Hotel “Continental”, 4-5. novembar 2010. Beograd

1. Totić S.1,2, Marinković D.1, Vuković O.1,2
1Klinika za psihijatriju, Klinički centar Srbije
2Medicinski fakultet, Beograd
DIJAGNOSTIČKE DILEME KOD RANIH
PSIHOTIČNIH ISPOLJAVANJA

3. Ernst, Baron von Feuchtersleben
ludilo - psihoza - psihopatija

4. Tradicionalna
Krepelijanska dihotomija
Shizophrenia
Dementia praecox
Bipolarni poremećaj
MD insanity
“... it is becoming increasingly obvious that we cannot satisfactorily distinguish
these two diseases .... We shall have to get accustomed to the notion that our much used
clinical checklist does not permit us to differentiate reliably manic-depressive insanity
from schizophrenia in all circumstances” Kraepelin, 1920 (pp. 26, 28).

6. DSM & ICD “Biblije”
DSM & ICD “Biblije”
PSIHOTIČNO - njegovo korišćenje ne podrazumeva pretpostavke o mehanizmima nastanka, već prosto ukazuje
na prisustvo halucinacija, iluzija ili ograničenog broja nekih abnormalnosti u ponašanju, kao što su preterana
uzbudjenost i preterana aktivnost, markirana psihomotorna retardacija i katatono ponašanje.

7. “Zašto kažemo psihoza, a mislimo na shizofreniju”
The new name for schizophrenia?
Evropa, Amerika
Dysfunctional Perception Syndrome
A salience dysregulation syndrome
Japan
Mind-split-disease (Seishin Bunretsu Byo)
Integration-dysregulation syndrome (Tōgō-shitchō-shō)

8. • rana psihoza (McGorry, 2006)
“Zašto kažemo psihoza, a mislimo na shizofreniju”

9. 2012
* The work group is recommending that this be
included in DSM-5 but is still examining the
evidence as to whether inclusion is merited in the
main manual or in an Appendix for Further
Research. As such, the work group strongly
encourages feedback regarding this disorder.

10. Hallucinations Delusions Disorganization Abnormal
Psychomotor
Behavior
Restricted
Emotional
Expression
Avolition Impaired
Cognition
Depression Mania
0 Not Present Not Present Not Present Not Present Not Present Not Present Not Present Not Present Not Present
1 Equivocal (severity or
duration not
sufficient to be
considered
psychosis)
Equivocal
(severity or
duration not
sufficient to be
considered
psychosis)
Equivocal (severity or
duration not sufficient
to be considered
disorganization)
Equivocal (severity
or duration not
sufficient to be
considered
abnormal
psychomotor
behavior)
Equivocal decrease
in facial
expressivity,
prosody, or
gestures
Equivocal
decrease in
self-initiated
behavior
Equivocal (cognitive
function not clearly
outside the range
expected for age or
SES, i.e., within 1 SD
of mean)
Equivocal (some
depressed mood, but
insufficient
symptoms, duration
or severity to meet
diagnostic criteria)
Equivocal (some
inflated or irritable
mood, but insufficient
symptoms, duration,
or severity to meet
diagnostic criteria)
2 Present, but mild
(little pressure to act
upon voices, not very
bothered by voices)
Present, but mild
(delusions are
not bizarre, or
little pressure to
act upon
delusional
beliefs, not very
bothered by
beliefs)
Present, but mild
(some difficulty
following speech
and/or occasional
bizarre behavior)
Present, but mild
(occasional
abnormal motor
behavior)
Present, but mild
decrease in facial
expressivity,
prosody, or
gestures
Present, but
mild in self-
initiated
behavior
Present, but mild
(some reduction in
cognitive function
below expected for
age and SES, b/w 1
and 2 SD from mean)
Present, but mild
(meets criteria for
Major Depression,
with minimum
number of
symptoms, duration,
and severity)
Present, but mild
(meets criteria for
Mania with minimum
number of symptoms,
duration, and
severity)
3 Present and
moderate (some
pressure to respond
to voices, or is
somewhat bothered
by voices)
Present and
moderate (some
pressure to act
upon beliefs, or
is somewhat
bothered by
beliefs)
Present and moderate
(speech often difficult
to follow and/or
frequent bizarre
behavior)
Present and
moderate (frequent
abnormal motor
behavior)
Present and
moderate decrease
in facial
expressivity,
prosody, or
gestures
Present and
moderate in
self-initiated
behavior
Present and
moderate (clear
reduction in
cognitive function
below expected for
age and SES, b/w 2
and 3 SD from mean)
Present and
moderate (meets
criteria for Major
Depression with
somewhat more
than the minimum
number of
symptoms, duration,
and/or severity
Present and
moderate (meets
criteria for Mania
with somewhat more
than the minimum
number of symptoms
duration, and/or
severity)
4 Present and severe
(severe pressure to
respond to voices, or
is very bothered by
voices)
Present and
severe (severe
pressure to act
upon beliefs, or
is very bothered
by beliefs)
Present and severe
(speech almost
impossible to follow
and/or behavior
almost always bizarre)
Present and severe
(abnormal motor
behavior almost
constant)
Present and severe
decrease in facial
expressivity,
prosody, or
gestures
Present and
severe in
self-initiated
behavior
Present and severe
(severe reduction in
cognitive function
below expected for
age and SES, > 3SD
from mean)
Present and severe
(meets criteria for
Major Depression
with many more
than the minimum
number of
symptoms and/or
severity)
Present and severe
(meets criteria for
Mania with many
more than the
minimum umber of
symptoms and/or
severity)

