SHIZOPHRENIA

AND
OTHER PSYCHOTIC
DISORDERS

Hyacinth C. Manood, MD,

DPBP
SCHIZOPHRENIA
 Benedict Morel - dÃmence prÃcoce
 deteriorated patients whose illness began in
adolescence

 Emil Kraepelin - dementia precox

 the change in cognition (dementia) and early onset
(precox) of the disorder.
 long-term deteriorating course and the clinical
symptoms of hallucinations and delusions
 manic-depressive psychosis -distinct episodes of
illness alternating with periods of normal functioning
 paranoia - persistent persecutory delusions; lacked the
deteriorating course of dementia precox and the
intermittent symptoms of manic-depressive psychosis.
 Eugene Bleuler - schizophrenia ; the presence of
schisms between thought, emotion, and
behavior in patients with the disorder.
 four As: associations, affect, autism, and ambivalence.
 accessory (secondary) symptoms - hallucinations and
delusions

 Ernst Kretschmer - “schizophrenia occurred more

often among persons with asthenic (i.e., slender, lightly
muscled physiques), athletic, or dysplastic body types
rather than among persons with pyknic (i.e., short,
stocky physiques) body types. “

 Kurt Schneider - first-rank symptoms

Kurt Schneider Criteria for
Schizophrenia
 First-rank symptoms  Second-rank symptoms

 Audible thoughts  Other disorders of

 Voices arguing or perception
discussing or both  Sudden delusional ideas
 Voices commenting  Perplexity
 Somatic passivity  Depressive and euphoric
experiences mood changes
 Thought withdrawal and  Feelings of emotional
other experiences of impoverishment
influenced thought
 Thought broadcasting
 Delusional perceptions
 All other experiences
involving volition made
affects, and made
impulses
 Karl Jaspers - existential psychoanalysis
 trying to understand the psychological meaning
of schizophrenic signs and symptoms such as
delusions and hallucinations.

 Adolf Meyer - founder of psychobiology

 reaction to life stresses ; schizophrenic reaction
EPIDEMIOLOGY

 lifetime prevalence of schizophrenia is

about 1 percent

 equally prevalent in men and women;

Onset is earlier in men than in women ( M
= 10 – 25; F= 25 – 35)

 Onset of schizophrenia before age 10 or

after age 60 is extremely rare; When onset
occurs after age 45, the disorder is
characterized as late-onset schizophrenia.
 In general, the outcome for female schizophrenia patients
is better than that for male schizophrenia patients

 higher mortality rate from accidents and natural causes

than the general population

 more likely to have been born in the winter and early

spring - Season-specific risk factors, such as a virus or a seasonal
change in diet, may be operative .
 gestational and birth complications,
exposure to influenza epidemics, or
maternal starvation during pregnancy,
Rhesus factor incompatibility, and an
excess of winter births. -
neurodevelopmental pathological process

 Substance abuse is common in

schizophrenia
Etiology
I. Genetic Factors:
Prevalence of Schizophrenia in Specific Populations

Population Prevalence (%)

General population1
Non-twin sibling of a schizophrenia patient 8
Child with one parent with Schizophrenia 12
Dizygotic twin of a schizophrenia patient 12
Child of two parents with schizophrenia 40
Monozygotic twin of a schizophrenia patient 47
II. Biochemical Factors:

1. Dopamine Hypothesis - schizophrenia results

from too much dopaminergic activity .

2. Serotonin - excess as a cause of both positive and

negative symptoms in schizophrenia.

3. Norepinephrine - selective neuronal

degeneration within the norepinephrine reward neural
system could account for the impaired capacity for
emotional gratification and the decreased ability to
experience pleasure.
4. GABA - GABA has a regulatory effect on
dopamine activity, and the loss of inhibitory
GABAergic neurons could lead to the
hyperactivity of dopaminergic neurons.

5. Neuropeptides -substance P and

neurotensin, are localized with the
catecholamine and indolamine
neurotransmitters and influence the action of
these neurotransmitters.
6. Glutamate - ingestion of phencyclidine, a
glutamate antagonist, produces an acute syndrome
similar to schizophrenia. The hypotheses proposed
about glutamate include those of hyperactivity,
hypoactivity, and glutamate-induced neuro- toxicity.

