SHIZOPHRENIA

AND
OTHER PSYCHOTIC
DISORDERS

Hyacinth C. Manood, MD, DPBP

SCHIZOPHRENIA
 Benedict Morel - dÃmence prÃcoce
 deteriorated patients whose illness began in adolescence

 Emil Kraepelin - dementia precox

 the change in cognition (dementia) and early onset (precox) of the
disorder.
 long-term deteriorating course and the clinical symptoms of
hallucinations and delusions
 manic-depressive psychosis -distinct episodes of illness alternating
with periods of normal functioning
 paranoia - persistent persecutory delusions; lacked the deteriorating
course of dementia precox and the intermittent symptoms of manic-
depressive psychosis.
 Eugene Bleuler - schizophrenia ; the presence of
schisms between thought, emotion, and behavior in
patients with the disorder.
 four As: associations, affect, autism, and ambivalence.
 accessory (secondary) symptoms - hallucinations and
delusions

 Ernst Kretschmer - “schizophrenia occurred more often

among persons with asthenic (i.e., slender, lightly muscled
physiques), athletic, or dysplastic body types rather than among
persons with pyknic (i.e., short, stocky physiques) body types. “

 Kurt Schneider - first-rank symptoms

Kurt Schneider Criteria for Schizophrenia
 First-rank symptoms  Second-rank symptoms

 Audible thoughts  Other disorders of perception

 Voices arguing or discussing  Sudden delusional ideas
or both  Perplexity
 Voices commenting  Depressive and euphoric mood
 Somatic passivity experiences changes
 Thought withdrawal and other  Feelings of emotional
experiences of influenced impoverishment
thought
 Thought broadcasting
 Delusional perceptions
 All other experiences
involving volition made
affects, and made impulses
 Karl Jaspers - existential psychoanalysis
 trying to understand the psychological meaning of
schizophrenic signs and symptoms such as delusions and
hallucinations.

 Adolf Meyer - founder of psychobiology

 reaction to life stresses ; schizophrenic reaction
EPIDEMIOLOGY

 lifetime prevalence of schizophrenia is about 1

percent

 equally prevalent in men and women; Onset is earlier

in men than in women ( M = 10 – 25; F= 25 – 35)

 Onset of schizophrenia before age 10 or after age 60

is extremely rare; When onset occurs after age 45, the
disorder is characterized as late-onset schizophrenia.
 In general, the outcome for female schizophrenia
patients is better than that for male schizophrenia
patients

 higher mortality rate from accidents and natural

causes than the general population

 more likely to have been born in the winter and early

spring - Season-specific risk factors, such as a virus or a
seasonal change in diet, may be operative .
 gestational and birth complications, exposure to
influenza epidemics, or maternal starvation during
pregnancy, Rhesus factor incompatibility, and an
excess of winter births. - neurodevelopmental
pathological process

 Substance abuse is common in schizophrenia

 Etiology
I. Genetic Factors:
Prevalence of Schizophrenia in Specific Populations

Population Prevalence (%)

General population 1
Non-twin sibling of a schizophrenia patient 8
Child with one parent with Schizophrenia 12
Dizygotic twin of a schizophrenia patient 12
Child of two parents with schizophrenia 40
Monozygotic twin of a schizophrenia patient 47
II. Biochemical Factors:

1. Dopamine Hypothesis - schizophrenia results from too much

dopaminergic activity .

2. Serotonin - excess as a cause of both positive and negative

symptoms in schizophrenia.

3. Norepinephrine - selective neuronal degeneration within the

norepinephrine reward neural system could account for the impaired
capacity for emotional gratification and the decreased ability to
experience pleasure.
4. GABA - GABA has a regulatory effect on dopamine
activity, and the loss of inhibitory GABAergic neurons could
lead to the hyperactivity of dopaminergic neurons.

5. Neuropeptides -substance P and neurotensin, are

localized with the catecholamine and indolamine
neurotransmitters and influence the action of these
neurotransmitters.
6. Glutamate - ingestion of phencyclidine, a glutamate
antagonist, produces an acute syndrome similar to
schizophrenia. The hypotheses proposed about glutamate
include those of hyperactivity, hypoactivity, and glutamate-
induced neuro- toxicity.

