Schizophrenia

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  • Echolalia: immediate and involuntary repetition of words
  • Simple schizophrenia (CD10)1- There is slow but progressive development, over a period of at least 1 year, of all three of the following:
    A-a significant and consistent change in the overall quality of some aspects of personal behavior, manifest as loss of drive and interests, aimlessness, idleness, a selfabsorbed attitude, and social withdrawal;
    B- gradual appearance and deepening of “negative” symptoms such as marked apathy, paucity of speech, underactivity, blunting of affect, passivity and lack of initiative, and poor nonverbal communication (by facial expression, eye contact, voice modulation, and posture);
    C- marked decline in social, scholastic, or occupational performance.
    2-At no time are there any of the symptoms referred to in criterion G1 for general schizophrenia, nor are there hallucinations or well-formed delusions of any kind; i.e., the individual must never have met the criteria for any other type of schizophrenia or for any other psychotic disorder.
    3-There is no evidence of dementia or any other organic mental disorder.
  • Schizophrenia

    1. 1. SCHIZOPHRENIASCHIZOPHRENIA And It’s DDxAnd It’s DDx Mohammed Nabil Al Ali Hassan Mohammed Al Awadh ABDULLAH ALKHAWAJAH, Majid AL-DanDan Ammar Mohammed Al Mulhem Mutaz Hasan AL-Hashem, Khaled Saud AL-Zahrani Mohammed Faisal Alkhazal Hussain Abdrabalameer Albahrani 5th Year Medical Students5th Year Medical Students At King Faisal UniversityAt King Faisal University AlHassaAlHassa Introduced byIntroduced by
    2. 2. OUTLINESOUTLINES :: - Schizophrenia - Schizophreniform Disorder - Schizoaffective Disorder - Delusional Disorder - Brief Psychotic Disorder  - Shared Psychotic Disorder  - Postpartum psychosis
    3. 3. SchizophreniaSchizophrenia To Know SchizophreniaSchizophrenia is to know PsychiatryPsychiatry
    4. 4. 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. SchizophreniaSchizophrenia ::
    5. 5. The most devastating illness that psychiatrist treat. One of the most challenging disease in medicine 1% of population has schizo. An enormous economic burden A major health concern SchizophreniaSchizophrenia ::
    6. 6. SchizophreniaSchizophrenia ::
    7. 7. The etiology and pathogenesis of schizophrenia is unknown but it could be SchizophreniaSchizophrenia ::
    8. 8. •Dopaminergic system hypothesis •Glutaminergic dysfunction •Serotonin abnormalities •Increased Ventricular size •Decreased brain volume in medial temporal areas •Changes in the hippocampus •Overactivation of immune system Alteration in brain structure & function •Metabolic disturbance (Insulin resistance) SchizophreniaSchizophrenia ::
    9. 9. DSM (Diagnostic & Statistical Manual) of Mental Disorders Published by APA ( American Psychiatry Association( DSM IV 1994 Classified Schizophrenia to 5 Subtypes DSM V 2013 Proposed the deletion of subtypes SchizophreniaSchizophrenia ::
    10. 10. SchizophreniaSchizophrenia ::
    11. 11. SchizophreniaSchizophrenia ::
    12. 12. SchizophreniaSchizophrenia ::
    13. 13. -Family history of Schizophrenia -Any potential cause of fetal hypoxic brain damage -History of brain complications -Advanced age of mother during pregnancy -Birth during winter months!! -Substance abuse -Single marital status -Low socioeconomic class -Urban environment -Environmental stress SchizophreniaSchizophrenia ::
    14. 14. Hallucination Delusions Illusions Disorganized speech Behavioral disturbances Absence of normal cognition Allogia Avolition Anhedonia Social isolation  Impaired - attention - Working memory - Executive functions  Seems cheerful or sad without obvious reasons SchizophreniaSchizophrenia ::
    15. 15. THREE PHASES OF SCHIZOPHRENIA SchizophreniaSchizophrenia ::
    16. 16. SchizophreniaSchizophrenia ::