7. Acetylcholine and Nicotine - decreased

muscarinic and nicotinic receptors ; dysregulation of
neurotransmitter systems involved in cognition
Neuropathology :
1. lateral and third ventricular enlargement
and some reduction in cortical volume;

2. reduced symmetry in several brain areas

in schizophrenia, including the temporal,
frontal, and occipital lobes ;

3. decrease in the size of the region

including the amygdala, the
hippocampus, and the parahippocampal
gyrus;
4. several symptoms of schizophrenia mimic
those found in persons with prefrontal
lobotomies or frontal lobe syndromes

5. The medial dorsal nucleus of the thalamus,

which has reciprocal connections with the
prefrontal cortex, has been reported to
contain a reduced number of neurons

6. cell loss or the reduction of volume of the

globus pallidus and the substantia nigra.
III. Psychosocial and Psychoanalytic
Theories
 Sigmund Freud - postulated that
schizophrenia resulted from developmental
fixations that occurred earlier than those
culminating in the development of neuroses.

 Margaret Mahler - there are distortions in the

reciprocal relationship between the infant and the
mother .

 Paul Federn - the defect in ego functions

permits intense hostility and aggression to distort
the mother-infant relationship, which leads to
eventual personality disorganization and
 Harry Stack Sullivan - schizophrenia is an
adaptive method used to avoid panic, terror, and
disintegration of the sense of self .

 All psychodynamic approaches are founded

on the premise that psychotic symptoms
have meaning in schizophrenia

 Learning theory - the poor interpersonal

relationships of persons with schizophrenia develop
because of poor models for learning during
childhood.
Family Dynamics
 Double Bind - children receive conflicting parental
messages about their behavior, attitudes, and feelings. In
Bateson's hypothesis, children withdraw into a psychotic
state to escape the unsolvable confusion of the double bind.
 Schisms and Skewed Families - In one family type,
with a prominent schism between the parents, one parent is
overly close to a child of the opposite gender. In the other
family type, a skewed relationship between a child and one
parent involves a power struggle between the parents and
the resulting dominance of one parent.
 Pseudomutual and Pseudohostile Families
-suppress emotional expression by consistently using
pseudomutual or pseudohostile verbal communication.
 Expressed Emotion - families with high levels of
expressed emotion, the relapse rate for schizophrenia is high
DSM-IV-TR Diagnostic Criteria for
Schizophrenia
A. Characteristic symptoms: Two (or more) of the following,
each present for a significant portion of time during a 1-
month period (or less if successfully treated):
 delusions
 hallucinations
 disorganized speech (e.g., frequent derailment or
incoherence)
 grossly disorganized or catatonic behavior
 negative symptoms, i.e., affective flattening, alogia, or
avolition
 Note: Only one Criterion A symptom is required if delusions
are bizarre 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.
B. Social/occupational dysfunction:
C Duration: > 6 months
D. Schizoaffective and mood disorder exclusion:
Schizoaffective disorder and mood disorder with psychotic
features have been ruled out because either (1) no major
depressive, manic, or mixed episodes have occurred
concurrently with the active-phase symptoms; or (2) if
mood episodes have occurred during active-phase
symptoms, their total duration has been brief relative to
the duration of the active and residual periods.
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:
SUBTYPES:
 Paranoid type
A type of schizophrenia in which the following criteria are met:
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.

 Disorganized type
A type of schizophrenia in which the following criteria are met:
A. All of the following are prominent:
 disorganized speech
 disorganized behavior
 flat or inappropriate affect
A. The criteria are not met for catatonic type
 Catatonic type
A type of schizophrenia in which the clinical picture is
dominated by at least two of the following:

 motoric immobility as evidenced by catalepsy (including

waxy flexibility) or stupor
 excessive motor activity (that is apparently purposeless
and not influenced by external stimuli)
 extreme negativism (an apparently motiveless
resistance to all instructions or maintenance of a rigid
posture against attempts to be moved) or mutism
 peculiarities of voluntary movement as evidenced by
posturing (voluntary assumption of inappropriate or
bizarre postures), stereotyped movements, prominent
mannerisms, or prominent grimacing
 echolalia or echopraxia
 Undifferentiated type

A type of schizophrenia in which symptoms that meet

Criterion A are present, but the criteria are not met for
the paranoid, disorganized, or catatonic type.

