Download Schizophrenia lecture 1 (4).

Schizophrenia
A severe mental condition 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 the presence of organic impairment.
Schizophrenia Spectrum and Other Psychotic
Disorders
Schizotypal personality disorder
Delusional Disorder
Brief Psychotic disorder
Schizophreinform Disorder
Schizophrenia
Schizoaffective disorder
Substance / medication – induced psychotic disorder
Psychotic disorder due to another medical condition
Catatonia
Diagnostic Criteria
A. Two or more of the following almost all day most days of
the month: at least one of these must be 1, 2, or 3
1. Delusions
– Bizarre delusions such as:
– Example
» A person’s belief that a stranger has removed his or her
internal organs and has replaced it with someone else’s
organs without leaving any wounds or scars
•
•
•
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Thought broadcasting
Thought insertion
Delusion of being controlled
Thought withdrawal
Paranoid delusions
Delusion Types
• Persecutory delusion: the person believes he or she
is being tormented, followed, tricked, spied on, or
ridiculed.
• Referential delusions: the person believes certain
gesture, comments, passage from a book,
newspapers, songs or other environmental cues are
specially directed towards him or her
• Thought broadcasting
• The person believes that his thoughts are being
broadcasted by TV, Radio, or being read by other
people
Delusion Types
• Thought withdrawal: a person’s belief that his or her
thought have been taken away by some outside force
(or stolen)
• Thought insertion: alien thoughts have been put into
his or her mind (thoughts are implanted in their minds
from outside source)
• Delusion of being controlled: the person’s body or
actions are being acted upon or manipulated by
some outside force
Delusion Types
• Erotomanic: With this type of delusion, the
individual believes that someone, usually of a higher
status, is in love with him or her.
• Grandiose: Individuals with grandiose delusions have
irrational ideas regarding their own worth, talent,
knowledge, or power.
• Somatic: Individuals with somatic delusions believe
they have some physical defect, disorder, or disease.
Delusion Types
• Jealousy: The content of jealous delusions centers on
the idea that the person’s sexual partner is
unfaithful.
• Nihilistic: The individual has a false idea that the self,
a part of the self, others, or the world is nonexistent
(e.g., “The world no longer exists,” “I have no
heart.”).
• Mixed
Diagnostic Criteria
2. Hallucinations: are perception like experiences that
occur without an external stimuli.
• They are vivid and clear
• With full force and impact of normal perceptions,
and not under voluntary control
• Mostly auditory
– Two talking about the patient as a third person,
– Voices conversing together
– One voice running commentaries on the patient’s thoughts
or behaviors
Diagnostic Criteria
• Note: Those hallucination that occur while falling asleep
(hypnagogic) or waking up (hypnopompic) are considered
within normal. Hallucination may be a normal part of religious
experience in certain cultural contexts.
• Types of Hallucination
1. Auditory: are false perceptions of sound or voices
2. Visual: These are false visual perceptions.
3. Gustatory: are false perceptions of the sense of touch, often
of something on or under the skin.
4. Tactile: This type of hallucination is a false perception of
taste.
5. Olfactory: are false perceptions of the sense of smell.
Diagnostic Criteria
3. Disorganized Speech: (impaired communication)
• loose association or derailment: slips from the track
from one topic to another
• Answers to questions obliquely related or completely
unrelated (Tangentiality, circumstantiality)
• Incoherent or ward salad, neologisms
Diagnostic Criteria
4. Odd behaviors (disorganized behavior)
– Child like silliness to unpredictable agitation
– May be noted in any form of goal-directed behaviors, leading to
difficulties in performing ADL, such as maintaining hygiene, the person
may dress in an unusual manner (wearing multiple overcoats, scarves,
and gloves in a hot day)
– Inappropriate sexual behavior (masturbation in public)
– Unpredictable and un-triggered agitation (shouting and swearing)
– Strange grimaces, sniffing, blowing out cheeks, wrinkling the forehead,
or ritualistic activities–
– Mannerism or catatonic--stupor, negativism, rigidity, excitement, waxy
flexibility, or posturing –
– Immobility, adopting odd postures for long periods of time.
