Psychotic Disorders: Insights from Schizophrenia

PSYCHOTIC DISORDERS

Jessica Nelson, M.D.

Assistant Professor of

Psychiatry

O

BJECTIVES



1.  Know and understand the diagnostic criteria

for schizophrenia, the major psychotic disorder



2.  Know the neurotransmitters suspected in the

pathophysiology of schizophrenia



3.  Understand the good and poor prognostic

factors in psychotic disorders

2

O

BJECTIVES



4.  Understand that psychotic symptoms can be

due to disorders other than schizophrenia



5.  Be able to make a reasonable differential

diagnosis of a patient with psychotic symptoms

3

T

YPES

OF

 P

SYCHOTIC

 D

ISORDERS



Schizophrenia (DSM IV-TR, V)



Schizophreniform Disorder (DSM IV-TR, V)



Schizoaffective Disorder (DSM IV-TR, V)



Delusional Disorder (DSM IV-TR, V)



Brief Psychotic Disorder (DSM IV-TR, V)



Other Psychotic Disorder (DSM V)



Secondary Psychotic Disorders (DSM IV-TR,

V)



Catatonia (DSM V)

4

S

CHIZOPHRENIA

-H

ISTORY



     Emil Kraepelin (1856-1926)- described

patients with “dementia praecox” as distinct from

those with manic-depressive psychosis



     Eugen Bleuler (1857-1939)- coined the word

schizophrenia; described the classic 4 A’s of

schizophrenia: associations, affect, autism,

ambivalence

5

S

CHIZOPHRENIA

-E

PIDEMIOLOGY



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

50%

6

S

CHIZOPHRENIA

-E

PIDEMIOLOGY



Age:



Peak onset 18-25 males, 25-35 females



Women have a bimodal distribution, with a

second peak appearing in middle age



Onset after age 45 is considered late onset (very

rare after age 60); generally paranoid, better

prognosis



Childhood onset is rare, but does occur



90% of patients in treatment are ages15-55

7

S

CHIZOPHRENIA

-E

PIDEMIOLOGY



Gender: equal in men and women, but outcomes are

better for women



Birth Season: higher rates in winter and early spring

births



Obstetrical and perinatal complications increase the

risk for schizophrenia



Higher rates in influenza epidemics and maternal

starvation



Geography: higher in urban areas of industrialized

countries, higher in some regions, i.e. Ireland

8

S

CHIZOPHRENIA

-E

PIDEMIOLOGY



Non-psychiatric morbidity and mortality:



Higher death rate from accidents



Higher rates of sudden death



Higher rates of metabolic syndrome: insulin

resistance, hypertension, dyslipidemia, increased

waist circumference



Up to 80% of patients with schizophrenia have

concurrent medical illnesses, half of which are

undiagnosed

9

S

CHIZOPHRENIA

-E

PIDEMIOLOGY



Suicide:



10-15% of patients with schizophrenia commit suicide



50% attempt suicide



Risk factors: male, young, post-psychotic depression,

realistic assessment of deterioration due to illness

10

S

CHIZOPHRENIA

-E

PIDEMIOLOGY



Substance Use:



Cigarette Smoking



75-90% of patients smoke (there may be brain abnormalities in

nicotinic receptors in schizophrenia)



Increases the metabolism of some antipsychotics



Nicotine appears to improve some cognitive impairments (may

decrease positive symptoms)

11

S

CHIZOPHRENIA

-E

PIDEMIOLOGY



Substance Use:



Alcohol



30-50% meet criteria for abuse or dependence



Cannabis and cocaine are the two other commonly used

drugs.  High cannabis use increases risk of developing

schizophrenia by 6x



Alcohol and drug use are associated with a poor prognosis

12

S

CHIZOPHRENIA

-E

PIDEMIOLOGY



Socioeconomic and Cultural Factors:



In industrialized nations a disproportionate number of

patients are in the low SE groups: downward drift

hypothesis vs. social causation hypothesis



Recent immigrants have a higher rate, suggesting the

stress of abrupt cultural change as a risk



Population density-prevalence rises with increasing density

in cities of > 1 million

13

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CHIZOPHRENIA

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PIDEMIOLOGY



Economics:



Onset at a young age, requires life-long care



Accounts for 2.5% of all health care expenditures



75% of patients are unemployed



Direct and indirect costs >$50 billion annually



Half of psychiatric beds occupied by these

patients



40-60% are re-admitted within 2 years of their

first hospitalization



1/3-2/3 of the homeless have schizophrenia

14

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CHIZOPHRENIA

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TIOLOGY



Schizophrenia is not a single disease, but a group of

disorders with heterogeneous causes



Stress-Diathesis Model:  The person has a specific

vulnerability (diathesis) that when acted on by a stress

leads to the development of schizophrenia.  The stress

can be environmental or biological or both.

