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Schizophrenia & other psychotic disorders

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Schizophrenia & other psychotic disorders

  1. 1. Schizophrenia Spectrum and Other Psychotic Disorders Mr. Johny Kutty Joseph Assistant Professor
  2. 2. Schizophrenia The broad category of schizophrenia includes a set of disorders in which individuals experience distorted perception of reality and impairment in thinking, behavior, affect, and motivation. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time. The term schizophrenia was coined in 1908 by the Swiss psychiatrist Eugene Bleuler. The word was derived from the Greek “ schizo” (split) and ‘phren’ (mind).
  3. 3. Common Misconception… People who have schizophrenia do not have multiple personalities or a split personality They are split from reality – cannot tell what is real and what is not… Eugen Bleuler (1857–1939) coined the term "Schizophrenia" in 1908
  4. 4. Psychosis/Scizophrenia Psychosis is severe mental condition disorder in which there is disorganization of the personality, deterioration in social functioning and loss of contact with, or distortion of reality. There may be evidence of hallucinations and delusional thinking. Psychosis can occur with or without presence of organic impairment. Schizophrenia is a psychotic condition characterized by a disturbance in thinking, emotions, volitions, and faculties in the presence of clear consciousness, which usually leads to social withdrawal.
  5. 5. Psychosis Vs Neurosis
  6. 6. Psychosis Some of the different types of psychosis include: • Schizophrenia • Schizoaffective disorder (Manic Depression) • Delusional disorder • Substance-induced psychosis • Dementia and Delirium • Bipolar disorder (manic depression) • Major Depressive Disorder • Postpartum psychosis • Psychosis due to a general medical condition:
  7. 7. Neurosis Some of the different types of Neurosis include: • Depression • Obsessive-compulsive disorders • Somatoform disorders (Hysteria, conversion, dissociation) • Anxiety Disorders • PTSD
  8. 8. Schizophrenia Development of Schizophrenia occurs in four phases The Pre-morbid Phase: It indicates social malfunctioning, social withdrawal, irritability, and antagonistic thoughts and behaviour. It has a pre-morbid personality of shyness, poor peer relationship, poor academic performance, antisocial behaviour (According Sadock & Sadock 2007) The Prodromal Phase: Occurrence of certain symptoms of illness. It is marked by the change from the pre-morbid functioning and extend up to the onset of psychotic symptoms. It usually range from few months or 2 to 5 years.
  9. 9. Schizophrenia Development of Schizophrenia occurs in four phases Schizophrenia: Prominent psychotic symptoms. Residual Phase: Schizophrenia characterized by periods of remission and exacerbation. The symptoms may be prominent or not. Impaired role functioning and flat affect is observed.
  10. 10. Epidemiology of Schizophrenia  0.3 to 0.7% is the prevalence in general population.  Moreover equally prevalent in men and women but 1.4 times more frequently in males than females  Peak age of onset for men is 20 to 28 years and 26 to 32 years in women.  More common for low socio economic groups.  In India every year 268.903/100000 people are affected. (as per WHO statistics 2000)  The prognosis of Psychosis rely upon the type of symptoms, age of onset and treatment adherence.
  11. 11. Predisposing / Etiology / Risk factors of Schizophrenia  The cause of schizophrenia is still uncertain.  Biological Factors; Genetics and twins.
  12. 12. Predisposing / Etiology / Risk factors of Schizophrenia  Biochemical Factors; Dopamine Hypothesis • Schizophrenia is caused by an excess of dopamine dependant neuronal activity in the brain. This excess activity leads to increases release of dopamine, increased receptor sensitivity to dopamine and number of dopamine receptors. • Pharmacological studies show that the use of amphetamines which is a stimulant to increase dopamine levels produce schizophrenia symptoms. Antipsychotics such as haloperidol and chlorpromazine block the dopamine receptors thus reducing the symptoms of schizophrenia.
  13. 13. Predisposing / Etiology / Risk factors of Schizophrenia  Biochemical Factors; Dopamine Hypothesis • Post-mortem studies of brain of persons who had schizophrenia show increased number of dopamine receptors. • The area affected by dopamine are mesolimbic pathway, mesocortical pathway, nigrostriatal pathway, tuberinfundibular pathway. • Mesolimbic pathway: connects midbrain to limbic system. Deals with memory, emotions, arousal and pleasure. Excess activity can cause hallucinations and delusions.
