Schizophrenia is a severe mental illness characterized by distortions in thinking, perception, emotions, and behavior. It affects about 1% of the population and is one of the most challenging diseases in medicine. The causes are unknown but may involve genetic and environmental factors. Symptoms include hallucinations, delusions, disorganized speech and behavior, and decreased emotional expression and motivation. Treatment involves antipsychotic medications and psychotherapy. The prognosis is varied, with about 30% recovering fully and others experiencing recurrent symptoms.

1. SCHIZOPHRENIASCHIZOPHRENIA
And It’s DDxAnd It’s DDx
Mohammed Nabil Al Ali
Hassan Mohammed Al Awadh
ABDULLAH ALKHAWAJAH, Majid AL-DanDan
Ammar Mohammed Al Mulhem
Mutaz Hasan AL-Hashem, Khaled Saud AL-Zahrani
Mohammed Faisal Alkhazal
Hussain Abdrabalameer Albahrani
5th Year Medical Students5th Year Medical Students
At King Faisal UniversityAt King Faisal University
AlHassaAlHassa
Introduced byIntroduced by

2. OUTLINESOUTLINES ::
- Schizophrenia
- Schizophreniform Disorder
- Schizoaffective Disorder
- Delusional Disorder
- Brief Psychotic Disorder
- Shared Psychotic Disorder
- Postpartum psychosis

3. SchizophreniaSchizophrenia
To Know
SchizophreniaSchizophrenia
is
to know
PsychiatryPsychiatry

4. The schizophrenic disorders
are characterized in general
by fundamental and
characteristic distortions of
thinking and perception, and
affects that are inappropriate
or blunted. Clear
consciousness and
intellectual capacity are
usually maintained although
certain cognitive deficits may
evolve in the course of time.
SchizophreniaSchizophrenia ::

5. The most devastating illness that
psychiatrist treat.
One of the most challenging disease
in medicine
1% of population has schizo.
An enormous economic burden
A major health concern
SchizophreniaSchizophrenia ::

6. SchizophreniaSchizophrenia ::

7. The etiology and
pathogenesis of
schizophrenia is
unknown but it could be
SchizophreniaSchizophrenia ::

8. •Dopaminergic system
hypothesis
•Glutaminergic
dysfunction
•Serotonin
abnormalities
•Increased
Ventricular size
•Decreased brain
volume in medial
temporal areas
•Changes in the
hippocampus
•Overactivation of
immune system
Alteration in brain
structure & function
•Metabolic
disturbance (Insulin
resistance)
SchizophreniaSchizophrenia ::

9. DSM (Diagnostic & Statistical Manual) of Mental Disorders
Published by APA ( American Psychiatry Association(
DSM IV 1994 Classified Schizophrenia to 5 Subtypes
DSM V 2013 Proposed the deletion of subtypes
SchizophreniaSchizophrenia ::

10. SchizophreniaSchizophrenia ::

11. SchizophreniaSchizophrenia ::

12. SchizophreniaSchizophrenia ::

13. -Family history of Schizophrenia
-Any potential cause of fetal hypoxic
brain damage
-History of brain complications
-Advanced age of mother during
pregnancy
-Birth during winter months!!
-Substance abuse
-Single marital status
-Low socioeconomic class
-Urban environment
-Environmental stress
SchizophreniaSchizophrenia ::

14. Hallucination
Delusions
Illusions
Disorganized speech
Behavioral disturbances
Absence of normal
cognition
Allogia
Avolition
Anhedonia
Social isolation
 Impaired
- attention
- Working memory
- Executive functions
 Seems cheerful or sad
without obvious reasons
SchizophreniaSchizophrenia ::

15. THREE PHASES OF SCHIZOPHRENIA
SchizophreniaSchizophrenia ::

16. SchizophreniaSchizophrenia ::

17. F. Significantly Social
/occupational
dysfunction
G. Continuous signs of the
disturbance persists for
at least six months
H. Schizoaffective and
mood disorder exclusion
I. Substance/medical
condition exclusion
J. Relationship to
pervasive
developmental disorder
autism+ schiz.<D/H-1 m
A. Characteristic
symptoms. At least 2
of the following; each
for 1- month period:
a. delusions
b. hallucinations
c. disorganized speech
d. grossly disorganized
or catatonic behavior
e. negative symptoms,
i.e. avolition, flattening
of affect, alogia
(poverty of speech)
 The diagnosis of schizophrenia is based entirely on the clinical
presentation – history and examination.
SchizophreniaSchizophrenia ::