15

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CHIZOPHRENIA

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TIOLOGY



Genetic Factors:



Significant genetic contribution to some, perhaps all,

forms of schizophrenia, involving multiple genes



Paternal age:  direct correlation of increased risk

with advancing paternal age (perhaps

spermatogenesis in older men is subject to greater

epigenetic damage)

16

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CHIZOPHRENIA

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TIOLOGY

-N

EUROBIOLOGY



Schizophrenia is a complex neurodevelopmental

disorder without one cause, defect or manifestation.

Research implicates dysfunction in certain areas of the

brain, primarily in the limbic system and basal

ganglia, including the cerebral cortex, thalamus and

brainstem.  Some patients have loss of brain volume

believed to be due to reduced density of axons,

dendrites, and synapses.

17

S

CHIZOPHRENIA

-E

TIOLOGY

-

N

EUROTRANSMITTERS



The Dopamine Hypothesis of Schizophrenia:



Disease results from too much dopaminergic activity as

evidenced by:



Dopamine receptor antagonists are effective antipsychotics



Drugs that increase dopamine (amphetamines) are psychotomimetics



This basic theory doesn’t speculate on whether the

dopaminergic hyperactivity is due to excessive release of

dopamine, excessive number of dopamine receptors,

hypersensitivity of receptors, or some combination.

19

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CHIZOPHRENIA

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TIOLOGY

-N

EUROTRANSMITTERS



It has become clear in recent years that the dopamine

hypothesis is not sufficient:



Newer theories posit serotonin excess



The  serotonin antagonist activity of clozapine and other atypical

antipsychotics support this, as does the psychotomimetic effect of

the serotonin agonist LSD



A single neuron can contain more than one

neurotransmitter and can have receptors for 6 or more

neurotransmitters

20

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CHIZOPHRENIA

-E

TIOLOGY

-N

EUROTRANSMITTERS



Norepinephrine likely modulates the

dopaminergic system, and the prominent feature

of anhedonia suggests dysfunction in the

norepinephrine reward neural system



GABA has a regulatory effect on dopamine

activity, and the loss of GABAergic neurons seen

in the hippocampus of some patients could lead to

hyperactivity of dopaminergic neurons

21

S

CHIZOPHRENIA

-E

TIOLOGY

-N

EUROTRANSMITTERS



Glutamate is implicated because phencyclidine (PCP), a

glutamate antagonist, causes psychosis.  New drugs are

in development that influence glutamate



Acetylcholine and nicotine are suspected, as

postmortem studies show decreased muscarinic and

nicotinic receptors (important in cognition)



Substance P and neurotensin are two neuropeptides

with altered concentrations in psychosis

22

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CHIZOPHRENIA

-E

TIOLOGY

-N

EUROPATHOLOGY



Limbic system



Post-mortem studies show decreased size in this region,

including the amygdala, hippocampus, and

parahippocampal gyrus



Disorganization of neurons within the hippocampus has

also been reported



The limbic system is important in controlling emotions

23

S

CHIZOPHRENIA

-E

TIOLOGY

-N

EUROPATHOLOGY



Basal Ganglia and Cerebellum are of theoretical

interest for several reasons:



Many antipsychotic drug-naive schizophrenia patients

show odd movements: awkward gait, facial grimacing, and

stereotypies



Movement disorders involving the basal ganglia are more

commonly associated with psychosis than are other

neurological disorders

24

S

CHIZOPHRENIA

-E

TIOLOGY

-N

EUROPATHOLOGY



Cerebral ventricles: lateral and third ventricle

enlargement and some degree of reduction in cortical

volume.