  14. 14. Predisposing / Etiology / Risk factors of Schizophrenia • Mesocortical pathway: midbrain to cortex. Deals with cognition, social behaviour, planning, problem solving, motivation etc. Diminished activity can cause anhedonia, flat affect lack of motivation which are the negative symptoms of schizophrenia. • Nigrostriatal pathway: substantia nigra (midbrain) to basal ganglia (cerebral hemisphere). It controls the motor control. Increased activity can cause psychomotor symptoms. • Tuberinfundibular pathway: hypothalamus to pituitary gland. Affects endocrine functions such as digestion, metabolism, sexual arousal, hunger etc.
  15. 15. Predisposing / Etiology / Risk factors of Schizophrenia Dopamine Receptors are located in • D1: basal ganglia, cerebral cortex. • D2: basal ganglia, anterior pituitary cerebral cortex. • D3: limbic regions, basal ganglia • D4: frontal cortex, hippocampus, amygdala • D5: hippocampus, hypothalamus
  16. 16. Predisposing / Etiology / Risk factors of Schizophrenia  Biochemical Factors; Other Factors/hypothesis • According to various research studies other neurotransmitters and neuroregulators such as norepinephrine, serotonine, acetylcholine, glutamate (Hashimoto in 2006 ), GABA and prostaglandins also predispose schizophrenia.  Physiological Factors: • Viral Infection: According to Sadock and Sadock in 2007 prenatal exposure to influenza can cause schizophrenia. Another study indicate infections of CNS during childhood can cause schizophrenia at later stage of life.
  17. 17. Predisposing / Etiology / Risk factors of Schizophrenia  Physiological Factors: • Neurostructural theories: Research suggest the improper development of prefrontal cortex and limbic cortex in case of schizophrenia. Imaging study shows decreased brain volume, larger lateral and third ventricle, atropy of frontal lobe, cerebellum and limbic structure etc, in case of schizophrenic patients. • Some studies reported that physical conditions such as epilepsy (temporal lobe), birth trauma, head injury, huntington's disease, tumour, CVA etc, in childhood may cause schizophrenia.
  18. 18. Predisposing / Etiology / Risk factors of Schizophrenia  Psychological Factors; • Developmental theories: regression to the oral stage, improper use of defence mechanism such as denial and projection, inadequate ego development, superego dominance, regressed ID behaviour can cause schizophrenia. • Family Theories: faulty mother child relationship such as overprotection and domineering cause poor ego development. Hostile/unfriendly behaviour of parents and poor parent child relationship can cause symptoms of schizophrenia in child. • In fact, these psychodynamic theories does not hold any credibility as on date since more evident biological factors are ruled out by different researchers as the causative factors of schizophrenia.
  19. 19. Predisposing / Etiology / Risk factors of Schizophrenia  Environmental Influences; • Socio-cultural factors: Lower socio economic class experience more symptoms of schizophrenia because of poverty, inadequate nutrition, absence of prenatal care, few resources for stress management, lifestyle and feeling of hopelessness. • Stressful Life events: There is no scientific evidence to indicate the relationship between stress and psychotic disorders. But few studies have shown that stress may contribute to the severity of illness. It can precipitate psychotic problems and it can exacerbate the condition and increase the
  20. 20. Classification of Schizophrenia/Psychotic disorders Name of the condition ICD - 10 Classificat ion DSM V Classificati on Schizotypal (Personality) Disorder F 21 303.22 Delusional Disorders F 22 297.1 Brief Psychiatric Disorders F 23 298.8 Schizophreniform disorders F 20.81 295.40 Schizophrenia F 20 --- Paranoid Schizophrenia F 20.0 --- Hebephrenic Schizophrenia F 20.1 --- Catatonic Schizophrenia F 20.2 ---
  21. 21. Classification of Schizophrenia/Psychotic disorders Name of the condition ICD - 10 Classification DSM V Classification Undifferentiated Schizophrenia F 20.3 --- Post Schizophrenic Depression F 20.4 --- Residual Schizophrenia F 20.5 --- Simple Schizophrenia F 20.6 --- Schizoaffective disorders F25.9 295.90 Substance/Medication induced Psychotic disorder F 25.1 295.70 Unspecified Schizophrenia & other Psychotic disorders. F 29 298.9
  22. 22. Schizophrenia Spectrum
  23. 23. Classification of Schizophrenia/Psychotic disorders  Delusional disorder: Presence of delusions at least for a month, but with no accompanying hallucinations, thought disorder, mood disorder, or affect disorders. They are; 1. Erotomanic Type: Presence of Erotomania in which a person believes that another person (typically of higher social status) is in love with them. They may follow, contact, hide or pursue to obtain it. 2. Grandiose Type: Delusion Of Grandiosity. 3. Jealous Type: Delusion of jealousy in which the person doubts the sexual partner for being unfaithful. 4. Persecutory type: more common. Delusion of persecution 5. Somatic Type: Somatic delusion of being sick. 6. Mixed Type.