    17. 17. F. Significantly Social /occupational dysfunction G. Continuous signs of the disturbance persists for at least six months H. Schizoaffective and mood disorder exclusion I. Substance/medical condition exclusion J. Relationship to pervasive developmental disorder autism+ schiz.<D/H-1 m A. Characteristic symptoms. At least 2 of the following; each for 1- month period: a. delusions b. hallucinations c. disorganized speech d. grossly disorganized or catatonic behavior e. negative symptoms, i.e. avolition, flattening of affect, alogia (poverty of speech)  The diagnosis of schizophrenia is based entirely on the clinical presentation – history and examination. SchizophreniaSchizophrenia ::
    18. 18.  Organic syndrome  Drug or Alcohol  Temporal lobe epilepsy  Delirium  Dementia  Diffuse brain disease  Psychotic mood disorder  Personality disorder  Schizoaffective disorder SchizophreniaSchizophrenia ::
    19. 19. Course SchizophreniaSchizophrenia ::
    20. 20. Prognosis  Recover completely/long term minimal symptoms- 30%(The percentage on the rise)  Recurrent illness -poorer prognosis  Young patient -high risk of suicide SchizophreniaSchizophrenia ::
    21. 21. Predictors for poor outcome Features of the illness Insidious onset Long 1st episode Previous psychiatric history Negative symptoms Younger age at onset Features of the patient Male Single, separated, widowed or divorced Poor psychosexual adjustment Poor employment Social isolation SchizophreniaSchizophrenia ::
    22. 22. ManagementManagement
    23. 23. 1-Mental status examination 2-Physical & neurological examination 3-Complete family & social history (take in consideration family history of response to drugs( 4-Psychiatric diagnostic interview 5-Laboratory work up ( CBC, electrolytes, hepatic & renal functions, ECG, FBG, lipid profile, thyroid functions and urine drug screening( SchizophreniaSchizophrenia ::
    24. 24. Atypical APs. Second generation Typical APs. first generation SchizophreniaSchizophrenia ::
    25. 25. Atypical APs. Second generation Typical APs. traditional, conventional, first generation antipsychotics, classical neuroleptics, major tranquilizers Low potency Chlorobromazine: Neurazine® Thioridazine: Mellcril® Medium potency Molindone: Moban® Thiothixene: Navane® Pimozide: Orape forte® High potency Trifluperazine: Stellazine® Haloperidol: Haldol® Fluphenazine: Modecate® Zuclopenthixol: Clopexol® Aripiprazole: Apilify® Clozapine: leponex® Olanzapine: Zyprexa® Quetiapine: Seroquil® Resperidone: Resperidal® Sulpiride: Dogmatil® Ziprasidone: Zeldox® SchizophreniaSchizophrenia ::
    26. 26. Atypical APs. Second generation Typical APs. first generation SchizophreniaSchizophrenia ::
    27. 27. Atypical APs. Second generation Typical APs. first generation Sed. EPS A.Ch O.HoTN CPZ +++ ++ ++ +++ Thioridazine +++ + +++ +++ Molindone ++ ++ + + Thiothixene + +++ + ++ Trifluperazine + +++ + + Haloperidol + +++ + + Fluphenazine + +++ + + Sed. EPS A.Ch O.HoTN Wt.G clozapine ++ + 0 +++ +++ +++ Resperidone + + 0 + ++ Olanzapine ++ + ++ + +++ Quetiapine ++ + 0 ++ ++ Ziprasidone 0 + 0 0 0 Aripeprazole + + 0 0 0 Sed : sedation, EXP: extrapyramidal side effects , A.Ch anticholinergic side effects , O.HoTN: orthostatic hypotension wt.G : weight gain SchizophreniaSchizophrenia ::
    28. 28. --Some SGAPs & phenothiazines cause elevation in serum TGs & cholesterol -Risk decreases with ; risperidone,ziprasidone & aripiprazole SchizophreniaSchizophrenia ::
    29. 29. Tardive dyskinesia: abnormal involuntary movement with chronic use of Aps e.g. Oro-facial movement. SchizophreniaSchizophrenia ::
    30. 30. SchizophreniaSchizophrenia ::
    31. 31. Schizophreniform Disorder
    32. 32. Definition According (DSM-IV-TR) describes schizophreniform disorder as : similar to schizophrenia, except that its symptoms last at least 1 month but less than 6 months. Schizophreniform Disorder
    33. 33. Etiology :  The cause of schizophreniform disorder is not known , most likely to be heterogeneous. Schizophreniform Disorder Epidemiology :  Common in adolescents and young adults.  Lifetime prevalence rate of 0.2 percent.  The relatives of patients with schizophreniform disorders are more likely to have mood disorders and psychotic mood disorders .
