordinary fashion (causing the sun to rise & set or by preventing earthquakes).
• Patients may also worry about allegedly life-threatening but bizarre and implausible somatic conditions
(aliens inside the patient's testicles affecting his ability to father children)
• The phrase loss of ego boundaries  lack of a clear sense of where the patient's own body, mind, &
influence end and where those of other animate & inanimate objects begin.
• Patients may think that other persons, the television, or the newspapers are referring to them (ideas of
refrence).
• physically fused with an outside object (e.g., a tree or another person) or that the patient has disintegrated and
fused with the entire universe (cosmic identity).
• With such a state of mind, some patients with schizophrenia doubt their gender or their sexual
orientation.
• These symptoms should not be confused with ansvestism, transsexuality, or other gender identity
problems.

Source: Kaplan and Sadocks Synopsis of Psychiatry 15.

Schizophrenia [Clinical Features]
Mood, Feelings, and Affect
• Thought
2. Form of thought
• Disorders of the form of thought  objectively observable in patients' spoken and written
language.
• The disorders include looseness of associations, derailment, incoherence, tangentiality,
circumstantiality, neologisms, echolalia, verbigeration, word salad, and mutism.
• Distinguishing between looseness of associations & tangentiality  difficult
• The following sample from with schizophrenia  preoccupation with the mind, the Trinity,
and other esoteric matters  peculiar restructuring of concepts by hyphenating the words
germ-any (the patient had a distinct fear of germs) and infer-no (inferring that there will be
no salvation).
• common factor in the thought process above  preoccupation with invisible forces,
radiation, witchcraft, religion, philosophy, and psychology and a leaning toward the esoteric,
the abstract, and the symbolic.
• Consequently, the thinking of a person with schizophrenia is characterized simultaneously by both
an overly concrete and an overly symbolic nature.

Source: Kaplan and Sadocks Synopsis of Psychiatry 15.

Schizophrenia [Clinical Features]
Mood, Feelings, and Affect
• Impulsiveness, Violence, Suicide, and Homicide
• Patients with schizophrenia  may be agitated & have little impulse control
when ill.
• also have ⬇ social sensitivity & appear to be impulsive (grab another patient's cigarettes,
change television channels abruptly, or throw food on the floor).
• Some apparently impulsive behavior, including suicide & homicide attempts,
may be in response to hallucinations commanding the patient to act.

Source: Kaplan and Sadocks Synopsis of Psychiatry 15.

