SCHIZOPHRENIADr.Deddy Soestiantoro Sp.KJ M.Kes

THE HISTORY OF SCHIZOPHRENIA 1860 : Morel -------------Demence precoce 1870 : Hecker------------Hebephrenia 1874 : Kahlbaum--------Katatonia 1896 : Kraepelin---------Dementia praecoc 1906 : Adolf Meyer----Adaptation reaction 1911 : Eugen Bleurer---Schizophrenia

EPIDEMIOLOGY: Around 0,3 % population , 60 % mental hospital in-patients ETIOLOGY: I. -Heredoconstitutional factor: the possibility of schizophrenia: -one parent (+) , children 7-16 % (+) -all parent (+) , children 40 % -monozygotic twin ----85,8 % -dizygotic twin -------14 % II. -Psychogenic factor III. -Exogenic factor

SYMPTOMATOLOGY -Attention and initiative markedly decrease -Lazy, lack of self care -Psychical contact limited,monosyllable, poker face -Flat affect , emotion difficult to feel, no empaty -Concentration decrease, discriminative insight disturbed, but no dementia -Thought process: association disorders--incoherence,often with delusion and hallucination. Dereistic thinking, neologisme, hemmung & sperrung.Sometimes there are depersonalization & derealization. -Behavioural symptoms: abulia or hypobulia and also often impulsivity.

Usually there's pre-schizophrenic periode around 2 years, e.g -emotional withdrawl, appearing faraway , apathy, feeling unwelcome, lack of social contacts, begining lack of nuance feeling, and finally went to poor emotional life & dysharmonious so it finally become unfelt and inapropriate. The symptoms above are similar with the residual type which there's remission with sequelle.

THE MAIN CLINICAL FEATURES

-a certain psychotic characteristic during the active phase, -multiple specific psychological symptoms, -deterioration, -onset before 45 years, -minimal 3-6 months (PPDGJ-II), -not because of affective /organic mental disorders

PRODORMAL OR RESIDUAL SYMPTOMS -isolation,social impairment, bizzare behavior,lack of self care, flat affect,blunted or inapropriate, unusual ideas or magical thought,unusual perception e.g ilusion.

During the phase of the illness minimal there's one of the following symtoms: -bizzare delusion,controlled,broadcast/insertion/withdrawl,with -somatic,megalomania,nihilistic delusions, -delusion of persecution or jealousy with hallucination, -auditoric hallucination-comment or dialogue -auditoric hallucination not related to depression or euphoria -incoherence

SUBTYPES OF SCHIZOPHRENIA It's better to look the longitudinal history of the illness. The classical subtypes of schizophrenia are: -hebephrenia, catatonia and paranoid type (Kraepelin), -simplex/simple type ( Bleurer). Simple type -slowly beginning, hallucination not frequent/rare, -limited thought, inability to absstract thought, -association disorders rare, -bizzare behavior ass. with emotion,attention & activity. Hebephrenic type -rapid disintegration, very disturbed association, a lot of incoherence, neologisme. -bizzare delusions, frequent cheerfull hallucinations, -severe regression, frequent mannerism, deep autism.Catatonic type -frequently as stupor or furor catatonic , -catalepsy symptoms or flexibilitas cerea.

Paranoid type -predominant delusions with hallucinations Schizophreiform disorder -premorbid tends to normal, -acute, during 2 weeks untill 6 months -hazy conciousness,oneroid, double book-keeping symptom

Schizoaffective type, -dominant affective symptoms,

Laten type -unclear symptoms, hide/silent

Residual type -remission with residual symptoms

DIAGNOSIS

1.Eugen Bleurer: 4 As Primary symptoms:-association disorders, -affect disorders, -autism, -ambivalence. Secondary symptoms:-delusions,hallucinations etc.

2.Kurt Schneider: First rank symptoms: -halucinations;audible thought, dialogue,commentary -somatic passivity experience, -thought process: -interruption/thought withdrawl,thought broadcast, -delusional peceptions, -changing desire-

3.PPDGJ (according to ICD & DSM ) In PPDGJ III schizophrenia is in Group II Hierarchi of Mental Illness Block Diagnosis ( F20-F29 ) where more completely ass.with schizotypal disorder , acute & transient psychotic disorders which can be followed by schizophrenic symptoms and also schizophrenic-like type ,and post schizophrenic depression.