 Residual type

A type of schizophrenia in which the following criteria

are met:
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).
Clinical Features

 no clinical sign or symptom is

pathognomonic for schizophrenia

 patient's symptoms change with time.

 clinicians must take into account the

patient's educational level, intellectual
ability, and cultural and subcultural
membership
 Premorbid Signs and Symptoms:
 patients had schizoid or schizotypal personalities
characterized as quiet, passive, and introverted;
as children, they had few friends; sudden onset of
obsessive-compulsive behavior as part of the
prodromal picture. The signs may have started
with complaints about somatic symptoms, such
as headache, back and muscle pain, weakness,
and digestive problems; develop an interest in
abstract ideas, philosophy, and the occult or
religious questions ;
Mental Status Examination
 appearance of a patient with
schizophrenia can range from that of a
completely disheveled, screaming,
agitated person to an obsessively
groomed, completely silent, and immobile
person ;

 Precox Feeling - an intuitive experience

of their inability to establish an emotional
rapport with a patient
 reduced emotional responsiveness, sometimes
severe enough to warrant the label of anhedonia,
and overly active and inappropriate emotions such
as extremes of rage, happiness, and anxiety.

 flat or blunted affect can be a symptom of the illness

itself, of the parkinsonian adverse effects of
antipsychotic medications, or of depression
 most common hallucinations are auditory,
with voices that are often threatening,
obscene, accusatory, or insulting;

 Cenesthetic hallucinations - are unfounded

sensations of altered states in bodily organs;

 may believe that an outside entity controls

their thoughts or behavior or, conversely,
that they control outside events in an
extraordinary fashion ;
 loss of ego boundaries describes the lack of a clear
sense of where the patient's own body, mind, and
influence end and where those of other animate
and inanimate objects begin: ideas of reference,
cosmic identity

 looseness of associations, derailment, incoherence,

tangentiality, circumstantiality, neologisms,
echolalia, verbigeration, word salad, and mutism
 Thought control, in which outside forces
are controlling what the patient thinks or
feels;

 Thought broadcasting - in which

patients think others can read their minds
or that their thoughts are broadcast
through television sets or radios.

 decreased social sensitivity and appear to

be impulsive
 Violence - Delusions of a persecutory nature,
previous episodes of violence, and neurological
deficits are risk factors for violent or impulsive
behavior

 Suicide is the single leading cause of premature

death among people with schizophrenia.

 usually oriented to person, time, and place; minor

cognitive deficiencies
 cognitive impairment is a better predictor of level of
function than is the severity of psychotic symptoms;

 poor insight - poor compliance with treatment

 Nonlocalizing signs ( soft signs) include

dysdiadochokinesia, astereognosis, primitive reflexes,
and diminished dexterity
COURSE / PROGNOSIS

 The classic course of schizophrenia is one

of exacerbations and remissions

 Further deterioration in the patient's

baseline functioning follows each relapse
of the psychosis

 Sometimes, a clinically observable

postpsychotic depression follows a
psychotic episode
 vulnerability to stress is usually lifelong

 10 to 20 % - good outcome; >50 % - poor

outcome
SCHIZOPHRENIFORM DISORDER
 acute psychotic disorder that has a rapid
onset and lacks a long prodromal phase

 similar to schizophrenia, except that its

symptoms last at least 1 month but
less than 6 months.

 return to their baseline level of functioning

once the disorder has resolved.
 lifetime prevalence rate = 0.2 percent

 1-year prevalence rate of 0.1 percent

 have more affective symptoms (especially mania) and a

better outcome

 increased occurrence of mood disorders in the relatives

 progression to schizophrenia range between 60 and 80

percent
DSM-IV-TR Diagnostic Criteria for
Schizophreniform Disorder

A. Criteria A, D, and E of schizophrenia are

met.

B. An episode of the disorder (including

prodromal, active, and residual phases)
lasts 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: as 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 the height of the psychotic
episode
 good premorbid social and occupational functioning
 absence of blunted or flat affect
Schizoaffective Disorder
 symptoms of both schizophrenia and
mood disorders

 onset of symptoms was sudden and often

occurred in adolescence.

 good premorbid level of functioning, and

often a specific stressor preceded the
onset of symptoms.

 0.5 to 0.8 percent lifetime prevalence

 depressive type of schizoaffective disorder may
be more common in older persons; bipolar type
may be more common in young adults;

 age of onset for women is later than that for men

 better prognosis than patients with schizophrenia

and a worse prognosis than patients with mood
disorders
 DSM-IV-TR Diagnostic Criteria for Schizoaffective Disorder

A. An uninterrupted 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.
Note: The major depressive episode must include Criterion A1:
depressed mood.
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.

