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Schizophrenia and Other

Psychotic Disorders
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
effects 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
Schizophrenic Delusions

 A delusion is a false belief Some common


schizophrenic delusions include:
 Being cheated
 Being harassed
 Being poisoned
 Being spied upon
 Being plotted against
 Most delusions are very grandiose and involve the
patient at the center of some large plot or scheme
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
Schizophrenic Hallucinations

 A hallucination is a non-existence of stimulus that is


perceived as real
 The most common schizophrenic hallucination is
hearing voices, however the patient may also have
visual hallucinations where they see a person or
object that does not exist •
 Hallucinated voices often interact with the patient:
 By commenting on their behaviour
 By ordering them to do things
 By warning of impending dangers
 By talking to other voices about the patient
Subtypes of Schizophrenia

 Paranoid Type (related to paranoia, a mental condition


characterized by delusions of persecution, unwarranted
jealously)
 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 (abnormality of movement & behavior arising


from disturbed mental state)
 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
(Diagnostic and Statistical Manual of Mental Disorders)

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