Will talk about the severe psychological disorders-- The familiar name for all might be -"Schizophrenia" - it is not just one category but has multiple categories combined under -"Schizophrenia spectrum" My forensic psychiatric research done in Indian jails shows most convicts under murder cases belong to schizophrenia spectrum (98% schizophrenia and 2% paranoid & schizoid personality disorders), and most have murdered their spouses, family members, friends or colleagues and surrendered themselves on the spot. This presentation on the "Schizophrenia spectrum" has been particularly shared with you all to extend my message to help these affected people at the right time and maintaining their condition to prevent them from committing such crimes as there is no proper mental health care--Clinical, Legal or authoritative help available for convicts suffering from mental disorder.

1. Presentation topic
Schizophrenia spectrum disorder
Presented by : Mangal Kardile

2. Spectrum?
indicate an apparent qualitative distinction arising from a
quantitative continuum

3. Schizophrenia spectrum
• A spectrum as it applies to mental disorder is a
range of linked conditions, sometimes also
extending to include singular symptoms and traits
1) schizotypal personality disorder
2) schizoid personality disorder
3) delusional disorder
4) schizoaffective disorder
5) schizophreniform disorder

4. History of Schizo-spectrum
• Paul Eugen Bleuler (1857-1939) Swiss
psychiatrist
• notable for understanding of mental illness
and for coining the terms "schizophrenia
• replaced Kraepelin's term dementia praecox
• especially interested in Sigmund Freud's work
in "introspective" & “unconscious” variant
• “Textbook of Psychiatry” (1916)- claimed
Nobel prize

5. What is schizophrenia?
• is a mental disorder characterized by
• breakdown of thought processes and by poor
emotional responsiveness
• features auditory hallucinations, paranoid or bizarre
delusions, or disorganized speech and thinking
• accompanied by significant social or occupational
dysfunction
• onset of symptoms occurs in young adulthood, with a
global lifetime prevalence of about 0.3–0.7%
• Diagnosis is based on observed behavior and the
patient's reported experiences.

6. Expression of Schizophrenia

7. How is it diagnosed?
• American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders, DSM-IV-TR
• World Health Organization's International Statistical
Classification of Diseases and Related Health Problems,
the ICD-10
• These criteria use the self-reported experiences of the
person and reported abnormalities in behavior
• clinical assessment by a mental health professional
• Symptoms associated with schizophrenia occur along a
continuum in the population and must reach a certain
severity before a diagnosis is made
• As of 2009 there is no objective test

8. Symptoms
• Characteristic symptoms: Two or more of the following,
each present for much of the time during a one-month
period (or less, if symptoms remitted with treatment).
• Delusions
• Hallucinations
• Disorganized speech, which is a manifestation of formal
thought disorder
• Grossly disorganized behavior (e.g. dressing
inappropriately, crying frequently) or catatonic behavior
• Negative symptoms: Blunted affect (lack or decline in
emotional response), alogia (lack or decline in speech), or
avolition (lack or decline in motivation)

9. Symptoms
• onset is in childhood or adolescence-failure to achieve
expected level of interpersonal, academic, or occupational
• Continuous signs of the disturbance persist for at least 6
months- include periods of prodromal or residual symptoms
(may be only negative symptoms-apathy)
• Schizoaffective Disorder and Depressive or Bipolar Disorder
With Psychotic Features have been ruled out because -
• either (1) no Major Depressive, Manic, or Mixed Episodes
have occurred concurrently with the active-phase symptoms;
• (2) if mood episodes have occurred during active-phase, their
total duration has been less than half of the total duration of
the active periods.

10. Symptoms
• Acc. To DSM- The disturbance is not due to the direct
physiological effects of a substance (e.g., an abused drug, a
medication) or a general medical condition
• If there is a history of Autistic Disorder or another Pervasive
Developmental Disorder or other communication disorder of
childhood onset
- additional diagnosis of Schizophrenia is made only if prominent
delusions or hallucinations are also present for at least 1
month (or less if successfully treated).

