schizophrenia and other psychotic...

SCHIZOPHRENIA AND

OTHER PSYCHOTIC

DISORDERS

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Bahagia Loebis

Mustafa M. Amin

Psychiatric Department

School of Medicine USU

Definition : schizophrenia

(ICD-X/PPDGJ III, 1993)

� Characterized in general by fundamental and

characteristic distortions of thinking &

perception, & by inappropriate or blunted

affect; clear consciousness; certain cognitive

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deficits may evolve in the course of time.

� The most intimate thoughts, feelings, & acts

are often felt to be known to or shared by

others.

�Delusions may develop to influence theafflicted the individual’s thought &actions. Hallucination, especially :auditory, are common & may commenton the individual’s behavior or thought.

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Incidence

�Mainly affecting adolescent & youngadulthood. Peak ages of onset for menare 15-25 yrs & women 25-35 yrs.

� If there is family had schizophrenia the

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� If there is family had schizophrenia theexpected rate about 1 % for all group ofages; if siblings without parents whohad schizophrenia, the expected rateabout 6.7-8.2 %

�Men are more likely to be impaired bynegative symptoms than are women, &that women are more likely to havebetter social functioning than are men;in general, the outcome for femaleschizophrenia patients is better thanthat for male schizophrenia patients.

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that for male schizophrenia patients.

�Suicide could be found in schizophreniacases, 50 % attempted suicide 1 X intheir live 10-15 % schizophreniapatients died because of suicide

Etiology

1.Stress Diathesis Model

according to the stress-diathesis model for

the integration of biological, psychosocial, &

environmental factors, a person may have a

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environmental factors, a person may have a

specific vulnerability (diathesis) that, when

acted on by stressful influence, allows the

symptoms of schizophrenia to develop.

Stress can be biological,environmental, or both. Biological eginfection; & psychological eg stressfulfamily situation. The biological basiscan be further shaped by epigeneticinfluences such as substance abuse

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influences such as substance abuse& trauma. Furthermore if added bythe presence of psychosocialstressor.

2. Dopamine Hypothesis

Posits that schizophrenia results fromtoo much dopaminergic activity. Bygiving haloperidol, an antipsychoticdrug that had efficacy & antipsychotic

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drug that had efficacy & antipsychoticpotention with their ability to act asthe antagonists of the dopamine D2receptor.

Drugs that increase dopamine activity, egamphetamine, can cause psychoticdisorder that mimic the features ofschizophrenia.

There is some assuming that D1 dopaminereceptor plays a role for the presence of

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receptor plays a role for the presence ofnegative symptoms.

�From the studies, D5 dopamine receptorcorrelates with D1; D3 & D4 dopaminereceptor correlates with D2 receptor.

�The use of antagonist dopaminereceptor drugs treats all psychoticsymptoms, not only schizophrenia.

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symptoms, not only schizophrenia.

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Serotonin–Dopamine Antagonist

Concept (SDA Concept)

�The possibility of 5 HT(serotonin) playsa role in schizophrenia; meaningdopamine (DA) & 5 HT at dysfunctionalstate.

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state.

�There is abnormality in the interaction of5 HT & DA correlates with thesymptoms of schizophrenia.

Schizophrenia Symptoms

�1. Positive symptoms

�2. Negative symptoms

�3. Cognitive deficit

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�4. Aggressive & hostility symptoms

�5. Depressive & anxious symptoms

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Positive and Negative Symptoms

Scale =PANSS ( from Kay )

�Divided to : 1. Positive symptoms (7)

2. Negative symptoms (7)

3. General psychopathologic

symptoms (16)

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symptoms (16)

Only talked about positive &

negative scales

A. Positive scale

�1. Delusion

�2. Conceptual disorganization; could becircumstantiality, tangentiality, looseassociation, non sequiturs, gross

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association, non sequiturs, grossillogicality, blocking

�3. Hallucinatory behavior; could beauditory, visual, olfactory or somatichallucination

�4. Excitement; hyperactivity as reflectedin accelerated motor behavior,heightened responsivity to stimuli,hypervigilance

�5. Grandiosity; exaggerated self opinion& unrealistic convictions of superiority,including delusions of extraordinary

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including delusions of extraordinaryabilities, wealth, knowledge, fame,power, & moral righteousness

�6. Suspiciousness/persecution

�7. Hostility; verbal & non verbalexpressions of anger & resentment,including sarcasm, passive-aggressive

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including sarcasm, passive-aggressivebehavior, verbal abuse, &assaultiveness

B. Negative scale

�1. Blunted affect diminished emotional responsiveness as characterized by a reduction in facial expression, modulation of feelings, &

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expression, modulation of feelings, & communicative gesture