DIFFERENTIAL DIAGNOSIS -Mental organic disorders -Other functional psychosis -Hysteria/Dissociative dsisorders -Beliefs, tradition, religious

TREATMENTS / MANAGEMENT THERAPY OF SCHIZOPHRENIA

I.Hospitalization

II.Somatic treatments/biological therapies -pharmacotherapy: usually using major tranquillizers (antipsychotic/neuroleptic drugs), first choice is the classic typical antipsychotic and if no progress use the newer generation of drugs it's the atypical antipsychotic drugs -other drugs : lithium,anticonvulsants,benzodiazepines -other biological therapies -ECT as the last choice if there's no progress in drugs therapy

III.Psychosocial therapies -Social skills training -Family-oriented therapies - Case management -Assertive community treatment(ACT) -Group therapy -Cognitive behavioral therapy -Individual psychotherapy -Vocational therapy

PROGNOSIS-I -40% remission-social recovery,60% deteriorated. -Less than one year 30% full remission,30% social recovery & 30% will be long stay in mental hospital

-Bad prognosis: flat affect, lack of initiative,depersonalization & derealization, bad premorbid personality,gradual symptoms too high perso nal aspiration,signs of hypochondriasis,persistent hallucination, recovery more than one year, deep regression.

-Good prognosis: acute,clear affective ..elements, clear anxiety or emotional signs, cyclothymic premorbid personality, self-accused hallucination, longer interval of remission.

-Robin & Guze : Good :good premorbid personality,clear precitating factor,negative family hystory or affective elements,clouding conciousness, acute onset, no flatness of affect, paranoid symptoms.

PROGNOSIS-II (Kaplan & Sadocks)

To evaluate the prognosis it's better to look up the longitudinal history of illness begins with the family hystory and at last how about the support system.

Features weighting towards good to poor pronosis in schizophrenia -Good prognosis -Family history of mood disorders -Good premorbid social,sexual & work hystories -Late onset -Married -Acute onset -Obvious precipitating factors -Mood disorder symptoms (especially depressive disorders) -Positive symptoms -Good support systems-Poor prognosis -Family history of schizoprenia -History of perinatal trauma -Young onset -Poor premorbid social,sexual & works histories -Single,divorced or widowed -Insidious onset -No precipitating factors -Neurological signs & symptoms -Withdrawn,autistic behavior -Negative symptoms -No remmission in 3 years -Many relapses -History of assaultiveness -Poor support systems

F 20. SCHIZOPHRENIA----PPDGJ III / ICD-10 *Schizophrenia and schizotypal --starting almost similar. *In schizophrenia: -distortion of thought & perception -hallucination & perception changes, ---confusion,elliptical & unclear thought, -motility--interrupted & interpolation, -thought insertion, -inappropriate & blunted affect, ---shallow,capricious,incongruous, -ambivalency & desire -disorders (volition ): -inertia,negativism,stupor catatonia, - the course of illness: -acute onset or gradual-silent, -later becomes broader variation, -not always chronic or become worse

DIGNOSTIC GUIDELINES Minimal one month at- least one of the following symptoms: a.thought echo/insertion/withdrawl/broadcast, b.delusion of control/influence-passivity, c.comment/dialogue/discussion hallucinations or from the organs of the body, d.bizzare delusion or at least two of the following symptoms: e.persistent hallucination/delusion/overvalued ideas, f.interrupted motility thought/insertion-incoherence/neologisme g.catatonic behavior:excitement,posturing,mutism,negativism flexibilitas cerea,stupor. h.negative symptoms :apathy, paucity speech,blunting/ incongruity emotional response,resulting in social withdrawl/ lowering social performance and all of these causing: i.a significant and consistent change in the overall quality of some aspect of personal behavior manifest as loss of interest, aimlessness,idleness,a self absorbed attitude and social withdrawl

Retrospective: -prodormal phase/non psychotic: -loss of interest in works,social activities and personal appearance and hygiene together with generalized anxiety and mild depression and preoccupation,before the psychotic symptoms for some weeks/month Pattern of course: -continuosly, -episodic with progressive deterioration, -episodic with stable deficit, -episodic remittent, -with incomplete remission or -complete remission. -other, -periode of observation less then one year. Criteria of time for residual schizophenia minimal 1 year and for schizotypal disorder 2 years, if the psychotic phase not yet 1 month, the preliminary diagnosis is Acute Schizophrenic-like Disorder.