18.  Organic syndrome
 Drug or Alcohol
 Temporal lobe epilepsy
 Delirium
 Dementia
 Diffuse brain disease
 Psychotic mood disorder
 Personality disorder
 Schizoaffective disorder
SchizophreniaSchizophrenia ::

19. Course
SchizophreniaSchizophrenia ::

20. Prognosis
 Recover completely/long
term minimal symptoms-
30%(The percentage on
the rise)
 Recurrent illness -poorer
prognosis
 Young patient -high risk
of suicide
SchizophreniaSchizophrenia ::

21. Predictors for poor outcome
Features of the illness
Insidious onset
Long 1st
episode
Previous psychiatric history
Negative symptoms
Younger age at onset
Features of the patient
Male
Single, separated, widowed or
divorced
Poor psychosexual adjustment
Poor employment
Social isolation
SchizophreniaSchizophrenia ::

22. ManagementManagement

23. 1-Mental status examination
2-Physical & neurological examination
3-Complete family & social history (take in consideration family history
of response to drugs(
4-Psychiatric diagnostic interview
5-Laboratory work up ( CBC, electrolytes, hepatic & renal
functions, ECG, FBG, lipid profile, thyroid functions and urine drug
screening(
SchizophreniaSchizophrenia ::

24. Atypical APs.
Second generation
Typical APs.
first generation
SchizophreniaSchizophrenia ::

25. Atypical APs.
Second generation
Typical APs.
traditional, conventional, first generation
antipsychotics, classical neuroleptics, major
tranquilizers
Low potency
Chlorobromazine: Neurazine®
Thioridazine: Mellcril®
Medium potency
Molindone: Moban®
Thiothixene: Navane®
Pimozide: Orape forte®
High potency
Trifluperazine: Stellazine®
Haloperidol: Haldol®
Fluphenazine: Modecate®
Zuclopenthixol: Clopexol®
Aripiprazole: Apilify®
Clozapine: leponex®
Olanzapine: Zyprexa®
Quetiapine: Seroquil®
Resperidone: Resperidal®
Sulpiride: Dogmatil®
Ziprasidone: Zeldox®
SchizophreniaSchizophrenia ::

26. Atypical APs.
Second generation
Typical APs.
first generation
SchizophreniaSchizophrenia ::

27. Atypical APs.
Second generation
Typical APs.
first generation
Sed. EPS A.Ch O.HoTN
CPZ +++ ++ ++ +++
Thioridazine +++ + +++ +++
Molindone ++ ++ + +
Thiothixene + +++ + ++
Trifluperazine + +++ + +
Haloperidol + +++ + +
Fluphenazine + +++ + +
Sed. EPS A.Ch O.HoTN Wt.G
clozapine
++
+
0 +++ +++ +++
Resperidone + + 0 + ++
Olanzapine ++ + ++ + +++
Quetiapine ++ + 0 ++ ++
Ziprasidone 0 + 0 0 0
Aripeprazole + + 0 0 0
Sed : sedation, EXP: extrapyramidal side effects , A.Ch anticholinergic side effects , O.HoTN: orthostatic hypotension wt.G : weight gain
SchizophreniaSchizophrenia ::

28. --Some SGAPs & phenothiazines
cause elevation in serum TGs &
cholesterol
-Risk decreases with ;
risperidone,ziprasidone &
aripiprazole
SchizophreniaSchizophrenia ::

29. Tardive dyskinesia:
abnormal involuntary
movement with chronic use of Aps
e.g. Oro-facial movement.
SchizophreniaSchizophrenia ::

30. SchizophreniaSchizophrenia ::

31. Schizophreniform
Disorder

32. Definition
According (DSM-IV-TR) describes
schizophreniform disorder as :
similar to schizophrenia, except that
its symptoms last at least 1 month but
less than 6 months.
Schizophreniform Disorder

33. Etiology :
 The cause of schizophreniform disorder is
not known , most likely to be
heterogeneous.
Schizophreniform Disorder
Epidemiology :
 Common in adolescents and young adults.
 Lifetime prevalence rate of 0.2 percent.
 The relatives of patients with
schizophreniform disorders are more likely to
have mood disorders and psychotic mood
disorders .