    34. 34. Clinical feature : • It is an acute psychotic disorder that has a rapid onset and lacks a long prodromal phase. • Patients with schizophreniform disorder return to their baseline level of functioning once the disorder has resolved. • The patients are unlikely to report a progressive decline in social and occupational functioning. Schizophreniform Disorder
    35. 35. DDx  Schizophrenia . lasts for more than 6 months  Brief psychotic disorder. lasts for less than 1 month  Substance- induced psychotic disorder. Drug history and toxicological screen  Psychotic disorder due to medical condition . history , physical examination , laboratory tests or imaging studies .  Mood disorder : the symptoms exclusively occur during periods of mood disturbance. Schizophreniform Disorder
    36. 36. Treatment  Hospitalization : allows effective assessment, treatment, and supervision of a patient's behavior.  Antipsychotic drugs for 3- 6 months.  If a patient has a recurrent episode : mood stabilizer is added.  Psychotherapy  ECT : for patient with marked catatonic or depressed features. Schizophreniform Disorder
    37. 37. Schizoaffective Disorder
    38. 38. Introduction  Schizoaffective disorder is a serious mental illness that affects about one in 100 people.  It is serious mental illness that has features of two different conditions: 1. schizophrenia 2. an affective (mood) disorder that may be diagnosed as either major depression or bipolar disorder. Schizoaffective Disorder
    39. 39.  Schizoaffective disorder is a lifelong illness that can impact all areas of daily living  Most people with this illness have periodic episodes, called relapses, when their symptoms surface.  there is no cure for schizoaffective disorder, symptoms often can be controlled with proper treatment. Schizoaffective Disorder
    40. 40. Symptoms  Schizoaffective Disorder is characterized by schizophrenia with one of the following: 1) Major Depressive Episode(must include depressed mood) 2) Manic Episode 3) Mixed Episode Schizoaffective Disorder
    41. 41. Management  combination of medications and counseling.  Treatment depending on the type and severity of symptoms, and whether the disorder is depressive- type or bipolar-type.  Medications: 1- Antipsychotics   paliperidone (Invega) and other antipsychotic medications that may be prescribed include clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa) and haloperidol (Haldol). Schizoaffective Disorder
    42. 42. 2-Mood-stabilizing medications. Include lithium (Lithobid) and divalproex (Depakote). Anticonvulsants such as carbamazepine (Carbatrol, Tegretol, others) and valproate (Depacon). 3-Antidepressants.  Common medications include citalopram (Celexa), fluoxetine (Prozac) and escitalopram (Lexapro). Schizoaffective Disorder
    43. 43. Psychotherapy Psychotherapy and counseling.  Family or group therapy.  Treatment can be more effective when people with schizoaffective disorder are able to discuss their real-life problems with others. Supportive group settings can also help decrease social isolation and provide a reality check during periods of psychosis. Schizoaffective Disorder
    44. 44. Delusional Disorder
    45. 45. Definition Delusional disorder is an illness characterized by the presence of nonbizarre delusions in the absence of other mood or psychotic symptoms Delusional Disorder
    46. 46. Epidemiology - The prevalence of delusional disorder in the USA is estimated in theDSM-IV-TR to be around 0.03% . - considerably lower than the prevalence of schizophrenia (1%) , mood disorders (5%) . - The mean age of onset is 40 years . - Men are more likely than women to develop paranoid delusions . - women are more likely than men to develop delusions of erotomania . Delusional Disorder
    47. 47. Etiology (a) Genetic : Not a variant of schizophrenia or mood disorders. No increase in first degree relatives. (b) Neurological conditions : - limbic system and the basal ganglia disorders . - Patients tend to have complex delusions similar to those in patients with delusional disorder . (c) Psychodynamic Factors : - socially isolated persons . - - Abuse . Delusional Disorder
