Schizophrenia & other psychotic disorder


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Schizophrenia & other psychotic disorder

  1. 1. Schizophrenia and Other Psychotic Disorders Dr. Rebwar G. Hama Psychiatrist University of Sulaimani School of Medicine
  2. 2. Nature of Schizophrenia and Psychosis: <ul><li>Schizophrenia vs. Psychosis </li></ul><ul><ul><li>Psychosis – Broad term (e.g., hallucinations, delusions) </li></ul></ul><ul><ul><li>Schizophrenia – A type of psychosis </li></ul></ul><ul><ul><li>Psychosis and Schizophrenia are heterogeneous </li></ul></ul><ul><ul><li>Disturbed thought, emotion, behavior </li></ul></ul>
  3. 3. Definition <ul><li>The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. </li></ul><ul><li>Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time. </li></ul>
  4. 4. Nature of Schizophrenia and Psychosis <ul><li>Historical Background </li></ul><ul><ul><li>Benedict Morel – Introduced dementia praecox </li></ul></ul><ul><ul><ul><li>Demence (loss of mind) precoce (early, premature) </li></ul></ul></ul><ul><ul><li>Emil Kraepelin – Used the term dementia praecox </li></ul></ul><ul><ul><ul><li>Focused on subtypes of schizophrenia </li></ul></ul></ul><ul><ul><li>Eugen Bleuler – Introduced the term “schizophrenia” </li></ul></ul><ul><ul><ul><li>“ Splitting of the mind” </li></ul></ul></ul><ul><ul><li>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 </li></ul></ul>
  5. 5. Schizophrenia: Some Facts and Statistics <ul><li>Onset and Prevalence of Schizophrenia worldwide </li></ul><ul><ul><li>About 0.2% to 1.5% (or about 1% population) </li></ul></ul><ul><ul><li>Often develops in early adulthood </li></ul></ul><ul><ul><li>Can emerge at any time </li></ul></ul><ul><li>Schizophrenia Is generally chronic </li></ul><ul><ul><li>Most suffer with moderate-to-severe lifetime impairment </li></ul></ul><ul><ul><li>Life expectancy is slightly less than average </li></ul></ul><ul><li>Schizophrenia affects males and females about equally </li></ul><ul><ul><li>Females tend to have a better long-term prognosis </li></ul></ul><ul><ul><li>Onset differs between males and females </li></ul></ul><ul><li>Schizophrenia has a strong genetic component </li></ul>
  6. 6. Schizophrenia: Some Facts and Statistics (cont.)
  7. 9. Schizophrenia: The “Positive” Symptom Cluster <ul><li>The Positive Symptoms </li></ul><ul><ul><li>Active manifestations of abnormal behavior </li></ul></ul><ul><ul><li>Distortions of normal behavior </li></ul></ul><ul><li>Delusions: The basic feature of psychosis </li></ul><ul><ul><li>Gross misrepresentations of reality </li></ul></ul><ul><ul><li>Include delusions of grandeur or persecution </li></ul></ul><ul><li>Hallucinations: Auditory and/or Visual </li></ul><ul><ul><li>Experience of sensory events without environmental input </li></ul></ul><ul><ul><li>Can involve all senses </li></ul></ul><ul><ul><li>Findings from SPECT studies </li></ul></ul>
  8. 10. Schizophrenia: The “Negative” Symptom Cluster <ul><li>The Negative Symptoms </li></ul><ul><ul><li>Absence or insufficiency of normal behavior </li></ul></ul><ul><li>Spectrum of Negative Symptoms </li></ul><ul><ul><li>Avolition (or apathy) – Lack of initiation and persistence </li></ul></ul><ul><ul><li>Alogia – Relative absence of speech </li></ul></ul><ul><ul><li>Anhedonia – Lack of pleasure, or indifference </li></ul></ul><ul><ul><li>Affective flattening – Little expressed emotion </li></ul></ul><ul><ul><li>Asociality – Isolation from public </li></ul></ul>
  9. 11. Schizophrenia: The “Disorganized” Symptom Cluster <ul><li>The Disorganized Symptoms </li></ul><ul><ul><li>Include severe and excess disruptions </li></ul></ul><ul><ul><li>Speech, behavior, and emotion </li></ul></ul><ul><li>Nature of Disorganized Speech </li></ul><ul><ul><li>Cognitive slippage – Illogical and incoherent speech </li></ul></ul><ul><ul><li>Tangentiality – “Going off on a tangent” </li></ul></ul><ul><ul><li>Loose associations – Conversation in unrelated directions </li></ul></ul><ul><li>Nature of Disorganized Affect </li></ul><ul><ul><li>Inappropriate emotional behavior </li></ul></ul><ul><li>Nature of Disorganized Behavior </li></ul><ul><ul><li>Includes a variety of unusual behaviors </li></ul></ul><ul><ul><li>Catatonia – Spectrum </li></ul></ul><ul><ul><ul><li>Wild agitation, waxy flexibility, immobility </li></ul></ul></ul>
