schizophrenia Al Azhar university Gaza Lama El Banna psychology other psychotic disorders and schizophrenic spectrum

1. lecture 5
Schizophrenia
Other psychotic disorders and schizophrenic spectrum
Part 1
1. Schizophrenia
2. Schizophrenoform disorder
3. Schizoaffective disorder
4. Brief psychotic disorder , cycloid psychosis and other acute psychosis
5. Delusional disorder ( paranoia )
6. Shared Psychotic Disorder
7. Drug induced psychosis
8. Psychosis due to general medical factors
9. Schizoid personality disorder
10. Schizotypal personality disorder
11. Paranoid personality disorder
12. Specific psychosis and other culturally modified psychosis

2. Schizophrenia
1. Definition
2. The history of the concept
a. Pre- Emil Kraepelin
b. Emil Kraepelin
c. Eugen Bleuler
d. Kurt Schneider
e. Positive vas negative schizophrenia ( Crow . N. andreason )
f. Recent diagnostic criteria DSM4r , ICD10
1. Clinical features
2. Diagnosis
3. Course and prognosis
4. Etiology

3. Definition
•Schizophrenia is a psychotic illness that, in its
active phase, includes delusions, hallucinations,
and disruption of thinking, feeling, and many
other mental functions , the disorder is always
severe and is usually long lasting ( with a chronic
course) which may persists throughout life
leaving profoundly disruptive residual
psychiatric symptoms and impaired social
functioning , the diagnosis of schizophrenia is
based entirely on the psychiatric history and
mental status examination. There is no laboratory
test for schizophrenia

4. History of the concept
•In the 18th century, Philippe Pinel, a
prominent French physician, was one in a
growing list of predecessors who believed that
mental illness was a disease of the central
nervous system and one that could be caused
by hereditary or environmental factors (this
was the first revolutionary and first scientific
step in psychiatry)

5. A Model of Mental treatment before Philippe Pinel

6. Kraepelin-pre
• An illness like schizophrenia has been
variously described over the years. Falvet
in 1851 described the paranoid feature
called it Folie circulaire, Hecker in 1871
described Hebephrenia, Kahlbaum in
1874 described Catatonia (a movement
disorder) and Paranoia ( recently called
delusional disorder)

7. Emil Kraepelin (1856–1926)

8. Emil Kraepelin 1
•Emil Kraepelin (1856–1926) was a German
psychiatrist who devoted his life’s work to the
task of describing and characterizing the
symptoms his patients manifested. From
these observations, he concluded that not all
mental patients suffered from the same
disease. He was the first to distinguish manic-
depressive psychoses from other chronic
psychotic illnesses,

9. Emil Kraepelin 2
•kraepelin used the term démence précoce
(“dementia praecox.”) used before by( Augustin
Morel) in 1850 , Morel used this term to
describe a previously normal young boy who
suddenly manifested symptoms of mental
deterioration , but kraepelin in his concept of
(“dementia praecox.”) connected 3 situations
had been good described before ,hebephrenic,
catatonic, and paranoid and categorized them in
one nosology called dementia praecox.

10. Emil Kraepelin criteria for his dementia praecox
1. Disturbance attention and comprehension
2. Hallucinations , especially auditory ( voices )
3. Audible thoughts
4. Experience of influenced thought
5. Disturbance of the flow of thought
6. Impairment of cognitive function and judgment
7. Affective flattening
8. Appearance of morbid behavior ( reduced drive , automatic obedience ,
echolalia , echopraxia , acting out , catatonic stereotypes and negativism
, autism , disturbance of verbal expression )

11. Eugen Bleuler (1857–1939).

12. Eugen Bleuler 1
•Eugen Bleuler was a Swiss psychiatrist who is
known, among other things, for coining the
term schizophrenia. In 1911, Euge Bleuler
published his monograph entitled Dement
Praecox, or the Group of Schizophrenias, and
argued the dementia praecox was not a
single disease, was not associated with
intellectual decline ( dementia )

13. Eugen Bleuler2
• and had its fundamental basis disorders of affectivity,
ambivalence , autism, attention and will. Other
symptoms such delusions, hallucinations, abnormal
behavior and catatonia were conceptualized as
secondary (accessory symptoms) , and except the three
types registered by Emil Kraepelin (, hebephrenic,
catatonic, and paranoid ) he added a new type called
it simple schizophrenia ( according his criteria simple
schizophrenia was the most nuclear type of
schizophrenia )

14. Eugen Bleuler criteria for his schizophrenia
1. Basic or fundamental disturbance ( the 4 and sometimes 6
A)
 Association loss
 Affective flattening
 Ambivalence
 Apathy
 Abolia
 Autism

15. Eugen Bleuler criteria for his schizophrenia
2- Accessory symptoms
 Disorders of perception ( hallucinations )
 Delusions
 Certain memory disturbance
 Modification of personality
 Changes of speech and writing
 Somatic symptoms
 Catatonic symptoms
 Acute syndromes ( such as melancholic , manic , catatonic , and other states )

16. Kurt Schneider (1887–1967)
Kurt Schneider probably contributed to our current diagnostic
classifications more than any other person. Schneider studied both
Kraepelin’s and Bleuler’s ideas during his psychiatric training in
Germany , In 1959 he listed the 'first rank features' of schizophrenia.
One of these symptoms, in the absence of organic disease, or persistent
affective disorder, or drug intoxication, was sufficient for a diagnosis of
schizophrenia

17. SCHNEIDER’S SYMPTOMS OF THE FIRST RANK
 Audible thoughts
 Voices heard arguing or discussing
 Voices heard commenting on one’s actions
 The experience of influences playing on the body
 Thought withdrawal and other interferences with thought
 Diffusion of thought
 Delusional perception
 Feelings, impulses and volitional acts experienced as the work
or influence of others