�2. Emotional withdrawal; lack of interestin, involvement with, & affectivecommitment to life’s events

� 3. Poor rapport

lack of interpersonal empathy, openness in conversation, & sense of closeness, interest, or involvement with the interviewer. This evidenced by interpersonal distancing & reduced verbal & nonverbal communication

� 4. Passive/apathetic social withdrawal;diminished interest & initiative in social

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4. Passive/apathetic social withdrawal;diminished interest & initiative in socialinteractions due to passivity, apathy, anergy,or avolition. This leads to reduced personalinvolvements & neglect of activities of dailyliving

�5. Difficulty in abstract thinking;impairment in the use of the abstractsymbolic mode of thinking, asevidenced by difficulty in classification,forming generalizations, & proceedingbeyond concrete or egocentric thinking

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beyond concrete or egocentric thinkingin problem solving tasks

�6. Lack of spontaneity & flow ofconversation; reduction in the normalflow of communication associated withapathy, avolition, defensiveness, orcognitive deficit.

�7. Stereotyped thinking

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�7. Stereotyped thinking

Decreased fluidity, spontaneity, & flexibility of thinking, as evidenced in rigid, repetitious, or barren thought content

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Cognitive Deficits

�Because of the reduce of dopamine inthe pre frontal area, could be seen as :

� Difficult in concentrating reduce

memory function

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memory function

� Difficult in doing the executive function

doing daily activities

Aggressive & Hostility

Symptoms

�Overt hostility, such as verbal orphysical abusiveness or even assault

�Self injurious behaviors, includingsuicide & arson or other property

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suicide & arson or other propertydamage

�Sexual acting out

Depressive and anxious

symptoms

� Depressed mood, anxious mood, guilt,tension, irritability, & worry � frequentlyaccompanied schizophrenia

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Diagnostic Criteria for

Schizophrenia ( PPDGJ III, 1993)

�The common symptoms inschizophrenia :

�a. Thought echo, thought insertion,thought withdrawal, thought broadcast

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thought withdrawal, thought broadcast

� b. Delusion of control, influence, orpassivity, clearly referred to body orlimb movements or specific thoughts,actions, or sensations; delusionalperception

�c. Hallucinatory voices giving a runningcommentary on the patient’s behavior,or discussing the patients amongthemselves, or other types ofhallucinatory voices coming from somepart of the body.

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part of the body.

�d. Persistent delusions of other kindsthat are culturally inappropriate &completely impossible; such assuperhuman powers (eg being able tocontrol the weather).

�e. Persistent hallucinations in anymodality, when accompanied either byfleeting or half-formed delusions withoutclear affective content, or by persistentover-valued ideas, or when occuringevery day for weeks or months on end.

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every day for weeks or months on end.

� f. Breaks or interpolations in the train ofthought, resulting in incoherence orirrelevant speech, or neologism.

�g. Catatonic behavior, such asexcitement, posturing, or waxy flexibility,negativism, mutism & stupor.

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negativism, mutism & stupor.

�h. Negative symptoms such as markedapathy, paucity of speech, & blunting orincongruity of emotional responses,usually resulting in social withdrawal &lowering social performance, it must beclear that these are not due todepression or to neuroleptic medication.

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depression or to neuroleptic medication.

� i. A significant & consistent change inthe overall quality of some aspect ofpersonal behavior, manifest as loss ofinterest, aimlessness, idleness, a self-absorbed attitude, & social withdrawal.

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absorbed attitude, & social withdrawal.

Diagnosis could be make if :

� A minimum of 1 very clear symptom (&usually two or more if less clear-cut). Thesymptoms :

� 1. one of the groups listed as (a) to (d) above

2. or symptoms from at least two of the

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� 2. or symptoms from at least two of thegroups referred to as (e) to (h)

� Should have been clearly present for most ofthe time during a period of 1 month or more,& the alertness had to be compos mentis.

Schizophrenia

�Was included in the group :schizophrenia, schizotypal disorder &delusional disorder (ICD-X, 1992;PPDGJ III,1993).

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PPDGJ III,1993).

�According to DSM -IV (1994) wasincluded in the group of schizophrenia &other psychotic disorders.

Subdivision of schizophrenia

(ICD-X/PPDGJ-III)

�1. Paranoid schizophrenia *

�2. Hebephrenic schizophrenia *

�3. Catatonic schizophrenia *

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�4. undifferentiated schizophrenia*

�5. Post schizophrenic depression

�6. Residual schizophrenia *

�7. Simple schizophrenia

�8. Other schizophrenia

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� * Types from DSM-IV

Schizophrenia types

�1. Paranoid schizophreniadelusions accompanied by

hallucinations, especially : auditoryhallucination. The onset tends to be

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hallucination. The onset tends to belater.

