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1. Chapter 5:Mood Disorders
1

2. Ω Mood is a pervasive and sustained feeling tone that is
experienced internally and that influences a person’s
behavior and perception of the world.
Ω Affect is the external expression of mood.
Ω Mood can be
Normal
Elevated
depressed 2
What is mood and affect?

3. ΩHealthy person
Ω Experience a wide range of mood and affect
Ω They feel in control of their moods and
affects
Ω Mood disorder
Ω Loss of sense of control
Ω Subjective experience of great distress
Ω Mood disorders involve a depression or elevation of
mood as the primary disturbance
Ω Can have other abnormalities (psychosis, anxiety,
etc.)
3

4. 4
Mood states

5. 5
Major Depressive Disorder (MDD)
Ω The Old Testament story of King Saul describes a
depressive syndrome.

6. Ω five or more of the following symptoms present for
the same two weeks; at least one of the symptoms is
1) depressed mood or 2) loss of interest or pleasure.
 Depressed mood
 Loss of interest or pleasure
 Marked weight loss or gain
 Insomnia or hypersomnia
6
DSM-5 diagnostic criteria for MDD

7.  Psychomotor retardation or agitation
 Fatigue or loss of energy
 Feeling of worthlessness or inappropriate
guilt
 Diminished ability to think or concentrate
 Recurrent thoughts of death, suicidal ideation
or suicidal attempt.
7
MDD continue …

8. For a diagnosis of Bipolar I disorder, it is necessary to meet the criteria
for manic episode.
8
Bipolar I disorder

9. Ω Abnormally and persistently elevated, expansive, or
irritable mood and abnormally and persistently
increased goal-directed activity or energy, lasting at
least 1 week and present most of the day
PLUS
Ω Three (four if the mood is irritable)of the following
symptoms
Inflated self esteem or grandiosity
Decreased need for sleep
Over talkativeness
Flight of ideas
9

10. Distractibility
Increased goal directed activity ( socially, at
school or sexually) or psychomotor agitation
Excessive involvement in activities that have
a high potential for painful consequences
(e.g., engaging in unrestrained buying
sprees, sexual indiscretions, or foolish
business investments).
10

11. Ω GA: Excited, talkative, sometimes amusing and
hyperactive. At times, grossly psychotic and disorganized .
Ω Mood &Affect: Classically are euphoric, can also be
irritable. Anger and hostility, may be emotionally labile.
Ω Speech: Difficult to interrupt louder, more rapid, and
difficult to interpret speech is filled with jokes and
irrelevancies .
11

12. Ω Perception/Thought: Delusions occur in 75 %.
 Mood-congruent manic delusions  grandiose
 Bizarre and mood-incongruent delusions and
hallucinations also appear in mania.
 Accelerated flow of ideas associations
become loosened and flight of ideas, clanging,
and neologisms appear  In acute manic can be
totally incoherent.
12

13. Ω Cognition:
Orientation and memory are intact
 although some may be so euphoric that they answer
questions testing orientation incorrectly.
Ω Impulse Control: 75% are assaultive or threatening.
Ω Judgment and Insight: Impaired judgment is a
hallmark, little insight.
Ω Reliability: Unreliable in their information, lying and
deceit are common in mania.
13

14. Goals
I. the patient's safety must be guaranteed.
II.A complete diagnostic evaluation of the patient is
necessary.
III. Treatment plan that addresses
Ω the immediate symptoms
Ω patient's prospective well-being should be initiated.
14

15. Treatment of depression
15

16. Principles of Treatment and Management
of depression
16

17. Acute phase
Goal
ΩTo reach full symptom remission and restoration of
full function
ΩFull remission is associated with lower relapse rate .
To increase the chances of reaching remission
Patient adherence is essential.
 The routine use of symptom and side-effect
17

18. …
The best setting( e.g., inpatient or outpatient)
A. An estimate of imminent suicidal risk
B. The capacity of patients to recognize and adhere to
recommendations.
C. The level of psychosocial support
D. Psychosocial stress and functional impairment.
18

19. Type of treatment (the strategy)
Medication
Psychotherapy
Combination
Electroconvulsive therapy (ECT)
light therapy alone or in combination with
medication or therapy.
19