  10. 12. Course of Illness <ul><li>Course of schizophrenia: </li></ul><ul><ul><li>continuous without temporary improvement </li></ul></ul><ul><ul><li>episodic with progressive or stable deficit </li></ul></ul><ul><ul><li>episodic with complete or incomplete remission </li></ul></ul><ul><li>Typical stages of schizophrenia: </li></ul><ul><ul><li>prodromal phase </li></ul></ul><ul><ul><li>active phase </li></ul></ul><ul><ul><li>residual phase </li></ul></ul>
  11. 13. Subtypes of Schizophrenia <ul><li>Paranoid Type </li></ul><ul><ul><li>Intact cognitive skills and affect </li></ul></ul><ul><ul><li>Do not show disorganized behavior </li></ul></ul><ul><ul><li>Hallucinations and delusions – Grandeur or persecution </li></ul></ul><ul><ul><li>The best prognosis of all types of schizophrenia </li></ul></ul><ul><li>Disorganized Type (Hebephrenic) </li></ul><ul><ul><li>Marked disruptions in speech and behavior </li></ul></ul><ul><ul><li>Flat or inappropriate affect </li></ul></ul><ul><ul><li>Hallucinations and delusions – Tend to be fragmented </li></ul></ul><ul><ul><li>Develops early, tends to be chronic, lacks remissions </li></ul></ul>
  12. 14. Subtypes of Schizophrenia (cont.) <ul><li>Catatonic Type </li></ul><ul><ul><li>Show unusual motor responses and odd mannerisms </li></ul></ul><ul><ul><li>Examples include echolalia and echopraxia </li></ul></ul><ul><ul><li>Tends to be severe and rare </li></ul></ul><ul><li>Undifferentiated Type (Atypical Schizophrenia) </li></ul><ul><ul><li>Wastebasket category </li></ul></ul><ul><ul><li>Major symptoms of schizophrenia </li></ul></ul><ul><ul><li>Fail to meet criteria for another type </li></ul></ul><ul><li>Residual Type </li></ul><ul><ul><li>One past episode of schizophrenia </li></ul></ul><ul><ul><li>Continue to display less extreme residual symptoms </li></ul></ul>
  13. 15. Schizophrenia Subtypes
  14. 16. DSM–IV diagnostic criteria for Schizophrenia <ul><li>1. Two of the following for most of 1 month; </li></ul><ul><li>Delusions </li></ul><ul><li>Hallucinations </li></ul><ul><li>Disorganized speech </li></ul><ul><li>Grossly disorganized or catatonic behavior </li></ul><ul><li>Negative symptoms </li></ul><ul><li>2. Marked social or occupational dysfunction </li></ul><ul><li>3. Duration of at least 6 Months of persistent symptoms </li></ul><ul><li>4. Symptoms of Schizoaffective & mood disorder are ruled out </li></ul><ul><li>5. Substance abuse & medical conditions are ruled out as aetiological </li></ul>
  15. 18. Causes of Schizophrenia: Findings From Genetic Research <ul><li>Family Studies </li></ul><ul><ul><li>Inherit a tendency for schizophrenia </li></ul></ul><ul><ul><li>Do not inherit specific forms of schizophrenia </li></ul></ul><ul><ul><li>Risk increases with genetic relatedness </li></ul></ul><ul><li>Twin Studies </li></ul><ul><ul><li>Monozygotic twins – Risk for schizophrenia is 48% </li></ul></ul><ul><ul><li>Fraternal (dizygotic) twins – Risk drops to 17% </li></ul></ul><ul><ul><li>Adoption Studies -- Risk for schizophrenia remains high </li></ul></ul><ul><ul><ul><li>Cases where a biological parent has schizophrenia </li></ul></ul></ul><ul><li>Summary of Genetic Research </li></ul><ul><ul><li>Risk for schizophrenia increases with genetic relatedness </li></ul></ul><ul><ul><li>Risk is transmitted independently of diagnosis </li></ul></ul><ul><ul><li>Strong genetic component does not explain everything </li></ul></ul>
  16. 19. Causes of Schizophrenia: Neurotransmitter Influences <ul><li>The Dopamine Hypothesis </li></ul><ul><ul><li>Drugs that increase dopamine (agonists) </li></ul></ul><ul><ul><ul><li>Result in schizophrenic-like behavior </li></ul></ul></ul><ul><ul><li>Drugs that decrease dopamine (antagonists) </li></ul></ul><ul><ul><ul><li>Reduce schizophrenic-like behavior </li></ul></ul></ul><ul><ul><li>Examples – Neuroleptics, L-Dopa for Parkinson’s disease </li></ul></ul><ul><ul><li>Current theories – Emphasize many neurotransmitters </li></ul></ul><ul><li>(Serotonin, GABA, & Glutamate) also have a role </li></ul>
  17. 20. Causes of Schizophrenia: Neurotransmitter Influences (cont.)