�2. Hebephrenic schizophrenia (ordisorganized schizophrenia)

regressive behavior & mannerism.Starts between the ages 15-25 yrs.Prognosis : tend to be poor &development of negative symptoms.

� 3. Catatonic schizophrenia

prominent : psychomotor disturbance,

alternate between extremes such as

hyperkinesis & stupor. Catatonic symptoms

eg : catalepsy, waxy flexibility, automatic

obidience, etc.

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obidience, etc.

� 4. Undifferentiated schizophrenia

conditions meeting the general diagnostic

criteria for schizophrenia but not conforming

to any of the above subtypes, or exhibiting

the features of more than one of them without

a clear predominance of a particular set of

diagnostic characteristics.

�5. Post-schizophrenic depressiondepressive episode arising in the

aftermath of schizophrenic illness;some schizophrenic symptoms muststill be present, these persistingschizophrenic symptoms may bepositive or negative (altough negative

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positive or negative (altough negativesymptoms more common). Thisdepressive disorder is associated withan increased risk of suicide (in thiscase the schizophrenia have takenplace for 1 year or more).

� 6. Residual schizophreniaa chronic stage in the development of aschizophrenic disorder, characterize by longterm negative symptoms (though notnecessarily reversible).

� 7. Simple schizophreniaan insidious but progressive development

of oddities of conduct, inability to meet thedemands of society, & decline in total

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demands of society, & decline in totalperformance. Delusions & hallucinations arenot evident. With increasing socialimpoverishment, vagrancy may ensue & theindividual may then become self-absorbed,idle, & aimless.

DELUSIONAL DISORDER

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Definition

�DSM-IV-TR � diagnosis of delusional

disorder is made when a person exhibits

nonbizarre delusion of at least 1 month’s

duration that can’t be attributed to other

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duration that can’t be attributed to other

psychotic disorder

�Nonbizarre � the delusions must be

about situations that can occur in real

life, such as being followed, infected, and

so on

Epidemiology

� Incidence� 0,7-3,0 per 100.000

�Prevalence � 24-30 per 100.000

�Onset � 18-80 yrs (average 34-45 yrs)

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�Sex � women >>

Etiology

� ??????

� Genetic � Biologic � abnormality in the limbic & basal ganglia

system

� Psychosocial :

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- Primarily psychosocial in origin

- Physical & emotional abuse, unreliable parenting- Basic trust (Erikson) � doesn’t develop

- History of deafness, blindness, social isolation, andloneliness, recent immigration or other abruptenvironmental changes, and advanced age

Diagnosis

� DSM-IV-TR

A. Nonbizarre delusion � 1 month

B. Criterion A for schizophrenia has never been met

C. Functioning is not markedly impaired and

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C. Functioning is not markedly impaired andbehavior is not obviously odd or bizarre

D. If mood episodes occur, their total durationhas been brief

E. Not due to the direct physiologic effects of asubstance

Type :

- Erotomanic � another person, usually of a

higher status, is in love with the individual

- Grandiose � inflated worth, power,

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- Grandiose � inflated worth, power,

knowledge, identity, or special relationship to

a deity or famous person

- Jealous � individual’s sexual partner is

unfaithful

- Persecutory � the person (someone towhom the person is close) is beingmalevolently treated in some way

- Somatic � the person has some

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- Somatic � the person has somephysical defect or general medicalcondition

- Mixed

- Unspecified

REACTIVE PSYCHOSIS

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Reactive Psychosis

�The psychosis condition precipitate bypsychosocial stressor. The clinicalfeatures is the same with the clinicalfeatures that had been classified.

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features that had been classified.

�Psychosocial stressor : is everysituation or event that cause the changein life of someone ( child, adult oradolescent) so that the peopleperforced to perform an adaptation orovercome the stressor.

� In multiaxial diagnosis : psychosocialstressor fills axis IV)

�Assessment of severity of the stressorfrom 1 to 7; and determined by clinical

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from 1 to 7; and determined by clinical

DIAGNOSIS

Brief reactive psychosis

�A. The psychotic symptoms occursuddenly after marked psychosocialstressor, which also will give grief

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stressor, which also will give griefmeaning to almost everyone.

�B. The clinical features includeemotional distortions and at least hadone of the symptoms from below :

� Incoherence or loose associations

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� Incoherence or loose associations

� Delusion

� Hallucination

� Disorganized or catatonic behavior

�C. The psychotic symptoms continuedmore than several hours but less thantwo weeks. And will full recovery againto the premorbid function level.

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to the premorbid function level.

�D. There is no period where shown arising psychopatological symptomsbefore the psychosocial stressor.

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