Impulsiveness, Violence, Suicide, and
Homicide. VIOLENCE:
• Violent behavior (excluding homicide): common
among untreated patients
• Delusions, previous episodes of violence, and
neurological deficits  risk factors
• Management: antipsychotic medication
• Lorazepam 1 - 2 mg IM, every hours as
needed
• Emergency treatment: restraints and seclusion
SUICIDE:
• leading cause of premature death
• most important factor is the presence of a major
HOMICIDE:
depressive episode.
• Patient with schizophrenia murders someone,
• for unpredictable or bizarre reasons based on
hallucinations or delusions
• Possible predictors: history of previous violence,
dangerous behavior while hospitalized, and
hallucinations or delusions involving such violence
Sensorium and Cognition
Orientation:
• usually oriented to person,
time, and place
• lack of such orientation 
investigate the possibility of a
medical or neurological brain
disorder
Memory:
• usually intact, but there can
be minor cognitive
deficiencies
Cognitive Impairment: Reliability:
• exhibit subtle cognitive • A patient with schizophrenia is
dysfunction in the domains of no less reliable than any other
attention, executive function, psychiatric patient
working memory, and
episodic memory
Judgment and Insight:
• patients with schizophrenia
are described as having poor
insight
Somatic Comorbidity
• Neurological Findings.
• Localizing and nonlocalizing neurological signs
• Nonlocalizing signs: dysdiadochokinesia, astereognosis, primitive reflexes, and
diminished dexterity
• neurological signs + symptoms  increased severity of illness, affective blunting, and
a poor prognosis
• Other abnormal neurological signs: tics, stereotypies, grimacing, impaired fine motor
skills, abnormal motor tone, and abnormal movements
• Eye Examination
• patients with schizophrenia have an elevated blink rate  reflect hyperdopaminergic
activity
• Speech.
• disorders of speech Indicate a thought disorder, a forme fruste of aphasia
Other Comorbidity
• Obesity.
• Patients with schizophrenia appear to be more obese  effect of many antipsychotic medications, poor
nutritional balance and decreased motor activity
• Diabetes Mellitus.
• Schizophrenia is associated with an increased risk of type II diabetes mellitus
• Due to the obesity, antipsychotic medications
• Cardiovascular Disease
• Many antipsychotic medications have direct effects on cardiac electrophysiology
• HIV.
• Patients with schizophrenia appear to have a risk of HIV infection that is 1.5 to 2 times that of the general
population
• Chronic Obstructive Pulmonary Disease
• Rates of chronic obstructive pulmonary disease are reportedly increased in schizophrenia compared with the
general population
• Rheumatoid Arthritis
• approximately one-third the risk of rheumatoid arthritis
DIFFERENTIAL
DIAGNOSIS
Course
• premorbid pattern of symptoms begin in adolescence  prdromal
symptoms into days to a few months  Social or environmental
changes precipitate the disturbing symptoms  prodromal syndrome
may last a year or more before the onset
Prognosis
Hospitalization
• indicated for:
• diagnostic purposes
• stabilization of medications
• patients’ safety
• grossly disorganized or inappropriate behavior (the inability to take care of
basic needs)
• 4 to 6 weeks : as effective as long-term hospitalizations
Treatment of Acute Psychosis
• 4– 8 weeks
• If patients are receiving an agent associated with extrapyramidal side effects (first-generation
antipsychotic)  trial with an anticholinergic anti-Parkinson medication, benzodiazepine, or
propranolol
• Antipsychotics and benzodiazepines  rapid calming of patients
• highly agitated patients  IM administration for rapid effect
• single intramuscular injection of
• haloperidol
• fluphenazine
• olanzapine
• ziprasidone
• calming effect without excessive sedation
• Low-potency antipsychotics, IM  often associated with sedation and postural hypotension
• Benzodiazepines  effective during acute psychosis
Treatment During Stabilization and
Maintenance Phase
• Goals: prevent psychotic relapse and to assist patients in improving
their level of functioning
• Recommendation: multiepisode patients receive maintenance
treatment for at least 5 years
• Noncompliance: very high
• 40-50 % of patients become noncompliant within 1 or 2 years
• Compliance increases when long-acting medication is used instead of oral
medication
MANAGING SIDE EFFECTS
• clinical response may be delayed for days or weeks after drugs are
started, side effects may begin almost immediately
• low-potency drugs
• sedation, postural hypotension, and anticholinergic effects
• high-potency drugs
• extrapyramidal side effects
Extrapyramidal Side Effects
• alternatives for treating extrapyramidal side effects
• reducing the dose
• adding an anti-Parkinson medication: anticholinergic anti-Parkinson drugs
• changing the patient to an SDA that is less likely to cause extrapyramidal side effects
• side effects: dry mouth, constipation, blurred vision, memory loss
• clinicians may consider prescribing prophylactic anti-Parkinson medications
• include patients who have a history of extrapyramidal side effect sensitivity
• indicated when high-potency drugs are prescribed for young men who tend to have an
increased vulnerability for developing dystonias
• For patients who highly sensitive to extrapyramidal side effects at the therapeutic
dose  medication side effects may seem worse than the illness
• should be treated routinely with an SDA
• result in substantially fewer extrapyramidal side effects than the DRAs.
Tardive Dyskinesia
• 20 to 30 % of patients on long-term treatment with a conventional DRA 
exhibit symptoms
• risk in elderly patients is much higher
• it can affect walking, breathing, eating, and talking when it occurs
• Recommendations for preventing and managing
• using the lowest effective dose of antipsychotic
• prescribing cautiously with children, elderly patients, and patients with mood
disorders
• examining patients on a regular basis for evidence of tardive dyskinesia
• considering alternatives to the antipsychotic being used and considering dosage
reduction when tardive dyskinesia is diagnosed
• considering a number of options if the tardive dyskinesia worsens (discontinuing the
antipsychotic or switching to a different drug)
Other Side Effects
• Sedation and postural hypotension
• low-potency DRAs
• elevate prolactin levels
• All DRAs, as well as SDAs
• galactorrhea and irregular menses
• Long-term elevations in prolactin  suppress gonadotropin-releasing
hormone  suppression in gonadal hormones