20. Duration
• At least a 6-week trial is often useful, especially
for those with more severe, chronic, or
complicated depressions.
• A suggested rule of thumb is that the treatment
should continue if at least a 25% reduction in
initial symptom severity is found at 4 to 6
weeks. 20

21. Continuation phase
ΩAims to sustain those gains, thereby preventing the
return of the index episode.
Ωbest prognosis in the continuation phase = best acute
phase outcome.
Type of treatment
ΩThe same types and doses of medication are
recommended.
ΩEarly medication discontinuation is associated with
higher relapse rates than later medication
discontinuation. 21

22. Ω Continuation phase medication treatment may end
with a gradual taper.
Ω Careful symptom assessment during and for several
months after discontinuation
Ω For psychotherapy, the visits may be reduced in
frequency.
Duration of treatment
• Continuation treatment typically lasts 4 to 9 months.
22

23. Maintenance treatment
ΩAims at preventing new episodes (recurrences).
ΩMaintenance medication has prophylactic efficacy.
ΩTypically, maintenance phase treatment is indicated if
there have been
 At least 2 and certainly 3 or more episodes, or if the
index episode has been chronic (>2 years).
Increased risk of recurrence.
23

24. Poor interepisode recovery between the two
episodes.
The presence of 2 episodes within the last 3 years.
Positive family history for recurrent MDD or
bipolar
Ω Maintenance treatment for at least 5 years for those
with highly recurrent depressions
Ω Early intervention shortens the length of the new
episode. 24

25. Choosing among Medications
 The available antidepressants differ in
Their pharmacology
Drug–drug interactions
Short- and long-term side effects
likelihood of discontinuation symptoms
Ease of dose adjustment.
 They do not differ in overall efficacy, speed of
response, or long-term effectiveness.
25

26. Ω SSRI(selective serotonin reuptake inhibitor)
 All SSRI causes insomnia, All SSRIs may cause
insomnia, agitation, sedation, GI distress, and
sexual dysfunction
Dosing is less complicated
 Better tolerated than TCAs
Have high safety in overdose.
 Flouxetine 20 - 80mg
 Sertraline 50 - 200mg
Antidepressant Medication

27. Ω TCAs( Tricyclic antidepressants)
 Drowsiness, insomnia and agitation, OSH, CA, GI
distress, weight ↑, anti-cholinergic
Overdose may be fatal.
 Dose titration is needed, TCAs typically are started
at lower doses
TCAs account for a greater percent of completed
suicides than the newer agents.
Amitriptyline 75- 300 mg
Imipiramine 75 – 300mg
Antidepressant Medication

28. Selecting Initial Treatments
ΩPrior course of illness and treatment response
ΩFamily history of illness and treatment response
ΩSymptom severity
ΩThe presence of concurrent general medical or other
psychiatric conditions
ΩPotential drug–drug interactions
ΩPatient preference
28

29. Timely Declaration of Treatment Failures
If less than a 20 % to 25% symptom reduction has
occurred at 6 weeks, then a treatment change is likely
needed.
Slow metabolizers encounter side effects earlier in
treatment or at lower doses.
Some side effects are dose dependent (e.g., sedation)
and can be reduced by decreasing the dose or slowing
the rate of dose escalation.
29

30. Some side effects are less dose dependent, and tolerance
to them is less likely (e.g., orthostatic hypotension)
A change in treatment is often indicated.
Moderate side effects, when encountered
Argue for withholding further dose escalations and
allowing time for physiological adaptation, which
often results in fewer side effects.
30

31. Provide for the safety of the client and others.
Institute suicide precautions if indicated.
 Begin a therapeutic relationship by spending nondemanding
time with the client.
 Promote completion of activities of daily living by assisting
the client only as necessary.
Establish adequate nutrition and hydration.
NURSING INTERVENTIONS for Depression

32. Promote sleep and rest.
Engage the client in activities.
 Encourage the client to verbalize and describe emotions.
Work with the client to manage medications and side effects.
NURSING INTERVENTIONS for Depression