Reduced Symmetry:  present in several brain areas,

including temporal, frontal, and occipital lobes



Believed by some to originate during fetal life and to be

indicative of a disruption in brain lateralization during

neurodevelopment

25

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CHIZOPHRENIA

-E

TIOLOGY

-

N

EUROPATHOLOGY



Prefrontal Cortex: postmortem studies show

anatomical abnormalities in this region, and

imaging has shown functional deficits



Some symptoms of illness are shared with patients

with frontal lobe syndromes and those who

underwent prefrontal lobotomies years ago



Thalamus: some patients (including

antipsychotic-naive) have shown volume

shrinkage or neuronal loss in particular thalamic

subnuclei

26

S

CHIZOPHRENIA

-E

TIOLOGY

-

N

EUROPATHOLOGY



Electroencephalography (EEG):  Many schizophrenic

patients have abnormal EEG’s



They also have an inability to filter out irrelevant

sounds and are extremely sensitive to background

noise



Complex partial epilepsy: schizophrenia-like psychoses

occur more commonly than expected, particularly with

a left-sided seizure focus, medial temporal location of

lesion, and early onset of seizures

27

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CHIZOPHRENIA

-E

TIOLOGY

-

N

EUROPATHOLOGY



Evoked Potentials: a number of abnormalities

have been found, both positive and negative.

Most studied is the P300; a large positive EP

wave that occurs about 300msec after a sensory

stimulus.  The major source of the P300 may be

in limbic system structures of the medial

temporal lobes

28

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CHIZOPHRENIA

-E

TIOLOGY

-

N

EUROPATHOLOGY



Eye Movement Dysfunction: 50-85% of pts, 25% of other

psych pts, and 10% of controls



Inability to accurately follow a moving visual target;

independent of drug treatment and also found in first degree

relatives of patients



Eye movement is partly controlled by centers in the frontal

lobes; a disorder in eye movement is consistent with theories

that implicate a frontal lobe pathological process in

schizophrenia

29

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CHIZOPHRENIA

-E

TIOLOGY

-

N

EUROPATHOLOGY



Psychoneuroimmunology:



Decreased T cell interleukin-2 production



Reduced number and responsiveness of peripheral lymphocytes



Abnormal cellular and humoral reactivity to neurons



Presence of brain-directed antibodies



Relevance of these abnormalities is unclear

30

S

CHIZOPHRENIA

-E

TIOLOGY

-

N

EUROPATHOLOGY



Psychoneuroendocrinology:



Many studies have shown differences in hormone levels and

responses to stimulation and suppression tests between

groups of patients with schizophrenia and groups of control

subjects

31

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CHIZOPHRENIA

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TIOLOGY

-S

OCIAL



Psychosocial Factors:



Many theories over the years blamed the family, especially the

mother, for the development of schizophrenia; these have been

largely discredited.



It has been shown that patients living with parents or other

caretakers with high levels of expressed emotion (criticism,

hostility, over involvement) have high relapse rates

32

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CHIZOPHRENIA

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IAGNOSIS



DSM IV-TR and DSM V (Diagnostic and Statistical

Manual of Mental Disorders) Diagnostic Criteria for

Schizophrenia (criteria A-F must all be met):

33

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CHIZOPHRENIA

 D

IAGNOSIS



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):



1) Delusions



2) Hallucinations



3) Disorganized speech (i.e. frequent derailment or

incoherence)



4) Grossly disorganized or catatonic behavior



5) Negative symptoms (i.e. affective flattening, alogia, or

avolition)

34

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CHIZOPHRENIA

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IAGNOSIS



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.

35

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CHIZOPHRENIA

-D

IAGNOSIS



B.  Social/occupational dysfunction:  For a significant

portion of the time since the onset of the disturbance,

one or more major areas of functioning such as work,

interpersonal relations, or self-care are markedly

below the level achieved prior to the onset (or when the

onset is in childhood or adolescence, failure to achieve

expected level of interpersonal, academic, or

occupational achievement)

36

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CHIZOPHRENIA

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IAGNOSIS



C. Duration: Continuous signs of the disturbance persist

for at least 6 months.  This 6 month period must include

at least 1 month of symptoms (or less if successfully

treated) that meet Criterion A (i.e. active phase

symptoms) and may include periods of prodromal or

residual symptoms.  During these prodromal or residual

periods, the signs of the disturbance may be manifested

by only negative symptoms or two or more symptoms

listed in Criterion A presented in an attenuated form

(e.g. odd beliefs, unusual perceptual experiences).

37

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CHIZOPHRENIA

-D

IAGNOSIS



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.