Subtypes of schizophrenia

F 20.0 Paranoid schizophrenia The general criteria for a diagnosis of schizopheni must be satisfied.In addition, hallucinations and/or delusions must be prominent,and disturbances of affect, volition and speech,and catatonic symptoms must be relatively inconspicious. Delusions can be of almost any kind but delusions of control,influence,or passivity, and persecutory belief of various kinds are the most characteristic., F20.1 Hebephrenic schizophrenia A form of schizopohrenia in which affective changes are prominent,delusions and hallucinatons fleeting and fragmentary,behaviour irresponsible and unpredictable, and mannerisms common.The mood is shallow and inappropriate and often accompanied by giggling or self-satisfied,self-absorbed smiling,or by a lofty manner, grimaces, mannerisms,pranks,hypochondriacal complaints,and reiterated phrases. Thought is disorganized and speech rambling and incoherent.There's a tendency to remain solitary, and behaviour seems empty of purpose and feeling. Usually starts between the age of 15 and 25 years and gendss to have a poor prognosis because of the rapid development of negative symptoms,particularly flattening of affect and loss of volition.

F20.2 Catatonic schizophrenia Prominent psychomotor disturbances are essential and dominant features and may alternate between extremes such as hyprkinesis ands stupor,or automatic obedience and negativism.Constraineds attitude and postures maybe maintained for long periods. Episodes of violent excitement maybe a striking feature of the condition.

F 20.3 Undifferentiated schizophrenia Condition meeting the general dignostic 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 of predominance of a particular set of diagnostic characteristic.

F 20.5 Residual schizophrenia A chronic stage in the development of a schizophrenic disorders in which there has been a clear progression from an early stage comprising one or more episodes of exacerbation to a later stage.

F 20.6 Simple schizophrenia Slowly progressive develpment of the characteristic negative symptoms of residual Schizophrenia without any history of hallucinations,delusions or other manifestations of earlier psychotic episode,and with significant changes in personal behaviour, manifest as a marked loss of interesr,idleness,and social withdrawal.

F 25 Schizoaffective disorders These are episodic disorders in which both affective and schizophrenic symptoms are prominent within the same episode of illness,preferably simultanously,but at least within a few days of each other.

F 25.0 Schizoaffective disorder,manic type There must be a prominent elevation of mood,or a less obvious elevation of mood combined with increased irritability or excitement.Within the same episode,at least one and preferably two typically schizophrenic symptoms should be clearly present.

F 25.1 schizoaffective disorder,depressive type. A disorder in which schizophrenic and depressive symptoms are both prominent in the same episodes of ilness.Depression of mood is usually accompanied by several characteristic depressive symptomsor behavioural abnormalities such as retardation , insomnia, lost of energy, appetite or weight reduction of normal interests,impairment of concentration guilt,feelings of hopelessness,and suicidal thoughts.At the same time or within the same episode,other more typically schizophrenic symptoms are present. This subtype usually less florid and alarming than manic type,but they tends to last longer and the prognosis is less favourable.Although the majority of patients recover completely,some eventually develop a schizophrenic defect.

F 25.2 Schizoaffective disorder,mixed type Disorders in which symptoms of schizophrenia coexist with those of a mixed bipolar affective disorder.

MOOD (AFFECTIVE) DISORDERS

AFFECTIVE DISORDERS

A group of mental disorders with the main disturbances in the affective aspect, with or without psychotic features,no signs of schizophrenia and can exacerbate periodically.

Mood fluctuation: ecstasy---------------- exaltation-------------- hyperthymia """"euphoria........."""""""""""""""" """"""""""""""""""""""""""""""""""""""""" ------ happy/cheerful------- -------n o r m a l ------------- normo/euthymia ------sadness------------------ """""""""""""""""""""""""""""""""""""""""" depression--------------- ------------ hypothymia suicidal-------------------

The term melancholia (Hippocrates) untill 19th century meant mild /severe depression, after Kraepelin era means only for depression in the elderly. At the end of the 20th century means only for severe depression, depression for the mild and bipolar depression for cyclic depression.