33. Treatment of bipolar
disorders
33

34. Acute treatment
1. Manic episode or mixed features
The primary goal
Return to normal levels of psychosocial
functioning.
The rapid control of agitation, aggression,
and impulsivity = safety.
34

35. Indication for hospitalization
ΩSuicidal or homicidal risk
ΩSeverely ill without social support
ΩSignificantly impaired judgment
ΩMedical complications
ΩWho not respond for out patient treatment
35

36. First-line pharmacological treatment
Ω Initiation of either lithium or valproate plus an
antipsychotic.
Ω adjunctive treatment with a benzodiazepine
Ω For less ill patients
 Monotherapy with lithium, valproate, or an
antipsychotic such as olanzapine may be sufficient.
Ω Anti depressant must be tapered and discontinued.
36

37. ΩECT may also be considered
ΩFor patients with severe or treatment-resistant illness
ΩDuring pregnancy.
ΩPatients displaying psychotic features during a manic
episode
ΩRequire antipsychotic medication.
ΩAtypical antipsychotics are favoured because of their
more benign side effect profile.
37

38. Mood stabilizers
1. Lithium
ΩTypical clinical features of manic patients responding to
lithium;
Ω Classic euphoric mania than dysphoric
Ω Fewer prior episodes & non-rapid cycling course
Ω No co-morbid anxiety or substance abuse
Ω Family history of affective illness , especially with
good response to lithium 38

39. ΩLithium is usually started in low, divided doses to
minimize side effects
- E.g., 300 mg B.i.d. or less, depending on the patient’s
weight and age, with the dose titrated upward .
Ωlevel of 0.9 mEq/l (minimum) to 1.2 mEq/l (limit above
which toxicity outweighs benefit)
ΩIts onset of action is relatively slow
ΩClinical improvement usually occurring over the first 1 to
3 weeks of treatment
39

40. 2. Valporate
ΩTypical dose level 750-2500mg/day.
ΩRapid oral loading with 15-20mg/kg was tolerated &
associated with rapid response.
ΩBlood level to be achieved is between 50-120ug/ml.
ΩResponse has been shown in patients;
With dysphoric mania
With history of lithium non-response
Rapid cyclers , substance abusers and co morbid
anxiety disorders. 40

41.  Laboratory monitoring
Serum lithium level: every 1- 2wks in the 1st 2
months, then every 3 – 6 months
Blood level maintained b/n 0.5 – 0.8 meq/l ; in
lower levels greater relapse rate seen.
Thyroid function test and renal function tests every
6 – 12 months

42. 3. Carbamazepine
ΩTypical dose for mania is between 600-1800mg/day with
blood level ranging between 4-12 ug/ml.
ΩThere is great individual variation with dose & side effect.
ΩResponse to carbamazepine seen in;
 Patients with a negative family history
 Those with co-morbid anxiety and substance abuse.
 Schizoaffective presentations with mood-incongruent
delusions.
42

43.  Laboratory monitoring
 Serum level every 1 – 2 wks & CBC, LFT monthly in the 1st
2 months of treatment
 Later serum level every 3 – 6 months & CBC , LFT every 6 –
12 months.

44. Combination of a Mood Stabilizer and an Atypical
Antipsychotic
ΩThis approach is associated with a more rapid onset
and higher remission rates and response rates (60 to 80
%)
ΩThan with mood stabilizers alone ( 50 %) or with the
atypical antipsychotics alone (about 50 %).
44

45. 2) Bipolar depression
 The first-line pharmacological treatment
• Initiation of either lithium or Valporate.
 Alternative approaches if 1st line fails
I.Optimizing the dose of the current mood stabilizer
regimen.
45

46. I. Augmenting with triiodothyronine (T3), lithium, or folate.
II. Adding another mood stabilizer.
III.Using or adding an atypical antipsychotic.
IV. ECT

47. Antidepressant monotherapy is not recommended .
 Depressive episodes with psychotic features usually
 Require adjunctive treatment with an antipsychotic
medication .
 ECT represents a reasonable alternative.
47