Diagnostic Criteria
5. Negative symptoms:
– Affective flattening (face immobile, unresponsive, poor
eye contact, and reduce and language)
– Alogia (poverty of speech lacks content, diminshed )
– Avolition (inability to initiate and persist in goal directed
activities) absence of interest in usual routines (grooming,
hygiene
– Anhedonia-inability to experience pleasure (relationships,
sex)
– Asociality: refers to the apparent lack of interest in social
interaction
Diagnostic Criteria
B. Social \ Occupational Dysfunction:
 Marked deterioration in role functioning in one or more of
major areas; work or school, interpersonal relations, self
care activities.
C. Duration:
Continuous signs persist for at least 6 months.
(includes at least one month of acute symptoms,
the other period there will be prodromal signs)
Diagnostic Criteria
D. Exclusion of affective disorders
 if affective disorder occur during acute period. it’s
period of presence must be short as related to the
acute period.
E. Exclusion to any medical or drug use disorder
Such as Alcohol, Cocaine, LSD, Anesthesia, AntiCholinergic agents, Chemotherapy, Carbon
monoxide, Volatile substances such as Fuel and
Paint
F. Not related to any developmental disorder
such as autistic disorder.
Associated Features with Schizophrenia
Inappropriate affect
Dysphoria Mood (depressed, anxiety)
Disturbed sleep pattern
Lack of interest in eating or food refusal
Depresonalization
Derealization
Somatic concern (Delusional proportions)
Anxiety and Phobias are common
Deficits in memory (working)
Associated Features with Schizophrenia
Deficits in language functions
Abnormalities in sensory processing and
inhibitory capacity
Reduction in attention
Social cognition deficits (inability to infer the
intentions of other people)
Lack of insight
Hostility and aggression
Functional Consequences of Schizophrenia
Schizophrenia is associated with significant social
or occupational dysfunction.
Individuals with schizophrenia have impaired
educational progress and are unable to maintain
employment (due Avolition or other symptoms)
Most individuals are employed at a lower level
than their parents.
Most of them don’t marry or have limited
contacts outside of their family.
CATATONIA
• The clinical picture is dominated by three or more of
the following symptoms:
• One or two of the following symptoms are present
for at least two weeks:
– Stupor: (marked decrease in reactivity to the
environment the person might seem as in coma
but still aware about the environment).
– Excitement (purposeless motor activity, not
influenced by external environment).
– Posturing (voluntary assumption and
maintenance of inappropriate or bizarre positions)
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CATATONIA
– Negativism: (motiveless resistance to any attempt
to move the patient)
– Mannerism: (odd movement, goal directed )
– Stereotypy: (repetitive, abnormal frequent- not
goal directed)
– Agitation: not influenced by external stimuli
– Echolalia: mimicking another speech
– Echopraxia: mimicking another movement
• Tends to be severe and quite rare
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CATATONIA
– Posturing: (spontaneous and active maintenance
of a posture against gravity)
– Rigidity: (maintenance of rigid posture against
efforts to be moved)
– Waxy flexibility: Slight resistance to positioning by
examiner
– Catalepsy: (Passive induction of a posture held
against gravity
– Mutism: (No or very little verbal response exclude
aphasia.
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Schizophrenia: Phases
• Phase I: Schizoid personality
– Emotional coldness (limited range of emotional
expression), Do not enjoy relationships, prefers
solitary activities
– Not all client who develop schizophrenia has schizoid
personality
• Phase II: The prodromal phase
– Social withdrawal, neglect of hygiene & grooming,
blunted or inappropriate affect, bizarre ideas, lack of
initiatives, interest or energy.