11. Schizophrenia subtypes
• Paranoid type: Delusions or auditory hallucinations, but thought disorder,
disorganized behavior, or affective flattening are not present
- Delusions are persecutory and/or grandiose, but in addition to these,
other themes such as jealousy, religiosity, or somatization may also be
present
• Disorganized type: Named hebephrenic schizophrenia in the ICD
- thought disorder and flat affect are present together
• Catatonic type: almost immobile or exhibit agitated, purposeless
movement. Symptoms can include catatonic stupor and waxy flexibility
• Undifferentiated type: Psychotic symptoms are present
- criteria for paranoid, disorganized, or catatonic types have not been met
• Residual type: positive symptoms are present at a low intensity only, but
continual disturbance of(odd beliefs, unusual perceptual experiences)

12. 1) Schizotypal personality disorder
• is a personality disorder characterized by a need for social isolation
• anxiety in social situations, odd behavior and thinking, and often unconventional
beliefs.
• feel extreme discomfort with maintaining close relationships with people
• They frequently misinterpret situations as being strange or having unusual meaning for
them
• paranormal and superstitious beliefs are common
• seek medical attention for things such as anxiety, depression, or other symptoms
• Unusual perceptual experiences, including bodily illusions
• Suspiciousness or paranoid ideation
• Inappropriate or constricted affect, Ideas of reference (excluding delusions of ref)
• Behavior or appearance is odd, eccentric or peculiar
- common in individuals related to people with schizophrenia and is believed to be part of
the genetic "spectrum" of schizophrenia
• DSM-IV-TR- beginning by early adulthood- DSM-IV designation of schizotypal as a
personality disorder is controversial
• In ICD-10- Schizotypal disorder is classified as a clinical disorder associated with
schizophrenia

13. 2) Schizoid personality disorder
• often aloof, cold, and indifferent, which causes interpersonal difficulty
• trouble establishing personal relationships or expressing their feelings in a
meaningful way, and may remain passive in the face of unfavorable
situations.
• unable to develop accurate reflections of themselves with respect to how
well they are getting along with others
• If personal space is violated, they feel suffocated
• "feel lost" without the people they are normally around because they
require a sense of security and stability
• it is possible for schizoid individuals to form relationships
long as these modes of relating do not require or force the need for
emotional intimacy---if invaded by others-------they prefer isolation
- beginning by early adulthood (age eighteen or older)
-It is a requirement of DSM-IV that a diagnosis of any specific personality
disorder also satisfies a set of general personality disorder criteria

14. 3) Delusional disorder
• A delusion is a belief held with strong conviction despite superior evidence to the
contrary
• uncommon psychiatric condition in which patients present with circumscribed
symptoms of non-bizarre delusions
• absence of prominent hallucinations, thought disorder, mood disorder, or significant
flattening of affect
• olfactory or tactile hallucinations related to the content of the delusion may be present
• the delusion or delusions cannot be due to the effects of a drug, medication, or general
medical condition
• cannot be diagnosed in an individual previously diagnosed with schizophrenia.
• A person may be high functioning in daily life as this disorder bears no relation to one's
IQ
• may not exhibit odd or bizarre behavior aside from these delusions
• Delusional disorders are present in 1.3% of all newly admitted patients to psychiatric
hospitals, otherwise uncommon in psychiatric practice
• Peters Delusion Inventory (PDI) which focuses on identifying and understanding
delusional thinking

15. Delusional disorder
• DSM defines six subtypes-
• erotomanic -believes that someone is in love with him/her,
• grandiose - believes that he/she is the greatest, strongest, fastest, richest,
and/or most intelligent person ever
• jealous - believes that the love partner is cheating on him/her
• persecutory -believes that someone is following him/her to do some harm
in some way
• somatic - believes that he/she has a disease or medical condition and
mixed
• The illness is chronic and frequently lifelong
• delusions are logically constructed and internally consistent
• Despite his/her profound conviction, there is often a quality of
secretiveness or suspicion when the patient is questioned about it
• Delusions also occur as symptoms of many other mental disorders,
especially the other psychotic disorders

16. 4) SCHIZOAFFECTIVE DISORDER
• A. uninterrupted period of illness during which- Criterion A symptoms of
Schizophrenia are present, also either a Major Depressive Episode or a Manic
Episode.
Note: The Major Depressive Episode must include Criterion A1: depressed mood.
• B. During the lifetime duration of the illness, delusions and/or hallucinations are
present at least for 2 weeks in the absence of a major mood episode (depressive
or manic)
• C. A major mood episode is present for the majority (≥ 50%) of the total duration
of the time after Criterion A has been met
• D. Disturbance is not due to direct physiological effects of a substance (e.g., a drug
of abuse, medication) or a general medical condition
• Specify Type:
• Bipolar Type: If the disturbance includes a Manic or a Mixed Episode (or a Manic
or a Mixed Episode and Major Depressive Episodes)
• Depressive Type: If the disturbance only includes Major Depressive Episodes
• Acc. To DSM- there must be a period of at least two weeks of psychosis
without mood disorder, and these symptoms cannot be due to
medication(s), substance use or another medical condition.