48. 3) Rapid cycling
The initial intervention
 Identify and treat medical conditions, such as
hypothyroidism
Drug or alcohol use.
Discontinue antidepressants.
The initial pharmacotherapy
Valproate or lithium
 An alternative treatment is lamotrigine.
 For many patients, combinations of medications are
required.
48

49. Psychosocial treatment
Concomitant psychosocial interventions addressing:
- Adherence , life style changes , early detection of
prodromal symptoms and Interpersonal difficulties
 Psycho education to patients & family about the illness
has shown to be effective in medication compliance
Family therapy ,Group psychotherapy
CBT has shown in some to be effective in preventing
relapse. 49

50. Special considerations
Pregnancy
Many of the drugs are associated with birth defects
lithium – CV defect, Ebstein anomaly
Valproate – NTD ,craniofacial & limb abnormality
Carbamazepine – craniofacial defects, NTD
Options of treatment are
Continuing medication through out pregnancy
 Discontinue medication before conception or only for the
first trimester
50

51. Risk benefit assessment should be made.
Patient should be informed on both consequences of
continuing or discontinuing medications.
ECT is a potential treatment during pregnancy.
 Serum levels of medications should be monitored
51

52. Postpartum issues
Discontinuing mood stabilizers is unwise due to
increased risk of mood episodes( 50%)
Advice maintaining normal sleep pattern to avoid
episodes.
Studies suggest lithium / valproate prophylaxis may
prevent post partum episodes.
All medications of bipolar disorder are secreted into the
breast milk but we should out weigh benefits of breast
feeding.
52

53. Geriatrics
Similar Rx with young adults but lower doses because:
• Decreased renal clearance & volume distribution
• Concomitant medical condition & medications may
alter metabolism & excretion
• May be sensitive to S/E.
• May tolerate only low serum level of lithium ( 0.4-
0.6meq/l) & respond to this level
53

54. • Provide for client’s physical safety and those
around.
• Set limits on client’s behavior when needed.
• Remind the client to respect distances between self
and others.
• Use short, simple sentences to communicate.
• Clarify the meaning of client’s communication.
• Frequently provide finger foods that are high in
calories and protein.
NURSING INTERVENTIONS for Mania

55. NURSING INTERVENTIONS for Mania
• Promote rest and sleep.
• Protect the client’s dignity when inappropriate behavior occurs.
• Channel client’s need for movement into socially acceptable motor
activities.

56. Deribachew H/mariam(Asst. professor)
Department of Psychiatry, Wolkite University
Chapter 5: SCHIZOPHRENIA SPECTRUM AND OTHER
PSYCHOTIC DISORDERS
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57. 10/2/2023 57
Learning objectives
After completing this session the students will be able to:
• Define schizophrenia
• Identify the epidemiology of schizophrenia
• Describe the etiology of schizophrenia
• Describe the clinical features of schizophrenia
• List the Diagnostic criteria of schizophrenia

58. Learning objectives…
10/2/2023 58
• Describe the subtypes of schizophrenia
• Describe the DDx of schizophrenia
• List the Diagnostic methods of schizophrenia
• Describe the treatment of schizophrenia
• Differentiate good and poor prognosis indicators of schizophrenia

59. Introduction to psychosis
• psychosis is a mental disorder in which the
thoughts, affective response, ability to recognize
reality, and ability to communicate and relate to
others are sufficiently impaired to interfere grossly
with the capacity to deal with reality.
Key Features That Define the Psychotic Disorders:
Delusions
Hallucinations
Disorganized Thinking (Speech)
Grossly Disorganized or Abnormal motor Behavior
(including Catatonia)
Negative Symptoms

60. Schizophrenia
Definition:
 The word schizophrenia is derived from a Greek word Schizo - split ,
Phrenia - mind meaning split mind
 A disorder characterized by disturbance of thinking, cognition,
perception, behavior, emotion leading to social and occupational
dysfunction in a clear consciousness
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61. Schizophrenia …
Epidemiology
 Prevalence:1% in the general population
 Age of onset: male= 15 -25 years , Female= 25-35years
 Sex: equal sex incidence
 Race: no difference
 Order of birth
-1st born children in small families
-Youngest in large families
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62. Schizophrenia …
 Class: more prevalent in low socioeconomic status
 Season: more common among winter births
 Marriage: more common in unmarried
 High mortality rates from accidents and natural causes
 10% commit suicide (50% attempt)
 Patients use substances like: cigarette, alcohol, cannabis more than the
general population
10/2/2023 62