7. Acetylcholine and Nicotine - decreased muscarinic

and nicotinic receptors ; dysregulation of neurotransmitter
systems involved in cognition
Neuropathology :
1. lateral and third ventricular enlargement and some
reduction in cortical volume;

2. reduced symmetry in several brain areas in

schizophrenia, including the temporal, frontal, and
occipital lobes ;

3. decrease in the size of the region including the

amygdala, the hippocampus, and the
parahippocampal gyrus;
4. several symptoms of schizophrenia mimic those
found in persons with prefrontal lobotomies or
frontal lobe syndromes

5. The medial dorsal nucleus of the thalamus, which

has reciprocal connections with the prefrontal
cortex, has been reported to contain a reduced
number of neurons

6. cell loss or the reduction of volume of the globus

pallidus and the substantia nigra.
III. Psychosocial and Psychoanalytic Theories
 Sigmund Freud - postulated that schizophrenia resulted
from developmental fixations that occurred earlier than those
culminating in the development of neuroses.

 Margaret Mahler - there are distortions in the reciprocal

relationship between the infant and the mother .

 Paul Federn - the defect in ego functions permits intense

hostility and aggression to distort the mother-infant
relationship, which leads to eventual personality
disorganization and vulnerability to stress.
 Harry Stack Sullivan - schizophrenia is an adaptive
method used to avoid panic, terror, and disintegration of the
sense of self .

 All psychodynamic approaches are founded on the

premise that psychotic symptoms have meaning in
schizophrenia

 Learning theory - the poor interpersonal relationships of

persons with schizophrenia develop because of poor models
for learning during childhood.
Family Dynamics
 Double Bind - children receive conflicting parental messages about
their behavior, attitudes, and feelings. In Bateson's hypothesis, children
withdraw into a psychotic state to escape the unsolvable confusion of the
double bind.
 Schisms and Skewed Families - In one family type, with a
prominent schism between the parents, one parent is overly close to a child
of the opposite gender. In the other family type, a skewed relationship
between a child and one parent involves a power struggle between the
parents and the resulting dominance of one parent.
 Pseudomutual and Pseudohostile Families -suppress emotional
expression by consistently using pseudomutual or pseudohostile verbal
communication.
 Expressed Emotion - families with high levels of expressed emotion,
the relapse rate for schizophrenia is high
DSM-IV-TR Diagnostic Criteria for Schizophrenia
A. Characteristic symptoms: Two (or more) of the following,
each present for a significant portion of time during a 1-month
period (or less if successfully treated):
 delusions
 hallucinations
 disorganized speech (e.g., frequent derailment or incoherence)
 grossly disorganized or catatonic behavior
 negative symptoms, i.e., affective flattening, alogia, or
avolition
 Note: Only one Criterion A symptom is required if delusions
are bizarre or hallucinations consist of a voice keeping up a
running commentary on the person's behavior or thoughts, or
two or more voices conversing with each other.
B. Social/occupational dysfunction:
C Duration: > 6 months
D. Schizoaffective and mood disorder exclusion:
Schizoaffective disorder and mood disorder with psychotic
features have been ruled out because either (1) no major
depressive, manic, or mixed episodes have occurred
concurrently with the active-phase symptoms; or (2) if mood
episodes have occurred during active-phase symptoms, their
total duration has been brief relative to the duration of the
active and residual periods.
E. Substance/general medical condition exclusion: The
disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general
medical condition.
F. Relationship to a pervasive developmental disorder:
SUBTYPES:
 Paranoid type
A type of schizophrenia in which the following criteria are met:
A. Preoccupation with one or more delusions or frequent auditory
hallucinations.
B. None of the following is prominent: disorganized speech, disorganized
or catatonic behavior, or flat or inappropriate affect.