38

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CHIZOPHRENIA

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IAGNOSIS



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

39

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CHIZOPHRENIA

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IAGNOSIS



F. Relationship to a pervasive developmental disorder:

If there is a history of autistic disorder or another

pervasive developmental disorder, the additional

diagnosis of schizophrenia is made only if prominent

delusions or hallucinations are also present for at least

a month (or less if successfully treated).

40

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CHIZOPHRENIA

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OOD

 P

ROGNOSIS



Late Onset



Obvious precipitating factors



Acute onset



Good premorbid social, sexual, and work histories



Mood disorder symptoms (especially depressive

symptoms)



Married



Family history of mood disorders



Good support systems



Positive symptoms

42

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CHIZOPHRENIA

-P

OOR

 P

ROGNOSIS



Young onset



No precipitating factors



Insidious onset



Poor premorbid social, sexual, and work histories



Withdrawn, autistic behavior



Single, divorced, or widowed



Poor support systems

43

S

CHIZOPHRENIA

-P

OOR

 P

ROGNOSIS



Negative Symptoms



Neurological signs and symptoms



History of perinatal trauma



No remission in 3 years



Many relapses



History of assaultiveness



Family history of schizophrenia

44

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CHIZOPHRENIA

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SYCHOLOGICAL

T

ESTING



Schizophrenia is a brain disease that disrupts the

normal functioning of many cognitive abilities



Vigilance, memory, and concept formation are most

affected and consistent with frontotemporal cortical

defects



Frequently there are impairments in attention,

retention time, and problem solving ability



Motor ability is also impaired



IQ is lower at onset of illness and may deteriorate

with progression of the disorder



Projective tests may indicate bizarre ideation

45

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Appearance:



Hygiene may be poor



Dress may be odd



Motor Behavior:



Eye contact may be poor, or patient may stare or look around

the room if paranoid



Psychomotor agitation or retardation may be present



Evaluate for posturing, grimacing, echopraxia, echolalia



Look for medication side effects, EPS or TD

46

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Mood:



Patient report of recent mood



Affect:  what the examiner sees: sad, tearful, blunted, flat,

agitated, reactive, appropriate, inappropriate, congruent (or

not) with mood



Speech:  spontaneous or not, rate, tone, volume, rhythm

47

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Perceptual Disturbances-Hallucinations:



Auditory-most common, frequently derogatory



Visual-also consider substance use or medication side

effect. Can be seen in some forms of dementia.



Tactile-uncommon; consider cocaine or delirium.



Gustatory and olfactory-uncommon in schizophrenia-

consider neurologic disorder.

48

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CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Thought Content-Delusions (fixed, false beliefs):



Paranoid: being watched, followed, listened to, spied on,

poisoned, plotted against



Somatic: believing one is infested with parasites, insides

are being eaten, or has HIV even in face of repeated

negative tests

49

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Delusions:



Of Control: a person or force is controlling one’s mind or

body



Thought Broadcasting: one’s thoughts are being broadcast

out loud



Thought Withdrawal: others are taking thoughts out of

one’s mind



Thought Insertion: others are putting thoughts in one’s

mind



Ideas of Reference: events have to do with you-newscaster

gave a message aimed at you on the news

50

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Form of Thought



Looseness of associations - no relationship between one

statement and the next



Word salad - incomprehensible speech



Neologisms - words made up by the patient



Circumstantiality - excessive detail, loss of goal directed

thinking



Tangentiality - patient loses the thread of conversation and

pursues tangents



Echolalia



Mutism

51

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Thought Process: disorders of thought process

concern the way in which ideas and languages

are formulated:



Flight of ideas, circumstantiality, perseveration



Thought blocking, idiosyncratic associations



Impaired attention and poor abstraction



Poverty of thought content



Thought control, thought broadcasting

52

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Violence risk factors: persecutory delusions, prior

episodes, neurological deficits



Is not uncommon among untreated patients with

schizophrenia:



Poor impulse control



Paranoia



Auditory hallucinations may be command



Mothers are the main recipients of violence, followed by other

family members

53

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Homicide:



Is uncommon, but always assess for ideation



Possible predictors: previous history of violence, dangerous

behavior while hospitalized, hallucinations or delusions

involving violence

54

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Suicide is always a risk-always assess.  Look for

depression that may be misdiagnosed as flat affect or

medication side effect.  Up to 80% of patients may

have a major depressive episode at some time in their

lives.  Antidepressant medication can help depression

in patients with schizophrenia.



