A 35-year-old woman believes her neighbors are spying on her through heating vents and has changed residences many times over 10 years due to this belief. She seems preoccupied by voices in her head and looks peculiar. Schizophrenia is characterized by disturbed thoughts, speech, behavior, social withdrawal, poor grooming, and abnormal affect. Diagnosis requires symptoms for at least six months including one period of actual psychosis and impairment in functioning. Treatment involves antipsychotic medications and long-term psychotherapy support. The prognosis is typically chronic with impairments but response to treatment varies between individuals.

1. SCHIZOPHRENIA ANDSCHIZOPHRENIA AND
OTHER PSYCHOTIC DISORDERSOTHER PSYCHOTIC DISORDERS
DR. A. P. SINGH

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SCHIZOPHRENIASCHIZOPHRENIA
A 35 – YEAR-OLD WOMAN TELLS YOU THAT
HER NEIGHBORS ARE SPYING ON HER BY
LISTENING TO HER THROUGH HEATING
VENTS. BECAUSE OF THIS, SHE HAS
CHANGED RESIDENCES MANY TIMES OVER
THE PAST 10 YEARS. SHE LOOKS PECULIAR
AND SEEMS PREOCCUPIED BY “VOICES
TALKING IN HER HEAD.”

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SCHIZOPHRENIASCHIZOPHRENIA
• Schizophrenia is a chronic mental disorder
characterized by:
– disturbed thoughts, speech, and behavior
– Odd appearance
– Social withdrawal
– Poor grooming
– Abnormal affect
• Flat
• Blunted or
• inappropriate

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• Usually the patient is well oriented to person, place, and
time
• The patients has intact memory
• In the residual phase the patient is in touch with reality
• In the psychotic phase the patient is not in touch with
reality
• According to the DSM-IV this diagnosis could only be
made if:
– Symptoms have been around for six months
– At least one period of actual psychosis occur within those six
months
– Impairment of occupational or social functioning must have
occurred during this time period

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• Prodromal signs
– Quiet
– Passive or irritable
– Few friendships
– Avoids social activities
– Daydreams
– Somatic complaints
– Interest in the occult, religion, or philosophy

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• During the acute psychotic episode the
following thought disorders are present:
– Disorders of perception (hallucinations)
– Disorders of thought content (delusions, ideas
of reference, loss of ego boundaries)
– Disorders of thought processes
– Disorders of form of thought

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• Residual signs and symptoms
– Flat affect
– Peculiar thinking and behavior
– Social withdrawal
• Hallucinations
– Hearing voices when alone in a room
– Smelling nonexistent odors
• Most commonly seen hallucinations:
– Auditory
– Visual
– Tactile
– Gustatory
– Olfactory
– Cenesthetic (visceral sensation) are also seen

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• Delusions
– False belief not based on simple ignorance or
shared by a culture or subculture
– Most commonly seen is delusions of
persecution
• Loss of ego boundaries
– Patient does not know where his/her mind and
body end and those of others begin
• Have ideas of reference
– Belief that others (including the media) are
referring to him/her when they are not

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• Disorder of thought processes
– Abrupt halt in the train of thought, often due to
hallucinations
– Deficiencies in thought or content of speech
[making up new words]
• Disorder of form of thought
– Incoherence, word salad (unrelated
combinations of words or phases)
– Loose associations (ideas shift from one subject
to another- in unrelated fashion)
– Echolalia (repeating a word over and over)

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Five Types of Schizophrenia
1. Disorganized:
• Disinhibited
• Poor organization
• Poor appearance and grooming
• Inappropriate emotional responses
• Age of onset is before 25
1. Catatonic:
• Bizarre posturing (waxy flexibility) or extreme excitability
• Rare since introduction of antipsychotic meds
1. Paranoid:
• Delusions of persecution
• Older age of onset
• Better functioning than other types

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4. Undifferentiated:
• Characteristics of more than one type
• This is the most common type
4. Residual:
• Has one schizophrenic episode and subsequently
shows residual symptoms but no psychotic
symptoms
• What are negative(deficit) symptoms and
positive (productive symptoms?

