Schizophrenia & other psychotic disorders

Schizophrenia Spectrum and
Other Psychotic Disorders
Mr. Johny Kutty Joseph
Assistant Professor

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).

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

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.

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:

Neurosis
Some of the different types of Neurosis include:
• Depression
• Obsessive-compulsive disorders
• Somatoform disorders (Hysteria, conversion, dissociation)
• Anxiety Disorders
• PTSD

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.

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.

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.

Predisposing / Etiology / Risk factors of Schizophrenia
 The cause of schizophrenia is still uncertain.
 Biological Factors; Genetics and twins.

 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.

 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.

• 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.

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

 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.

 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.

 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.

 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

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 ---

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

 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.

 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.

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.

 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.

 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.

 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.

 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

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.

 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.)

 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.

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

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.

Quality of response
Adaptive Maladaptive
Initial psychotic episode or exacerbation of
schizophrenic symptoms
Hallucinations, delusions, social isolations,
violence, inappropriate affect, bizarre behaviour,
apathy, autism.

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.

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.

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.

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

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

Negative Symptoms of Schizophrenia
Interpersonal Functioning
 Impaired social interaction
 Social isolation
Psychomotor Behaviour
 Anergia
 Waxy Flexibility
 Posturing
Associated Features
 Anhedonia
 Regression

Schizophrenia & other psychotic disorders

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