20-50% of patients attempt suicide, 10-13% commit

suicide

55

S

CHIZOPHRENIA

-M

ENTAL

 S

TATUS

 E

XAM



Sensorium and Cognition:



Usually oriented



Memory as tested in formal MSE usually intact if

patient can pay attention



There are subtle cognitive impairments in attention,

executive function, working and episodic memory



Insight frequently impaired, which can lead to non-

compliance



Judgment may be impaired in some spheres

56

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CHIZOPHRENIA

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THER

 F

INDINGS



Localizing and non-localizing neurological signs

(also known as hard and soft signs) occur more

frequently in people with schizophrenia than in

other psychiatric patients.  These signs are

correlated with severity of illness, affective

blunting, and poor prognosis.



Elevated eye blink rate, which is thought to reflect

hyperdopaminergic activity



Minor physical anomalies



Compulsive water drinking (up to 10 L/d)

57

S

CHIZOPOHRENIA

-D

IFFERENTIAL

D

IAGNOSIS



Secondary Psychotic Disorders-due to a medical

condition or substance



Other Psychotic Disorder-schizophreniform, brief

psychotic, schizoaffective, delusional



Mood Disorders



Personality Disorders



Malingering (material goal) and Factitious

Disorder (emotional goal)

58

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CHIZOPHRENIA

-C

OURSE

AND

 P

ROGNOSIS



Prodromal syndrome may last a year or more

before the onset of overt psychosis



Classic course one of exacerbations and remissions

with progressive deterioration after each relapse



Positive symptoms tend to become less severe with

time, but negative symptoms may worsen



In the 5-10 years after first hospitalization, 10-

20% of patients have a good outcome, more than

50% have a poor outcome

59

S

CHIZOPHRENIA

-T

REATMENT



Complex, multifaceted illness requires a

multifaceted approach:



Pharmacotherapy is the mainstay



Psychosocial treatments augment the medication, and

most patients do better when they receive both



Hospitalization is indicated for diagnostic evaluation,

medication stabilization, and for safety due to suicidal

or homicidal thoughts or inability to care for self.

Stays of 4-6 weeks with active behavioral approaches

and establishment of an aftercare plan tend to give

the best results.

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HARMACOTHERAPY



Introduction of antipsychotic medication in the 1950s

revolutionized the treatment of this disease. Patients

are 2-4 times more likely to relapse when treated with

placebo than with antipsychotics.

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HARMACOTHERAPY



Two major classes:



Dopamine receptor antagonists (first generation

antipsychotics, typical antipsychotics) (haloperidol,

fluphenazine, thiothixene)



Serotonin-dopamine receptor antagonists (second

generation antipsychotics, atypical antipsychotics)

(clozapine, risperidone, paliperidone, asenapine, lurasidone,

olanzapine, quetiapine, ziprasidone, aripiprazole)



These are considered first line agents by most psychiatrists (except

clozapine which has significant side effects) because of the more

benign side effect profile

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HARMACOTHERAPY



Typical Antipsychotics Side Effects:



Extra Pyramidal Symptoms (EPS): parkinsonism

(bradykinesia, tremor, rigidity)



Treatment is anticholinergic meds like benztropine,

but they can cause dry mouth, constipation, blurred

vision, memory loss



Akathisia: internal restlessness, inability to sit

still, very distressing to patients



Treatment is beta-blockers like propranolol



Elevated Prolactin: sexual dysfunction, menstrual

irregularities, galactorrhea, osteoporosis



Tardive Dyskinesia: permanent movement

disorder

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HARMACOTHERAPY



Tardive Dyskinesia (TD): a serious and likely

permanent movement disorder related to therapy

with dopamine blocking drugs



20-30% of long-term patients on typical

antipsychotics exhibit symptoms



3-5% of young patients per year on typical

antipsychotics develop TD



Higher incidence in females, older age, organic and

affective mental illness

64

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-P

HARMACOTHERAPY



Atypical Antipsychotics:



Decreased EPS and TD (primary benefit)



Do not cause elevated Prolactin (except risperidone and

paliperidone))



Were thought to be more effective at treating negative

symptoms than typical antipsychotics, although that now

seems to not be the case



Some are associated with weight gain and metabolic

abnormalities (monitoring is needed)

65

S

CHIZOPHRENIA

-P

HARMACOTHERAPY



Clozapine



Most effective antipsychotic drug



0.3% risk of agranulocytosis in first year.  Weekly

WBC for first 6 mo, then biweekly for 6 mo, then q 4

weeks



Higher risk of seizures than other drugs, almost 5%

at doses > 600mg (manage with AED’s)