63. Schizophrenia …
Cause
• The cause of schizophrenia is unknown
• However, there are several theories that propose the factors
contributing to the disorder
10/2/2023 63

64. Schizophrenia …
10/2/2023 64
1. Genetics
• There is a genetic contribution to all forms of schizophrenia
• For example, schizophrenia and schizophrenia-related disorders (e.g.,
schizotypal, schizoid, and paranoid personality disorders) occur at an
increased rate among the biological relatives of patients with
schizophrenia.

65. Schizophrenia …
Genetic disease risks
• General population - 1%
• 2nd grade relative - 5%
• 1st grade relatives - 10%
• Dizygotic twins - 15%
• Two patients suffering from schizophrenia - 40%
• Identical twins - 50%
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66. Schizophrenia …
2. Biochemical factors
 The dopamine theory explains that high level of dopamine in the brain
triggers psychosis including symptoms of schizophrenia
3. Psychosocial factors
 Traumatic experiences in utero , infancy and early adulthood
predispose to schizophrenia
10/2/2023 66

67. Schizophrenia …
Signs and symptoms
 The clinical manifestation of schizophrenia depends on the phase/stage
, age of onset and duration of the total disturbance.
 There are 3 stages of schizophrenia:
1. Prodromal phase
2. Active phase
3. Residual phase
10/2/2023 67

68. Schizophrenia …
1. Prodromal phase
It is characterized by:
 Odd behavior and appearance
 Vague physical complaints
 Vague language
 Social withdrawal
 Decline in performance and self care
 Concern about abstract topics such as religion and philosophy
10/2/2023 68

69. Schizophrenia …
2. Active phase
It is characterized by
 Full blown psychotic symptoms like
Delusion
Hallucination
Disorganized speech
Disorganized or catatonic behavior
 These symptoms are also known as positive symptoms because they
indicate true psychosis and responding to drug treatment
10/2/2023 69

70. Schizophrenia …
3. Residual phase
It is characterized by negative symptoms such as
 Affective flattening
 Alogia
 Avolition-apathy
 Anhedonia-asociality
 Attentional impairment
 This occurs among chronically ill patients who have not been
effectively treated
10/2/2023 70

71. Schizophrenia …
Other symptoms
Bleuler’s 4 A’s
 Association Loosening
 Affective flattening
 Autism
 Ambivalence
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72. Schizophrenia …
10/2/2023 72
Kurt Schneider's first rank symptom
 Thought insertion
 Thought Withdrawal
 Thought Broadcasting
 Thought Reading
 Thought control
 Thought echo

73. Schizophrenia …
Kurt Schneider's second rank symptoms
 Delusion
 Hallucination
 Disorganized behaviour
10/2/2023 73

74. Schizophrenia …
DSM-5 diagnostic criteria
A- Two or more symptoms each present for 1 month period. At least one
of these must be (1),(2) or(3)
1- Delusions
2- Hallucinations
3- Disorganized speech
4- Disorganized or catatonic behavior
5- Negative symptoms
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75. Schizophrenia …
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B- Social and occupational dysfunction in work, interpersonal relation,
or self care
C- Duration: continuous signs of disturbance for at least 6 months,
include at least one month of symptoms
D- Exclude schizoaffective and mood disorder
E- Exclude substance induced and general medical condition

76. Schizophrenia …
DDx
• Psychotic Disorder Due to a General Medical Condition
• Substance-Induced Psychotic Disorder
• Delirium
• Dementia
• Schizophreniform Disorder
10/2/2023 76

77. Schizophrenia …
10/2/2023 77
DDx…
• Brief Psychotic Disorder
• Schizoaffective Disorder
• Delusional Disorder
• Psychotic disorder not otherwise specified

78. Schizophrenia …
10/2/2023 78
Diagnostic methods
• History
• MSE
• P/E
• Lab tests: CBC, liver, thyroid & renal function tests

