Psychopathology SCHIZOPHRENIA

SCHIZOPHRENIA • a chronic, debilitating mental disorder characterized by periods of loss of touch with reality (psychosis), however 7-15% have only one episode and full remission • usually involves repeated psychotic episodes and a chronic, downhill course over years • persistent disturbances of thought, behavior, appearance, and speech; • abnormal affect; • social withdrawal. • often stabilizes in midlife. General characteristics SCHIZOPHRENIA General characteristics SYMPTOMS OF SCHIZOPHRENIA • Positive - things additional to expected behavior and include delusions, hallucinations, agitation, and talkativeness. • Negative - things missing from expected behavior and include lack of motivation, social withdrawal, flattened affect, cognitive disturbances, poor grooming, and poor (i.e., impoverished) speech content. General characteristics PSYCHOSIS Is associated with abnormal functioning of frontal systems, temporal lobes, and dopaminergic projections to this areas. All individuals are at risk for its developing. Contributing factors include: • genetic predispositions • environmental factors: • damage sustained through trauma, disease, substance abuse • effects of experience on neuronal structures and neurochemical release • neuronal and biochemical changes during normal human development Psychosis will develop when a threshold of damage or changes to frontal system, temporal structures and dopaminergic projections is attained Framework for developing psychosis (Fujii, Ahmed, 2002) DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA • A. Two (or more) of the following symptoms, each present for a significant portion of time during a 1-month period (or less if successfully treated): • 1. Delusions • 2. Hallucinations • 3. Disorganized speech (e.g., frequent derailment or incoherence) • 4. Grossly disorganized or catatonic behavior • 5. Negative symptoms, i.e., affective flattening, alogia, or avolition • Note: Only one Criterion A symptom is required if delusions arce bizzare or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other. DSM-IV DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA • C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period most include at least 1 months of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. • During these prodromal or residual periods, the signs of the disturbance may he manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). • D. Schizoaffective and Mood Disorder exclusion DSM-IV DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA • E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. • F. Relationship to a Pervasive Developmental Disorder. If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusion, or hallucinations are also present for at least a month (or less if successfully treated). DSM-IV COURSE OF SCHIZOPHRENIA • These specifiers can he applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms • Episodic With Interepisode Residual Symptoms:. • Episodic With No Interepisode Residual Symptoms: • Continuous • Single Episode In Partial Remission • Single Episode In Full Remission • Other or Unspecified Pattern classification STAGES OF SCHIZOPHRENIA (Fenton, McGlashan, 2000) 1. Prodromal 2. Acute (active) 3. Subacute, stabilization 4. Moratorium or adaptative plateau 5. Changes points with the possibily of improvement or decompensation 6. Final stage or stable plateau classification SCHIZOPHRENIA • • • • Epidemiology: Schizophrenia – 1% Schizoaffective disorder - 0.5-0.8% Delusional disorder – 0.025 – 0.03% General information SCHIZOPHRENIA • Etiology is not known, certain factors have been implicated in its development. • Occurs in 1% of the population. Persons with a close genetic relationship to a patient with schizophrenia are more likely than those with a more distant relationship to develop the disorder. • Markers on chromosomes 5, 11, 18, 19 and 22 and, most recently, 6, 8, and 13 have been associated with schizophrenia. General characteristics SCHIZOPHRENIA genetics SCHIZOPHRENIA Neural pathology 1. Anatomy a. Abnormalities of the frontal lobes, as evidenced by decreased use of glucose in the frontal lobes on positron emission tomography (PET') scans are seen in the brains of people with schizophrenia. b. Lateral and third ventricle enlargement, abnormal cerebral symmetry, and changes in brain density also may be present. c. Decreased volume of limbic structures (e.g., amygdala, hippocampus) is also seen. General characteristics SCHIZOPHRENIA Neural pathology 2. Neurotransmitter abnormalities a. The dopamine hypothesis of schizophrenia states that schizophrenia results from excessive dopaminergic activity (e.g., excessive number of dopamine receptors, excessive concentration of dopamine, hypersensitivity of receptors to dopamine). As evidence for this hypothesis, stimulant drugs that increase dopamine availability (e.g., amphetamines and cocaine) can cause psychotic symptoms. Laboratory tests may show elevated levels of homovanillic acid (HVA), a metabolite of dopamine, in the body fluids of patients with schizophrenia. b. Serotonin hyperactivity is implicated in schizophrenia because hallucinogens