• effects on libido and sexual functioning
• Elevated prolactin may cause decreases in bone density and lead to
osteoporosis
Health Monitoring in Patients Receiving
Antipsychotics
• Patients should be weighed and their BMIs calculated for every visit
for 6 months after a medication change
Side Effects of Clozapine
• agranulocytosis.
• weekly blood monitoring for the first 6 months and biweekly monitoring for
the next 6 months
• After 1 year of treatment without hematological problems, monitoring can be
performed monthly
• seizures
• reducing the dose and adding an anticonvulsant (valproate)
• hypersalivation, sedation, tachycardia, weight gain, diabetes, fever,
and postural hypotension
OTHER BIOLOGICAL THERAPIES
• Electroconvulsive therapy (ECT)  acute and chronic schizophrenia
• as effective as antipsychotic medications and more effective than
psychotherapy
• antipsychotic medications + ECT is more effective than antipsychotic
medications alone
PSYCHOSOCIAL THERAPIES
• variety of methods to
• increase social abilities
• selfsufficiency
Social Skills Training
• sometimes referred to as behavioral skills therapy
• can be directly supportive and useful to the patient
• poor eye contact, unusual delays in response, odd facial expressions,
lack of spontaneity in social situations, and inaccurate perception or
lack of perception of emotions in other people
Family-Oriented Therapies
• therapists must help both the family and the patient understand and
learn about schizophrenia
• Therapists must control the emotional intensity of family sessions
with patients with schizophrenia
• excessive expression of emotion during a session can damage a
patient’s recovery process
LI 4 BRIEF PSYCHOTIC DISORDER
• psychotic condition
• sudden onset, lasts 1 day or more but less than 1 month
• Remission  premorbid level of functioning
• acute and transient psychotic syndrome
• occurs more often among younger patients (20s and 30s) than among
older patients
• Women > men
• Low socioeconomic classes and in those who have experienced disasters or
major cultural changes (e.g., immigrants).
• often seen in patients with personality disorders
Etiology
• unknown.
• Patients, personality disorder  biological or psychological
vulnerability for the development of psychotic symptoms
• borderline, schizoid, schizotypal, or paranoid qualities
• psychodynamic theories suggest:
• psychotic symptoms are a defense against a prohibited fantasy, the fulfillment
of an unattained wish, or an escape from a stressful psychosocial situation
Diagnosis
• psychotic symptoms last at least 1 day but less than 1 month and are
not associated with a
• mood disorder,
• a substance-related disorder,
• or a psychotic disorder caused by a general medical condition.
• Three subtype:
1. the presence of a stressor
2. the absence of a stressor
3. a postpartum onset
Clinical Features
• always include at least one major symptom of psychosis
• hallucinations,
• delusions,
• disorganized thoughts
• labile mood, confusion, and impaired attention  may be more common
at the onset of brief psychotic disorder than the chronic psychotic disorder
• Characteristic symptoms in brief psychotic disorder:
• Emotional volatility,
• strange or bizarre behavior
• screaming or muteness
• impaired memory of recent events
• Precipitating Stressors
• Ex: major life events that would cause any person significant emotional upset
Differential Diagnosis
• psychotic symptoms > 1 month  schizophreniform disorder,
schizoaffective disorder, schizophrenia, mood disorders with
psychotic features, delusional disorder, and psychotic disorder not
otherwise specified
• psychotic symptoms of sudden onset < 1 month in response to an
obvious stressor  brief psychotic disorder
• DD:
• factitious disorder
• malingering,
• psychotic disorder caused by a general medical condition
• Substance induced psychotic disorder
Course and Prognosis
• brief psychotic disorder is less than 1 month
• development of such a significant psychiatric disorder  signify a
patient’s mental vulnerability
• generally have good prognoses
• acute and residual symptoms: few days
• Suicide: concern during both the psychotic phase and the
postpsychotic depressive phase
Treatment
• Hospitalization.
• evaluation and protection
• Evaluation: close monitoring of symptoms and assessment of the patient’s
level of danger to self and others
• While clinicians wait for the setting or the drugs to have their effects,
seclusion, physical restraints, or one-to-one monitoring of the patient
may be necessary
Pharmacotherapy.
• antipsychotic drugs and the benzodiazepines
• antipsychotic drug: high-potency antipsychotic drug
• Ex: haloperidol or a serotonin dopamine agonist such as ziprasidone
• Px with high risk for the development of extrapyramidal adverse
effects
• Use Serotonin dopamine antagonist drug as prophylaxis
• Alternative: benzodiazepam in short-term treatment of psychosis
• Clinicians should avoid long-term use of any medication in the
treatment of the disorder
Psychotherapy.
• discuss the stressors and the psychotic episode
• helping patients deal with the loss of self-esteem and to regain self-
confidence
• Family involvement in the treatment process may be crucial to a
successful outcome
Classification of Antipsychotic drugs
• Main categories are:
• Typical antipsychotics
Phenothiazines (chlorpromazine, perphenazine,
fluphenazine, thioridazine et al)
Thioxanthenes (flupenthixol, clopenthixol)
Butyrophenones (haloperidol, droperidol)
• Atypical antipsychotics (e.g. clozapine, risperidone, sulpiride,
olanzapine)
Classification of Antipsychotic drugs
• Distinction between ‘typical’ and ‘atypical’ groups
is not clearly defined, but rests on:
• Incidence of extrapyramidal side-effects (less in
‘atypical’ group)
• Efficacy in treatment-resistant group of patients
• Efficacy against negative symptoms.
 MECHANISM OF ACTION
There are many type of DA-receptors (see upper).
The antipsychotic drugs probably owe their therapeutic effects mainly to
blockade of D2 receptors. The main groups, phenothiazines, thioxanthines
and butyrophenones, show preference for D2 over D1 receptors; some newer
agents (e.g. remoxipride) are highly selective for D2 receptors, whereas
clozapine is relatively non-selective between D1 and D2, but has high affinity
for D4.
DA, the naturally occurring agonist, interacts with D1 and D2 receptors, and
both receptors are found in high density in the corpus striatum and nucleus
accumbens. Most striatal neurons have D1 responses and most
accumbens neurons have D2 responses.