Hypersalivation, sedation, postural hypotension,

tachycardia, myocarditis, metabolic issues

66

S

CHIZOPHRENIA

-P

HARMACOTHERAPY



Therapeutic principles for antipsychotic use:



1. Target the symptoms to be addressed



2. Use a drug that has worked in the past, if

possible.  Choose a drug based on the side effect

profile



3. Minimum length of a medication trial is 6

weeks at a therapeutic dose



4. Rarely indicated to use more than one

antipsychotic at a time



5.  Maintain patient on lowest effective dose

67

S

CHIZOPHRENIA

-P

HARMACOTHERAPY



Non-response:



Major cause is non-compliance; consider long-

acting injectable medication



If patient is compliant, switch to another drug.

After 2 failed drug trials, consider clozapine.  It is

the most effective drug, but requires weekly white

blood cell counts due to a risk of agranulocytosis.



Sometimes augmenting an antipsychotic with a

mood stabilizer such as lithium, valproate, or

carbamazepine is helpful

68

S

CHIZOPHRENIA

-ECT



ECT (electroconvulsive therapy):



Can be beneficial in acute and chronic illness not

responding adequately to drug therapy



Difficult to access, expensive



Usually reserved for severe symptoms with very

problematic behavioral issues

69

S

CHIZOPHRENIA

-P

SYCHOSOCIAL

 T

HERAPIES



Social Skills Training



Family Oriented Therapies



NAMI (National Alliance for the Mentally Ill)



Case Management



Assertive Community Treatment (ACT)



Group Therapy, Art Therapy



Cognitive Behavioral Therapy



Individual Psychotherapy, Personal Therapy



Vocational Therapy

70

S

CHIZOPHRENIFORM

 D

ISORDER



Similar to schizophrenia but symptoms last between 1

and 6 months



Typical presentation is rapid onset without a

significant prodrome, with return to baseline

functioning within 6 months



If patient does not have good prognostic features, may

have early schizophrenia

71

S

CHIZOPHRENIFORM

 D

ISORDER



Good prognostic features:



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

72

S

CHIZOPHRENIFORM

 D

ISORDER



Course: 60-80% progress to schizophrenia



Treatment: initial hospitalization for evaluation and

stabilization followed by 3-6 month course of

antipsychotic medication

73

S

CHIZOAFFECTIVE

 D

ISORDER



Has features of both schizophrenia and

affective (mood) disorders



Epidemiology



Lifetime prevalence of 0.5-0.8%



Depressive type may be more common in older

patients, bipolar in younger



Slightly higher rates in females than males, age of

onset later in women



Men may exhibit antisocial behavior and flat or

inappropriate affect

74

S

CHIZOAFFECTIVE

 D

ISORDER



Etiology-theories:



A type of schizophrenia or a type of mood disorder



Simultaneous expression of schizophrenia and

mood disorder



A distinct third type of psychosis



A heterogeneous group of disorders encompassing

all of the above (most likely)

75

S

CHIZOAFFECTIVE

 D

ISORDER

-D

IAGNOSIS



DSM IV-TR and DSM V Diagnostic Criteria:



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

76

S

CHIZOAFFECTIVE

 D

ISORDER

-D

IAGNOSIS



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.

77

S

CHIZOAFFECTIVE

 D

ISORDER



Course: A chronic mental illness requiring long term

treatment.  Patients with more mood symptoms do

better than those with more psychotic symptoms.



Treatment is with an antipsychotic medication and a

mood stabilizer for the bipolar type or an

antidepressant plus antipsychotic for the depressed

type, and psychosocial therapies for both.

78

D

ELUSIONAL

 D

ISORDER



Epidemiology



Rare, 0.025-0.03%. 1-2% of admissions to inpatient mental

health facilities



Mean age of onset is 40 yo



Slightly more females than males



Females likely to have erotomanic delusions



Males likely to have paranoid delusions

80

D

ELUSIONAL

 D

ISORDER



Etiology is unknown:



It is not related to schizophrenia or mood disorders. Studies

do show an increased rate of delusional disorder,

suspiciousness, jealousy and secretiveness in family

members of delusional disorder patients.