Melancholia attack associated with hypoactivity/ motoric retardation, elation/ maniacal attack associated with hyperactivity

According to Hippocrates the disorder associated with affective aspect,while Arateus said there's a relation between melancholia and mania ; Freud claimed that there's a fusion between ego and super ego ; id and ego cyclic.

Abraham & Freud : in mourning condition, loss of object because of death, in melancholia there's internal/ identification ------introjection

Etiology: Mostly endogenous ( 25x ----------> in sibling and 50% in monozygotic twin

Epidemilogy: ~ 2-36 in 100.000 population ~ 3x in high societies & professionals ~ women 2x men ~ 5-15% of psychotic patients in mental hospital

Precipitating factors: Loss one of the valuable objects e.g: -death, -failures in interpersonal relationship, -frustation associated with loyalty

SYMPTOMATOLOGY The symptoms in the affective aspect, thought process and behavioral although pathological but more or less is still harmonious and it's clearly apart between manic & depression.

MANIC EPISODE -afect---elated -rare hallucination (mostly flattery/praise) -associations:-flight of ideas,logorrhoe-clang-associations -thought contents : expansive hallucinations (megalomania), non-systematic,wishfullfilling,sometimes persecutory delusions, -hyperactivity ,singing,dancing,shouting, impolite, unproperly, irritable, lack of sleep and never being tired/exhausted, attention easily changed, many plans but never finished. -mild condition: -hypomania: mild type e.g: talk too much,busy,self confidence, self pride, agressive,irritable,argumentative, extravagance,more chronic,.becoming milder -impression: overconfident but actually overdependent

PROGNOSIS -early onset 20-25 years, if younger will be worse -more acute will be better -more often excarcerbation tends to poor prognosis -mixed with schizophrenic symptomsnot good -without therapy the attack last about 6 months -difficult to prevent excacerbation even with good drugs -chronic condition rarely before 40 years

DEPRESSION EPISODE -affect : hypothymia,with pessimism,annoyed&gloomy -association not smooth with hemmung & sperrung, monosylable talked,sometimes no voices -thought content: ideas of guilty feeling and sin, hypochondriasis, self-accused and nihilistic delusions, paranoid idea, hallucinations followed the affect until suicidal thought, -behavior:hypoactive sometimes until stupor,refuse to eat & drink and resulting dehydration, -sometimes homiside as an extention from the suicidal act & it happened when the motoric retardation reduces but the suicidal thoght still present,often in condition with anxiety & positive family history.

PROGNOSIS -early onset 30-35 years -more younger the prognosis will be worse -if depression come firstly, it's uncertain will be back again, -mostly more endogenusly, the prognosis will be worse, -growing older the depression will be more often, -without therapy the recovery needs 9 months, -more acute will be better, more chronic become milder, -more often means worse -compared with mania this type tends to become chronic, -hypochondriasis & severe nihilism with a lot of anxieties means poor prognosis.

AFFECTIVE DISORDERS-PPDGJI III/ ICD X A group of affect disorders with elation or depression with or without anxiety accompanied with changes in activity. The variation of the diorders: -single or multiple episode -level of symptoms severity: -psychotic mania---mania without pschotic symptoms---- hypomania ; -mild &---middle depression (with or without somatic symptoms)--severe with or without psychotic symptoms. -mild condition but relatively longer & persistant.

Classification: F30 Manic episode include hypomania F31 Bipolar affective disorder,with recent episode manic/depression /mixed F32 Depressive episode F33 Reccurent depressive disorder F34 Persistant affective disorders include cyclothymia and dysthymia F38 Other mood (affective) disorders. F39 Unspecified mood (affective) disorders

In hypomania: -milder than mania, -at least for several days -intensity more then cyclothymia

Manic episode: -acute, duration 1-2 weeks untill 4-5 months

Depressive episode: -longer,duration about 2weeks untill 6 months rarely more then 1 year except in old age -Often begins with stress but not always, specifically: full recovery between episode.

Diagnosis: -for bipolar minimally there should be once for other affective episode.

Depressive episode -PPDGJ III/ICD X -Main symptoms:-decrease affect/depressed mood -loss of interest/enjoyment -lack of energy -Other symptoms:-reduced attention/concentration -reduced self esteem & self confidence -ideas of guilt and unworthyness -bleak and pessimistic view of the future -ideas of acts of self harm or suicide -disturbed sleep -diminished appetite

-The lowered mood varies,often unresponsive to circumtances sometimes there's diurnal variation,severe symptoms maybe shorter than 2 weeks.