 Disorganized type
A type of schizophrenia in which the following criteria are met:
A. All of the following are prominent:
 disorganized speech
 disorganized behavior
 flat or inappropriate affect
B. The criteria are not met for catatonic type
 Catatonic type
A type of schizophrenia in which the clinical picture is
dominated by at least two of the following:

 motoric immobility as evidenced by catalepsy (including

waxy flexibility) or stupor
 excessive motor activity (that is apparently purposeless and
not influenced by external stimuli)
 extreme negativism (an apparently motiveless resistance to
all instructions or maintenance of a rigid posture against
attempts to be moved) or mutism
 peculiarities of voluntary movement as evidenced by
posturing (voluntary assumption of inappropriate or bizarre
postures), stereotyped movements, prominent mannerisms,
or prominent grimacing
 echolalia or echopraxia
 Undifferentiated type

A type of schizophrenia in which symptoms that meet Criterion

A are present, but the criteria are not met for the paranoid,
disorganized, or catatonic type.

 Residual type

A type of schizophrenia in which the following criteria are met:

A. Absence of prominent delusions, hallucinations, disorganized
speech, and grossly disorganized or catatonic behavior.
B. There is continuing evidence of the disturbance, as indicated by
the presence of negative symptoms or two or more symptoms
listed in Criterion A for schizophrenia, present in an attenuated
form (e.g., odd beliefs, unusual perceptual experiences).
Clinical Features

 no clinical sign or symptom is pathognomonic for

schizophrenia

 patient's symptoms change with time.

 clinicians must take into account the patient's

educational level, intellectual ability, and cultural and
subcultural membership
 Premorbid Signs and Symptoms:
 patients had schizoid or schizotypal personalities
characterized as quiet, passive, and introverted; as children,
they had few friends; sudden onset of obsessive-compulsive
behavior as part of the prodromal picture. The signs may
have started with complaints about somatic symptoms, such
as headache, back and muscle pain, weakness, and digestive
problems; develop an interest in abstract ideas, philosophy,
and the occult or religious questions ;
Mental Status Examination
 appearance of a patient with schizophrenia can range
from that of a completely disheveled, screaming,
agitated person to an obsessively groomed,
completely silent, and immobile person ;

 Precox Feeling - an intuitive experience of their

inability to establish an emotional rapport with a
patient
 reduced emotional responsiveness, sometimes severe
enough to warrant the label of anhedonia, and overly
active and inappropriate emotions such as extremes
of rage, happiness, and anxiety.

 flat or blunted affect can be a symptom of the illness

itself, of the parkinsonian adverse effects of
antipsychotic medications, or of depression
 most common hallucinations are auditory, with
voices that are often threatening, obscene, accusatory,
or insulting;

 Cenesthetic hallucinations - are unfounded

sensations of altered states in bodily organs;

 may believe that an outside entity controls their

thoughts or behavior or, conversely, that they control
outside events in an extraordinary fashion ;
 loss of ego boundaries describes the lack of a clear
sense of where the patient's own body, mind, and
influence end and where those of other animate and
inanimate objects begin: ideas of reference, cosmic
identity

 looseness of associations, derailment, incoherence,

tangentiality, circumstantiality, neologisms, echolalia,
verbigeration, word salad, and mutism
 Thought control, in which outside forces are
controlling what the patient thinks or feels;

 Thought broadcasting - in which patients think

others can read their minds or that their thoughts are
broadcast through television sets or radios.

 decreased social sensitivity and appear to be

impulsive
 Violence - Delusions of a persecutory nature,
previous episodes of violence, and neurological
deficits are risk factors for violent or impulsive
behavior

 Suicide is the single leading cause of premature death

among people with schizophrenia.

 usually oriented to person, time, and place; minor

cognitive deficiencies
 cognitive impairment is a better predictor of level of
function than is the severity of psychotic symptoms;

 poor insight - poor compliance with treatment

 Nonlocalizing signs ( soft signs) include

dysdiadochokinesia, astereognosis, primitive reflexes,
and diminished dexterity
COURSE / PROGNOSIS

 The classic course of schizophrenia is one of

exacerbations and remissions

 Further deterioration in the patient's baseline

functioning follows each relapse of the psychosis

 Sometimes, a clinically observable postpsychotic

depression follows a psychotic episode
 vulnerability to stress is usually lifelong