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• Negative symptoms is characterized by:
– Loss of function
• flattened affect,
• thought blocking,
• poor grooming
• Lack of motivation
• Social withdrawal
• Poor speech content
– These respond better to clozapine than to
traditional antipsychotics

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• Positive symptoms are characterized by
excessive function:
• Hallucinations
• Agitation
• Strange behavior
• Delusions
• Talkativeness
– These respond better to anti-psychotics than
negative symptoms do

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Physiologic Abnormalities
• EEG
– Decreased alpha waves
– Increased theta and delta waves
– Epileptiform activity
• Eye movement
– EOM are poor in 50 – 80 % of the patients
• Neuroendocrinology
– Decrease in LH and FSH
– Abnormal regulation of cortisol
• Laboratory findings
– May find elevated levels of homovanillic acid
(metabolite of dopamine) in body fluids

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Mimics of Schizophrenia
• Medical illnesses
– Temporal lobe epilepsy
– Neurologic disease or trauma
– Poisoning
– Endocrine disorders
• Psychiatric illnesses
– Brief psychotic disorder
– Schizophreniform disorder
– Schizoaffective disorder
– Manic phase of bipolar
– Schizoid and schizotypal personality disorders
– Substance abuse (amphetamines and hallucinogens)

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Epidemiology
• 50% for monozygotic twins of
schizophrenic persons
• 40% of children where both parents have
the disease
• 12% for first degree relatives (child,
sibling)
• 1% of the general population
• Peak age for men is 15 – 25
• Peak age for women is 25 – 35
• No gender difference

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Treatment
• Pharmacological treatment
– Traditional antipsychotics
• Particularly effective against positive symptoms
• Significant improvement is seen in 70% of patients
– Atypical antipsychotics
• Useful against negative symptoms
• Psychological treatment
– Long term support is very useful and should consists of
individual, family, and group psychotherapy

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Classification Agent (Duration) Dose
(mg/day)
Clinical use
Traditional
Low - potency
Thioridazine
(Mellaril)
200 -600 Depression with
intense anxiety or
agitation
Chlorpromazine
(Thorazine)
100 – 800 To treat nausea and
vomiting
Hiccups
Traditional
High - potency
Haloperidol
(Haldol)
2 – 15 Psychosis secondary
to organic syndrome;
Tourette disorder
Perphenazine
(Trilafon)
8 – 40 To treat nausea and
vomiting
Pimozide (Orap) 1 –10 Tourette disorder,
body dysmorphic
disorder
Trifluoperazine
(Stelazine)
4 – 20 Non-psychotic anxiety
(up to 12 weeks)

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Classification Agent (Duration) Dose
(mg/day)
Clinical use
Atypical
Anti-psychotics
Clozapine
(Clozaril)
300 – 900 Effective for
negative, chronic, and
refractory symptoms
Risperidone
(Risperdal)
4 – 8 Useful for negative
symptoms; has few
side effects
Olanzapine
(Zyprexa)
10 – 20 Useful for negative
symptoms; has few
side effects

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Side Effects of Anti-Psychotics
• Low – potency
– Mainly anticholinergic side effects
• High – potency
– Mainly neurologic side – effects
• Atypical (Clozapine)
– More likely to cause agranulocytosis and
seizures

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• Anti-cholinergic side effects:
– Dry mouth
– Blurred vision
– Constipation
– Urinary retention
– Severe agitation and confusion

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• Neurologic side effects
– Parkinsonian effects : reduce dose and add
Cogentin (1 – 4 mg/day) or Benadryl (25 – 50
mg/day)
– Acute dystonia
– Akathisia
– Neuroleptic malignant syndrome: Medical
Emergency
– Tardive dyskinesia : spontaneously remit in
50% of the cases. Otherwise give
Bromocriptine 0.75 – 7.5 mg/day ( effective in
@ 20% of cases); substitute Clozapine

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• Increasing agitation, depression and
insomnia may indicate that the patient is
going to have a psychotic episode
• Usual course of illness is
– repeated psychotic episodes
– Chronic downhill course
– Often stabilizes in midlife
• 50% of patients have depression after an
acute psychotic episode [watch for suicide
attempts]

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Prognosis
• Chronic, lifelong impairment
• Better prognosis if:
– Patient has mood symptoms
– Is older at onset
– Is married or has social relationships
– Is female
– Has good employment history
– Has positive symptoms
– Has had few relapse