  24. 24.  Brief psychotic disorder. A sudden onset of psychotic symptoms for short duration which may include delusions, hallucinations, disorganized speech or behaviour. These symptoms last at least 1 day but less than 1 month. Catatonic features also may be shown.  Schizotypal personality disorder. They are odd or eccentric and usually have few close relationships. They may also misinterpret others' motivations and behaviours and develop significant distrust of others. Classification of Schizophrenia/Psychotic disorders
  25. 25. Schizophreniform disorder. The symptoms of schizophrenia are present for a significant portion of the time within a one-month period or may last up to 6 months.. The symptoms of both Schizophrenia & Schizophreniform can include delusions, hallucinations, disorganized speech, and social withdrawal. While impairment in social, occupational, or academic functioning is required for the diagnosis of schizophrenia, in schizophreniform disorder an individual's level of functioning may or may not be affected. While the onset of schizophrenia is often gradual over a number of months or years, the onset of schizophreniform disorder can be relatively rapid. Classification of Schizophrenia/Psychotic disorders
  26. 26.  Schizoaffective disorder. Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression. The client may appear depressed with psychomotor retardation and suicidal ideation or symptoms include euphoria, grandiosity and hyperactivity.  Psychosis associated with substance use or medical conditions. Presence of prominent hallucinations and delusions attributable to substance intoxication. The symptoms are more severe and excessive than that is usually associated with withdrawal symptoms. Classification of Schizophrenia/Psychotic disorders
  27. 27.  Schizophrenia. Paranoid Schizophrenia: The word paranoid means delusional. It is the common type of schizophrenia. Intact cognitive skills and affect. Do not show disorganized behaviour. Delusions such as Grandeur, persecution, reference (self), jealousy. Hallucinations such as auditory. The best prognosis of all types of schizophrenia Hebephrenic Schizophrenia: Early in onset and poor pre- morbid personality. The marked features are thought disorders, incoherence, severe loosening of association and social impairment. Delusions and hallucinations are fragmentary and changeable. Worst prognosis of all subtypes. Classification of Schizophrenia/Psychotic disorders
  28. 28.  Schizophrenia. Catatonic Schizophrenia: is characterized by marked disturbance of motor behaviour. This may take form of catatonic stupor, catatonic excitement and mixed. In case of excited catatonia it shows restlessness, agitation, excitement, increased speech production, loosening of association. In case of catatonic stupor it shows mutism, rigidity, negativism, stupor, echolalia, echopraxia, waxy flexibility and automatic obedience. With suitable and effective treatment, the symptoms can be controlled and the affected individuals can lead a better quality of life. Classification of Schizophrenia/Psychotic disorders
  29. 29.  Schizophrenia. Residual Schizophrenia: There should be at least one episode of schizophrenia in the past but without prominent psychotic symptoms at present. The symptoms include emotional blunting, eccentric behaviour, illogical thinking and social withdrawal. Undifferentiated Schizophrenia: No other subtypes are satisfied. Simple Schizophrenia: Similar to residual schizophrenia but no history of early episode. It is early and insidious onset with symptoms of wandering, hypochondriasis and aimless activity. Post Schizophrenic Depression: Similar to Schizoaffective Classification of Schizophrenia/Psychotic disorders
  30. 30. Psychopathology of Schizophrenia  According to Bleuler;  Due to different predisposing factors there is loosening of association which is the primary and fundamental disturbance.  Through the loosened links in the chains of association instinctual desired and unconscious wishes can intrude into the consciousness of the patient.  His repressed complexes gain the mastery and can entirely rule his life and behaviour.  There is disruptions and distortions of personality.