18. SCHNEIDER’S SYMPTOMS OF THE SECOND RANK
 Other disorders of perceptions
 Sudden delusional ideas
 Perplexity
 Depressive or euphoric changes
 Feeling of emotional impoverishment ( apathy –
abolia )
 Motor disturbances

19. T crow. N Anderson (positive vas
negative schizophrenia) 1990
• Negative schizophrenia (loss of some mental functions),
poor prognosis, hypo dopaminergic pathology, brain
ventricular enlargement (brain atrophy) poor responding to
antipsychotics.
• 1-Social withdrawal
• 2-Apathy
• 3-Self-neglect
• 4-and other symptoms described as fundamental (the 6 A)
by Eugen Bleuler

20. T crow. N Anderson (positive vas negative
schizophrenia) 1990
• Positive schizophrenia (Reality distortion) good
prognosis, hyper dopaminergic pathology, no
brain structure observed, good responding to
antipsychotics
1.Delusions
2. Hallucinations
3. Passivity phenomena (SCHNEIDER’S SYMPTOMS
OF THE FIRST RANK)

21. Clinical feature (main symptoms and signs) in schizophrenia
•Hallucinations in schizophrenia may involve any of the sensory
modalities. The most common are auditory hallucinations in the
form of voices, which occur in 60–70% of patients diagnosed with
schizophrenia. Although voices in the second person are most
common, the characteristic Schneiderian’ voices are in the third
person and provide a running commentary on the patient’s actions,
arguing about the patient or repeating the patient’s thoughts.
Voices may be imperative, ordering the patient to harm him or
others. Visual hallucinations occur in about 10% of patients, but
should make one suspicious of an organic disorder. Olfactory
hallucinations are more common in temporal lobe epilepsy than
schizophrenia, and tactile hallucinations are probably experienced
more frequently than is reported by patients No single type of
hallucination is specific to schizophrenia, and the duration and
intensity are probably most important diagnostically

22. CATATONIC SYMPTOMS
•Ambitendence Alternation between opposite movements.
•Echopraxia Automatic imitation of another person’s movements even when asked
not to
•Stereotypies Repeated regular fixed parts of movement (or speech) that are not
goal directed, e.g. moving the arm backwards and outwards repeatedly while
saying ‘but not for me
•Negativism Motiveless resistance to instructions and attempts to be moved, or
doing the opposite of what is asked
•Posturing Adoption of inappropriate or bizarre bodily posture continuously for a
substantial period of time
•Waxy flexibility the patient’s limbs can be ‘molded’ into a position and remain
fixed for long periods of time

23. THOUGHT DISORDERS
•Derailment occurs when the patient moves from one train of thought to another which has no
apparent connection to the first a less severe form is called loosening of associations
which merges into tangential thinking and loss of goal
•Some patients may invent neologisms (new words), exhibit verbal stereotypy (repetition of
a single word or phrase out of context), or use metonyms (ordinary words given a special
personal meaning))
•Negative thought disorder includes poverty of speech (limited quantity of speech), and poverty of
content of speech (limited meaning conveyed by speech)
•Thought insertion the patient believes that thoughts that are not his own are being put into his
mind by an external agency.
•Thought withdrawal the patient believes that thoughts are being removed from his mind by an
external agency.
•Thought broadcasting the patient believes that his thoughts are being ‘read’ by others, as if they
were being broadcast.
•Thought blocking involves a sudden interruption of the train of thought, before it is completed,
leaving a ‘blank’. The patient suddenly stops talking and cannot recall what he has been saying or
thinking

24. DELUSIONS
•Persecution An outside person or force is in some way interfering with the sufferer’s life or wishes them
harm, e.g. “The people upstairs are watching me by using satellites and have poisoned my food”.
•Reference The behavior of others, objects, or broadcasts on the television and radio have a special
meaning or refer directly to the person, e.g. “A parcel came from Sun Alliance and the radio said that
‘the son of man is here’, on a Sunday, so I am the son of God”.
•Control The sensation of being the passive recipient of some controlling or interfering agent that is alien
and external. This agent can control thoughts, feeling and actions (passivity experiences), e.g. “I feel as if
my face is being pulled upwards and something is making me laugh when I’m sad”.
•Grandeur Exaggerated belief of one’s own power or importance, e.g. “I can lift mountains by moving my
hands, I could destroy you!”.
•Nihilism Others, oneself, or the world does not exist or is about to cease to exist (often called Cotard’s
syndrome), e.g. “The inside of my tummy has rotted away. I have no bowels”.
•Infidelity One’s partner is being unfaithful (also known as delusional jealousy or the Othello syndrome.)
•Doubles A person known to the patient, most frequently their spouse, has been replaced by another
(also known as Capgras’ syndrome or, confusingly, ‘illusion’ of doubles.)
•Infatuation A particular person is in love with the patient (also known as erotomania or de Clerambault’s
syndrome).)
•Somatic Delusional belief pertaining to part of the person’s body, e.g. “My arms look like they’ve
been melted and squashed into a mess

25. Emotional-Expression
• People with schizophrenia often show “blunted” or “flat” affect.
This refers to a severe reduction in emotional expressiveness. A
person with schizophrenia may not show the signs of normal
emotion, perhaps may speak in a monotonous voice, have
diminished facial expressions, and appear extremely apathetic. The
person may withdraw socially, avoiding contact with others; and
when forced to interact,he or she may have nothing to say, reflecting
“impoverished thought.” Motivation can be greatly decreased, as
can interest in or enjoyment of life. In some severe cases, a person
can spend entire days doing nothing at all, even neglecting basic
hygiene. These problems with emotional expression and motivation,
which may be extremely troubling to family members and friends,
are symptoms of schizophrenia – not character flaws or personal
weakness