79. Schizophrenia …
Treatment
Medications Antipsychotics:
 Haloperidol( 1–40 mg/day)
 chlorpromazine( 200–800 mg/day) etc.
 Mood stabilizers: Lithium, carbamazepine (usually as
supplementary to antipsychotics)
Psychiatric rehabilitation, including supported
employment or education
Psychotherapy
Family interventions
10/2/2023 79

80. Schizophrenia …
10/2/2023 80
Sign of good prognosis
 Short episode<1 month
 Abrupt/sudden onset
 Older age of onset
 Good compliance
 Married
Sign of poor prognosis
 Long episode>1 month
 Insidious/gradual onset
 Younger age of onset
 poor compliance
 Single , divorced or
widowed

81. Schizophrenia …
10/2/2023 81
Sign of good prognosis…
 Good work record
 Family and social support
 Positive symptoms
 Family history of mood
disorder
 Obvious precipitating
factors
Sign of poor prognosis..
 Poor work record
 Lack of social support
 Negative symptoms
• Family history of
schizophrenia
• No precipitating factors

82. Schizoaffective Disorder
Is a disorder which has features of both schizophrenia mood
disorder.
patients can receive the diagnosis of schizoaffective disorder
if they fit into one of the following :
patients with schizophrenia who have mood symptoms
patients with mood disorder who have symptoms of
schizophrenia
 patients with both mood disorder and schizophrenia

83. patients with a third psychosis unrelated to schizophrenia
and mood disorder
 patients whose disorder is on a continuum between
schizophrenia and mood disorder
patients with some combination of the above

84. Epidemiology
The lifetime prevalence ranges from 0.5 to 0.8
percent
Gender and Age Differences:
The depressive type more common in older
persons than in younger persons
Bipolar type may be more common in young
adults than in older adults.
It is lower in men than in women, particularly
married women
Etiology
unknown

85. DSM-V-TR Diagnostic Criteria for
Schizoaffective Disorder
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.
During the same period of illness, there have been delusions
or hallucinations for at least 2 weeks in the absence of
prominent mood symptoms.

86. 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.
The disturbance is not due to the direct physiological effects
of a substance or a general medical condition.

87. Differential Diagnosis
differential diagnosis includes all the possibilities usually
considered for mood disorders and for schizophrenia.
Treatment
Mood stabilizers
antidepressants
Antipsychotics

88. Schizophreniform Disorder
• It is similar to schizophrenia, except that its
symptoms last at least 1 month but less than 6
months
• Patients with schizophreniform disorder return
to their baseline level of functioning once the
disorder has resolved
• Epidemiology
• It is most common in adolescents and young
adults
• A lifetime prevalence rate of 0.2 percent and a 1-
year prevalence rate of 0.1 percent have been
reported

89. Schizophreniform …
DSM-5 diagnostic criteria
A- Two or more symptoms each present for 1 month period. At least one
of these must be (1),(2) or(3)
1- Delusions
2- Hallucinations
3- Disorganized speech
4- Disorganized or catatonic behavior
5- Negative symptoms
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90. Schizophreniform …
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B- Social and occupational dysfunction in work, interpersonal relation,
or self care
C- Duration: continuous signs of disturbance for at least 1month but less
than 6 months
D- Exclude schizoaffective and mood disorder
E- Exclude substance induced and general medical condition

91. Brief psychotic disorder
Brief psychotic disorder is defined as a psychotic condition
that involves the sudden onset of psychotic symptoms, which
lasts 1 day or more but less than 1 month.
It is an acute and transient psychotic syndrome

92. Epidemiology
• It is generally considered uncommon
• It occurs more often among younger patients
• The age of onset in industrialized settings may
be higher than in developing countries.
• Persons who have gone through major
psychosocial stressors may be at greater risk
for subsequent brief psychotic disorder.

93. Etiology
The exact cause is not known
Biologically, Patients who have personality
disorder may have vulnerability
Psychodynamic :
Because of the presence of inadequate coping
mechanisms
The possibility of secondary gain for patients with
psychotic symptoms
 The psychotic symptoms are a defense against a
prohibited fantasy the fulfillment of an unattained
wish
 An escape from a stressful psychosocial situation.