84
 Phenothiazines
• Chlorpromazine

Pharmacologic effects and mechanism:

(1) CNS: a. neuroleptic effect--- D1, D5---D1-like receprtors
D2-4------D2-like receptors

• Antipsychotic drugs probably owe their therapeutic effects mainly to blockade

of D2-receptors (lies in midbrain-cortex and midbrain-limbic system ).

b. antiemetic effect--- inhibit chemoreceptor trigger zone

or directly depress the medullary vomiting center.
c. temperature-regulating effect--- produce hypothermia
Phenothiazines
Pharmacologic effects:
(2) autonomic nervous system: block α-adrenergic
and M-Cholinergic receptors and result in
hypotension, dry mouth, constipation and blurred
vision.
(3) Endocrine system: increase the release of prolactin
and decrease corticotropin release and secretion of
pituitary growth hormone.
Therapeutic uses
• (1) treatment of psychotic disorders: schizophrenia, mania, paranoid
states, alcoholic hallucinosis.
• (2) treatment of nausea and vomiting of certain causes.
• (3) anesthesia in hypothermia and artificial hibernation (used with
pethidine and promethazine).
Adverse Effects

• Extrapyramidal motor disturbances: (1) Parkinson-

like symptoms; (2) akathisia; (3) acute dystonias.
Treatment: anticholinergic
Adverse Effects

• Tardive dyskinesia comprises mainly involuntary

movements of face and tongue, but also of trunk
and limbs, appearing after months or years of
antipsychotic treatment. It may be associated with
proliferation of dopamine receptors (possibly
presynaptic) in corpus striatum. Treatment is
generally unsuccessful.
Adverse Effects