34. Clinical feature :
• It is an acute psychotic disorder that has a
rapid onset and lacks a long prodromal
phase.
• Patients with schizophreniform disorder return
to their baseline level of functioning once the
disorder has resolved.
• The patients are unlikely to report a
progressive decline in social and
occupational functioning.
Schizophreniform Disorder

35. DDx
 Schizophrenia . lasts for more than 6 months
 Brief psychotic disorder. lasts for less than 1
month
 Substance- induced psychotic disorder.
Drug history and toxicological screen
 Psychotic disorder due to medical
condition . history , physical examination ,
laboratory tests or imaging studies .
 Mood disorder : the symptoms exclusively
occur during periods of mood disturbance.
Schizophreniform Disorder

36. Treatment
 Hospitalization : allows effective
assessment, treatment, and supervision of
a patient's behavior.
 Antipsychotic drugs for 3- 6 months.
 If a patient has a recurrent episode :
mood stabilizer is added.
 Psychotherapy
 ECT : for patient with marked catatonic or
depressed features.
Schizophreniform Disorder

37. Schizoaffective
Disorder

38. Introduction
 Schizoaffective disorder is a serious mental
illness that affects about one in 100 people.
 It is serious mental illness that has features of
two different conditions:
1. schizophrenia
2. an affective (mood) disorder that may be
diagnosed as either
major depression or bipolar disorder.
Schizoaffective Disorder

39.  Schizoaffective disorder is a lifelong illness that can
impact all areas of daily living
 Most people with this illness have periodic episodes,
called relapses, when their symptoms surface.
 there is no cure for schizoaffective disorder,
symptoms often can be controlled with proper
treatment.
Schizoaffective Disorder

40. Symptoms
 Schizoaffective Disorder is characterized
by schizophrenia with one of the following:
1) Major Depressive Episode(must include
depressed mood)
2) Manic Episode
3) Mixed Episode
Schizoaffective Disorder

41. Management
 combination of medications and counseling.
 Treatment depending on the type and severity of
symptoms, and whether the disorder is depressive-
type or bipolar-type.
 Medications:
1- Antipsychotics
paliperidone (Invega) and other antipsychotic
medications that may be prescribed include
clozapine (Clozaril), risperidone (Risperdal),
olanzapine (Zyprexa) and haloperidol (Haldol).
Schizoaffective Disorder

42. 2-Mood-stabilizing medications.
Include lithium (Lithobid) and divalproex
(Depakote). Anticonvulsants such as
carbamazepine (Carbatrol, Tegretol, others)
and valproate (Depacon).
3-Antidepressants.
Common medications include citalopram
(Celexa), fluoxetine (Prozac) and
escitalopram (Lexapro).
Schizoaffective Disorder

43. Psychotherapy
Psychotherapy and counseling.
Family or group therapy.
Treatment can be more effective when people
with schizoaffective disorder are able to discuss
their real-life problems with others.
Supportive group settings can also help decrease
social isolation and provide a reality check
during periods of psychosis.
Schizoaffective Disorder

44. Delusional
Disorder

45. Definition
Delusional disorder is an illness
characterized by the presence of
nonbizarre delusions in the absence of
other mood or psychotic symptoms
Delusional Disorder

46. Epidemiology
- The prevalence of delusional disorder in the USA is estimated in
theDSM-IV-TR to be around 0.03% .
- considerably lower than the prevalence of schizophrenia (1%) ,
mood disorders (5%) .
- The mean age of onset is 40 years .
- Men are more likely than women to develop paranoid
delusions .
- women are more likely than men to develop delusions of
erotomania .
Delusional Disorder

47. Etiology
(a) Genetic :
Not a variant of schizophrenia or mood disorders. No
increase in first degree relatives.
(b) Neurological conditions :
- limbic system and the basal ganglia disorders .
- Patients tend to have complex delusions similar to
those in patients with delusional disorder .
(c) Psychodynamic Factors :
- socially isolated persons .
- - Abuse .
Delusional Disorder