 Specify type:

      Bipolar type: if the disturbance includes a manic or a mixed episode

(or a manic or a mixed episode and major depressive episodes)

Depressive type: if the disturbance only includes major depressive

episodes
Delusional Disorder and Shared
Psychotic Disorder
 nonbizarre delusions of at least 1 month's
duration that cannot be attributed to other
psychiatric disorders

 .025 to 0.03 percent

 mean age of onset is about 40 years

 slight preponderance of female

 Men are more likely to develop paranoid
delusions

 women are more likely to develop

delusions of erotomania.

 defense mechanisms of reaction

formation, denial, and projection
Mental Status
 may seem eccentric, odd, suspicious, or hostile.

 quite normal except for a markedly abnormal delusional

system

 moods are consistent with the content of their delusions

 do not have prominent or sustained hallucinations

 delusions are usually systematized and are
characterized as being possible

 no insight into their condition and are

almost always brought to the hospital by
the police, family members, or employers.
Judgment can best be assessed by
evaluating the patient's past, present, and
planned behavior.

Men are more likely to develop paranoid

delusions
Types :
 Persecutory Type

 Jealous Type

 Erotomanic Type

 Somatic Type

 Grandiose Type
DSM-IV-TR Diagnostic Criteria for Delusional Disorder

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 be present in delusional disorder if they are related to the
delusional theme.

C. Apart from the impact of the delusion(s) or its ramifications, 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 the direct physiological effects of a substance

(e.g., a drug of abuse, a medication) or a general medical condition.
 Shared Psychotic Disorder - shared paranoid
disorder, induced psychotic disorder, folie
á deux, folie impose, and double insanity)

 characterized by the transfer of delusions

from one person to another.
DSM-IV-TR Diagnostic Criteria for Shared
Psychotic Disorder

A. 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 drug of abuse, a
medication) or a general medical condition.
Brief Psychotic Disorder
 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

 occurs more often among younger patients (20s

and 30s)

 with personality disorders (most commonly,

histrionic, narcissistic, paranoid, schizotypal, and
borderline personality disorders).

 precipitating stressors - major life events

DSM-IV-TR Diagnostic Criteria for 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 by 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
•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 within 4

weeks postpartum
DSM-IV-TR Diagnostic Criteria for Psychotic Disorder Not Otherwise
Specified
This category includes psychotic symptomatology (i.e.,
delusions, hallucinations, disorganized speech, grossly
disorganized or catatonic behavior) about which there is
inadequate information to make a specific diagnosis or about
which there is contradictory information, or disorders with
psychotic symptoms that do not meet the criteria for any
specific psychotic disorder.
Examples include
1.Postpartum psychosis that does not meet criteria for mood
disorder with psychotic features, brief psychotic disorder,
psychotic disorder due to a general medical condition, or
substance-induced psychotic disorder
2.Psychotic symptoms that have lasted for less than 1 month
but that have not yet remitted, so that the criteria for brief
psychotic disorder are not met
3.Persistent auditory hallucinations in the absence of any other
features
4.Persistent nonbizarre delusions with periods of overlapping
mood episodes that have been present for a substantial portion
of the delusional disturbance
Culture-bound Syndromes

 amok - A dissociative episode characterized by a

period of brooding followed by an outburst of
violent, aggressive, or homicidal behavior directed
at persons and objects. The episode tends to be
precipitated by a perceived slight or insult and
seems to be prevalent only among men. The
episode is often accompanied by persecutory idea;
automatism, amnesia, exhaustion, and a return to
premorbid state following the episode.
 ataque de nervios - uncontrollable
shouting, attacks of crying, trembling, heat in the
chest rising into the head, and verbal or physical
aggression. Dissociative experiences, seizurelike
or fainting episodes, and suicidal gestures
 sense of being out of control
 association of most ataques with a precipitating

event and the frequent absence of the hallmark

symptoms of acute fear or apprehension
distinguish them from panic disorder.
 bouffée délirante - a sudden outburst
of agitated and aggressive behavior, marked
confusion, and psychomotor excitement.

 brain fag -initially used in West Africa to refer

to a condition experienced by high school or
university students in response to the challenges
of schooling ; difficulties in concentrating,
remembering, and thinking.
 koro - an episode of sudden and intense anxiety that the
penis (or, in women, the vulva and nipples) will recede into
the body and possibly cause death

 piblokto - An abrupt dissociative episode accompanied

by extreme excitement of up to 30 minutes' duration and
frequently followed by convulsive seizures and coma lasting
up to 12 hours.

 spell - A trance state in which persons communicated

with deceased relatives or spirits.