Psycotic Disoders

Elfarini
405110034
Blok Neuropsikiatri

Learning Objective
Psikotik akut, Skizofrenia (teori & psikopatologi)
Pemeriksaan penunjang CT, MRI, EEG, Lab
gambaran klinik ggn psikosis (schizo, ggn waham
menetap, psikosis akut, aszikoafektif)
Diagnosis berdasarkan diagnosis multiaksial sistem
(aksis1: deskripsi klinis, 2: ggn kepribadian dan
perkembangan, 3: ggn fisik, 4: stres psikososial, 5:
penyusuaian diri dlm setahun terakhir)
Terapi pendahuluan pd keadaan yg bukan emergency
Rujukan dan tindakan lanjutan sesudah dirujuk
Summary dari kasus dan prognosis

Schizophrenia
A. Characteristic symptoms (active phase): 2 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
Grossly disorganized or catatonic behavior
Negative symptoms (affective flattening, alogia, or avelition)
NOTE: only 1 a symp is required if delutions are bizarre or
hallutination consist of a voice keeping a running commentary
of persons behavior or thoughts, or 2 voices conversing with
each other.

B. Social/occupational dysfunction: 1 major areas of

functioning (work, interpersonal relations, self care)mrkedly
below the level achievedprior to the onset of symptoms.
C. Continous signs of disturbance for 6 months, including 1
month of active phase symptoms, may include prodormal or
residual phase.
D. Schizoaffective and mood disorder excluded
E. The disturbance is not due to the direct physiological effects
of a substance or a GMC.
F. If history of pervasive developmental disorder, additional
diagnosis of schizophrenia is made only if prominent
delusions or hallucinations are also present for at least 1
month

Subtypes
Paranoid:
preoccupation with one or more delusions (typically
persecutory or grandiose) or frequent auditory hallucinations
relative preservation of cognitive functioning and affect; onset
tends to be later in life; believed to have the best prognosis
Catatonic:
at least two of: motor immobility (catalepsy or stupor);
excessive motor activity (purposeless, not influenced by external
stimuli); extreme negativism (resistance to instructions/attempts
to be moved) or mutism; peculiar voluntary movement
(posturing, stereotyped movements, prominent mannerisms);
echolalia (repeating words/phrases of another's speech) or
echopraxia (imitative repetition of another's movements,
gestures or posture)

Disorganized:
disorganized speech and behaviour; flat or inappropriate affect
poor premorbid personality, early and insidious onset, and continuous
course without significant remissions
Undifferentiated:
symptoms of criteria A met, but does not fall into the 3 previous
subtypes
Residual:
absence of prominent delusions, hallucinations, disorganized speech,
grossly disorganized or catatonic behaviour
continuing evidence of disturbance indicated by the presence of
negative symptoms or 2 symptoms in criteria A present in attenuated
form

Epidemiology
Prevalence: 0.5%-1 %; M:F = 1:1
Mean age of onset: females 27;
males 21

Etiology
Multifactorial: disorder is a result of interaction between both biological and environmental
factors
Genetic - 50% concordance in monozygotic (MZ) twins; 40% if both parents have
schizophrenia; 10% of dizygotic (DZ) twins, siblings, children affected
Neurochemistry - "dopamine hypothesis" theory: excess activity in the mesolimbic
dopamine pathway may mediate the positive symptoms of psychosis (i.e. delusions,
hallucinations, disorganized speech and behaviour, and agitation)
Neuroanatomy - decreased frontal lobe function, asymmetric temporal/limbic function,
decreased basal ganglia function; subtle changes in thalamus, cortex, corpus callosum, and
ventricles; cytoarchitectural abnormalities
Neuroendocrinology - abnormal growth hormone, prolactin, cortisol, and ACTH
Neuropsychology - global defects seen in attention, language, and memory suggest lack
of connectivity of neural networks
Indirect evidence of geographical variance, winter season of birth, and prenatal viral
exposure

Pathophysiology
Neurodegenerative theory
natural history may be rapid or gradual decline in function
and ability to communicate
glutamate system may mediate progressive degeneration
by excitotoxic mechanism which leads to production of free
radicals
Neurodevelopmental theory: abnormal development of
the brain from prenatal life
Neurons fail to migrate correctly, make inappropriate
connections, and break down in later life
inappropriate apoptosis during neurodevelopment resulting
in faulty connections between neurons

Management
Biological
Acute treatment and maintenance with anti psychotics
(Chlorpromazine, Dozapine) anticonvulsants anxiolytics
Management of side effects
Psychosocial
Psychotherapy (individual, family, group): supportive, CBT
Assertive community treatment (ACT)
Social skills training, employment programs, disability
benefits
Housing (group home, boarding home, transitional home)

Prognosis
The majority of individuals display some type of
prodromal phase
Course is variable: some individuals have exacerbations
and remissions and others remain chronically ill; accurate
prediction of the long term outcome is not possible
Early in the illness, negative symptoms may be
prominent; positive symptoms appear and typically
diminish with treatment; negative symptoms may
become more prominent and more disabling
Over time, 1/3 improve, 1/3 remain the same, 1/3
worsen

Good Prognostic Factors

Acute onset
Precipitating factors
Good cognitive functioning
Good premorbid functioning
No family history
Presence of affective symptoms
Absence of structural brain abnormalities
Good response to drugs
Good support system

Schizoaffective Disorder
A. Uninterrupted period of illness during which there is either a MDE
(MDE), manic episode, or a mixed episode concurrent with
symptoms meeting criteria A for schizophrenia
B. In the same period, delusions or hallucinations for <':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 total duration of active and residual periods
of the illness.
D. The disturbance is not due to the direct physiological effects of a
substance or GMC
Treatment: antipsychotics, mood stabilizers, antidepressants
Prognosis: between that of schizophrenia and of mood disorder

Delusional Disorder
A. Non-bizarre delusions for 1 month
B. Criterion A for schizophrenia has never been met (though patient may have
tactile or olfactory hallucinations if they are related to the delusional theme)
C. Functioning not markedly impaired; behaviour not obviously odd or bizarre
D. If mood episodes occur concurrently with delusions, total duration has been
brief relative to duration of the delusional periods
E. The disturbance is not due to the direct physiological effects of a substance
or GMC
Subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed,
unspecified
Treatment: psychotherapy, antipsychotics, antidepressants
Prognosis: chronic, unremitting course but high level of functioning

 Toronto Notes 2012

American Psychiatric Association,
DSM IV (2000)