  18. 21. Causes of Schizophrenia: Other Neurobiological Influences <ul><li>Structural and Functional Abnormalities in the Brain </li></ul><ul><ul><li>Enlarged ventricles and reduced tissue volume </li></ul></ul><ul><ul><li>Hypofrontality – Less active frontal lobes </li></ul></ul><ul><ul><ul><li>A major dopamine pathway </li></ul></ul></ul><ul><li>Viral Infections during early prenatal development </li></ul><ul><ul><li>Findings are inconclusive </li></ul></ul><ul><ul><li>Structural and functional brain abnormalities </li></ul></ul><ul><ul><ul><li>Not unique to schizophrenia </li></ul></ul></ul>
  19. 22. Causes of Schizophrenia: Other Neurobiological Influences (cont.)
  20. 23. Causes of Schizophrenia: Psychological and Social Influences <ul><li>The Role of Stress </li></ul><ul><ul><li>May activate underlying vulnerability </li></ul></ul><ul><ul><li>May also increase risk of relapse </li></ul></ul><ul><li>Family Interactions </li></ul><ul><ul><li>Families – Show ineffective communication patterns </li></ul></ul><ul><ul><li>High expressed emotion – Associated with relapse </li></ul></ul><ul><li>The Role of Psychological Factors </li></ul><ul><ul><li>Exert only a minimal effect in producing schizophrenia </li></ul></ul>
  21. 24. Causes of Schizophrenia: Neurodevelopmental Model <ul><li>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. </li></ul><ul><li>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. </li></ul>
  22. 25. Treatment of Schizophrenia <ul><li>The acute schizophrenic patients will respond usually to antipsychotic medication </li></ul><ul><li>Development of Antipsychotic (Neuroleptic) Medications </li></ul><ul><ul><li>Often the first line treatment for schizophrenia </li></ul></ul><ul><ul><li>Began in the 1950s </li></ul></ul><ul><ul><li>Most reduce or eliminate positive symptoms </li></ul></ul><ul><ul><li>Acute and permanent side effects; </li></ul></ul><ul><ul><li>(Extrapyramidal and Parkinson-like side effects, Tardive dyskinesia) </li></ul></ul><ul><ul><li>Compliance with medication is often a problem </li></ul></ul><ul><li>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. </li></ul>
  23. 26. <ul><li>Conventional antipsychotics - (classical neuroleptics); </li></ul><ul><li>Chlorpromazine, Clopenthixole, Levopromazine, Thioridazine, Droperidole, Flupentixol, Fluphenazine, Haloperidol, Perphenazine, Pimozide, Prochlorperazine, Trifluoperazine </li></ul><ul><li>Depot antipsychotics: (Fluphenazine deconate- Modecate), Flupenthixol, and Zuclopenthixole </li></ul><ul><li>Atypical antipsychotics - (new neuroleptics); </li></ul><ul><li>Amisulpiride, Clozapine, Olanzapine, Quetiapine, Risperidone, Sertindole, Sulpiride </li></ul>
  24. 27. Psychosocial Treatment of Schizophrenia <ul><li>Psychosocial Approaches: </li></ul><ul><ul><li>Behavioral (i.e., token economies) on inpatient units </li></ul></ul><ul><ul><li>Community care programs </li></ul></ul><ul><ul><li>Social and living skills training </li></ul></ul><ul><ul><li>Behavioral family therapy </li></ul></ul><ul><ul><li>Vocational rehabilitation </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  25. 28. Treating Schizophrenia
  26. 29. Prognosis <ul><li>Good prognosis Poor prognosis </li></ul><ul><li>Old age of onset Young age of onset </li></ul><ul><li>Female Male </li></ul><ul><li>Married Unmarried </li></ul><ul><li>No family history Family history </li></ul><ul><li>Good premorbid personality Personality problems </li></ul><ul><li>High IQ Low IQ </li></ul><ul><li>Precipitants No obvious precipitants </li></ul><ul><li>Positive symptoms Negative symptoms </li></ul><ul><li>Treatment compliance Poor treatment compliance </li></ul><ul><li>Good support Low support </li></ul><ul><li>Acute onset Insidious onset </li></ul><ul><li>Presence of mood component No mood component </li></ul><ul><li>  </li></ul>