• Pseudodepression and Schizophrenia-like

syndrome.
• Seizures.
• Cardiac toxicity and endocrine effects.
Adverse Effects
• Other side-effects (dry mouth, constipation,
blurred vision, hypotension, etc.) are due to block
of other receptors, particularly α–adrenoceptors
and muscarinic ACh receptors.
Contact dermatitis, blood dyscrasias, obstructive
jaundice sometimes occurs with phenothiazines.
Thioxanthenes
• Chlorprothixene: mild antipsychotic action, and antianxiety and
antidepressant action.
Butyrophenones
• Haloperidol: control psychomotor excitement.
• Adverse effects: severe extrapyramidal symptoms.
Others
• Clozapine:
• (1) be effective in treating some patients with
psychosis unresponsive to standard neuroleptic
drug.
• (2) blocks D4 receptor and have low affinity for D1
and D2 dopamine receptors.
• (3) lacks extrapyramidal side effects.
• (4) must monitor the granulocyte counts weekly.
Others

• Risperidone: be used first episode in and chronic

schizophrenia.
Clinical Efficacy of Antipsychotic Drugs
• Antipsychotic drugs are effective in controlling symptoms of acute
schizophrenia, when large doses may be needed.
• Long-term antipsychotic treatment is often effective in preventing
recurrence of schizophrenic attacks, and is a major factor in allowing
schizophrenic patients to lead normal lives.
Clinical Efficacy of Antipsychotic Drugs
• Depot preparations are often used for maintenance therapy.
• Antipsychotic drugs are not generally effective in improving negative
schizophrenic symptoms.
• Approximately 40% of chronic schizophrenic patients are poorly
controlled by antipsychotic drugs; clozapine may be effective in some
of these ‘antipsychotic-resistant’ cases.
102
Mood altering drug
Ⅰ. Mood-stabilizing: lithium carbonate
Mechanism
(1) effects on electrolyte and ion transport. (2)
effects on neurotransmitters---NA, DA. (3) effects
on second messengers— hormone-sensitive
adenylate.
Therapeutic uses: prevention of bipolar illness and
treatment of acute mania.
Ⅰ. Mood-stabilizing: lithium carbonate

Adverse effects:
(1) Nausea, vomiting and diarrhoea.
(2) Tremor.
(3) Renal effect: polyuria (with resulting thirst)
(4) Various neurological effects, progressing from confusion and motor
impairment , to coma, convulsion and death.
♫ narrow therapeutic limit for the plasma means the monitoring is
essential.
Ⅱ.antidepressant
• Types of antidepressant drug
Tricyclic antidepressant (TCA): imipramine
amitriptyline

Selective 5-HT uptake inhibitors: Fluoxetine,paro

xetine,
sertraline
NE uptake inhibitors: desipramine

Atypical antidepressant: phenelzine

imipramine
Mechanism: block the amines (NE and 5-HT).
Pharmacologic effects:
• (1) CNS: a nondepressed person experiences sleeping. In the
depressed patient, an elevation of mood occurs 2-3 weeks after
administration begins.
• (2) autonomic nervous system: anticholinergic effects.
• (3) cardiovascular effects: orthostatic hypotension and arrhythmias.
Therapeutic uses
• (1) Treatment of severe endogenous depression
(characterized by regression and inactivity).
• (2) Treatment of enuresis.
• (3) Treatment of obsessive-compulsive neurosis
accompanied by depression, and phobic-anxiety
syndromes, chronic pain and neuralgia.

Adverse effects: anticholinergic effects

Fluoxetine
Mechanism of action:
• (1) is a selective inhibitor of serotonin uptake in the CNS.
• (2) has little effect on central norepinephrine and dopamine function.
• (3) has less adverse effects because of minimal binding to cholinergic,
histaminic, and α-adrenergic receptors.
• Therapeutic uses:
• (1) is used for treatment of mild to moderate
endogenous depression.
• (2) be useful in treating obsessive-compulsive
disorder, obesity.
Adverse effects:
• (1) cause anorexia.
• (2) precipitate mania or hypomania.
• (3) result in nausea, nervousness, headache, and
insomnia.
• (4) cause 5-HT syndromes (hyperpyrexia,
convulsions, and coma) when combinated with
and MAO inhibitor.
LI 6 Schizoaffective Disorder
• features of both schizophrenia and mood disorders
• Diagnosis:
1. patients with schizophrenia who have mood symptoms
2. patients with mood disorder who have symptoms of schizophrenia
3. Patients with both mood disorder and schizophrenia
4. patients with a third psychosis unrelated to schizophrenia and mood
disorder
5. patients whose disorder is on a continuum between schizophrenia and
mood disorder
6. patients with some combination of the above
• Equal numbers of men and women who have the bipolar subtype
• more than twofold female to male predominance among individuals
with the depressed subtype of schizoaffective disorder
• depressive type: common in older persons
• bipolar type: common in young adults
• age of onset for women is later than that for men
ETIOLOGY
• unknown.