94. DSM-V-TR Diagnostic Criteria
Presence of one (or more) of the following symptoms:
• delusions
• hallucinations
• disorganized speech (e.g., frequent derailment or incoherence)
• grossly disorganized or catatonic behavior

95. Differential Diagnosis
If psychotic symptoms are present longer than 1 month consider:
Schizophreniform disorder
Schizoaffective disorder
Schizophrenia
mood disorders with psychotic features
 delusional disorder
 psychotic disorder not otherwise specified

96. Treatment
• Antipsychotic
• Benzodiazepines

97. Delusional Disorder
Delusions are false fixed beliefs not in keeping with the
culture
Its diagnosis is made when a person exhibits nonbizarre
delusions of at least 1 month
Epidemiology
The annual incidence of delusional disorder is 1 to 3 new
cases per 100,000 persons.
The mean age of onset is about 40 years, but 18 to the 90s.

98. It is slightly common in female
Men are more likely to develop paranoid type
Women are more likely to develop delusions of erotomania
It is common among:
Married
Employed
Immigrant
 Low socioeconomic status.

99. Etiology
biological
Psychodynamic Factors
many patients with delusional disorder are socially isolated and have
attained less than expected levels of achievement.
Freud's Contributions
He believed that delusions are part of a healing process.

100. Paranoid Pseudocommunity
seven situations that favor the development of
delusional disorders
An increased expectation of receiving sadistic
treatment
Situations that increase distrust and suspicion
Social isolation
Situations that increase envy and jealousy

101. situations that lower self-esteem
 Situations that cause persons to see their own defects in
others
Situations that increase the potential for rumination over
probable meanings and motivations

102. Risk Factors Associated with Delusional Disorder
• Advanced age
Sensory impairment or isolation
Family history
Social isolation
Personality features
• Recent immigration

103. DSM-5 Diagnostic Criteria for Delusional
Disorder
A. Nonbizarre delusions of at least 1 month's
duration.
B. Criterion A for schizophrenia has never been met.
Note: Hallucinations, if present, are not
prominent and related to delusional theme
C. functioning is not markedly impaired and
behavior is not obviously odd or bizarre.
D. If manic or MD episodes have occurred, 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 or a general
medical condition.

104. Types delusional disorder
Persecutory Type: Patients with this subtype are
convinced that they are being persecuted or
harmed
Jealous Type: One’s spouse has been unfaithful
Erotomanic Type: is patient’s delusional conviction
that another person, usually of higher status, is in
love with him or her.
Somatic type: This subtype applies when the
central theme of the delusion involves bodily
functions or sensations
Grandiose type: This subtype applies when the
central theme of the delusion is the conviction of
having some great (but unrecognized) talent or
insight or having made some important discovery
Mixed type:
Unspecified type:

105. Shared Psychotic Disorder
Is characterized by the transfer of delusions from one person
to another
Both persons are closely associated for a long time and
typically live together in relative social isolation
the individual who first has the delusion is often chronically
ill and typically is the influential one
If the pair separates, the secondary person may abandon the
delusion
The occurrence of the delusion is attributed to the strong
influence of the more dominant member

106. Factors for shared psychosis
Old age
Low intelligence
Sensory impairment
Cerebrovascular disease
Alcohol abuse

107. Differential diagnosis
Medical Conditions
Disorders affecting the limbic system and basal ganglia
Neurodegenerative disorders
Vascular disease
Infectious disease
Metabolic disorder
Endocrinopathies
Vitamin deficiencies
Medications
Substances
Toxins

108. • Delirium
• Dementia
• Substance-Related Disorders

109. Diagnosis and Management of Delusional Disorder
• Rule out other causes of paranoid features
• Confirm the absence of other psychopathology
• Assess consequences of delusion-related behavior
• Demoralization
• Despondency
• Anger, fear
• Depression

110. Dx and mgt
Impact of search for ‘’medical diagnosis’’ , legal solution,
proof of infidelity
Assess anxiety and agitation
Assess potential for violence, suicide
Assess need for hospitalization
Institute pharmacological and psychological therapies
Maintain connection through recovery