Important to rule out medical conditions which can have

associated delusions, i.e. toxic-metabolic disorders, and

especially CNS disorders such as Huntington’s, CVA,

dementia.

81

D

ELUSIONAL

 D

ISORDER



Clinical Features:



Appearance unremarkable.  May be eccentric, odd,

suspicious or hostile, sometimes litigious.  Mental status

exam remarkably normal except for the delusional system.

The delusions are non-bizarre and have been present at

least a month.



Main defense mechanisms of reaction formation, denial,

and projection



Multiple factors associated with formation of delusions

82

D

ELUSIONAL

 D

ISORDER

-S

UBTYPES



Erotomanic type: delusions that another person,

usually of higher status, is in love with the individual;

more common in females, males may become

aggressive



Grandiose type: delusions of inflated worth, power,

knowledge, identity, or special relationship to a deity

or famous person



Jealous type: delusions that the individual’s sexual

partner is unfaithful; usually affects males

83

D

ELUSIONAL

 D

ISORDER

-S

UBTYPES



Persecutory type: delusions that the person (or

someone to whom the person is close) is being

malevolently treated in some way.  Patient may be

litigious or become aggressive.



Somatic type: delusions that the person has some

physical defect or general medical condition



Mixed type: delusions characteristic of more than one

of the above types but no one theme predominates



Unspecified type

84

D

ELUSIONAL

 D

ISORDER

 - C

OURSE

AND

P

ROGNOSIS



Psychosocial stress may precede the onset



IQ may be lower than average



Premorbid personality may be extroverted, dominant,

hypersensitive



The initial concerns become more and more involved

until delusional in quality



50% recover at long term follow up



20% have a decrease in symptoms



30% have no change



Good prognostic factors: high functioning, female, age

   <30, sudden onset, short illness, precipitating factors

85

D

ELUSIONAL

 D

ISORDER

-T

REATMENT



Difficult to treat



Try antipsychotic although patient may be resistant

and it may not help



Psychotherapy-the essential element is to establish a

trusting relationship.  Patient may not give up

delusions but therapy may improve functioning.

86

B

RIEF

 P

SYCHOTIC

 D

ISORDER



An acute and transient psychotic disorder:



Uncommon, occurs more often among younger

patients.  Higher incidence in women and people

in developing countries, particularly those who

have experienced disasters or major cultural

changes (immigrants).



Often seen with personality disorders.

Psychodynamic formulations have emphasized

the presence of inadequate coping mechanisms.

88

B

RIEF

 P

SYCHOTIC

 D

ISORDER

 - D

IAGNOSIS



A.  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

89

B

RIEF

 P

SYCHOTIC

 D

ISORDER

-

D

IAGNOSIS



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), without marked

stressor(s) or with postpartum onset

.

90

B

RIEF

 P

SYCHOTIC

 D

ISORDER



Clinical Features:



Labile mood, confusion, strange or bizarre behavior,

screaming or muteness, impaired memory for recent events



Course and Prognosis:



Up to 50% are later diagnosed with a chronic  disorder



Good prognostic features indicating a high likelihood of

recovery are:  good premorbid adjustment, few premorbid

schizoid traits, severe precipitating stressor, sudden onset

of symptoms, affective symptoms, confusion and perplexity

during psychosis, little affective blunting, short duration of

symptoms, absence of schizophrenic relatives.

91

B

RIEF

 P

SYCHOTIC

 D

ISORDER

 -

T

REATMENT



Hospitalization may be needed for evaluation and

protection.



Pharmacotherapy with antipsychotics and adjunctive

benzodiazepines may be needed until the patient has

recovered.



Psychotherapy is beneficial in integrating the

psychotic experience and exploring the precipitating

stress, if present.  Exploration and development of

coping strategies and strengthening the ego structure

in individual therapy is helpful.