• may be a type of schizophrenia, a type of mood disorder, or the

simultaneous expression of each.
• family and genetic
• disrupted in schizophrenia 1 (DISC1) gene  possible
• schizoaffective disorder have a better prognosis than patients with
schizophrenia and a worse prognosis than patients with mood
disorders
DIAGNOSIS AND CLINICAL FEATURES
DIFFERENTIAL DIAGNOSIS
• Mood disorders and for schizophrenia
• substance use  substance-induced disorder
• Psychotic disorder caused by seizure disorders
COURSE AND PROGNOSIS
• course similar to an episodic mood disorder, a chronic schizophrenic
course, or some intermediate outcome
• After 1 year, patients with schizoaffective disorder had different
outcomes, depending on whether their predominant symptoms were
affective (better prognosis) or schizophrenic (worse prognosis).
TREATMENT
• Mood stabilizers
• Ex: lithium, carbamazepine
• these medications are used extensively alone, in combination with each
other, or with an antipsychotic agent
• manic episodes: dosages, middle to high
• Maintenance phase: reduce to avoid adverse effect
• schizoaffective have major depressive episodes  Treatment with
antidepressants mirrors treatment of bipolar depression
• Selective serotonin reuptake inhibitors
• sertraline
• less effect on cardiac status and have a favorable overdose profile
Psychosocial Treatment
• combination of family therapy, social skills training, and cognitive
rehabilitation
Delusional Disorder
• Delusions: false fixed beliefs not in keeping with the culture
• Diagnosis: when a person exhibits nonbizarre delusions of at least 1
month’s duration that cannot be attributed to other psychiatric disorders
• Nonbizarre: delusions must be about situations that can occur in real life,
such as being followed, infected, loved at a distance, and so on
• delusional disorder is much rarer than schizophrenia
• mean age of onset: 40 years
• range for age of onset: 18 – 90s
• Men are more likely to develop paranoid delusions than women
• slight preponderance of female patients exists
ETIOLOGY
• unknown.