– May last for many years (gradual onset)
Schizophrenia: Phases
• Phase III: Schizophrenia
– Acute episode of signs & symptoms
• Phase IV: Residual phase
– Periods of remission & exacerbation
– Similar to prodromal phase
Symptoms of Schizophrenia
Positive (Type I)
• Hallucinations
• Delusions
Disorganized
• Disorganized speech
• Disorganized thought
• Disorganized or
catatonic behavior
Negative (Type II)
• Affect - blunted or flat
• Alogia - little speech
• Avolition
• Anhedonia
• Agnosia (inability to
recognize familiar
situations, persons, …)
• Social withdrawal
Associated features
• Acute onset
• Normal pre-morbid
functioning
• No family history
• Normal functioning
during remission
• Absence of intellectual
impairment
• Slow onset
• Pre-morbid
emotional problems
• Family history
• Chronic
deterioration in
social functioning
• Intellectual
impairments
Associated features
• Normal CT
• Cerebellar atrophy
• Normal neuro• Abnormal
neuropsychological
psychological testing
tests
• Good response to
antipsychotic
medications
• Poor response to
antipsychotic
medications
PREVALENCE
• The lifetime prevalence of schizophrenia appears to be 0.3% 0. 7%.
• Schizophrenia occurs in 1 person from 1000 person in the
society.
• The psychotic features of schizophrenia usually emerge
between the late teens and the mid-30s.
• The peak onset of schizophrenia is early to mid 20s for males
and in the late-20s for females
RISK FOR SUICIDE
• Approximately 5%-6% of individuals with schizophrenia die by
suicide, about 20% attempt suicide on one or more occasions.
• Suicidal behavior is sometimes in response to command
hallucinations
• High risk for young male with comorbid substance use.
• Other risk factor include having depressive symptoms or
feelings of hopelessness and being unemployed, and the risk
is higher, also, in the period after psychotic episode or
hospital discharge.
OTHER PSYCHOTIC DISORDERS: SCHIZOPHRENIFORM
• Two or more of the following, each present for a significant
portion of time during a 1 month period. At least one of these
must be (1), (2), or (3)
• Prodromal, acute, & residual occur at least for one month &
less than 6 months
• Specify:
– Without good prognostic feature
– With good prognostic features
 Onset of prominent psychotic symptoms within 4 weeks of the
first noticeable change in usual functioning
 Confusion or perplexity at the height of the psychotic episode
 Good pre-morbid personality
 Absence of blunted affect
OTHER PSYCHOTIC DISORDERS: SCHIZOAFFECTIVE DISORDER
• Uninterrupted period of illness during which the person
shows symptoms of mood disorder (depression or mania or
mixed) concurrent with Criterion A of schizophrenia
• During the period of illness the person has delusions or
hallucinations at least 2 weeks in the absence of a major mood
episode (manic or depressive)
• The person experience symptoms of mood disorder that is
relatively brief compared to the total duration of delusion or
hallucination episodes
• Exclude physical disorder or substance use
• Specify:
– Bipolar type
– Depressive
OTHER PSYCHOTIC DISORDERS: Delusional disorder
• A. the presence of one or more delusions with a
duration of 1 month or longer.
• B. Criterion A for schizophrenia has never been met
• C. Functioning is not markedly impaired, and
behavior is not obviously bizarre or odd
• D. if manic or depressive episodes have occurred,
these have been brief and relative to the duration of
the delusional periods.
• E. the disturbance is not attributable to the
physiological effects of a substance or another
medical condition and is not better explained by
another mental disorder.
Other psychotic disorders: Delusional disorder
• Delusions involve situation that occur in real life and
has a specific theme such as:
–
–
–
–
–
Erotomanic
Grandiose
Jealousy
Persecutory
Somatic
– Mixed
OTHER PSYCHOTIC DISORDERS: Brief
psychotic Disorder
• Presence of 1 or more of the following symptoms. At least one
of these must be (1), (2), or (3).
–
–
–
–
Delusion
Hallucination
Disorganized speech
Grossly disorganized or catatonic behavior
• Duration of an episode is at least 1 day but less than 1 month
with full return to normal function level
• Exclude other psychiatric disorders, substance use or physical
problems
• Specify:
– With marked stressors (brief reactive psychosis)
– Without marked stressor
– With postpartum onset
Schizophrenia Co-morbid Conditions
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•
•
•
Depression
Anxiety
Aggression
Substance use disorder
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