  27. 30. Summary of Schizophrenia <ul><li>Schizophrenia – Spectrum of Dysfunctions </li></ul><ul><ul><li>Affecting cognitive, emotional, and behavioral domains </li></ul></ul><ul><ul><li>Positive, negative, and disorganized symptom clusters </li></ul></ul><ul><li>DSM-IV and DSM-IV-TR </li></ul><ul><ul><li>Five subtypes of schizophrenia </li></ul></ul><ul><ul><li>Includes other disorders with psychotic features </li></ul></ul><ul><li>Several Bio-Psycho-Social Variables are Involved </li></ul><ul><li>Successful Treatment Rarely Includes Complete Recovery </li></ul>
  28. 32. Other Psychotic Disorders <ul><li>Schizophreniform Disorder </li></ul><ul><ul><li>Schizophrenic symptoms for a few months (less than 6 months) </li></ul></ul><ul><ul><li>Associated with good premorbid functioning </li></ul></ul><ul><ul><li>Most resume normal lives </li></ul></ul><ul><ul><li>The same treatments recommended for schizophrenia may also be utilized here </li></ul></ul>
  29. 33. <ul><li>Brief Psychotic Disorder </li></ul><ul><ul><li>One or more positive symptoms of schizophrenia </li></ul></ul><ul><ul><li>Usually precipitated by extreme stress or trauma </li></ul></ul><ul><ul><li>experience a psychosis which, while lasting at least a day, undergoes a full, complete and spontaneous remission within one month </li></ul></ul><ul><ul><li>Tends to remit on its owns </li></ul></ul>
  30. 34. <ul><li>Delusional Disorder </li></ul><ul><ul><li>Delusions that are contrary to reality </li></ul></ul><ul><ul><li>Lack other positive and negative symptoms </li></ul></ul><ul><ul><li>Types of delusions include </li></ul></ul><ul><ul><ul><li>Erotomanic, Grandiose, Jealouse, Persecutory, Somatic </li></ul></ul></ul><ul><ul><li>appears to pursue a chronic, waxing and waning course </li></ul></ul><ul><ul><li>Patients with paranoia rarely seek treatment with a psychiatrist on their own initiative </li></ul></ul><ul><ul><li>Better prognosis than schizophrenia </li></ul></ul>
  31. 35. <ul><li>Shared Psychotic Disorder ( Folie à Deux) </li></ul><ul><ul><li>Delusions from one person manifest in another person </li></ul></ul><ul><ul><li>The most common relationships are among parents and children, spouses, and siblings </li></ul></ul><ul><ul><li>Separation from the dominant person and immersion into normal social interaction </li></ul></ul>
  32. 36. <ul><li>Schizoaffective Disorder </li></ul><ul><ul><li>Symptoms of schizophrenia and a mood disorder </li></ul></ul><ul><ul><li>Both disorders are independent of one another </li></ul></ul><ul><ul><li>Such persons do not tend to get better on their own </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  33. 37. <ul><li>Schizotypal disorder </li></ul><ul><li>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 </li></ul><ul><li>May reflect a less severe form of schizophrenia </li></ul>
  34. 38. <ul><li>Postpartum Psychosis (puerperal psychosis) </li></ul><ul><li>rare disorder, occurring in perhaps less than 1 or 2 per 1000 deliveries </li></ul><ul><li>It is more common in primiparous than multiparous women </li></ul><ul><li>many of these patients never experience another psychotic illness unless they again become pregnant </li></ul><ul><li>Symptoms generally appear abruptly within about 3 days to several weeks after delivery </li></ul><ul><li>Hospitalization is generally indicated </li></ul>