-For diagnostic minimal 2 main symptoms ,severity between 2-4 additional symptoms with mild till severe impairment & psychotic if there're delusions, hallucintions (auditoric/ olfactoric) or depressive stupor. -Recurrent depression at least had more than 2 episodes, more infrequent than bipolar attacks.

-In cyclothymia the specific characteristics is persistent instability between mild depressive periode and hypomania.

-In dysthymia,the depression very long but mild, minimal can be several years.

DELUSIONAL ( PARANOID ) DISORDERS

PARANOID DISORDERS A group of severe mental diorders with the main symptoms is a variety of delusions, often systematic with or without hallucinations. The psychotic symptoms often very clear & sometimes only delusions which is dominant. Since Hippocrates,paranoia means "sanity",used again by Vogel, and more confirmed by Kahlbaum (1863).

Kraepelin: introduce the term paraphrenia and there're 4 type: systematic,expansive,confabulative and fantastic.

Freud: paraphrenia is identically the same as paranoid schizophrenia.

In PPDGJ II these disorders includes: -paranoia -shared paranoid disorders, -paraphrenia, -unspecified paranoid disorders

In PPPDGJ III -F22 Persistent delusional diorders -F 23.3 Other acute predominantly delusional psychotic disorder. -F 24 Induced delusional disorder

EPIDEMIOOGY Prevalence (USA) 0.025-0.03% ( Schizophrenia 0.1 % and affective disorders 0.5%).Women twice than men and usually single and suspected with homosexual orientation and chronic prejudice. Age:average 40 years,when the delusions cannot be tolerated anymore, the agression drive will invite counter agression from the environment and so make it easier to develope delusion of persecution, nihilistic etc.,resulting abandoned by friends, feeling isolated/unwelcome and inferior, finally become more paranoid.

ETIOLOGY -Psychogenic cause: frustated ambition drive -Freud :homosexual fixation -sadistic experiences during early childhood ( anal sadistic phase)

-Genuine paranoid rarely seen,usually an extension of paranoid premorbid personality. -more often in the form of paranoid reaction, -the defence mechanism which is used: denial & projection

-Heriditary / constitutional e.g: -low threshold for frustation, -rigid in relationship, -hypersensitivity etc.

SYMPTOMS The main symptoms:delusions,logic,sistimatic,complex,sometimes looks like isolated /apart from the personality,so the personality seems intact, and disturbed when the delusions being touch. -Persecuted delusions:feels being hatred- by relatives,want to be unmistakeable, the misintepretation & misunderstanding resulting in persecuted delusions.

-Delusion of reference if there's a feeling that someone is talking or commenting obout him/her

-Litygious type: feeling of being treated unfair,feeling of being right and superior.

-Exaltase type:delusions of grandeur,megalomania,often appear long time after persecuted delusions, often feels as Gods mission

-Erotic type:feeling the celebrities fall in love with him/her. Often appear as suicidal homocidal action.

SHARED PARANOID DISORDER (Folie a Deux / Trois) 1877: Laseque & Falret: induced psychosis with symptom of delusions,in close relatives, the induced person which is submissive,suggestibel, dependent and emotionally depends on the first. The used defence mchanism is identification.

INVOLUTIONAL PARAPHRENIA Rarely genuine,often mixed wirth melancholia Premorbid full of defence mechanism projection, inferior,critical,tends to blame others,jealous, cannot forgive,suspicious.

Symptoms:-organized persecutory delusion, annoyed, feeling of hostility.

Prognosis:-worse than involutional melancholia

Premorbid usually paranoid personality e.g blame on others easily,many prejudice, uneasy to confess wrong,often irritable easily hurt, angry, egocentric and easily paranoid/ suspicious.

Prognosis: Not so good in genuine paranoia with paranoid personality back ground which begins gradually or if there's a picture of schizophrenic symptoms because of rarely full remission.