    48. 48. Current Diagnosis Criteria * DSM-IV-TR   defines delusional disorder with the following criteria: A) Non bizarre delusions . B) Criterion A for schizophrenia has never been met . C)  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 a drug of abuse, medication or general medical condition. Delusional Disorder
    49. 49. Clinical Features - Mental State Examination usually normal except presence of abnormal delusional beliefs. - Mood and affect are consistent with delusional content. - Tactile and olfactory hallucinations may be present if they are related to delusional theme. - The thought content is notable for systematized, well- organized, nonbizarre delusions that are possible to occur. Delusional Disorder
    50. 50. - The thought process is usually not impaired; however, some circumstantiality and idiosyncrasy may be observed. - Patients usually have little insight and impaired judgment regarding their pathology. - Assessment of homicidal or suicidal ideation is extremely important in evaluating the patients. erotomanic, jealous, and persecutory > ↑violence Delusional Disorder
    51. 51. Subtypes of delusional disorder Persecutory  Most common type  believes that they are being persecuted and harmed  The delusions are systematized, coherent, and defended with clear logic. (contrary to schizo)  No deterioration in social functioning and personality  emotional distress such as irritability, anger, and resentment  may resort to violence Delusional Disorder
    52. 52. Erotomanic :  Thinks that another person, usually of higher status, is in love with the patient.  F>M  Leads to stalking behaviour (pursuing the lover, texting, phone calling, etc). Delusional Disorder Grandiose  believes that they possess some great and unrecognized talent, have made some important discovery, have a special relationship with a prominent person, or have special religious insight.
    53. 53. Jealous  Pathological jealousy  M>F  her or his spouse or lover is unfaithful.  Lead to acts of violence, including suicide and homicide. Delusional Disorder
    54. 54. Somatic:  delusions around bodily functions and sensations.  Non-bizarre.  most common are the belief that one is infested with insects or parasites.  Patients are totally convinced in physical nature of this disorder. Delusional Disorder
    55. 55. Differential Diagnosis 1. Medical Conditions (a) Basal ganglia disorder - Parkinson’s disease - Huntington’s chorea (b) Deficiencies: - B12 - folate - thiamine (c) Delirium: Fluctuating level of consciousness, altered sleep/wake cycle, hallucinations and impaired cognition. Delusional Disorder
    56. 56. (d) Dementia (e) Endocrinopathies: - adrenal, thyroid (f) Limbic disorders: - epilepsy, cerebrovascular disease (g) Systemic: - hepatic encephalopathy, porphyria, uremia 2. Drugs (a) Amphetamines, cocaine: - Most common substances - Persecutory delusions. (b) Antiocholinergies, antituberulous drugs, Dimifram Delusional Disorder
    57. 57. 3. Paranoid Personality Disorder - no true delusions. Overvalued ideas - enduring, deeply ingrained 4. Paranoid Schizophrenia - auditory hallucinations - personality deterioration - disturbance in role functioning 5. Mania - Grandiose delusions, but these are clearly secondary to primary and prominent mood disorder 6. Depression - Mood symptoms prominent (depressed) - delusions are secondary Delusional Disorder
    58. 58. Management Plan: * Investigations: - To rule out substance abuse: drug screening . - To rule out medical causes: CT, MRI. - To choose a proper medication (prevent side effects) - Blood glucose level, lipid profile (anti-psychotics) RFT, thyroid FT, LFT, ECG (Lithium & others) Delusional Disorder
    59. 59. * Treatment A) if suicidal or homicidal ideas present (hospitalization ) or if refuse eating . B) Medication: - Antipsychotics- Pimozide . - If there are somatic delusion & depressive symptoms Antidepressants (SSRIs) may be used C) Should also add supportive and educational psychotherapy sessions to help the patient (to improve insight & compliance). Delusional Disorder
    60. 60. Brief Psychotic Disorder