12. Krepelinova klasifikacija
• osporavana od samog starta
– fenomenolozi Birnbaum (1928) je predvideo kraj Krepelinove
nozologije (“Krepelinovi klinički entiteti su samo tipologija
psihijatrijskih sindroma”)
– savremene neurobiološke studije (šta se proučava psihotičnost ili
shizofrenija vs. bipoalrni afektivni poremećaj)
• opstaje do danas
– konceptualno jednostavna i omogućuje jednostavnu i jasnu
dijagnostiku slozenih kliničkih slika

13. Neokrepelijanski pokret
Krepelinove pretpostavke o kategorijalnoj prirodi psihijatrijskih poremećaja
obuhvaćene su u DSM-III a njegove pristalice sebe nazivaju “neoKrepelijancima”
u svojoj knjizi, The broken brain (1990), neokrepelijanksa Nancy
Andreasen predvidja da ce u buducnosti biti dovoljan
psihijatrijski intervju od 15 minuta da bi se postavila dijagnoza
mentalnog poremećaja

14. Kategorijalni model
• Prednosti (Mellsop i sar. 2007)
– odluka (dijagnoza, lečenje)
– dijagnostička pouzdanost
– olakšava komunikaciju
• Nedostaci (Bannister, 1968)
– “Kineski meni” dva od pet

15. Karl Menninger
“If the patient has, let us say, five symptoms, one
can look up each of these symptoms and find which
disease is so characterized under all five
headings. Then, voilà! The diagnosis!”
1893 - 1990
American psychiatrist and a member of the famous
Menninger family of psychiatrists who founded the
Menninger Foundation and the Menninger Clinic in Topeka,
Kansas.

16. Kontinuum u somatskoj medicini
• mnogi somatski poremećaji predstavljaju ekstremni kraj kontinuuma (npr. gojaznost,
hipertenzija, dijabetes, anemija)
• kategorijalna podela je poželjna u momentu kada treba započeti lečenje
ZDRAVLJE BOLEST
dijastolni pritisak 85 mmHg
Psihotični poremećaji su ekstrem dimenzije koje nam nameću kategorijalnu
distinkciju u trenutku kada treba započeti lečenje

17. • odražava kontinuum psihotičnosti u populaciji
• obuhvata veći broj podataka
• smanjuje incidencu komorbiditeta
• veća validnost
Dimenzionalni model

18. Nema jasne granice izmedju “zdravlja” i “bolesti”
Populacione studije pokazuju da se psihotični simptomi mnogo češće doživljavaju
nego što to pokazuju podaci kliničkih studija.
Životna prevalenca prema DSM-kriterijumima:
•halucinacije: 11.1% (Tein, 1991); 7.9% (van Os et al., 2000); 13.2% (Poulton et al.,
2000)
•sumanute ideje: 12.0% (van Os et al., 2000); 12.6% paranoja (Poulton et al., 2000)
There are many happy, functioning psychotic people in the population!

19. Know Your Own Psychosis Levels
• Do you ever feel that others are
against you?
• Do you believe that others are influencing your mind?
• Do you believe that other people talk
about you?
• Can you communicate with animals?
Do you ever feel that your manager/professor is against you?
Do you believe that drug companies are influencing your
mind?
If you have a pet, can you tell what it
is thinking?
Do members of your clinical/research team gossip about
you?

20. Aktuelno stanje
• hibridni kategorijalno-dimenzionalni model
– prednost: bolje razumevanje kliničkih karakteristika bez
izostavljanja tradicionalne Krepelinove dihotomije

21. 2012

23. umesto zaključka

24. • Šta su rane pihoze:
– dimenzija vs. kategorija
– težina – kvantitet vs. kvalitet poremećaja
• Prevencija
– kojeg poremećaja
– kojim sredstvima
– do sada ne postoje konzistentni podaci da rane intervencije redukuju prevenciju razvoja
psihotičnog poremećaja
Umesto zaključka

25. • Ukoliko se prihvati koncept rane psihoze sta se leči:
– simptom, sindrom
– dimenzija vs. kategorija
– psihotičnost sch., afektivnog, sumanutog poremećaja...primarnu-sekundarnu
psihotičnost
– da li ćemo imati istim leko lečiti svaku ranu psihozu iako mogu da imaju razlicitu genezu
– farmakološka indukcija psihotičnih ispoljavanja ili promena toka
• Rana psihoza:
– Nova indikacija za farmakoterapiju?
Umesto zaključka