Schizophrenia and Other Psychotic Disorders
Dr. Rebwar G. HamaPsychiatrist
University of SulaimaniSchool of Medicine
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 affects 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
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
Subtypes of Schizophrenia
Paranoid Type 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 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
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