111. Psychotherapy
Pharmacotherapy
Start with low doses of antipsychotics
 2 mg of haloperidol
2 mg of risperidone, then increase slowly

112. If the patient receives no benefit from antipsychotic
medication, discontinue use of the drug.
In patients who do respond to antipsychotic drugs, some
data indicate that maintenance doses can be low.
Although essentially no studies evaluate the use of
antidepressants or anticonvulsants in the treatment of
delusional disorder trials with these drugs may be warranted
in patients who do not respond to antipsychotic drugs

113. Psychotic Disorders due to a General Medical Condition and Substance-
Induced Psychotic Disorder

114. Psychotic due to GMC or Substance induced
Is a psychotic disorder resulted a general medical condition
such as a brain tumor or the ingestion of a substance such as
phencyclidine (PCP)
Epidemiology
There is scarcity of data
The delusional syndrome that may accompany complex
partial seizures is more common in women

115. Etiology
cerebral neoplasms of the occipital or temporal
areas, can cause hallucinations.
Sensory deprivation, as in people who are blind or
deaf, can also result in hallucinatory or delusional
experiences.
Lesions involving the temporal lobe, right
hemisphere and the parietal lobe, are associated
with delusions.
The most commonly involved substances are
alcohol, lysergic acid diethylamide (LSD),
amphetamine, cocaine, mescaline, PCP, and
ketamine.
Many other substances, including steroids and
thyroxine, produce hallucinations.

116. Diagnostic Criteria
A. Presence of one or both of the following
symptoms:
1. Delusions.
2. Hallucinations.
B. There is evidence from the history, physical
examination, or laboratory findings of both (1)and
(2):
1. The symptoms in Criterion A developed during
or soon after substance intoxication or withdrawal
or after exposure to a medication.
2. The involved substance/medication is capable
of producing the symptoms in Criterion A.

117. C. The disturbance is not better explained by a psychotic
disorder that is not substance/ medication-induced.
D. The disturbance does not occur exclusively during the
course of a delirium.
E. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning

118. Psychotic Disorder
Due to Another Medical Condition
Diagnostic Criteria
A. Prominent hallucinations or delusions
B. There is evidence that the disturbance is the
direct pathophysiological consequence of
another medical condition.
C. The disturbance is not better explained by
another mental disorder.
D. The disturbance does not occur exclusively
during the course of a delirium.
E. The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.

119. Deferential Diagnosis
Delirium
Dementia
Schizophrenia
Treatment
Is directed toward identifying underlining condition and
immediate behavioral condition
Antipsychotic
Benzodiazepam

120. Psychotic Disorder not Otherwise Specified
Is a variety of clinical presentations that do not fit within
current diagnostic rubrics
it includes psychotic symptomatology 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.

121. NURSING INTERVENTIONS for Clients with
Schizophrenia
Promoting safety of client and others and right to privacy
and dignity
 Establishing therapeutic relationship by establishing trust
Using therapeutic communication (clarifying feelings and
statements when speech and thoughts are disorganized or
confused)
Interventions for delusions:
Do not openly confront the delusion or argue with the client.
Establish and maintain reality for the client.

122. Use distracting techniques.
Teach the client positive self-talk, positive thinking, and to
ignore delusional beliefs.
Interventions for hallucinations:
Help present and maintain reality by frequent contact and
communication with client.
Elicit description of hallucination to protect client and
others.
The nurse’s understanding of the hallucination helps him or
her know how to calm or reassure the client.

123. Engage client in reality-based activities such as card
playing, occupational therapy, or listening to music.
Coping with socially inappropriate behaviors:
Redirect client away from problem situations.
Deal with inappropriate behaviors in a nonjudgmental and
matter-of-fact manner; give factual statements; do not scold.
Reassure others that the client’s inappropriate behaviors or
comments are not his or her fault.

124. Try to reintegrate the client into the treatment
milieu as soon as possible.
Do not make the client feel punished or shunned
for inappropriate behaviors.
Teach social skills through education, role
modeling, and practice.
Client and family teaching
Establishing community support system