  31. 31. Psychopathology of Schizophrenia  According to Bleuler;  Withdrawn from the reality whenever opposed to the impulses of his complexes.  Primary symptoms occur (weak will power, emotional stiffness, and ambivalence.)  Secondary symptoms occur (Delusions, hallucinations and catatonic symptoms.)
  32. 32. Psychopathology of Schizophrenia  According to Berze in 1914;  Due to organic damage caused by the predisposing factors insufficient thought and low psychic activity occur.  The lowered mental activity prevent the person from making distinction of reality and imagination.  Delusional ways of thinking, hallucinations and other associated symptoms occur.  Commonly affected mental functions are disturbance in thinking, volition, perception, emotions and catatonic symptoms.
  33. 33. The dynamics of schizophrenia using transactional model of stress adaptation. Precipitating Event (Any event sufficiently stressful to threaten an already weak ego) Predisposing Factors (Genetic influences, biochemical, birth defects, prenatal exposure to viral infections, abnormal brain structure, physical problems) Cognitive appraisal: Personal interpretation of the situation and possible reactions to it
  34. 34. The dynamics of schizophrenia using transactional model of stress adaptation. Primary: Perceived threat to self concept or physical integrity Secondary: because of weak ego strength, patient is unable to use effective coping mechanisms effectively rather they use maladaptive mechanisms such as denial, regression etc.
  35. 35. The dynamics of schizophrenia using transactional model of stress adaptation. Quality of response Adaptive Maladaptive Initial psychotic episode or exacerbation of schizophrenic symptoms Hallucinations, delusions, social isolations, violence, inappropriate affect, bizarre behaviour, apathy, autism.
  36. 36. Clinical Features of Schizophrenia Positive and Negative Symptoms of Schizophrenia “Positive” symptoms refer to characteristics that are added to someone’s state of being. “Negative” symptoms, in contrast, are characteristics that are removed from the person’s state of being. The difference between positive and negative symptoms of schizophrenia is what they do to the person who is living with schizophrenia. Schizophrenia positive symptoms create distortions and new ways of experiencing the world, while schizophrenia negative symptoms take things away.
  37. 37. Positive Symptoms of Schizophrenia Content of thought  Delusions: different types such as persecution, grandeur, reference, control, somatic etc.  Religiosity: Excess obsession of religious ideas and behaviour.  Paranoia: Extreme suspiciousness  Magical thinking: a strong belief that one’s thought can control a specific situation or people as seen in children.
  38. 38. Positive Symptoms of Schizophrenia Form of thought  Associative looseness: speech unrelated each other  Neologisms: new words  Clang associations: choosing words by sounds  Word salad: group of words with no logical connection  Circumstantiality: unnecessary details in speech before returning to the point of communication.  Tangentiality: person never return back to the point of communication.  Mutism  Preservation: repetition of same words or ideas in response to different questions.
  39. 39. Positive Symptoms of Schizophrenia Perception  Hallucinations: auditory, visual, tactile, gustatory, olfactory  Illusions Sense of Self  Echolalia: repeat the words that one hear  Echopraxia: repeat the action that one see  Depersonalization: unstable personal identity
  40. 40. Negative Symptoms of Schizophrenia Affect  Inappropriate affect: emotional tone is incongruent with the circumstances.  Flat Affect: voiding of emotion tone or its expression  Apathy: Lack of interest in the matters/environment. Volition  Inability to initiate goal directed activity  Emotional ambivalence: coexistence of opposite emotions towards same object.  Deteriorated appearance: neglecting personal grooming
  41. 41. Negative Symptoms of Schizophrenia Interpersonal Functioning  Impaired social interaction  Social isolation Psychomotor Behaviour  Anergia  Waxy Flexibility  Posturing Associated Features  Anhedonia  Regression

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