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Other Psychotic Disorders
• There are five disorders other than
schizophrenia that present with psychotic
symptoms.
• Brief Psychotic disorder
• Schizophreniform disorder
• Schizoaffective disorder
• Delusional disorder
• Shared Psychotic disorder [Folie a duex]

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Brief Psychotic Disorder
• At least one psychotic symptom lasting 1 day but
less than 1 month
• More common in patients with concomitant
borderline and histrionic personality disorders
• Duration of symptoms is shorter than in
schizophrenia
• Symptoms often follow exposure to a
psychosocial stressor [unlike in schizophrenia]

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• Patients are relatively normal in the pre-
morbid period [schizophrenia see
withdrawal, strange behavioral and odd
beliefs]
• No family history of schizophrenia

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Typical Patient Presentation
• 27 year-old woman whose brother died
recently of HIV disease is brought by
relatives to the hospital. They claim that
over the past week she has begun to show
bizarre, dramatic behavior and claims that
she hears her brother “talking to her inside
her head.”

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Treatment
• Short hospital stay
• Antipsychotics
• Benzodiazepines
• Psychotherapy for dealing with the stressful
precipitating event
Prognosis
• 50 – 80 % recover completely
• The others may ultimately be diagnosis with
schizophrenia or a mood disorder

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Schizophreniform Disorder
• Two or more psychotic symptoms lasting at least 1
month but not more than 6 months
• Duration of symptoms is shorter than
schizophrenia
• Patient relatively normal in the pre-morbid period
• Symptoms come on more suddenly and terminate
more abruptly than in schizophrenia

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Typical Patient Presentation
26 year-old man with no previous history of
psychiatric illness is brought to the
emergency room by his girlfriend. She tells
you that about 3 months ago, he suddenly
began to show bizarre behavior, often
seemed preoccupied as though he was
listening to something and showed abrupt
mood changes.

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Treatment
• Hospitalization
• Anti-psychotics
• Psychotherapy to deal with the experience
of having had a psychotic episode
Prognosis
• 33% recover completely
• 66% progress to schizoaffective disorder or
schizophrenia

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Schizoaffective Disorder
• Fits the criteria for both mood disorder and
schizophrenia
• Chronic impairment in functioning between
episodes
• Meets the criteria for mania or depression
as well as for schizophrenia

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Typical Patient Presentation
35 year-old man with a history of psychotic
symptoms and severe depression has never
held a job for more than 3 months. He is
brought to the emergency room by his
sister, with whom he lives, when he begins
to show increasingly strange behavior

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Treatment
•Hospitalization
•Antidepressants,
•Anti-manic, and
•Electro-convulsive therapy
•Anti-psychotic agents are used for psychotic
episodes and when other medications fail
Prognosis
•Better than for schizophrenia, worse than for
mood disorder

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Delusional Disorder
• A rare disorder
• Fixed non- bizarre delusional symptom (often
paranoid)
• Few if any other thought disorders
• More common in:
• Immigrants
• Hearing impaired
• Patients older than 40 years of age
• Most commonly has a sudden onset

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• Though delusion is of the paranoid type it is
unlikely bizarre
• Patients functions relatively normally
socially [unlike schizophrenia]

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Typical Patient Presentation
• 55 year –old patient tells you that his
neighbor has been plotting for years to get
him arrested by listening in on all of his
phone conversations. The patient is married
and has been in the same job for 25 years

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Treatment
• Psychotherapy is important – to gain patient’s trust
• Pimozide (Orap) can be given especially for somatic
delusions
• Haldol can also be given
Prognosis
• 50% recover
• 30% remain the same
• 20% show decreased symptoms
• Good prognosis if:
• Younger age onset
• Sudden onset
• Presence of precipitant

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Shared Psychotic Disorder
• Also called Folie A Deux
• Development of psychotic symptoms in a
person in a close relationship with another
person
• More common in women and in people
from low socio-economic groups
• Psychotic symptoms occur only after
exposure to the inducer

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Typical Patient Presentation
• 20 year-old woman whose psychotic mother
believes that the landlord is trying to poison
her now begins to believe the same thing

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Treatment
• REMOVE THE PATIENT FROM THE
INFLUENCE OF THE INDUCER
• Social support and psychotherapy
• Anti-psychotic medications
Prognosis
• 10 – 40 % resolve with separation

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