that increase serotonin concentrations cause psychotic symptoms and because some effective antipsychotics, such as clozapin, have anti-serotonergic-2 (5-HT2) activity. c. Glutamate is implicated in schizophrenia because antagonists of the Nmethyl-D-aspartate (NMDA) subtype of glutamate receptors (e.g., phencyclidine) increase and agonists of NMDA receptors alleviate psychotic symptoms. General characteristic SCHIZOPHRENIA • The season of birth is related to the incidence of schizophrenia. More people with schizophrenia are born during cold weather months (i.e., January - April in the northern hemisphere and July September in the southern hemisphere). One possible explanation for this finding is viral infection of the mother during pregnancy, since such infections occur seasonally. General information SCHIZOPHRENIA No social or environmental factor causes schizophrenia. However, because patients with schizophrenia tend to drift down the socioeconomic scale as a result of their social deficits (the "downward drift" hypothesis), they are often found in lower socio-economic groups (e.g., homeless people). General information SCHIZOPHRENIA Premorbid features - 25-50%: • decreased social adjustment and school achievements • decrease emotional reactivity • social withdrawal • introversion • suspiciousness • impulsive behavior • abnormal reactions to usual events and situations • problems with focusing attention for the longer time • delays in the psychomotoric development • problems with sensorimotoric and motoric coordination course SCHIZOPHRENIA Onset of illness • 50% prodromal syndromes worse prognosis than those with acute, sudden onset • The course: • 55% - rather good, • 45% - rather unfavorable, including 5% with definitely unfavorable (15% in the past) • antipsychotic medications improve the course (decreases symptoms) and reduces relapse rate (40- 50% of reduction). course SCHIZOPHRENIA • Suicide is common in patients with schizophrenia. More than 50"/o attempt suicide (often during post-psychotic depression or when having hallucinations "commanding" them to harm themselves), and 10% of those die in the attempt. • The prognosis is better and the suicide risk is lower if the patient is older at onset of illness, is married, has social relationships, is female, has a good employment history, has mood symptoms, has few negative symptoms, and has few relapses. • The better course in developing countries course SCHIZOPHRENIA types SCHIZOPHRENIA SUBTYPES Paranoid Type • A. Preoccupation with one or more delusions or frequent auditory hallucinations. • B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. DSM-IV SCHIZOPHRENIA SUBTYPES Disorganized Type A. All of the following are prominent: (1) disorganized speech (2) disorganized behavior (3) flat or inappropriate affect B. The criteria are not met for Catatonic Type DSM-IV SCHIZOPHRENIA SUBTYPES Catatonic Type The clinical picture is dominated by at least two of the following: (1) motoric immobility as evidenced by catalepsy (in-cluding waxy flexibility) or stupor (2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli) (3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism (4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing (5) echolalia or echopraxia DSM-IV SCHIZOPHRENIA SUBTYPES Undifferentiated Type • A type in which symptoms that meet Criterion A are present, but the criteria are not met for the paranoid, disorganized, or catatonic type. DSM-IV SCHIZOPHRENIA SUBTYPES Residual Type • A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. • B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). DSM-IV SCHIZOPHRENIA DIFFERENTIAL DIAGNOSIS Medical illnesses that can cause psychotic symptoms, and thus mimic schizophrenia (i.e., psychotic disorder caused by a general medical condition), include neurological infection, neoplasm, trauma, disease (e.g., Huntington disease, multiple sclerosis), tem-poral lobe epilepsy, and endocrine disorders (e.g., Cushing syndrome, acute intermittent porphyria). DSM-IV SCHIZOPHRENIA DIFFERENTIAL DIAGNOSIS Medications that can cause psychotic symptoms include analgesics, antibiotics, anti-cholinergics, antihistamines, antineoplastics, cardiac glycosides (e.g., digitalis), and steroid hormones. DSM-IV SCHIZOPHRENIA DIFFERENTIAL DIAGNOSIS A.Other psychotic disorders - characterized at some point during their course by a loss of touch with reality. However, the other psychotic disorders do not include all of the criteria required for the diagnosis of schizophrenia: • brief psychotic disorder • schizophreniform disorder • delusional disorder • shared psychotic disorder B. Mood disorders (e.g., the manic phase of bipolar disorder, major depression). C. Cognitive disorders (e.g., delirium, dementia, and amnestic disorder) D. Substance-related disorders E. Schizotypal, paranoid and borderline personality disorders are not characterized by frank psychotic symptoms but have other characteristics of schizophrenia, (e.g., odd behavior, avoidance of social relationships). DSM-IV SCHIZOPHRENIA TREATMENT Pharmacologic: - traditional antipsychotics [dopamine-2 (D2)-receptor antagonists] first generation of antipsychotic