48. Current Diagnosis Criteria
* DSM-IV-TR
defines delusional disorder with the
following criteria:
A) Non bizarre delusions .
B) Criterion A for schizophrenia has never been met .
C) functioning is not markedly impaired and
behavior is not obviously odd or bizarre.
D) If mood episodes have occurred concurrently with
delusions, their total duration has been brief relative
to the duration of the delusional periods.
E) The disturbance is not due to a drug of abuse,
medication or general medical condition.
Delusional Disorder

49. Clinical Features
- Mental State Examination usually normal except
presence of abnormal delusional beliefs.
- Mood and affect are consistent with delusional
content.
- Tactile and olfactory hallucinations may be present
if they are related to delusional theme.
- The thought content is notable for systematized, well-
organized, nonbizarre delusions that are possible to
occur.
Delusional Disorder

50. - The thought process is usually not impaired;
however, some circumstantiality and idiosyncrasy
may be observed.
- Patients usually have little insight and impaired
judgment regarding their pathology.
- Assessment of homicidal or suicidal ideation is
extremely important in evaluating the patients.
erotomanic, jealous, and persecutory > ↑violence
Delusional Disorder

51. Subtypes of delusional disorder
Persecutory
 Most common type
 believes that they are being persecuted and
harmed
 The delusions are systematized, coherent, and
defended with clear logic. (contrary to schizo)
 No deterioration in social functioning and
personality
 emotional distress such as irritability, anger, and
resentment  may resort to violence
Delusional Disorder

52. Erotomanic :
 Thinks that another person, usually of higher status, is
in love with the patient.
 F>M
 Leads to stalking behaviour (pursuing the lover,
texting, phone calling, etc).
Delusional Disorder
Grandiose
 believes that they possess some great and
unrecognized talent, have made some important
discovery, have a special relationship with a
prominent person, or have special religious insight.

53. Jealous
 Pathological jealousy
 M>F
 her or his spouse or lover is unfaithful.
 Lead to acts of violence, including suicide and
homicide.
Delusional Disorder

54. Somatic:
 delusions around bodily functions and sensations.
 Non-bizarre.
 most common are the belief that one is infested
with insects or parasites.
 Patients are totally convinced in physical nature of
this disorder.
Delusional Disorder

55. Differential Diagnosis
1. Medical Conditions
(a) Basal ganglia disorder
- Parkinson’s disease
- Huntington’s chorea
(b) Deficiencies:
- B12
- folate
- thiamine
(c) Delirium:
Fluctuating level of consciousness, altered sleep/wake
cycle, hallucinations and impaired cognition.
Delusional Disorder

56. (d) Dementia
(e) Endocrinopathies:
- adrenal, thyroid
(f) Limbic disorders:
- epilepsy, cerebrovascular disease
(g) Systemic:
- hepatic encephalopathy, porphyria, uremia
2. Drugs
(a) Amphetamines, cocaine:
- Most common substances
- Persecutory delusions.
(b) Antiocholinergies, antituberulous drugs, Dimifram
Delusional Disorder

57. 3. Paranoid Personality Disorder
- no true delusions. Overvalued ideas
- enduring, deeply ingrained
4. Paranoid Schizophrenia
- auditory hallucinations
- personality deterioration
- disturbance in role functioning
5. Mania - Grandiose delusions, but these are
clearly secondary to primary and
prominent mood disorder
6. Depression - Mood symptoms prominent
(depressed)
- delusions are secondary
Delusional Disorder

58. Management Plan:
* Investigations:
- To rule out substance abuse: drug screening .
- To rule out medical causes: CT, MRI.
- To choose a proper medication (prevent side
effects)
- Blood glucose level, lipid profile (anti-psychotics)
RFT, thyroid FT, LFT, ECG (Lithium & others)
Delusional Disorder

59. * Treatment
A) if suicidal or homicidal ideas present
(hospitalization ) or if refuse eating .
B) Medication:
- Antipsychotics- Pimozide .
- If there are somatic delusion & depressive symptoms
Antidepressants (SSRIs) may be used
C) Should also add supportive and educational
psychotherapy sessions to help the patient (to
improve insight & compliance).
Delusional Disorder