92

O

THER

 P

SYCHOTIC

 D

ISORDER



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

93

O

THER

 P

SYCHOTIC

 D

ISORDER



Examples include:



Postpartum psychosis that does not meet criteria for mood

disorder with psychotic features, psychotic disorder due to a

general medical condition, or substance-induced psychotic

disorder



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



Persistent auditory hallucinations in the absence of any

other features



Shared Psychotic Disorder

94

O

THER

 P

SYCHOTIC

 D

ISORDER



Examples



Persistent non-bizarre delusions with periods of

overlapping mood episodes that have been present for a

substantial portion of the delusional disturbance



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

95

P

OST

 P

ARTUM

 P

SYCHOSIS



Occurs in 0.1% of pregnancies



50-60% of patients have just had their first child



50% of children have experienced perinatal

complications



Most cases represent an underlying mood disorder,

usually bipolar disorder



2/3 go on to have a mood episode within a year



Post partum psychosis is a psychiatric emergency:



5% commit suicide



4% commit infanticide

96

P

OST

 P

ARTUM

 P

SYCHOSIS



Clinical Features:



Mean time to onset 2-3 weeks after delivery



Symptoms: fatigue, insomnia, restlessness, emotional

lability, progressing to suspiciousness, confusion, irrational

statements, obsessive concern about the baby’s health,

delusions and or hallucinations.  The mother may have

thoughts of not loving or wanting the baby, or thoughts of

harming self or baby.

97

P

OST

 P

ARTUM

 P

SYCHOSIS



Treatment:



Hospitalization



Medication



Psychotherapy after the psychosis resolves



High rates of recovery

98

S

ECONDARY

 P

SYCHOTIC

 D

ISORDERS



Diagnostic Criteria for Psychotic Disorder Due to a

Another Medical Condition



A. Prominent hallucinations or delusions



B. There is evidence from the history, physical examination

or laboratory findings that the disturbance is the direct

physiological consequence of a general medical condition.



C. The disturbance is not better accounted for by another

mental disorder.



D. The disturbance does not occur exclusively during the

course of a delirium

99

S

ECONDARY

 P

SYCHOTIC

 D

ISORDERS



Substance-Induced Psychotic Disorder



This category only applies to people with

impaired reality testing.  If a patient has

hallucinations or delusions but realizes they

are due to a substance, then he is diagnosed as

having a substance-related disorder, not a

psychotic disorder.



Diagnostic Criteria



A. Prominent hallucinations or delusions



B. There is evidence from the history, physical

examination, or laboratory findings of either (1) or

(2):

100

S

ECONDARY

 P

SYCHOTIC

 D

ISORDERS



Substance Induced Psychotic Disorder



(1) the symptoms in Criterion A developed during,

or within a month, of substance intoxication or

withdrawal



(2) medication use is etiologically related to the

disturbance



C. The disturbance is not better accounted for by a

psychotic disorder that is not substance induced.

Evidence that the symptoms are better accounted

for by a psychotic disorder that is not substance

induced might include the following: the symptoms

precede the onset of the substance use (or

medication use); the symptoms persist for a

substantial period

101

S

ECONDARY

 P

SYCHOTIC

 D

ISORDERS

    of time (e.g. about a month) after the cessation of acute

withdrawal or severe intoxication, or are substantially in

excess of what would be expected given the type or amount

of the substance used or the duration of use; or there is

other evidence that suggests the existence of an

independent non-substance-related psychotic disorder (e.g.

a history of recurrent non-substance-related episodes)



D. The disturbance does not occur exclusively during the course of

a delirium



Note: This diagnosis should be made instead of a diagnosis

of substance intoxication or substance withdrawal only

when the symptoms are in excess of those usually

associated with the intoxication or withdrawal syndrome

and when the symptoms are sufficiently severe to warrant

independent clinical attention.

102

S

ECONDARY

 P

SYCHOTIC

 D

ISORDERS



Differential Diagnosis:



Psychotic disorder due to a another medical

condition and Substance-induced psychotic

disorder must be distinguished from:



Delirium: clouding of consciousness and change in

cognition which develops over a short period of time



Dementia: multiple cognitive deficits with stable

sensorium



Other Psychotic Disorders

103

S

ECONDARY

 P

SYCHOTIC

 D

ISORDERS



Treatment



Treat the underlying medical or substance condition.  Use

antipsychotics and/or anxiolytics as needed to manage

behavior

104

C

ATATONIA



Clinical picture dominated by three (or more) of the

following symptoms:



Stupor



Catalepsy



Waxy flexibility



Mutism



Negativism



Posturing



Mannerisms



Stereotypy



Agitation not influenced by external stimuli



Grimacing



Echolalia



Echopraxia

105

C

ATATONIA



May occur in the context of a mental or medical

disorder



May be a medical emergency secondary to

dehydration, hyperpyrexia, exhaustion, and

muscle breakdown



Aggressive hydration



Administer benzodiazepines



Treat underlying mental or medical conditions

106

T

HANK

 Y

OU

!

Questions?