 10 to 20 % - good outcome; >50 % - poor outcome

SCHIZOPHRENIFORM DISORDER
 acute psychotic disorder that has a rapid onset and
lacks a long prodromal phase

 similar to schizophrenia, except that its symptoms last

at least 1 month but less than 6 months.

 return to their baseline level of functioning once the

disorder has resolved.
 lifetime prevalence rate = 0.2 percent

 1-year prevalence rate of 0.1 percent

 have more affective symptoms (especially mania) and

a better outcome

 increased occurrence of mood disorders in the relatives

 progression to schizophrenia range between 60 and 80

percent
DSM-IV-TR Diagnostic Criteria for
Schizophreniform Disorder

A. Criteria A, D, and E of schizophrenia are met.

B. An episode of the disorder (including prodromal,

active, and residual phases) lasts at least 1 month
but less than 6 months. (When the diagnosis must
be made without waiting for recovery, it should be
qualified as provisional)
 Specify if:

Without good prognostic features

   With good prognostic features: as evidenced by two (or

more) of the following:

 onset of prominent psychotic symptoms within 4 weeks of

the first noticeable change in usual behavior or functioning
 confusion or perplexity at the height of the psychotic
episode
 good premorbid social and occupational functioning
 absence of blunted or flat affect
Schizoaffective Disorder
 symptoms of both schizophrenia and mood disorders

 onset of symptoms was sudden and often occurred in

adolescence.

 good premorbid level of functioning, and often a

specific stressor preceded the onset of symptoms.

 0.5 to 0.8 percent lifetime prevalence

 depressive type of schizoaffective disorder may be
more common in older persons; bipolar type may be
more common in young adults;

 age of onset for women is later than that for men

 better prognosis than patients with schizophrenia and

a worse prognosis than patients with mood disorders
 DSM-IV-TR Diagnostic Criteria for Schizoaffective Disorder

A. An uninterrupted period of illness during which, at some time, there is either a

major depressive episode, a manic episode, or a mixed episode concurrent
with symptoms that meet Criterion A for schizophrenia.
Note: The major depressive episode must include Criterion A1: depressed
mood.
B. During the same period of illness, there have been delusions or hallucinations
for at least 2 weeks in the absence of prominent mood symptoms.
C. Symptoms that meet criteria for a mood episode are present for a substantial
portion of the total duration of the active and residual periods of the illness.
D. The disturbance 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 type:

      Bipolar type: if the disturbance includes a manic or a mixed episode (or a

manic or a mixed episode and major depressive episodes)

Depressive type: if the disturbance only includes major depressive episodes

Delusional Disorder and Shared Psychotic
Disorder
 nonbizarre delusions of at least 1 month's duration
that cannot be attributed to other psychiatric disorders

 .025 to 0.03 percent

 mean age of onset is about 40 years

 slight preponderance of female

 Men are more likely to develop paranoid delusions

 women are more likely to develop delusions of

erotomania.

 defense mechanisms of reaction formation, denial,

and projection
Mental Status
 may seem eccentric, odd, suspicious, or hostile.

 quite normal except for a markedly abnormal

delusional system

 moods are consistent with the content of their

delusions

 do not have prominent or sustained hallucinations

 delusions are usually systematized and are
characterized as being possible

 no insight into their condition and are almost always

brought to the hospital by the police, family
members, or employers. Judgment can best be
assessed by evaluating the patient's past, present, and
planned behavior.

Men are more likely to develop paranoid delusions

Types :
 Persecutory Type

 Jealous Type

 Erotomanic Type

 Somatic Type

 Grandiose Type
DSM-IV-TR Diagnostic Criteria for Delusional Disorder

A. Nonbizarre delusions (i.e., involving situations that occur in real life, such
as being followed, poisoned, infected, 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 in delusional disorder 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 (e.g., a drug of abuse, a medication) or a general medical
condition.
 Shared Psychotic Disorder - shared paranoid disorder,
induced psychotic disorder, folie á deux, folie impose, and
double insanity)

 characterized by the transfer of delusions from one

person to another.
 DSM-IV-TR Diagnostic Criteria for Shared Psychotic
Disorder

A. A delusion develops in an individual in the context of a close relationship

with another person(s), who has an already-established delusion.