60. Brief Psychotic
Disorder

61. Acute psychotic condition that
involves the sudden onset of psychotic
symptoms, which lasts 1 day or more
but less than 1 month. Remission is full,
and the individual returns to the
premorbid level of functioning.
Definition
Brief Psychotic Disorder

62. The disorder occurs more often
among younger patients (20s
and 30s)
More commen in women.
Epidemiology
Brief Psychotic Disorder

63.  Presence of one (or more) of the following
symptoms:
 delusions
 hallucinations
 disorganized speech
 grossly disorganized or catatonic behavior
 Duration of an episode of the disturbance is
at least 1 day but less than 1 month, with
eventual full return to premorbid level of
functioning.
Diagnostic Criteria
Brief Psychotic Disorder

64. Associated symptoms may include the
following:
 Disorientation,
 Impaired attention,
 Emotional volatility,
 strange or bizarre behavior,
 Screaming,
 Impaired memory for recent events.
Brief Psychotic Disorder

65.  Schizophrenia,
 Schizophreniform Disorder,
 Brief Psychotic Disorder,
 Delusional Disorder,
 Mood disorder with psychotic features,
 Substance-induced psychotic disorder,
 Psychosis due to a medical condition.
Differential Diagnosis
Brief Psychotic Disorder

66.  Brief hospitalization,
 Antipsychotics (haloperidol or
ziprasadone),
 Benzodiazepines (short-term treatment ).
Prognosis:
 A good prognosis is usually associated
with sudden onset, short duration of
symptoms, and good premorbid
adjustment
Treatment
Brief Psychotic Disorder

67. Shared Psychotic
Disorder

68. Case
 A 28-year-old woman taking care of her
schizophrenic husband starts believing her
husband’s claim that he invented the telephone.
When she went abroad for a few months, her
beliefs disappeared.

69.  Also known as folie à deux, shared
psychotic disorder is diagnosed when a
patient develops the same delusional
symptoms as someone he or she is in a
close relationship with. Most people
suffering from shared psychotic disorder
are family members.

70. DSM-IV-TR Diagnostic Criteria for
Shared Psychotic Disorder
 A delusion develops in an individual in the context
of a close relationship with another person(s), who
has an already-established delusion.
 The delusion is similar in content to that of the
person who already has the established delusion.
 The disturbance is not better accounted for by
another psychotic disorder (e.g., schizophrenia) or
a mood disorder with psychotic features and is not
due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication)
or a general medical condition.

71. PROGNOSIS
 Twenty to 40% will recover upon removal
from the inducing person.
Shared Psychotic Disorder

72. TREATMENT
 The first step is to separate the patient from the
person who is the source of shared delusions
(usually a family member with an underlying
psychotic disorder).
 Psychotherapy should be undertaken.
 Antipsychotic medications should be used if
symptoms have not improved in 1 to 2 weeks
after separation
Shared Psychotic Disorder

73. Postpartum
psychosis

74. POST PARTUM PSYCHOSIS
 Postpartum psychosis (sometimes called puerperal
psychosis) is an example of psychotic that occurs
in women who have recently delivered a baby.
 The incidence of postpartum psychosis is about 1
to 2 per 1,000 childbirths.
 About 50 to 60 percent of affected women have
just had their first child.
 About 50 percent of the affected women have a
family history of mood disorders.
 Most available data suggest a close relation
between postpartum psychosis and mood
disorders, particularly bipolar disorder and major
depressive disorder.
Postpartum psychosis

75. Clinical features:
The symptoms of postpartum psychosis
can often begin within days of the
delivery, although the mean time to
onset is within 2 to 3 weeks and almost
always within 8 weeks of delivery.
Insomnia, restlessness and emotional
liability
Progress to confusion, delusions.
Thoughts of harming self or baby
characteristic
Postpartum psychosis

76. Treatment:
 Postpartum psychosis is a psychiatric
emergency.
 Antipsychotic medications and lithium often in
combination with an antidepressant, are the
treatments of choice.
 Psychotherapy is indicated after the period of
acute psychosis.
 Changes in environmental factors may also be
indicated.
Postpartum psychosis

77. SUMMARY

78. yes
no
no
no
yes
yes
SUMMARY

79. Any question ?

80. REFERENCES

81. Thank youThank you