17. 5) Schizophreniform disorder
• Delusions, hallucinations, disorganized speech, grossly abnormal
psychomotor behavior, including catatonia, negative
symptoms(diminished emotional expression)
• No schizoaffective, Major Depressive, Manic, or Mixed Episodes have
occurred concurrently with the active-phase symptoms;
• if mood episodes occurred during active-phase symptoms, their total
duration very less
• not due to the direct physiological effects of a substance, medication or a
general medical condition
• episode of the disorder lasts at least 1 month but less than 6 months,
required to diagnose as schizophrenia
• absence of blunted or flat affect
• diagnosis must be made without waiting for recovery, it should be
qualified as “Provisional” ( with/without good prognostic features)
e.g. confusion or perplexity at the height of the psychotic episode
• good premorbid social and occupational functioning

18. causes of spectrum???
• Genetic- heritability vary because of the difficulty in
separating the effects of genetics and the environment,
greatest risk for first-degree relative (6.5%); more than
40% of monozygotic twins
• Environment- factors associated the living environment,
prenatal stressors, parenting style
• Substance misuse- more than 50% use cannabis, cocaine,
predominantly alcohol abuse
• Socioeconomic, cultural factors- demands frequent
medication, rehabilitation, hospital care
• Developmental factors- hypoxia and infection, or stress and
malnutrition in the mother during fetal development, born
in winter or spring (cold regions and hot regions)

19. Etiology of spectrum???
• Biochemical factors- too much dopamine activity
• Serotonin- increment in negativity (Clozapine-
drug)
• Norepinephrine - impaired emotional
gratification,
• GABA- loss of GABAergic neurons in hippocampus
• Glutamate – induce attack (phencyclidine-drug)
• Nicotine – regulates neurotransmitters involved
in cognition (good for short term memory)

20. Etiology of Neuropathology
- Potential Neuropathological basis-
- gray matter loss that occurs as schizophrenia develops neurochemical
abnormalities in cerebral cortex, basal ganglia, limbic system
- Loss of brain volume, reduced density of axons, dendrites and synapses
- Enlarged ventricles- (lateral and third- computer tomography)
- Reduced symmetry in brain areas
- Anatomical abnormalities and functional deficits in Prefrontal cortex
- Disorder of brain neural circuits (early developmental lesion of the dopaminergic
tracts to prefrontal cortex- connection of basal ganglia and cerebellum)- causing
negative, positive and cognitive impairments
- Brain metabolism- magnetic resonance spectroscopy (study of specific molecules
found – lower level of phosphomonoester, inorganic phosphate, higher level of
phosphodiester

21. Etiology of Neuropathology

22. Management
• Treated with antipsychotic medications, often in combination with
psychological and social supports
• Family Support - individuals diagnosed with schizophrenia are
emotionally responsive, particularly to stressful or negative stimuli
• Psychiatric Medicines -atypical antipsychotic medication (e.g.
Risperidone, Clozapine)
• Hospitalization may occur for severe episodes either voluntarily or
involuntarily
• (Serious side effect of medication -neuroleptic malignant syndrome)
• Functional magnetic resonance imaging (fMRI) and other brain
imaging technologies allow for the study of differences in brain
activity in people diagnosed with schizophrenia.
• Psychological- Cognitive biases have been identified, insensitivity to
problem may cause vulnerability to symptoms or to the disorder

23. Prognosis
• Consumes great human and economic costs
• decreased life expectancy of 12–15 years, primarily
because of its association with obesity, sedentary
lifestyles, and smoking, with an increased rate of
suicide(occurring in the period following onset or first
hospital admission)
• 16.7 million people globally are deemed to have
moderate or severe disability from the condition
• Outcomes for schizophrenia appear better in the
developing than the developed world
• Schizophrenia and smoking have shown a strong
association(80% to 90% as compared with normal 20%)

24. Epidemiology
Disability-adjusted life year for schizophrenia per 100,000 inhabitants in 2004

25. Epidemiology
• Schizophrenia affects around 0.3–0.7% of people at
some point in their life, or 24 million people worldwide
as of 2011
• It occurs 1.4 times more frequently in males than
females and typically appears earlier in men
• the peak ages of onset are 20–28 years for males and
26–32 years for females
• Onset in childhood is much rarer, as is onset in middle-
or old age.
• Some forensic psychiatric studies support serious
crimes by schizophrenics – mainly murder of a
near/dear one—then surrendering on the spot

26. • Ongoing research required……….....

27. Thank you