The Schizophrenias and Delusional Disorder

Schizophrenias mental disorders characterized by the breakdown of integrated persoanolity functioning, withdrawal from reality, emotional blunting and distortion, and disturbances in thought and behavior.

Psychosis- a significant loss of contact with reality, as when hallucinations or delusions are present.

Delusional Disorder a paranoid disorder in which a person nurtures, gives voice to, and sometimes takes action on beliefs that are considered completely false and absurd by others.

Entrance into a delusional system.

Brief Psychotic Disorder

The SchizophreniasOrigins go back to Benedict Morel

Demence Precoce (mental deterioration at early age)Adopted by Kraeplin

Term is misleading however, as there is no compelling evidence of progressive brain degeneration in the natural course of the disorder

In 1911 Eugen Bleuler termed these disorders “schizophrenia” (split mind). A disorganization of thought processes:

Split between the intellect and emotionSplit between the intellect and external reality

Split Mind: Prevalence & Onset

Difficult to assess based on cultural beliefs (can you think of some in local cultures?)Lifetime prevalence (0.7)During any given year in the U.S. 1% meet criteria (over 2 million)Diagnosis in 40% of all state hospital admissionsNo gender differences in prevalence

Split Mind: Prevalence & Onset

Three fourths of onsets occur between the ages of 15 and 45 with a median age in the mid 20sMales have earlier onset (early 20s)Females have later onset (late 20s)Based on brain imaging studies it appears that males develop more severe forms of these disorders

Onset

The Clinical Picture in Schizophrenia

(see next slide)

Positive-syndromeNegative-syndromeType I schizophreniaType II schizophrenia

Type I & II Association to Pos & Neg

Positive SyndromeHallucinationsDelusionsDerailment of Assoc.Bizarre BehaviorMin. Cog ImpairmentSudden OnsetVariable Course

TYPE I.--------------------The above plus

Good Med ResponseLimbic System AbnormalityNormal Brain Ventricles

Negative SyndromeEmotional FlatteningPoverty of SpeechAsocialityApathySig. Cog ImpairmentInsidious OnsetChronic Course

Type II.-------------------Plus

Uncertain Med ResponseFrontal Lobe AbnormalityEnlarged Brain Ventricles

The Clinical Picture in Schizophrenia

Disturbances of associative thinkingCognitive Slippage or Loosening of Associations

Disturbances of thought contentDelusions (false beliefs; thoughts controlled by others)

Disruption of perceptionHallucinations (auditory, olfactory, visual, etc.)Unable to sort out and process sensory information

Emotional dysfunctionAnhedonia (inability to experience joy)Blunting

The Clinical Picture in Schizophrenia

Confused sense of selfDisrupted volition

Disruption in goal directed behavior

Retreat to an inner worldRejection of external worldLoosened ties to external world

Disturbed motor behaviorPsychomotor agitation and

retardation & other peculiarities of movement

Schizophrenia DSM-IV CriteriaA. Characteristic Symptoms (2 or more during a 1 month period)

DelusionsHallucinationsDisorganized SpeechGrossly disorganized or catatonic behaviorNegative symptoms

B. Social/Occupational DysfunctionC. DurationD. Schizoaffective and Mood Disorder ExclusionsE. Substance/General Medical Condition ExclusionF. Relationship to a Pervasive Developmental Dis.

The Classic SubtypesUndifferentiated (waste basket)Catatonic (pronounced motor signs both extreme stupor and excitement)Disorganized (earlier more severe disintegration of the personality)Paranoid (person becomes centered on themes of suspiciousness, persecution, and/or grandeur)Schizophrenia Residual (considerable recovery with mild signs of past disorder)

Split Mind: Causal Factors IBiological Factors

Genetic studies demonstrate heritablilityAdoption studies demonstrate moderate genetic effect (heritability)Biochemical factors appear to include dopamine Neurophysiological factors

Cognitive dysmetria and smooth pursuit eye movement

Neuroanatomical factorsBrain mass anomalies include enlargement of ventricles and sulci are noted

Onset

Split Mind: Causal Factors II

Psychosocial FactorsDamaging Parent-Child and Family Interactions

Popular view in the 1950’sFaulty communication and the double blind

Sociocultural FactorsLess common in less “well-developed” countriesIn U.S. lower socioeconomic status is associated with a higher prevalence

Treatments and OutcomesAntipsychotic MedicationPsychosocial Approaches

Family Therapy (focus on expressed emotion)Individual Psychotherapy (coping skills and personal management)Social-Skills Training

Outcome studies demonstrate around 40% social recoveries with medication use in conjunction with other treatment

Delusional Disorder IIndividual feels singled out and taken advantage of, mistreated, plotted against, stolen from, spied on, ignored or otherwise mistreatedHold a delusional system usually centered on one themeAside from delusional system such individuals may appear perfectly normal in conversation, emotionality, and conduct

Delusional DisorderA. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration. B. Criterion A for Schizophrenia has never been met.

Note: Tactile and olfactory hallucinations may be present if they are related to the delusional theme.

C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (drug abuse, medication or a medical condition)

Delusional DisorderTypes (based on theme)

Persecutory (they are being subjected to spying, stalking, rumors)** most common of the types.Jealous (sexual partner is being unfaithful)Erotomanic (a high status person wants to start a sexual liaison with them)Somatic (belief of having some physical illness or disorder whose nature is delusionally absurd)Grandiose (person has extrordinary status, power, ability, talent, beauty, etc.)Mixed (combinations of the above themes)

Delusional Disorder IICausal Factors and Treatment

Poorly understood

Delusional Disorder: Causal Factors

Brief Psychotic Disorder1) Presence of one (or more) of the following symptoms:

delusions hallucinations disorganized speech (e.g., frequent derailment or incoherence) grossly disorganized or catatonic behavior

Note: Do not include a symptom if it is a culturally sanctioned response pattern.

2) Duration of an episode of the disturbance is at least 1 day but less

than 1 month, with eventual full return to premorbid level of fx.

3) The disturbance is not better accounted for by a Mood Disorder With

Psychotic Features, Schizoaffective Disorder, or Schizophrenia and is

not due to the direct physiological effects of a substance (e.g., a drug

of abuse, a medication) or a general medical condition. Specify if: with Marked Stressor, without Marked Stressor, or Postpartum onset.