DELUSIONAL DISORDER IN PPDGJ III/ICD-10-Having uncertain relation with schizophrenia

-Specifically:persistent single/systematic delusions, sometimes all life ---long.-Often delusions of persecutory,hypochondriac,grandiose or which is related with court,jealousy,abormal body,feels that the body has bad smell or homosexual.-Depression symptoms can be found intermittently.-Maybe there're olfactoric and tactil hallucinatios-Auditoric hallucination appears temporaly & generally in old age.-Usually in midslife age ,except in abnormal body delusion which often in young age-Often related with environtmental situation,persecutrory delusion frequently in minority group.

-Apart from the behavior & attitude related with delusions, the affect, talking & behaviour still normal.

Other persistent delusional disorder -Delusional disorder with persistent hallucination or schizophrenic symptoms which not enough for schizophrenic criteria and minimally 3 months duration. -Includes here: delusional dysmorphobia & involutional paranoid state.

OTHER NON-ORGANIC PSYCHOSIS

Includes here are depressive type psychosis or excitation, reactive confusional state, acute or psychogenic paranoid disorders, brief reactive psychosis and unspecified psychosis. Usually there's a real stressor in interpersonal relatioship problems or environmental problems which are very stressfull and generally last during 2weeks until 6 months and the prognosis usually good enough

G0LONGAN OBAT ANTIPSIKOTTIK / NEUROLEPTIK

I.OBAT ANTI PSIKOTIK TIPIKAL

-phenothiazine: -chlorpromazine: tablet 25mg; 100mg -levomepromazine: tablet 25 mg; 100 mg -perphenazine : tablet 4 mg; 8 mg -trifluoperazine: tablet 5 mg -thioridazine: 10 mg; 100 mg

-butyrophenone: -haloperidol: tablet 0,5mg;1,5mg;2mg;5mg

-diphenyl-butyl-piperidine: -pimozide : tablet 2mg; 4 mg

II.OBAT ANTI PSIKOTIK ATIPIKAL

-benzamide: -sulpiride :tablet 50mg; 200mg

-dibenzodiazepine: -clozapine:tablet 25mg; 100mg -olanzapine:tablet 5mg; 10 mg -quetiapine: tablet 25mg; 100mg; 200mg -zotepine:tablet 25mg; 50mg -aripiprazole; tablet 10mg; 15 mg -benzisoxazole: -risperidone: tablet 1mg; 2mg; 3 mg -paliperidone : kapsul 3mg; 6 mg ;9mg

GOLONGAN ANTIDEPRESAN 1.Golongan ikatan trisiklik -amitriptyline : tablet 25 mg -imipramine: tablet 10 mg; 25 mg -tianeptine: tablet 12,5 mg 2.Golongan ikatan tetrasiklik -maprotiline : tablet 25 mg; 50mg -mianserine: tablet 10 mg; 30 mg -amoxapine: tablet 100 mg 3.Golongan Mono Amine Oxidase Inhibitor (MAOI)Reversible -moclobemide: 150 mg 4.Golongan Selective Serotonin Reuptake Inhibitor (SSRI) -sertraline: tablet 50 mg -fluoxetine: tablet 20 mg -paroxetine : tablet 20 mg -fluvoxamine: tablet 50 mg -citalopram : tablet 20 mg 5.Golongan antidepresan atipikal -mirtazapine: tablet 15mg; 30mg; 45 mg -duloxetine: tablet 60mg; 120mg -venlafaxine Hcl: tablet 75mg; 150mg; 225mg

OBAT ANTIMANIK

1.Mania akut: -haloperidol:tab 0,5mg; 1,5mg; 2mg; 5mg -carbamazepine: tablet 200mg -valproic: tablet 200mg -lithium carbonate: tablet 200 mg

2.Profilaksis: -lithium carbonate tablet 200mg

REALITY TESTING ABILITY

There are 3 aspects of the personality, wether psychotic or not,its depends on the dysfuntion/disorder/disturbance of these aspect.

Affective /Stimmung -afeftive state:normo/euthymia,hyperthymia, hypothymia, poikilothymia,disthymia, blunted/flat/inappriate affect -emotional stateThought /Denken -intellectual function:memory,concentration, orientation,discriminative judgement/insight, intelligency level,dementia etc -sensation & perception:illusion,hallucination -thought process:-psychomotility,quality -associations,content and form etcBehaviour and instinctual drive/ Handlung -abulia/hypobulia ,stupor,raptus,impulsivity,sexual deviation, vagabondage,pyromania,mannerism, mutisme,autisme etc