    61. 61. Acute psychotic condition that involves the 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. Definition Brief Psychotic Disorder
    62. 62. The disorder occurs more often among younger patients (20s and 30s) More commen in women. Epidemiology Brief Psychotic Disorder
    63. 63.  Presence of one (or more) of the following symptoms:  delusions  hallucinations  disorganized speech  grossly disorganized or catatonic behavior  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. Diagnostic Criteria Brief Psychotic Disorder
    64. 64. Associated symptoms may include the following:  Disorientation,  Impaired attention,  Emotional volatility,  strange or bizarre behavior,  Screaming,  Impaired memory for recent events. Brief Psychotic Disorder
    65. 65.  Schizophrenia,  Schizophreniform Disorder,  Brief Psychotic Disorder,  Delusional Disorder,  Mood disorder with psychotic features,  Substance-induced psychotic disorder,  Psychosis due to a medical condition. Differential Diagnosis Brief Psychotic Disorder
    66. 66.  Brief hospitalization,  Antipsychotics (haloperidol or ziprasadone),  Benzodiazepines (short-term treatment ). Prognosis:  A good prognosis is usually associated with sudden onset, short duration of symptoms, and good premorbid adjustment Treatment Brief Psychotic Disorder
    67. 67.  Shared Psychotic Disorder 
    68. 68. Case  A 28-year-old woman taking care of her schizophrenic husband starts believing her husband’s claim that he invented the telephone. When she went abroad for a few months, her beliefs disappeared.
    69. 69.  Also known as folie à deux, shared psychotic disorder is diagnosed when a patient develops the same delusional symptoms as someone he or she is in a close relationship with. Most people suffering from shared psychotic disorder are family members.
    70. 70. DSM-IV-TR Diagnostic Criteria for Shared Psychotic Disorder  A delusion develops in an individual in the context of a close relationship with another person(s), who has an already-established delusion.  The delusion is similar in content to that of the person who already has the established delusion.  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.
    71. 71. PROGNOSIS  Twenty to 40% will recover upon removal from the inducing person.  Shared Psychotic Disorder 
    72. 72. TREATMENT  The first step is to separate the patient from the person who is the source of shared delusions (usually a family member with an underlying psychotic disorder).  Psychotherapy should be undertaken.  Antipsychotic medications should be used if symptoms have not improved in 1 to 2 weeks after separation  Shared Psychotic Disorder 
    73. 73. Postpartum psychosis
    74. 74. POST PARTUM PSYCHOSIS  Postpartum psychosis (sometimes called puerperal psychosis) is an example of psychotic that occurs in women who have recently delivered a baby.  The incidence of postpartum psychosis is about 1 to 2 per 1,000 childbirths.  About 50 to 60 percent of affected women have just had their first child.  About 50 percent of the affected women have a family history of mood disorders.  Most available data suggest a close relation between postpartum psychosis and mood disorders, particularly bipolar disorder and major depressive disorder. Postpartum psychosis
    75. 75. Clinical features: The symptoms of postpartum psychosis can often begin within days of the delivery, although the mean time to onset is within 2 to 3 weeks and almost always within 8 weeks of delivery. Insomnia, restlessness and emotional liability Progress to confusion, delusions. Thoughts of harming self or baby characteristic Postpartum psychosis
    76. 76. Treatment:  Postpartum psychosis is a psychiatric emergency.  Antipsychotic medications and lithium often in combination with an antidepressant, are the treatments of choice.  Psychotherapy is indicated after the period of acute psychosis.  Changes in environmental factors may also be indicated. Postpartum psychosis
    77. 77. SUMMARY
    78. 78. yes no no no yes yes SUMMARY
    79. 79. Any question ?
    80. 80. REFERENCES
    81. 81. Thank youThank you

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