medication - atypical antipsychotic agents –second generation of antipsychotic medication - Because of their better side-effect profiles, the atypical agents are now first-line treatments. DSM-IV SCHIZOPHRENIA TREATMENT Psychosocial treatments: - Psychotherapy: individual, family, and group - Psychoeducation with activity of patients or enhancing motivation to the treatment - Social support DSM-IV SCHIZOPHRENIA-LIKE DISORDERS SYMPTOMS SCHIZOPHRENIFORM DISORDER Criteria A, D, and E of schizophrenia are met An episode of the disorder (including prodromal, active, and residual phases) lasted at least 1 month but less than 6 months (when the diagnosis must be made without waiting for recovery, it should be qualified as “provisional”). Specify if: • Without good prognostic features • With good prognostic features if evidenced by two or more of the following: DSM-IV SCHIZOPHRENIFORM DISORDER With good prognostic features if evidenced by two or more of the following: • onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning • confusion or perplexity at he height of psychotic episode • good premorbid social functioning • absence of blunted or flat affect DSM-IV SCHIZOAFFECTIVE DISORDER A. An interrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for schizophrenia. • B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. • C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. • D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. DSM-IV SCHIZOAFFECTIVE DISORDER Specify type: • Bipolar Type: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed and Major Depressive Episodes) • Depressive Type: if the disturbance only includes Major Depressive Episodes DSM-IV DELUSIONAL DISORDER (PARANOIA) A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month’s duration. B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory hallucinations may he pres-ent in Delusional Disorder if they are related to the delusional theme. C. Apart from the impact of the delusion(s) its ramifications, functioning is not markedly impaired and behav-ior 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 the direct physiological effects of a substance (e.g., a drag of abuse, a medica-tion) or a general medical condition. DSM-IV DELUSIONAL DISORDER (PARANOIA) Specify type (the following types are assigned based on the predominant delusional theme): • Erotomanic: delusions that another person, usually of higher status, is in love with the individual • Grandiose: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person • Jealous: delusions that the individual's sexual partner is unfaithful • Persecutory: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way • Somatic: delusions that the person has some physical defect or general medical condition • Mixed Type: delusions characteristic of more than one of the above types but no one theme predominates • Unspecified Type DSM-IV BRIEF PSYCHOTIC DISORDER A. Presence of one (or more) of the following symptoms: • (1) delusions • (2) hallucinations • (3) disorganized speech (e.g., frequent derailment or incoherence) • (4) grossly disorganized or catatonic behavior • Note: Do not include a symptom if it is a culturally sanctioned response pattern. B. 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. C. The disturbance is not better accounted for b a Mood Disorder With Psychotic features, Schizoaffective Disorder, or Schizophrenia 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. DSM-IV BRIEF PSYCHOTIC DISORDER Specify if: • With Marked Stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture • Without Marked Stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture. • With Postpartum Onset: if onset is within 4 weeks postpartum DSM-IV SCHRED 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. B. The delusion is similar in content to that of the person who already has the established delusion C. 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 drag of abuse, a medication) or a general medical condition. DSM-IV PSYCHOTIC DISORDER DUE TO … (INDICATE THE GENERAL MEDICAL CONDITION) • • • • • Psychotic Disorder Due to . . . (Indicate the General Medical Condition) A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by another mental disorder. D. The disturbance does not occur exclusively during the course of a delirium. DSM-IV SUBSTANCE-INDUCED PSYCHOTIC DISORDER A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2) • the symptom in Criterion A developed during, or within month of substance intoxication or withdrawal • medication use is etiologically related to the disturbance DSM-IV SUBSTANCE-INDUCED PSYCHOTIC DISORDER • C. The disturbance ins not better accounted for psychotic disorder that is not substance induced. Evidence that symptoms are better accounted for the psychotic disorder the is not substance induced may include following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about month) after cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the durations of use; or there is other evidence that suggest s the existence of an independent non-substance-induced psychotic disorder (e.g. a history of recurrent non-substance-related episodes). • • DSM-IV