B. The delusion is similar in content to that of the person who already has the
established delusion.

C. The disturbance is not better accounted for by another psychotic disorder

(e.g., schizophrenia) or a mood disorder with psychotic features 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.
Brief Psychotic Disorder
 sudden onset of psychotic symptoms, which lasts 1 day or
more but less than 1 month

 Remission is full, and the individual returns to the premorbid

level of functioning

 occurs more often among younger patients (20s and 30s)

 with personality disorders (most commonly, histrionic,

narcissistic, paranoid, schizotypal, and borderline personality
disorders).

 precipitating stressors - major life events

DSM-IV-TR Diagnostic Criteria for Brief Psychotic Disorder

A. Presence of one (or more) of the following symptoms:

1.delusions

2.hallucinations
3.disorganized speech (e.g., frequent derailment or

incoherence)
4.grossly disorganized or catatonic behavior
Note: Do not include a symptom if it is a culturally sanctioned
response pattern.

B. 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
functioning.

C. 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(s) (brief reactive psychosis): if

symptoms occur shortly after and apparently in response to
events that, singly or together, would be markedly stressful
to almost anyone in similar circumstances in the person's
culture

• Without marked stressor(s): if psychotic symptoms do not

occur shortly after, or are not apparently in response to
events that, singly or together, would be markedly stressful
to almost anyone in similar circumstances in the person's
culture

•   With postpartum onset: if onset within 4 weeks

postpartum
DSM-IV-TR Diagnostic Criteria for Psychotic Disorder Not Otherwise
Specified
This category includes psychotic symptomatology (i.e., delusions,
hallucinations, disorganized speech, grossly disorganized or catatonic
behavior) about which there is inadequate information to make a specific
diagnosis or about which there is contradictory information, or disorders with
psychotic symptoms that do not meet the criteria for any specific psychotic
disorder.
Examples include
1.Postpartum psychosis that does not meet criteria for mood disorder with
psychotic features, brief psychotic disorder, psychotic disorder due to a general
medical condition, or substance-induced psychotic disorder
2.Psychotic symptoms that have lasted for less than 1 month but that have not
yet remitted, so that the criteria for brief psychotic disorder are not met
3.Persistent auditory hallucinations in the absence of any other features
4.Persistent nonbizarre delusions with periods of overlapping mood episodes
that have been present for a substantial portion of the delusional disturbance
5.Situations in which the clinician has concluded that a psychotic disorder is
present, but is unable to determine whether it is primary, due to a general
medical condition, or substance induced
Culture-bound Syndromes

 amok - A dissociative episode characterized by a

period of brooding followed by an outburst of violent,
aggressive, or homicidal behavior directed at persons
and objects. The episode tends to be precipitated by a
perceived slight or insult and seems to be prevalent
only among men. The episode is often accompanied
by persecutory idea; automatism, amnesia,
exhaustion, and a return to premorbid state following
the episode.
 ataque de nervios - uncontrollable shouting, attacks of
crying, trembling, heat in the chest rising into the head, and
verbal or physical aggression. Dissociative experiences,
seizurelike or fainting episodes, and suicidal gestures
 sense of being out of control
 association of most ataques with a precipitating event and

the frequent absence of the hallmark symptoms of acute

fear or apprehension distinguish them from panic disorder.
 bouffée délirante - a sudden outburst of agitated and
aggressive behavior, marked confusion, and psychomotor
excitement.

 brain fag -initially used in West Africa to refer to a

condition experienced by high school or university students in
response to the challenges of schooling ; difficulties in
concentrating, remembering, and thinking.
 koro - an episode of sudden and intense anxiety that the penis
(or, in women, the vulva and nipples) will recede into the body
and possibly cause death

 piblokto - An abrupt dissociative episode accompanied by

extreme excitement of up to 30 minutes' duration and frequently
followed by convulsive seizures and coma lasting up to 12
hours.

 spell - A trance state in which persons communicated with

deceased relatives or spirits.