• Biological Factors
• not everyone with a brain tumor, for example, has delusions
• neurological conditions: delusions affect the limbic system and the basal
ganglia
• Delusional disorder can arise as a normal response to abnormal experiences
in the environment (PNS or CNS)
Psychodynamic Factors
• many patients: socially isolated and have attained less than expected
levels of achievement
• psychodynamic theories about the cause and the evolution of
delusional symptoms involve suppositions regarding hypersensitive
persons and specific ego mechanisms, which are reaction formation,
projection, and denial
• Freud’s Contributions
• Delusions: part of a healing process
• projection as the main defense mechanism in paranoia
• Paranoid Pseudocommunity
• seven situations that favor the development of delusional disorders: an increased
expectation of receiving sadistic treatment, situations that increase distrust and suspicion,
social isolation, situations that increase envy and jealousy, situations that lower self-esteem,
situations that cause persons to see their own defects in others, and situations that increase
the potential for rumination over probable meanings and motivations
• Frustration  withdrawn and anxious  realize something is wrong  seek explanation for
the problem and crystallize a delusional system as a solution
• Elaboration of the delusion to include imagined persons and attribution of malevolent
motivations to both real and imagined persons
• projected fears and wishes to justify the patient’s aggression and to provide a tangible target
for the patient’s hostilities
• Other Psychodynamic Factors.
• many, if not all, paranoid patients experience a lack of trust in relationships
• hostile family environment,
• Erik Erikson’s concept of trust versus mistrust in early development
• Defense Mechanisms
• Patients with delusional disorder use primarily the defense mechanisms of reaction
formation, denial, and projection.
• reaction formation: defense against aggression, dependence needs, and feelings of
affection and transform the need for dependence into staunch independence
• Denial: avoid awareness of painful reality
• they project their resentment and anger onto others and use projection to protect
themselves from recognizing unacceptable impulses in themselves
• Other Relevant Factors.
• social and sensory isolation, socioeconomic deprivation, and personality
disturbance
Mental Status
• General Description
• usually well groomed and well dressed
• yet they may seem eccentric, odd, suspicious, or hostile
• sometimes litigious
• Patients may attempt to engage clinicians as allies in their delusions 
clinician should not pretend to accept the delusion  distrust
• Mood, Feelings, and Affect
• Mood: consistent with the content of their delusions
• grandiose delusions: euphoric;
• persecutory delusions: suspicious
• Perceptual Disturbances
• Patients: do not have prominent or sustained hallucinations
• Few patients: hallucinatory experiences – auditory rather than visual
• Thought.
• Disorder of thought content: delusions
• usually systematized and are characterized as being possible (e.g., delusions
of being persecuted, having an unfaithful spouse, being infected with a virus,
or being loved by a famous person)
• some may be verbose, circumstantial, or idiosyncratic in their speech when
they talk about their delusions
• Sensorium and Cognition.
• ORIENTATION.: usually have no abnormality in orientation unless they have a
specific delusion about a person, place, or time
• MEMORY.: intact in patients with delusional disorder
• Impulse Control
• Clinicians must evaluate ideation or plans to act on their delusional material
by suicide, homicide, or other violence
• Destructive aggression: most common in patients with a history of violence
• If patients cannot control their impulses  hospitalization
• Judgment and Insight
• no insight into their condition and are almost always brought to the hospital
by the police, family members, or employers
• Reliability.
• usually reliable in their information
• except when it impinges on their delusional system
TYPES
• Persecutory Type
• Patients: convinced that they are being persecuted or harmed
• Beliefs are often associated with querulousness, irritability, and anger, and the
individual who acts out his or her anger may at times be assaultive or even homicidal
• Jealous Type
• usually affects men, with no prior psychiatric illness
• may appear suddenly
• serve to explain a host of present and past events involving the spouse’s behavior
• difficult to treat and may diminish only on separation, divorce, or death of the
spouse
• can be potentially dangerous and has been associated with violence, notably both
suicide and homicide
• Physical and verbal abuse occur more frequently
Erotomanic Type
• delusional conviction that another person,
usually of higher status, is in love with him • characteristics:
or her
• Patients: solitary, withdrawn, dependent,
and sexually inhibited
• criteria for the diagnosis:
1. a delusional conviction of amorous
communication
2. object of much higher rank
3. object being the first to fall in love
4. object being the first to make advances,
5. sudden onset (within a 7-day period)
6. object remains unchanged
7. patient rationalizes paradoxical behavior of
the object
8. chronic course
9. absence of hallucinations
• generally unattractive women in low-level
jobs
• lonely lives
• Single and have few sexual contacts
• Separation from the love object
• men are less commonly affected, may be
more aggressive and possibly violent in
their pursuit of love
• Aggression: companions or protectors of
the love object who are viewed as trying to
come between the lovers
• Absence reaction  put the love in danger
Somatic Type
• fixed, unarguable, and presented intensely
• patient is totally convinced of the physical nature of the disorder
• three main types
• delusions of infestation (including parasitosis)
• delusions of dysmorphophobia, such as of misshapenness, personal ugliness, or
exaggerated size of body parts (this category seems closest to that of body
dysmorphic disorder)
• delusions of foul body odors or halitosis  sometimes referred to as olfactory
reference syndrome
• earlier age of onset (mean, 25 years), male predominance,
• single status, and absence of past psychiatric treatment
• Onset: gradual or sudden
Grandiose Type
• Megalomania

• Mixed Type
• two or more delusional themes
• Unspecified Type
• predominant delusion cannot be subtyped within the previous categories.
• Example: Capgras syndrome
• belief that a familiar person has been replaced by an impostor
• variants of the Capgras syndrome
• Frégoli’s phenomenon: delusion that persecutors or familiar persons can assume the guise of strangers
• Intermetamorphosis: familiar persons can change themselves into other persons at will
• Rare and may also be associated with schizophrenia, dementia, epilepsy, and other organic disorders
• predominantly in women, have has associated paranoid features, and have included feelings of
depersonalization or derealization.
• delusion may be short lived, recurrent, or persistent
• Frégoli and intermetamorphosis delusions have bizarre content and
are unlikely
• Delusion in Capgras syndrome  possible candidate for delusional
disorder